Elbow Injuries in Athletes Elbow Injuries in Athletes • Ligamentous and Bony Anatomy • Elbow Dislocations • Ulnar (Medial) Collateral Ligament Timoth y L . Mill er, MD Tears Assistant Professor • Distal Biceps Tendon Ruptures OSU Orthopaedic Surgery and Sports Medicine OSU Track and Field Team Physician • Triceps Tendon Ruptures The Ohio State University Wexner Medical Center • Lateral Epicondylitis

MCL (UCL) Complex

Elbow Ligamentous • UCL complex: and Bony Anatomy • Anterior bundle • Anterior band • Posterior band • Posterior bundle • Oblique bundle (transverse ligament) J Am Acad Orthop Surg 2004;12:405-415

ElAttrache, N, JAAOS, 2001

1 MCL (UCL) Complex Lateral Collateral Ligament Complex

• Anterior Bundle • LCL (radial collateral) • Origin: inferior aspect of the • Lateral EC merges with medial epicondyle annular ligament • Inserts: sublime tubercle • LUCL (ulnar part of LCL) (medial aspect of the • Lateral humeral EC to coronoid process) the tubercle of the • EtillltdithEccentrically located with supinator crest of the respect to axis of elbow ulna motion • Accessory LCL • Provides stability • Stabilizes annular throughout full ROM ligament during varus • Functionally most important stress in providing stability to • Annular ligament J Am Acad Orthop Surg 2004;12:405-415 valgus stress of the elbow. ElAttrache, N, JAAOS, 2001

Secondary Elbow Stabilizers “Elbow Instability” - Morrey • At < 30°: A condition which results from both the injury and • Radial head the resultant loss of function due to damage to • Ulnohumeral articulation the articular surface and the ligamentous • Anterior capsule structures that stabilize the elbow. • At Full Extension: • OlecranonOlecranon//OlecranonOlecranon Fossa In order to provide a rationale for the reliable • Muscles originate from ME: treatment of the spectrum of these injuries… • PT …there must be a thorough • FCR Netter orthopaedic atlas understanding the contributions of the • FDS articulation and the ligamentsto the normal • FCU stability. • Provide dynamic functional resistance to valgus stress Morrey, BF. JBJS. 1997; 79-A; 460-9.

2 Elbow Dislocation

• Second in frequency to shoulder Elbow Dislocations dislocations • Incidence of 6 per 100, 000 persons • Most common: • Posterior J Am Acad Orthop Surg 1996;4:117-128 • Posterolateral • 80% dislocations

Elbow Dislocation Pathophysiology

• Often caused by fall on • 3 Stages of Injury: Lateral→Medial outstretched hand • Stage 1: • Diagnosis is suspected • LUCL and made on XR • Stage 2: • One must determine • Ant. and Post. Capsular disruption association of articular • Stage 3: injuries • MUCL • 25 – 50% • Stage 3B: • Essential lesion which • MUCL + Common allows this… flex/pronator origin disruption • Disruption of the LUCL J Am Acad Orthop Surg 2004;12:405-415 Morrey, BF. Acute and chronic instability of the elbow. JAAOS. 1996; 4; 117-128. O’Driscoll, Clin Orthopaedics 1992.

3 Elbow Dislocation-Treatment Elbow Dislocation-Treatment • Without Associated Fracture: • If Unstable Post Reduction: • PrePre--reductionreduction PE • Immediate reduction • Splinted in a position of sufficient flexion for under conscious immediate stability sedation • Motion in a stable arc after 5 –7– 7 days • Longitudinal traction ibt45din about 45 degrees of • Gradual progression of motion over next 3 – flexion 4 weeks • Pressure on olecranon • If > 50 degrees of extension loss at 6 weeks, • Post reduction assessment of stability with a stable elbow, start hyperextension • Examine joint bracing at night. throughout ROM • Gradual regaining of motion by 12 months. • Post reduction imaging

Morrey, BF. Acute and chronic instability of the elbow. JAAOS. 1996; 4; 117-128.

Elbow Dislocation-Treatment Elbow Dislocation-Treatment • Length of immobilization? • Role for Surgery?? • Little value in • Residual pain and loss uncomplicated dislocations of motion was a • Prospective study function of the period • Non surgical elbows had of immobilization less flexion contracture (Mehlhoff, T et al., JBJS, 1988) than surgically treated elbows • 80% of patients treated w/ surgery considered their elbow “not normal” compared w/ 50% of those treated non-non- operatively Josefsson, PO, et al. JBJS. 1987; 69-A; 605-8.

4 Dislocations w/ Associated Fractures • More difficult to treat

• Requires reduction of the elbow Medial Ulnar Collateral • Management of the Ligament Injury fracture on the basis of its individual characteristics

• Beware of the “Terrible Triad”

• Elbow Dislocation Matthew PK, JAAOS, 2009. • Radial Head Fx • Coronoid Fx

MUCL Tears MUCL Tears: Pathophysiology • Tears of the MCL are the most frequent isolated • Late cocking and early acceleration ligamentous injury of the forces may exceed tensile strength of elbow UCL • Seen commonly in • Combination of valgus and extension throwing athletes loads produce tensile stress along the (i(pitch ers) media l res tra in ts (UCL, fl exor-pronator • c/o acute / chronic pain m., medial epicondyle epiphysis, and along the medial elbow ulnar nerve) • Associated with valgus • Repetitive micro-trauma leads to stress to the joint, which gradual attenuation of anterior bundle occurs commonly at the of UCL time of delivering a pitch/ throwing. Conway JE, Jobe FW JBJS Am 1992;74:67-83

5 Clinical Presentation Clinical Presentation

• Physical Exam • +/- ecchymosis • Local TTP just inferior to the medial eppyicondyle • History Digiovine NM, JSES, 1992. • Especially over the • Generally chronic and progressive medial elbow pain anterior band of the with repeated throwing MUCL • Pain most severe in the cocking and acceleration Chen FS, JAAOS, 2001. phases of throwing • Occasional “Pop” followed by sharp pain (acute injuries) • May be accompanied by ulnar n. signs or posteromedial impingement pain • Pt. may report loss of velocity in pitch assoc. w/ pain

Clinical Presentation Physical Examination • Physical Exam • Diminished ROM • loss of full • Moving valgus extension, bony stress test block to ext. • Pain 70° to 120° • Flexion contracture flexion range as in up to 50% the elbow is professional pitchers rapidly extended • Pain to palpation of Chen FS, JAAOS, 2001. • Milking maneuver MCL at 50-70° flexion

• Evaluate for ulnar n. Chen FS, JAAOS, 2001. subluxation, Tinel’s

6 Imaging Treatment

• AP/Lateral Xray • TREATMENT CONSIDERATIONS • Fluoroscopy • career level • Stress views • career potential • ability to participate • MRI in extensive • 92% sensitive, 100% rehabilitation specific for UCL tears • patient motivation • desire to continue • MR Arthrography throwing Sandy Koufax pitching for the Los Angeles Dodgers in the 1960s (photo, public domain)

Gaary EA, Potter HG, Altchek DW. AJR Potter HG. CORR 2000;370:9-18. 1997;168:795-800.

Surgical Reconstruction of the MUCL • “Docking Technique” • Muscle splitting approach • Single inferior humeral tunnel with 2 small superior exiting tunnels • Place the tendon graft in bone tunnels; Simplify graft tensioning and improve fixation • 36 elite athletes • 92% returned to same activity level at 3.3 year followfollow--upup

Nassab and Schickendantz. Eval. and Rx of medial UCL injuries in the throwing athlete. Sports Med Arthrosc Rev. 2006; 14 (4); 221-31. Rohrbough, JT, et al. MCL recon using the Docking Technique. AJSM. 2002. 30:4; 541-48

7 Reconstruction Results • Systematic review of all published reports of UCL reconstruction in overhead athletes. • Average 83% of patients in all studies had an excellent Distal Biceps result. • UCL reconstruction has TdTendon R Rtuptures made return to previous or higher level of athletic participation in sports highly likely. • Vitale, M. and Ahmad, C. The outcome of elbow ulnar collateral ligament reconstruction in overhead athletes. A systematic review. AJSM. 2008; 36 (6): 1193-1205.

Demographics Demographics

. Incidence of distal biceps rupture is 1.2 per 100,000 . Incidence of distal biceps rupture is 1.2 per 100,000 persons per year. Safran MR CORR, 2002 persons per year. Safran MR CORR, 2002

. Injuries tend to occur in the dominant elbow (86%) of . Injuries tend to occur in the dominant elbow (86%) of men (93%) in their 40s, laborers. Morrey, BF JBJS 1985 men (93%) in their 40s, laborers. Morrey, BF JBJS 1985

. 7.5 times greater risk of distal biceps tendon ruptures . 7.5 times greater risk of distal biceps tendon ruptures in persons who smoke. Sutton KM, JAAOS, 2010 in persons who smoke. Sutton KM, JAAOS, 2010

8 Demographics Classification

. Incidence of distal biceps rupture is 1.2 per 100,000 1. Temporal – Acute vs. Safran MR CORR, 2002 persons per year. Chronic . Injuries tend to occur in the dominant elbow (86%) of 2. Morphologic – Complete men (93%) in their 40s, laborers. Morrey, BF JBJS 1985 vs. Partial . 7.5 times greater risk of distal biceps tendon ruptures 3. Anatomic in persons who smoke. Sutton KM, JAAOS, 2010 . Bone Attachment (Type I) Athwal, et al. JHS 2007 . Intratendinous (Type II) . Musculotendinous Junction (Type III)

History and Physical Exam Physical Exam . Patients with a complete biceps rupture . Rupture is frequently present with: associated with a traumatic . A visible deformity with a “Popeye” muscle event (eccentric load) proximally . A forceful extension . Lifting a heavy object . A palpable defect of the insertion . Weakness of supination and elbow flexion . Patients report a painful “pop” . Tendon can be palpable at, or proximal to, the in the elbow. antecubital fossa

. Ecchymosis of the elbow and medial forearm is common.

Sutton, KM, JAAOS 2010

Sutton, KM, JAAOS 2010

9 Examination: Hook test Examination: Hook test

Sensitivity Specificity

Complete

Hook Test 100% 100%

MRI 98% 83%

Partial

Hook Test 75% 80%

MRI 60% 98%

O’Driscoll, SW et al. AJSM 2007 O’Driscoll, SW et al. AJSM 2007

Indications for MRI Non-operative Management .Diagnosis is unclear .Tear thought to be at myotendinous junction .Evaluation of retraction in a chronic tear . Low demand or medically infirm .Suspected partial tendon rupture patients . Without repair patients may have: . Activity related pain . Weakness, especially of power supination . Early fatigue of supination and flexion

10 Operative Management

JBJS 1985 . Oppperative Tx superior to non-op Tx in terms of restoring:

. Elbow flexion strength (30% improved)

. Supination strength (40% improved)

. Upper extremity endurance

11 12 Operative Management Post-op Xrays  Results  > 95% ROM return in flexion- extension and pronosupination.  Return of 97% of flexion and 95% suppgination strength.  Overall excellent functional outcomes in acute repairs.  Less predictable outcomes for patients treated with chronic injuries. King J,JAAOS, 2008.

Triceps Tendon Tears

• Rare injuries • <1% of all tendon problems related to the upper extremity • Seen in weight lifters with anabolic steroid use Triceps Tendon • Local Factors: • Local corticosteroid injections Ruptures • Attritional changes from degenerative arthritis • Olecranon bursitis • Disruption occurs most commonly: • As a result of a FOOSH • Eccentric load • Can occur from direct trauma

13 Presentation Triceps Tendon Tears

 Pain and swelling over • Treatment: posterior elbow • Operative repair  Eccymosis  Palpable defect • Many different proximal to olecranon techniques  Frequently not palpable due to swelling – Suture, suture anchors, biotenodesis  Inability to extend the elbow against gravity screws etc.  However extension is • Chronic triceps frequently preserved (50%) avulsions:  Intact lateral expansion • May require allograft  Anconeus contribution reconstruction to bridge defect

Lateral Epicondylitis

• Common extensor origin arises from the lateral epicondyle • ECRB origin is Lateral Epicondylitis deepest & superior • Microscopically: “Tennis Elbow ” invasion by fibroblasts and vascular Stemcelldoc granulation tissue • ‘Angiofibroblastic Hyperplasia’ • Absence of acute & chronic inflammatory cells Normal Muscle Angiofibroblastic Calfee RP, JAAOS, 2008. Hyperplasia

14 Lateral Epicondylitis Lateral Epicondylitis - Treatment • Presentation • NON OPERATIVE • Lateral elbow pain which may radiate to forearm TREATMENT • History of repetitive use of extensor tendons or • Success rate up to 90% repetitive trauma. • Rest +/+/-- icing. • Waxing and waning of symptoms related to • PT/stretching activity level. • Physical Exam • CtfBCounterforce Braces • Maximal tenderness just • Corticosteroid distal lateral epicondyle injections • Pain with passive wrist & finger flexion with the • PRP: 81% improvement Athletico Physical Therapy, 2013 elbow extended at 6 months. • Pain with resisted wrist & finger extension with elbow Mishra, A, AJSM, 2006 extended Nirschl, Clinical Sports Medicine, 2003.

Lateral Epicondylitis - Treatment Conclusions

• OPERATIVE • Elbow injuries can be devastating TREATMENT problems. • Success rate> 85% of • Most concerning for overhead patients and throwing athletes. • Excision of • When necessary, immobilization dtdtddegenerated tendons shldbiiidthould be minimized to prevent + repair loss of ROM. • Arthroscopic release • Acute tendon repairs produce • Percutaneous release overall good outcomes. • Full recovery is less predictable in chronic injuries.

Scher, DL, Orthopaedics, 2009.

15 Lower Extremity Injuries in the Outline and Objectives Athlete • Case 1. Hip • Groin pain in hockey player • Clinical Pearl: Stress Fractures • Case 2. Knee Michael Jonesco, DO • Acute knee pain in triathlete Assistant Clinical Professor, • Clinical Pearl: Knee effusions • Case 3. Lower Leg Department of Internal Medicine • Exertional Shin Pain in Runner Team Physician, Capital University • Case 4. Foot/Ankle Head Physician, Columbus Clippers • Tennis player with lateral foot Division of Sports Medicine pain The Ohio State University Wexner Medical Center • Clincal Pearl: Pediatric Athletes

Case 1 Differential Diagnosis • Glut tendonitis • 29 year old recreational hockey goalie • Stress Fracture Hip presents with anterior hip pain for 3 • Piriformis syndrome • Greater Trochanteric Bursitis months. Denies trauma or associated MOI. • SI dysfunction Pain exacerbated by flexion, relieved with • Hip osteoarthritis • Iliopsoas tendonitis restDt. Descr ibes occasi onal l“liki” “clicking” or • Radicular Leg pain • Hip Flexor strain “popping”. Has taken NSAID with some • Femoral acetabular • Hip Pointer relief, but pain returns whenever he impingement • ITB syndrome of Hip resumes hockey activity. • Acetabular Labral Tear • Osteitis Pubis • Adductor Syndrome • Athletic Pubalgia • Meralgia paresthetica

16 Femoral Acetabular Impingement CAM . “Hip Impingement” . Abnormal contact between proximal femur and acetabular rim during flexion of the hip . CAM: Prominence of femoral head . Pincer: Overcoverage of acetabulum . Can lead to Labral Tears premature OA if left untreated

Pincer FAI, Acetabular Labral Tear . History . Insidious groin pain (FAI) vs singular event (labrum?) . 2nd-6th decades . Pivoting/twisting . Pain with activity . flexion sports . Sitting painful . Car rides, class, work • Pain worse over time – true FAI generally does not resolve spontaneously

17 FAI/Labral Tear FAI/Labral Tear, Treatment . Exam . “C” sign • Conservative Tx • Few (if any) studies . +FADIR done on long-term . + “Scour” or conservative Circumduction management . Eval/Imaging • Core Strengthening . Xrayygg AP, Frog Leg • Positional avoidance . MRI • Modify sport . More sensitive w/ • NSAIDs arthography for LABRAL TEAR • Injections . (increases sens from • Blind, US, or Fluoro- 30%-90% guided . Specificity w/ • Elliptical bupivicaine injection up • Less hip flexion, impact to 90% for IA disorder vs running

FAI/Labral Tear, Treatment Stress Fracture Hip

• Surgical studies limited  Considered in any runner w/ hip • Most with short term follow-up pain, thigh, buttock, or groin pain  Signs and Symptoms • Surgical treatment . Pain increases w/ weight bearing • Addresses bonyy( abnormalities (+ . Limitations in strength, ROM (esp labrum) IR) • 80-90 short term improvement (pain)  Evaluation/Imaging • Moderate evidence may prevent OA . Xray typically negative . MRI, low index of suspicion • People w/ OA had worse surgical  Treatment outcomes . Depends on WHERE the bony edema/stress rxn

Ng et al, AJSM, 2010

18 Stress Fracture Hip Stress Fracture Hip COMPRESSION COMPRESSION • >younger • >younger • Inferior medial margin • Inferior medial margin • No Fracture line • No Fracture line • Treatment • Treatment • Conservative • Conservative • NWB initially (crutches) • NWB initially (crutches) • Crutches and progressive • Crutches and progressive wt bearing over 3 m wt bearing over 3 m • Gradual RTP • Gradual RTP

Stress Fracture Hip Stress Fracture Hip TENSION TENSION • Older • Older • Superior neck • Superior neck • Treatment • Treatment • Prompt Orthopedic • Prompt Orthopedic referral referral

19 Stress Fracture Hip Clinical Pearls: Stress Fractures* • Imbalance in bony formation TENSION and bony breakdown • Older • Inadequate remodeling • Osteoclasts > Osteoblast • Superior neck • History • Training, Shoes, Diet & Nutrition, • Treatment IjInjury hi hitstory • Prompt Orthopedic • Imaging • Xray typically negative, esp in referral first 3 wks or so • MRI most specific, sensitive • Treatment • Generally rest • Be aware of high risk stress fractures!

High Risk Stress Fractures High Risk Stress Fractures

• Navicular • Navicular • Hip, Tension-sided • Hip, Tension-sided • Medial Malleolus • Medial Malleolus • Base of 5 th MT • Base of 5 th MT • Sesamoid • Sesamoid

20 High Risk Stress Fractures High Risk Stress Fractures

• Navicular • Navicular • Hip, Tension-sided • Hip, Tension-sided • Medial Malleolus • Medial Malleolus • Base of 5 th MT • Base of 5 th MT • Sesamoid • Sesamoid

High Risk Stress Fractures Case 1 Follow Up

• Navicular • Exam, xrays suggestive of FAI • PT, NSAID • Hip, Tension-sided • At 6 weeks, pain had improved • Medial Malleolus 80% th • Returned to sport, symptoms • Base of 5 MT returned • Sesamoid • Intra-articular injection (kenalog+lidocaine) in office • Now 6 months out and still playing hockey • Less goalie • Aware of increased risk of degeneration/OA

21 Differential Dx: Case 2 Knee Injuries in the Athlete • 44 yr old biker presents to your clinic with ACUTE SUBACUTE/CHRONIC right lateral knee pain. He has been • Ligamentous • Patellar Tendonitis training for triathlon (run, bike, swim). Pain • ACL, PCL • Pes Bursitis increases when running downhill and • MCL, LCL • IT Band Syndrome crossing right leg over left knee. Denies • Cartilaginous • Patellofemoral swelling, mechanical symptoms. • Chondral Injury Syndrome • Exam reveals NO effusion, FROM, full • Meniscus Tear • Quad tendonitis strength. There is ttp posterior to LCL. • Patellar Dislocation • Popliteal Tendonitis • Tendon Rupture • Quad, Patellar

Clinical Pearls: Knee Effusion* Knee Effusion: Sweep Test

• Aspiration aids • Effusion warrants examination! MRI! • Sweep test* • Indicative of intra- articular damage • Red or yellow? • Hemarthrosis in athlete? • Don’t be fooled • Anterior cruciate • Pre or suprapatellar bursitis vs effusion • Patellar Dislocation • Tibial Plateau Fracture • Straw colored • Meniscus, chondral injury

22 Case 2: Follow up Case 3 • Diagnosed Popliteal • Tx: conservative Tendonitis measures • Down-hill hiking, • Rest or activity running modification • > 15-30 flexion • Ice • Bracing (mixed results) • Figure 4 exam • Shoe wear • 20 y/o female runner presents with bilateral • “Shoe Kick-off” Test • Case by case • Anti-inflammatory lower extremity pain. She localizes pain • PO, Topical NSAID vs diffusely over anterior shins. It is Injection aggravated by running and relieved with rest. NSAIDs have minimal benefit. Despite 1 month of rest she is unable to return to running without return of symptoms.

MTSS or “Shin Splints” Tibial Stress Fracture . Misnomer: shin splints, periostitis . Newer evidence suggests pain related to bony  Posterior Medial Tibial Pain overload . Runningwalkingrestnight . Continuum w/ stress fracture?  Exam  Exam . More localized . Diffuse TTP (vs isolated), middle/distal 1/3 . Tuning Fork (away from sight)  Imaging/Eval  Imaging? If needed . Xray neg  Xray neg <3 w ks (res t!) . MRI or bone scan reasonable if competitive . Bone Scan vs MRI athlete; r/o stress fx  Treatment  Treatment  Rest . Nsaids, RICE, Modify shoe wear (orthotic)  Pneumatic Boots . Posterior chain stretching . Non-wt bearing; crutches (if . Cut mileage ~50% and gradually return <10%/wk , needed) cross-train . AS PAIN ALLOWS! Beware…

23 Anterior Mid Tibia Anterior Mid Tibia

• Tension sided • Tension sided • High risk for non-union • High risk for non-union and complete fx and complete fx • Jumping Athlete • Jumping Athlete • “Dreaded Black Line” • “Dreaded Black Line” • Aggressive Conservative • Aggressive Conservative Tx Tx • NWB (+/- cast/boot) x 6-8 • NWB (+/- cast/boot) x 6-8 wks wks • If fails Ortho for IM rod • If fails Ortho for IM rod

Anterior Mid Tibia Exertional Compartment Syndrome (ECS) • Tension sided • Dynamic Exercise • High risk for non-union • Elevated interstitial and complete fx pressures • Jumping Athlete • Closed fascial • “Dreaded Black Line” compartments • Aggressive Conservative • Presents as ischemia pain Tx • (microvascular • NWB (+/- cast/boot) x 6-8 compromise) wks • ~30% chronic leg pain! • If fails Ortho for IM rod (Edwards) • Boy=girl, common b/l • Runners>>bikers

24 ECS: H&P ECS: Imaging & Evaluation • Xray/MRI • Rule out other • Crescendo-Decrescendo • Exam pathology • Normal • “Cramping”, • Muscle herniations • Evaluation/Imaging paresthesias, (40%) • Compartment testing weakness • Intra-compartmental pressure • Normal at rest…so • Escalates w/ activity exercise the patient! • Rest, 1 min, 5 min • Stops quickly w/ rest • Rigid • Confirmatory test • Defects • >15, >30, > 20 mm • Neuro findings? • Tender w/ Hg passive motions

ECS: Treatment Case 3 Follow-up • Pt sent for compartment testing • Rest (atrophy) • Anterior and Lateral Pressures • Compression socks >60 mm Hg • Switch Sport • Referred for fasciotomy • Runbiking? • Anterior and Lateral, • Surgery: Fasciotomy laporoscopic • 90% RTP • Returned to sport 3 m later successfully • Competing at previous level at 6 months w/o complaint

25 Case 4 Achilles Rupture

• 12 year old football and tennis player • Largest, strongest complains of lateral foot pain. He tendon in the body describes several weeks of symptoms that • Subjected to up to 10x acutely worsened following a 2 day tennis body wt during activity tournament. Pain worsens w/ walking and • Begins at junction of he walks with a limp. Improves with rest gastrocnemius and and ibuprofen (400 mg PO tid). soleus tendons in middle of calf • Typically 3 to 11 cm in length

Achilles Rupture Achilles Rupture • Antecedent tendinitis/tendinosis in 15% • History & Exam • Physical Exam • “Kicked in the leg” • Palpable defect • 75% of sports-related ruptures happen in • Mechanism • Thompson Test + patients between 30-50 years of age. • Eccentric loading • Bruising/Swelling (running backwards • Weakness with plantar in tennis) • Most ruptures occur in watershed area 2-6cm flexion proxiltthlimal to the calcaneal liti insertion. • Sudden unexpected dorsiflexion of ankle

26 Achilles Rupture GastrocnemiusTear • “Tennis Leg” • Tear of gastroc fibers, • Management depends on physician and typically medial head patient preference • Pain isolates to • Surgery treatment of choice for athletes, muscle belly yygpoung patients and delay ed ru pture • Often presents like achilles rupt ure • Acute rupture in non-athletes can be • Exam: Negative treated nonoperatively Thompson, No defect • Return to sport ~9 m regardless • Boot w/ wedges, WB as tolerated • Early physical therapy

Clinical Pearls: Pediatric Athletes Clinical Pearls: Pediatric Athletes Common Lower Extremity Apophyseal Injuries Common Lower Extremity Apophyseal Injuries • Hip • Hip • ASIS, Iliac crest • ASIS, Iliac crest

• Knee: • Knee: • Osgood Schlatter • Osgood Schlatter

• Sinding-Larsen- • Sinding-Larsen- Johansson Johansson

• Foot • Foot • Sever’s • Sever’s

• Iselin’s • Iselin’s

27 Clinical Pearls: Pediatric Athletes Clinical Pearls: Pediatric Athletes Common Lower Extremity Apophyseal Injuries Common Lower Extremity Apophyseal Injuries • Hip • Hip • ASIS, Iliac crest • ASIS, Iliac crest

• Knee: • Knee: • Osgood Schlatter • Osgood Schlatter

• Sinding-Larsen- • Sinding-Larsen- Johansson Johansson

• Foot • Foot • Sever’s • Sever’s

• Iselin’s • Iselin’s

Clinical Pearls: Pediatric Athletes Common Lower Extremity Apophyseal Injuries Case 4: Follow-up • Hip • Pt w/ point ttp base of 5th MT • ASIS, Iliac crest • Xray: • Radiolucency parallel! • Knee: • Osgood Schlatter • Iselin Disease • Placed in short pneumatic boot • Sinding-Larsen- • x 2 wks Johansson • 23 h/day, posterior chain stretching • Foot • Modified shoe wear • Sever’s • Gradual RTP • NSAIDs PRN if tolerated • Iselin’s

28