SPORTSMEDICINEMEDIA GUIDE

AN ILLUSTRATED RESOURCE ON THE MOST COMMONINJURIES AND TREATMENTS IN SPORTS

Material developed in partnership by:

FALL 2011

SPORTS MEDICINE 2

Created by the American Orthopaedic Society for Sports Medicine (AOSSM), inpartnership with the American Academy of Orthopaedic Surgeons (AAOS), this mediaguide 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 lighton 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 oursports medicine experts, please don’t hesitate to contact media relations staff at AOSSM or AAOS.

AOSSM: lisa@aossm.org or 847-292-4900AAOS: media@aaos.org or 847-823-7186

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

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

About AAOSThe American Academy of Orthopaedic Surgeons serves orthopaedic surgeons who are medicaldoctors with training in the diagnosis and non-surgical as well as surgical treatment of themusculoskeletal 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 organizationthat provides education programs for orthopaedic surgeons and allied health professionals, championsthe interests of patients and advances the highest quality musculoskeletal health. Orthopaedicsurgeons and the Academy are the authoritative sources of information for patients and the generalpublic on musculoskeletal conditions, treatments and related issues. An advocate for improvedpatient care, AAOS is participating in the Bone and Joint Initiative (www.usbjd.org) — the globalinitiative established in 2002 — to raise awareness of musculoskeletal health, stimulate researchand improve people’s quality of life.

This information is brought to you by the American Orthopaedic Society for Sports Medicine and the American Academy of OrthopaedicSurgeons. 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 MEDIA GUIDE

SPORTS MEDICINE 3

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/LigamentDisorders with Platelet-Rich Plasma 32

Sources 33

SPORTS MEDICINEMEDIA GUIDE

Copyright © 2011. American Orthopaedic Society for Sports Medicine. All rights reserved.

AC JOINTINJURIES

EXPERT CONSULTANT | Edward McFarland, MD

SPORTS MEDICINE | AC Joint Injuries 4

What is the AC joint?The AC (acromioclavicular) jointis a joint in the shoulder where thecollarbone (clavicle) meets the shoulderblade (scapula). The specific part of thescapula adjacent to the clavicle is calledthe acromion, hence the name AC joint.

What kinds of problemsoccur at the AC joint?The most common problems thatoccur at the AC joint are arthritis,fractures and “separations.” Arthritisis a condition characterized by loss ofcartilage in the joint. AC joint arthritisis common in weight lifters, especiallywith the bench press, and (to a lesser

extent) military press. AC joint arthritismay also be present when there arerotator cuff problems.

What is an AC separation?When the AC joint is “separated,” itmeans that the ligaments connectingthe acromion and clavicle have beendamaged, and the two structures nolonger line up correctly. AC separationscan be anywhere from mild to severe,and AC separations are “graded”depending upon which ligamentsare torn and how badly they are torn.

Grade I Injury — the least damageis done, and the AC joint still lines up.

Grade II Injury — damage to theligaments which reinforce the AC joint.In a grade II injury these ligamentsare only stretched but not entirely torn.When stressed, the AC joint becomespainful and unstable.

Grade III Injury — AC and secondaryligaments are completely torn andthe collarbone is no longer tetheredto the shoulder blade, resultingin a visible deformity.

How is AC joint arthritistreated?If rest, ice, medication, and modifyingactivity does not work, then the next stepis a cortisone shot. One shot into thejoint sometimes takes care of the painand swelling permanently, although the

effect is unpredictable and may not bepermanent. Surgery may be indicated ifnonsurgical measures fail. Since the painis due to the ends of the bones makingcontact with each other, the treatmentis removal of a portion of the end of theclavicle. This outpatient surgery can beperformed through a small incision aboutone inch long or arthroscopically usingseveral small incisions. Regardless ofthe technique utilized, the recovery andresults are about the same. Most patientshave full motion by six weeks andreturn to sports by 12 weeks.

What is the treatmentfor AC separation?These can be very painful injuries, so theinitial treatment is to decrease pain. Thisis best accomplished by immobilizingthe arm in a sling, and placing an icepack to the shoulder for 20–30 minutesevery two hours as needed.

Statistics� In 2008, nearly 95,000 peoplevisited a physician withan AC joint related injury.

� More males than femalessuffer AC joint injuries.

Athletes who have hadAC joint injuries� Sam Bradford, St. Louis RamsQuarterback

� Matthew Stafford, Detroit Lions

Acetaminophen and non-steroidal anti-inflammatorydrugs can also help the pain. As the pain starts tosubside, it is important to begin moving the fingers,wrist, and elbow, and eventually the shoulder in orderto prevent a stiff or “frozen” shoulder. The length oftime needed to regain full motion and function dependson the severity or grade of the injury. Recovery froma 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 fullactivity with few restrictions. In some cases a painfullump may persist, necessitating partial clavicleexcision in selected individuals such as high caliberthrowing athletes. Surgery can be very successfulin these cases, but as always, the benefits mustbe weighed against the potential risks.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

AC JOINT INJURIES

SPORTS MEDICINE | AC Joint Injuries 5

EXPERT CONSULTANT | Michael S. George, MD

ANKLE SPRAINS

What is an ankle sprain?A sprain is a stretch injury of theligaments that support the ankle. Theligaments on the outside of the ankleare the most commonly injured whenthe foot is turned inward (inverted).A “lateral” ankle sprain is a stretchinjury to the ligaments in the outer/lowerpart of the ankle. This most commonlyoccurs with an inversion injury whenthe ankle is twisted inward.

A “high” ankle sprain (or syndesmosisinjury) is a stretch injury to the ligamentthat holds the tibia and fibula together

in the lower leg. This most commonlyoccurs with an eversion injury whenthe ankle is twisted outward.

The ankle is tender and swollen onthe outside, below, and just in frontof the ankle bone. Typically, the boneis not as tender at the area above andin front of it. A sprain may be mild,causing only modest pain, or severeenough to prevent weightbearing.

How is an ankle spraintreated?The initial treatment is RICE (rest, ice,compression, and elevation). Severeinjuries may benefit from a walkingboot to help support the ankle. The goalof rehabilitation is to reduce pain andswelling and to restore strength, rangeof motion, and balance.

Recovery time for lateral ankle sprainsis typically one to three weeks. Recoverytime for high ankle sprains is typicallythree to six weeks.

Rehabilitation can begin a few daysafter the injury, when the swelling starts

to go down. There are three goals toaim for in rehabilitation:

1. Restore motionand flexibility.

2. Restorestrength.

3. Restorebalance.

How can an ankle sprainbe prevented?Taping the ankle or using a bracefor support can help prevent re-injury.There are many different types of braces:some made of neoprene, some madeof elastic material, and some that haveextra straps or ties for support. Braceswith straps or ties generally providegreater support.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

SPORTS MEDICINE | Ankle Sprains 6

Statistics� About 25,000 ankle sprains occurin the United States every day.

� Ankle sprains are commonin all sports that involve cuttingand pivoting.

Athletes with similar injuries� In 2011, Maurkice Pouncey,Pittsburgh Steelers center, suffereda high ankle sprain in the AFCChampionship game against theNew York Jets and was forced tomiss the Super Bowl two weeks later.

� In 2011, Tim Duncan, San AntonioSpurs center, suffered a lateralankle sprain. He required crutchesfor several days, then returned8 days later to score 20 points in 33minutes against the Boston Celtics.

What is the ACL?ACL stands for anterior cruciate ligamentof the knee. The knee is the largestand most complex joint in the body.It depends on four primary ligamentsas well as multiple muscles, tendons,and secondary ligaments to functionproperly. There are two ligaments on thesides of the knee: the medial collateralligament (MCL) and the lateral collateralligament (LCL), and two crossedligaments in the center of the knee,the anterior cruciate ligament (ACL) andthe posterior cruciate ligament (PCL).

The ACL connects the front top partof the shin bone to the back bottompart of the thigh bone and keepsthe shin bone from sliding forward.

How is the ACL injured?One of the common ways for the ACL tobe injured is by a direct blow to the knee,which commonly happens in football.In this case, the knee is forced intoan abnormal position that results in thetearing of one or more knee ligaments.

However, most ACL tears actuallyhappen without contact betweenthe knee and another object. Suchnoncontact injuries happen when therunning athlete changes direction orhyperextends their knee when landingfrom a jump. These movements arecommon to all agility sports.

How is an ACL teardiagnosed?The physician will examine the knee,and, in most cases, be able to identifywhich ligaments are injured. However,there may also be injuries to thejoint surface that are more difficult todiagnose. At times, swelling may makeit difficult to diagnose a tear. This willnecessitate the use of an MRI scan orarthroscope to ensure that an accuratediagnosis is made.

ANTERIORCRUCIATELIGAMENTINJURIES

EXPERT CONSULTANT | Wayne J. Sebastianelli, MD

SPORTS MEDICINE | ACL Injuries 7

Statistics� One of the most commonlyinjured ligaments in the knee

� Approximately 150,000 ACLinjuries each year in U.S.

� Female athletes participating inbasketball and soccer are 2–8 timesmore likely to suffer ACL injury.

� Athletes who suffer ACL injuryat increased risk of arthritisdevelopment later in life.

� ACL injuries account for anestimated half-billion dollarseach year in health care costs.

Athletes who had ACL injuries� Tiger Woods, PGA Golfer

� Tom Brady, New England PatriotsQuarterback

How can ACL injuries be prevented?Several prevention programs have been developed inan attempt to decrease the incidence of noncontactACL injuries. The focus of current prevention programsis on proper nerve/muscle control of the knee.These programs focus on plyometrics, balance,and strengthening/stability exercises.

Plyometrics is a rapid, powerful movement which firstlengthens a muscle (eccentric phase) then shortensit (concentric phase). The length-shortening cycleincreases muscular power. An example would bean athlete jumping off a small box and immediatelyjumping back into the air after contact with the floor.

Balance training commonly involves use of wobbleor balance boards. On-field balance exercisesmay include throwing a ball with a partner whilebalancing on one leg.

To improve single-leg core strength and stability,athletes perform exercises such as jumping andlanding on one leg with the knee flexed and thenmomentarily holding that position.

How are ACL tears treated surgically?Many different surgical approaches have beendeveloped for the ACL injured knee. Years ofexperience have shown that simply stitching theligament together is rarely successful. Therefore,current techniques involve reconstructing the ACLby building a new ligament out of tissue harvestedfrom one of the other tendons around the knee

or from an organ donor. This tissue is passed throughdrill holes in the thigh bone and shin bone and thenanchored in place to create a new ACL. Over timethis graft matures and becomes a new, livingligament in your knee.

What does ACL injury recovery entail?Rehabilitation of the knee after ACL reconstructionrequires time and hard work. Return to full functioncan vary from 6 weeks to 6 months depending onseverity and activity levels. The rate of rehabilitationmay take longer, depending on the specificrequirements of the individual’s sport/activity.

The overall success rate for ACL surgery is very good.Many studies have shown that more than 90 percentof patients are able to return to sports withoutsymptoms of knee instability. Although some patientsdo complain of stiffness and pain after surgery, theseproblems have been minimized by current surgicaltechniques and aggressive rehabilitation.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

ACL INJURIES

SPORTS MEDICINE | ACL Injuries 8

ARTICULARCARTILAGEINJURIES

EXPERT CONSULTANTS | Daniel Romanelli, MD, John Uribe, MD, Diane S. Watanabe, ATC, Bert R. Mandelbaum, MD

SPORTS MEDICINE | Articular Cartilage Injuries 9

What is articular cartilage?Articular cartilage can sometimesbe confusing, because there are threedifferent types of cartilage found inthe body: articular or hyaline cartilage(covers joint surfaces), fibrocartilage(knee meniscus, vertebral disk), andelastic cartilage (outer ear). Thesedifferent cartilages are distinguishedby their structure, elasticity, and strength.

Articular cartilage is a complex, livingtissue that lines the bony surfaceof joints. Its function is to providea low friction surface enabling the jointto withstand weight bearing throughthe range of motion needed to performactivities of daily living as well asathletic endeavors. In other words,articular cartilage is a very thin shock

absorber. It is organized into five distinctlayers, with each layer having structuraland biochemical differences.

What causes an articularcartilage injury?Articular cartilage injuries can occur asa result of either traumatic or progressivedegeneration (wear and tear). Withmechanical destruction, a direct blowor other trauma can injure the articularcartilage. Depending on the extentof the damage and the location of theinjury, it is sometimes possible for thearticular cartilage cells to heal. Articularcartilage has no direct blood supply,thus it has little or no capacity to repairitself. If the injury penetrates the bonebeneath the cartilage, the underlyingbone provides some blood to the area,improving the chance of healing.

Mechanical degeneration (wear and tear)of articular cartilage occurs with theprogressive loss of the normal cartilagestructure and function. This initial lossbegins with cartilage softening thenprogresses to fragmentation. As the lossof the articular cartilage lining continues,the underlying bone has no protectionfrom the normal wear and tear of dailyliving and begins to break down,leading to osteoarthritis.

How often does an articularcartilage injury occur?In many cases, a patient will experienceknee swelling and vague pain. At this

point continued activity may not bepossible. If a loose body is present,words such as “locking” or “catching”might be used to describe the problem.With wear and tear, the patient oftenexperiences stiffness, decreased rangeof motion, joint pain, and/or swelling.

How is an articular cartilagedefect (injury) diagnosed?The physician examines the knee,looking for decreased range of motion,pain along the joint line, swelling,fluid on the knee, abnormal alignmentof the bones making up the joint, andligament or meniscal injury. Injuriesto the articular cartilage are difficultto diagnose, and evaluation withMRI (magnetic resonance imaging)or arthroscopy may be necessary.

Statistics� On the basis of published studiesto date, the overall prevalenceof articular cartilage defects in theknee is 36% among all athletes andup to 59% among asymptomaticbasketball players and runners.

Athletes who have had articularcartilage injuries� Greg Oden, Penny Hardaway,Chris Webber (NBA)

� Tracy Porter, Marques Colston,New Orleans Saints

� Brandon Graham,Philadelphia Eagles

Plain X-rays are not usually good in diagnosingarticular cartilage problems but are usually takento rule out other abnormalities.

How is an injury treated?Injuries to the cartilage that do not extend to thebone will generally not heal on their own. Injuriesthat penetrate to the bone may heal, but the type ofcartilage that is laid down is structurally unorganizedand does not function as well as the original articularcartilage. Defects smaller than 2 cm have the bestprognosis and treatment options. Those optionsinclude arthroscopic surgery using techniques toremove damaged cartilage and increase blood flowfrom the underlying bone (e.g. drilling, pick procedure,or microfracture). For smaller articular cartilagedefects which are asymptomatic, surgery may notbe required. For larger defects, it may be necessaryto transplant cartilage from other areas of the knee(joint). Consult your specialist for further informationon the decision to have surgery.

For patients with osteoarthritis, non-surgical treatmentconsists of physical therapy, lifestyle modification(e.g., reducing activity), bracing, supportive devices,oral and injection drugs (i.e., non-steroidal anti-inflammatory drugs, cartilage protective drugs),and medical management. Surgical options arevery specific to osteoarthritis severity and can providea reduction in symptoms that are generally only shortlived. Total joint replacement can provide relief forthe symptom of advanced osteoarthritis, but generallyrequires a change in a patient’s lifestyle and/oractivity level.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

ARTICULAR CARTILAGE INJURIES

SPORTS MEDICINE | Articular Cartilage Injuries 10

CONCUSSIONEXPERT CONSULTANTS | Jeffrey S. Kutcher, MD, Wayne Sebastianelli, MD, Kenneth Fine, MD

SPORTS MEDICINE | Concussion 11

What is a concussion?A concussion is a traumatic injury to thebrain that alters mental status or causesother symptoms. Many people assumethey do not have a concussion if theyhave not lost consciousness. However,significant injury can occur withoutlosing consciousness at all. Footballplayers often say, “I just got my bellrung,” when a blow to the head causesringing in the ears, but those symptomsare often consistent with concussion.

What are the signs/symptomsof a concussion?� Balance problems

� Difficulty communicating,concentrating

� Dizziness

� Drowsiness

� Fatigue

� Feeling emotional

� Feeling mentally foggy

� Headache

� Irritability

� Memory difficulties

� Nausea

� Nervousness

� Numbness or tingling

� Sadness

� Sensitivity to light or noise

� Sleeping more than usualor difficulty falling asleep

� Visual problems —blurry or double vision

� Vomiting

How is a concussiondiagnosed?When concussion is suspected,a trained coach, certified athletictrainer, or the team physician shouldimmediately perform an initial“sideline” evaluation, including:

� Symptoms list review

� Focused neurological exam

� Focused orientation exam that testsshort-term memory recall suchas the event, play, opponent, score,or last meal

� Focused orientation exam that testslong-term recall such as name,birth date, place of birth

� Assessment of athlete’s ability to stayattentive to a complex task suchas reciting months backwards

If left undiagnosed, a concussion mayplace an athlete at risk of developingsecond impact syndrome (SIS)—a potentially fatal injury that occurswhen an athlete sustains a secondhead injury before a previous headinjury has completely healed.

What is second impactsyndrome?Second impact syndrome is a potentiallyFATAL injury that occurs when anathlete sustains a second head injurybefore a previous head injury hascompletely healed. Unfortunately itis difficult to determine if the brain hashealed from the first injury. Even afterall symptoms have resolved, healing maynot be complete and the brain may still

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

StatisticsAccording to the Centersfor Disease Control:

� Each year, U.S. emergencydepartments treat an estimated135,000 sports- and recreation-related traumatic brain injuries,including concussions, amongchildren ages 5 to 18.

� Athletes who have ever hada concussion are at increasedrisk for another concussion.

� Children and teens are morelikely to get a concussion andtake longer to recover than adults.

Athletes who had concussions� Ted Johnson, New England PatriotsLinebacker

� Tim Tebow, University of FloridaQuarterback, Denver Broncos

be at increased risk of second impact syndrome.Neurocognitive testing may help doctors determinewhen it is safe to return to competition.

What is neurocognitive testing?Neurocognitive testing is a questionnaire the athletetakes (usually by computer) that tests multiple areasof brain function including memory, problem solving,reaction times, brain processing speeds, and postconcussion symptoms. It is most valid if the athletehas a pre-injury baseline test on file to compare thepost concussion test. This information can be veryhelpful to the physician in determining return to play.It is not a substitution for an evaluation by a physician.

When should a concussed athletereturn to play?All athletes who sustain a concussion—no matterhow minor—should undergo an evaluation by aqualified health care provider before returning to play.Athletes can return to play after they are completelyfree of all symptoms of a concussion and remainsymptom free during and after physical testing.

Baseline testing is important for assessing concussionsymptoms after an incident. The baseline testingoften includes neurocognitive tests, symptomchecklists, sideline assessment tools such asthe Sideline Concussion Assessment Tool (SCAT),and balance testing.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

CONCUSSION

SPORTS MEDICINE | Concussion 12

It is recommended that all athletes who sustain a concussiveepisode, no matter how minor, undergo an evaluation by amedical physician before return to play.

Every summer hundreds of people fallprey to the sun and the heat. Beingprepared and hydrated can largelyprevent a large variety of heat illnessesfrom happening.

Why does heat illness occur?When an athlete exercises, the body’stemperature is elevated and the bodysweats to cool itself down. During thisprocess, body fluid as well as criticalelectrolytes are lost. If the body isn’treplenished with fluids and electrolytes,dehydration may occur and increase therisk of a heat illness such as heat stroke.

What are the symptomsof heat illness?Some symptoms include:

� Chills

� Dark colored urine

� Dizziness

� Dry mouth

� Headaches

� Thirst

� Weakness

If heat illness progresses, more serioussymptoms such as difficulty breathing,body temperature increasing todangerous levels, muscle cramps,nausea, tingling of the limbs,and even death may occur.

How can heat-relatedillnesses be prevented?The most effective treatment for heat-related illnesses is prevention, including:

� Proper training for the heat

� Fluid replacement before,during, and after exertion

� Appropriate clothing—light colored, loose fitting,and limited to one layer

� Early recognition via directmonitoring of athletes by otherplayers, coaches, and medical staff

� Monitoring the intensity of physicalactivity appropriate for fitnessand how an athlete has acclimatedto conditions

� If possible, having an athletic traineron site during events and practicesto properly prevent and treat heatillnesses

At the beginning of a strenuous exerciseprogram or after traveling to a warmerclimate, an athlete should initially limitthe intensity and duration of exerciseand then gradually increase it duringa period of 7–14 days to allow time forthe body to adjust to the new climateand environmental conditions. Athleteswith respiratory, gastrointestinal,or other illness should be evaluatedbefore exercise, as these conditionsincrease the risk of heat illness.

When should an athletehydrate?Hydration should begin before theexercise period. Drinking 16 ounces ofwater or a sports drink is recommendedone hour before exertion. Hydrationshould continue with 4–8 ouncesof fluid every 15–20 minutes as longas exertion continues.

The type of fluid replacement dependson the duration of the event. Plainwater is adequate for events lastingless than one hour. However, for eventsthat last more than one hour or multiple

HEAT ILLNESSEXPERT CONSULTANT | Douglas Casa, PhD, ATC, FACSM, FNATA, Marjorie J. Albohm, MS, ATC

SPORTS MEDICINE | Heat Illness 13

Statistics� Heat stroke, a severe form of heat-related illness, is one of the threeleading causes of death in athletesand likely the leading cause of deathamong athletes in July and August.

� The body produces a half of gallonof perspiration to cool it everyhour. If there’s not enough fluidor the heat overwhelms the body,the person develops a heatrelated illness.

� While many cases of heat stroke,heat-related disorders aren’t lethal;about 175 to 200 people diefrom heat stroke each yearin the United States.

Athlete who had heat illness� Korey Stringer, Minnesota Vikings(died from heat illness)

bouts of exercise in the same day, the replacementfluid should contain carbohydrates, sodium,and potassium, which are standard componentsof commercial sports drinks.

Weighing oneself before and after activity providesgood feedback on the level of hydration. If the athleteis lighter after an activity, then it is likely a fluiddeficit has occurred and it is necessary to replacethe weight loss by drinking more during the nextpractice to approximate sweat losses. An athletewho loses more than two percent to three percentof body weight during exercise may be at a pointof compromising performance and physiologicalfunction. If the athlete gains weight after an activity,then the quantity of rehydration fluid during activityshould be reduced.

How can heat illnesses be treated?When you see any signs of heat illness or heatstroke, you may be dealing with a life-threateningemergency. Have someone call for immediatemedical assistance while you begin coolingthe individual at risk.

Treatment tips include:

� Getting the athlete to a shaded area.

� If it is heat stroke, cool the athlete rapidlyusing cold water immersion. If immersionis not available you may use spray froma hose, cold water sponging, or placingcold towels over the entire body.

� Monitoring body temperature.

� Providing cool beverages if possible (i.e., if theathlete does not have altered consciousness).

� Getting medical assistance as soon as possible.

Heat exhaustion is a form of heat illness that candevelop after several days of exposure to hightemperatures and inadequate or unbalancedreplacement of fluids.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

HEAT ILLNESS

SPORTS MEDICINE | Heat Illness 14

THE MATUREATHLETE

EXPERT CONSULTANT | Paul R. Reiman, MD

SPORTS MEDICINE | The Mature Athlete 15

Exercise is not only for the young, but forthe mature population as well. Exercisecan be a good way for older adultsto maintain independence and remainhealthy in body and mind. Major healthproblems the mature population oftenfaces can include arthritis, high bloodpressure, heart disease, lung disease,depression, and hearing and sight loss.With the exception of hearing and sightloss, all of these problems can potentiallyimprove in the mature athlete witha controlled exercise program.

All mature athletes should havea comprehensive medical andmusculoskeletal evaluation prior tobeginning any exercise program. Theseexaminations and subsequent medicaland exercise counseling may preventcatastrophic health events and injuries.The evaluation should satisfy themature athlete’s needs for diseaseprevention, endurance, strength,body image, and competitiveness.

How can exercise benefitthe mature athlete?Creating a specialized program witha qualified personal trainer can improveflexibility, balance, endurance, andstrength. If the exercise programincludes sports, such as golf or tennis,technique education by qualifiedinstructors may also be useful forperformance and injury prevention.To achieve results, any program mustbe done consistently for at least 30–45

minutes, three to four days per week.If there are physical conditions thatneed correction, a cardiac, pulmonary,or physical therapy rehabilitative programmay be helpful before beginning anexercise program. These rehabilitationprograms should instruct the matureathlete to a fitness level where theymay then pursue their own program.

What type of exercises shoulda program include?The types of exercises an individualtakes on should be based on theathlete’s desires, pre-existing conditions,and the ability to exercise pain-free.For individuals with lower extremity jointissues, such as arthritis or instability, it isbest to avoid repetitive impact activitieslike running. Athletes with shoulderdisabilities should avoid repetitiveoverhead activities, such as militarypresses and pull-ups. Using multipletypes of activities to enhance strengthcan allow for even better muscle andtendon tissue recovery. If the matureadult desires to play a sport which mayaggravate pre-existing muscle, tendon,or bone problems, they should be ingood condition prior to performing thesport. A decrease in the frequency of thesport may decrease painful symptoms.

What types of equipment willthe mature athlete need?Wearing shoes that match the specificexercise and/or sport program can bebeneficial. If the individual’s foot has

significant deformity, such as flat feet(fallen arches), the use of foot orthoticscan decrease stress on the entire lowerextremity. Symptoms from arthriticchanges in the knee may be decreasedthrough the use of specialized braces.

How can the mature athleteprevent injury or discomfortduring exercise?Any discomfort during or afterexercise should be investigated toprevent reoccurrence or worsening.Over-the-counter pain relievers andanti-inflammatory medications canbe used short-term if there are noadverse interactions with other medicalconditions. Additionally, the use of ice,heat, massage, and flexibility programscan relieve many exercise-inducedsymptoms. More aggressive treatmentswith narcotic analgesics and/orcortisone injections should be reservedto treat a specific injury and not simplyto allow for short-term competition.

SummaryBy working together with a medicaland/or exercise professional to createa tailored program, the mature athletecan maintain independence, increasephysical capabilities, prevent injury andadd significantly to one’s quality of life.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

What is a meniscus tear?Meniscal injuries are one of the mostcommon knee injuries in athletes andcan occur acutely after a traumatic twistor after a contact injury. The meniscusis a wedge of cartilage that providesa cushion in both the medial andlateral part of the knee joint. Acting asa shock absorber, the meniscus actuallyincreases the contact area of the jointto minimize the load on the articularcartilage and helps stabilize the kneeas well. In addition, the meniscus helpsprovide nutrition to the knee by aidingin diffusion of joint fluid. Athletes canfeel acute pain with this injury as wellas swelling and often a catching orlocking sensation.

How is a meniscal teardiagnosed?An injury to the meniscus canbe diagnosed based upon thehistory that the patient provides anda physical examination of the knee.

The orthopaedic surgeon may alsorequire further diagnostic studies likean MRI (magnetic resonance imaging)which provides a three-dimensionalimage of the interior of the knee joint.In some cases, surgeons may alsorecommend arthroscopic inspectionof the knee joint, a minimally invasivesurgical procedure.

How is a meniscaltear treated?Meniscal tears, if small, can be treatedwith rest, ice and anti-inflammatorymedication. However, if there issignificant loss of motion or catchingthen the appropriate treatment is oftensurgical. Depending on the location andtype of tear, treatment can be a simplearthroscopy to remove the torn fragment.Athletes can return to full activity inas little as a week to as long as a fewmonths depending on how quicklythe inflammation goes away. In athleteswith a repairable tear, sutures are usedto sew the meniscus back together andthen the knee is braced for 6 weeks,these athletes take at least 3 to 6 monthsto return to full activity but maintainthe full cushion in their knee.

Can meniscal tearsbe prevented?There is no real way to prevent ameniscal tear aside from a conditioningprogram to try to prevent an ACL tearand knee instability.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

MENISCAL TEARSEXPERT CONSULTANT | Sabrina Strickland, MD

SPORTS MEDICINE | Meniscal Tears 16

Statistics� Acute meniscal tears are commonaffecting 61 out of 100,000 personsper year.

� Females suffer meniscal injuriesmore often than men and at anearlier age and these tears areoften associated with ACL injury.

� Only some variants of meniscaltear can be repaired and despiterepair they do not always heal.However, arthritis can be avoidedin most cases if repair is successful.In one study, 60% of patientsundergoing meniscectomy (partialremoval) demonstrated somedegree of progressive arthritis.

Athletes who had meniscal tears� Adam Moore, Seattle Mariner,had a torn meniscus

� Kendrik Perkins, Boston Celtics,underwent an ACL reconstructionwith a meniscal repair.

� T. J. Schiller, extreme skier, sufferedan ACL and a meniscal tear.

� Marc-Andre Tarte, a professionalsnowboarder, required an ACLreconstruction and meniscal repair.

� Gilbert Arenas, Washington Wizardspoint guard, underwent a lateralmeniscal repair and microfracture.

� Fernando Torres, a professionalsoccer player from Spain,underwent a partial meniscectomy.

MRSA INFECTIONSEXPERT CONSULTANT | Matthew Matava, MD

SPORTS MEDICINE | MRSA Infections 17

What causes MRSAinfections?Methicillin-resistant Staphylococcusaureus (S. aureus) bacteria, or MRSA,is an organism known for causing skininfections as well as many other types ofinfections. MRSA was first seen in U.S.hospitals during the 1970s as a bacteriathat caused healthcare-associatedinfections among the elderly and sick.Since that time, MRSA has spread tohealthcare facilities throughout the world,and has become the most commonpathogen to cause healthcare-associatedinfections. Recently, a new strain ofMRSA know as Community AcquiredMethicillin-Resistant Staphylococcusaureus, or CA-MRSA, has left hospitalsand began to spread in the community.This is the strain that is prevalentamong athletes. The difference betweenCA-MRSA and Healthcare-AssociatedMRSA (HA-MRSA) lies in their effects,as CA-MRSA typically causes skininfection while HA-MRSA causesbloodstream, urinary tract, and surgicalsite infections. As a result, CA-MRSAis less dangerous than HA-MRSA.Another major difference betweenthe two strains is that CA-MRSAis more vulnerable to antimicrobials.

What are the symptomsof MRSA?Signs of infection include redness,warmth, swelling, pus, and pain at siteswhere there are skin sores, abrasions,

or cuts. MRSA also has the capabilityof spreading to any organ in the body,and when this occurs, more severesymptoms may result. These symptomsinclude fever, chills, low blood pressure,joint pain, severe headaches, shortnessof breath, and an extensive rash overthe body. These more advanced,systemic symptoms require immediatemedical attention.

How is MRSA treated?The first choice for treatment for a MRSAskin infection is the use of an antibioticthat has been determined to reliably killthe bacteria with minimal side effects.Most early infections without widespreadsymptoms can be treated with oralantibiotics. Because of the nature of thisdisease and antibiotic options, somepatients think they are “cured” after justa few doses, and decide to stop takingtheir prescribed medication. However,MRSA is capable of re-infecting thepatient and becoming resistant to thepreviously used antibiotics. Moderate-to-severe infections may requiretreatment with intravenous antibiotics.Those infections associated with deepabscesses or boils require open surgicaldrainage in addition to antibiotic therapy.Most infections resolve with appropriatetreatment within seven to 10 days,though a deep abscess may take upto four weeks in order to eradicatethe infection with resolution of theabscess cavity.

Early identification and treatment ofMRSA infections will reduce the amountof playing time lost and decrease thechance that the infection will becomesevere. Skin can be protected by wearingprotective clothing or gear designedto prevent skin abrasions or cuts.

Statistics� Today, MRSA accounts for about50–70% of the S. aureus infectionsthat are present in healthcarefacilities across the world.

� Statistics from the Kaiserfoundation in 2007 indicatedthat approximately 1.2 millionhospitalized patients contractMRSA infections, and thatas many as 19,000 people peryear die from MRSA in the U.S.

� Serious MRSA infection is stillpredominantly related to exposurein the healthcare setting, whereapproximately 85 percent of allserious MRSA infections occur.

� Fortunately, in children under18 years of age, mortality ratesare much lower (1%), eventhough the number of hospitalizedchildren with MRSA has almosttripled since 2002.

Athlete who had MRSA infections� Tom Brady, New England Patriots

How can MRSA be prevented?In addition to practicing good personal hygiene,athletes and visitors to athletic facilities should alsokeep their hands clean by washing frequently withsoap and water or using an alcohol-based hand rub.At a minimum, hands should be cleaned before andafter playing sports and activities such as using sharedweight-training equipment, when caring for wounds(including changing bandages), and after using thetoilet. Both plain and antimicrobial soap are effectivefor hand washing, but liquid soap is preferred over barsoap in these settings to limit sharing. Alcohol-basedhand antiseptics with at least 60 percent alcoholcontent are preferred. Athletes should showerimmediately after exercise and not share bar soapor towels. It is important to wash all uniforms andclothing after each use. Athletes should avoid sharingitems that come into contact with the skin and avoidsharing personal items such as towels and razorsthat contact bare skin. Fortunately, most surfacesdo not pose a risk of spreading staph and MRSA.

Athletes Who Have Had MRSA

Several high school, college, and professional athleteshave contracted MRSA infections. In some situationsthere have been large outbreaks among multipleathletes of the same team. A study published inThe New England Journal of Medicine observedMRSA infection among members of the St. LouisRams professional football franchise. During thatsingle season, 8 MRSA infections were found among5 of the 58 Rams players (9 percent) that weretested. All infections developed on areas of the bodythat are common locations for turf injury.

Additional Information

www.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

MRSA INFECTIONS

SPORTS MEDICINE | MRSA Infections 18

OVERUSE INJURIESEXPERT CONSULTANT | Matthew J. Matava, MD

SPORTS MEDICINE | Overuse Injuries 19

There are basically two types of injuries:acute injuries and overuse injuries.Acute injuries are usually the resultof a single, traumatic event. Commonexamples include wrist fractures, anklesprains, and shoulder dislocations.While overuse injuries are morecommon in sports than acute injuries,they are subtle and usually occurover time, making them challengingto diagnose and treat. They arethe result of repetitive micro-traumato the tendons, bones, and joints.Common examples include tenniselbow, swimmer’s shoulder, Pitcher’selbow, runner’s knee, Achillestendinitis, and shin splints.

Why do overuse injuries occur?The human body has a tremendouscapacity to adapt to physical stress.We tend to think of “stress” in thecontext of its negative effect on ouremotional wellbeing, but physicalstress, which is simply exercise andactivity, is beneficial for our bones,muscles, tendons, and ligaments,making them stronger and morefunctional. This happens because ofan internal process called remodeling.The remodeling process involves boththe breakdown and buildup of tissue.There is a fine balance between the two,and if breakdown occurs more rapidlythan buildup, an overuse injury occurs.

What factors causeoveruse injuries?Training errors are the most commoncause of overuse injuries. Theseerrors involve rapid accelerationof the intensity, duration, or frequencyof activity. Overuse injuries also happenin people who are returning to a sportor activity after injury and trying tomake up for lost time by pushingthemselves to achieve the level ofparticipation they were at before injury.Proper technique is critical in avoidingoveruse injuries, as slight changes inform may be the culprit. For this reason,coaches, athletic trainers, and teacherscan play a role in preventing recurrentoveruse injuries.

Some people are more prone thanothers to overuse injuries. Imbalancesbetween strength and flexibility aroundcertain joints predispose individualsto injury. Body alignment, such asknock-knees, bowlegs, unequal leglengths, and flat or high arched feet,also impact overuse injuries. Manypeople also have weak links due toold injuries, incompletely rehabilitatedinjuries, or other anatomic factors.

Other factors include equipment,such as the type of running shoeor ballet shoe, and terrain—hardversus soft surface in aerobic danceor running.

How are overuse injuriesusually diagnosed?The diagnosis can usually be madeafter a thorough history and physicalexamination. This is best done by asports medicine specialist with specificinterest and knowledge of your sport oractivity. In some cases, X-rays are neededand occasionally additional tests like abone scan or MRI are required as well.

What is the treatmentfor overuse injuries?Some tips for treating an overuseinjury include:

� Cutting back the intensity, duration,and frequency of an activity

� Adopting a hard/easy workoutschedule and crosstrainingwith other activities to maintainfitness levels

� Learning about proper trainingand technique from a coachor athletic trainer

� Performing proper warm-upactivities before and after

Statistics� Nearly 50% of all injuries sustainedby middle school and high schoolathletes are overuse.

� 3.5 million kids are treatedfor overuse injuries each year.

� Using ice after an activity for minor aches and pain

� Using anti-inflammatory medications as necessary

If symptoms persist, a sports medicine specialist willbe able to create a more detailed treatment plan foryour specific condition. This may include a thoroughreview of your training program and an evaluationfor any predisposing factors. Physical therapy andathletic training services may also be helpful.

Can overuse injuries be prevented?Most overuse injuries can be prevented with propertraining and common sense. Learn to listen to yourbody. Remember that “no pain, no gain” does notapply here. The 10 percent rule is very helpful indetermining how to take things to the next level.In general, you should not increase your trainingprogram or activity more than 10 percent per week.This allows your body adequate time for recovery andresponse. This rule also applies to increasing paceor mileage for walkers and runners, as well as to theamount of weight added in strength training programs.

Always remember to warm up and cool downproperly before and after activity. Incorporatingstrength training, increasing flexibility, and improvingcore stability will also help minimize overuse injuries.

Seek the advice of a sports medicine specialist orathletic trainer when beginning an exercise programor sport to prevent chronic or recurrent problems.Your program can also be modified to maintain overallfitness levels in a safe manner while you recoverfrom your injury. You should return to play only whenclearance is granted by a health care professional.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

OVERUSE INJURIES

SPORTS MEDICINE | Overuse Injuries 20

ROTATORCUFF TEARS

EXPERT CONSULTANT | Dan Solomon, MD

SPORTS MEDICINE | Rotator Cuff Tears 21

What is the rotator cuffand what does it do?The rotator cuff is a group of fourmuscles and their tendons that combineto form a “cuff” around the head ofthe humerus (the upper end of thearm). The four muscles—supraspinatus,infraspinatus, subscapularis and teresminor—originate from the scapula(shoulder blade). The tendon for eachmuscle inserts on the tuberositiesof the humerus.

The rotator cuff helps to lift and rotatethe arm and to stabilize the humeruswithin the joint.

What causes a rotatorcuff tear?A rotator cuff tear may result froman acute injury such as a fall or may becaused by chronic wear and tear withdegeneration of the tendon. Pinchingof the tendon on the undersurface ofthe scapula may contribute to cuff tearsin individuals older than 40 years.

How are rotator cuff tearsdiagnosed?Rotator cuff tears are diagnosed basedon examination and/or a diagnosticstudy such as MRI (magnetic resonanceimaging) to confirm the diagnosis. Earlydiagnosis and treatment of a rotator cufftear may help improve treatment results.

What is the treatmentfor a rotator cuff tear?The goals of treatment are to relievepain and restore strength to the involvedshoulder. Many rotator cuff tears can betreated nonsurgically. Anti-inflammatorymedication, steroid injections, andphysical therapy may all be of benefitin treating symptoms of a cuff tear.Even though a full-thickness tear cannotheal without surgery, satisfactoryfunction can often be achievedwith non-surgical treatments.

At what point does a rotatorcuff tear require surgery?Surgery is recommended if there ispersistent pain or weakness in the

shoulder that does not improve withnonsurgical treatment. Frequently,patients who require surgery will reportpain at night and difficulty using thearm for lifting and reaching. Manywill report ongoing symptoms despiteseveral months of medication andlimited use of the arm.

Surgery is also indicated in activeindividuals who use the arm foroverhead work or sports.

What options are availablefor surgical repair?The type of repair performed is basedon the findings at surgery. A partialtear may require only a trimmingor smoothing procedure called adébridement. A full-thickness tear withthe tendon torn from its insertion on thehumerus is repaired directly to bone.

Statistics� Rotator cuff tears occur in 5–40%of individuals with risk significantlyincreasing with increased age.Relative risk in the 30–40 year oldage group is small, but in somestudies tears are more common thannot in the over 70 year old group.

Athletes who had a rotator cuff tear� Monica Seles, ProfessionalTennis Player

� John Smolz, Atlanta BravesBaseball Pitcher

� Janet Evans, Professional Swimmer

Rotator cuff tear on an MRI

Three techniques are used for rotator cuff repair:

� open repair (through a traditional incision)

� mini-open repair (partially assisted by a cameraview, with a smaller incision)

� arthroscopic (performed with only a small camerainserted through multiple small puncture wounds)

What does the recovery andrehabilitation process entail?Rehabilitation plays a critical role in both thenonsurgical and surgical treatment of a rotatorcuff tear. Typical recovery can be six monthsor more depending on the extent of the tear.

When a tear occurs, there is frequently lossof motion of the shoulder. An exercise or physicaltherapy program is necessary to regain strengthand improve function in the shoulder.

Even though surgery repairs the defect in the tendon,the muscles around the arm remain weak, anda strong effort in rehabilitation is necessary forthe procedure to succeed. Complete rehabilitationafter surgery may take several months.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

ROTATOR CUFF TEARS

SPORTS MEDICINE | Rotator Cuff Tears 22

SHOULDERIMPINGEMENT

EXPERT CONSULTANT | Ben Shaffer, MD

SPORTS MEDICINE | Shoulder Impingement 23

What is shoulderimpingement?Impingement refers to mechanicalcompression and/or wear of the rotatorcuff tendons. The rotator cuff is actuallya series of four muscles connecting thescapula (shoulder blade) to the humeralhead (upper part of the shoulder joint).The rotator cuff is important inmaintaining the humeral head withinthe glenoid (socket) during normalshoulder function and also contributesto shoulder strength during activity.Normally, the rotator cuff glides smoothlybetween the undersurface of theacromion, the bone at the point ofthe shoulder and the humeral head.

How does shoulderimpingement occur?Any process which compromises thisnormal gliding function may lead toimpingement. Common causes includeweakening and degeneration within thetendon due to aging, the formation ofbone spurs and/or inflammatory tissuewithin the space above the rotator cuffand overuse injuries. Overuse activitiesthat can lead to impingement are mostcommonly seen in tennis players,pitchers and swimmers.

How is shoulder impingementdiagnosed?The diagnosis of shoulder impingementcan usually be made with a carefulhistory and physical exam. Patients withimpingement most commonly complainof pain in the shoulder, which is worsewith overhead activity and sometimessevere enough to cause awakening inthe night. Manipulation of the shoulderin a specific way by your doctor willusually reproduce the symptoms andconfirm the diagnosis. X-rays are alsohelpful in evaluating the presenceof bone spurs and/or the narrowingof the subacromial space.

How is shoulderimpingement treated?The first step in treating shoulderimpingement is eliminating anyidentifiable cause or contributing factor.

This may mean temporarily avoidingactivities like tennis, pitching orswimming. A nonsteroidal anti-inflammatory medication may alsobe recommended by your doctor.The mainstay of treatment involvesexercises to restore normal flexibilityand strength to the shoulder girdle,including strengthening both therotator cuff muscles and the musclesresponsible for normal movementof the shoulder blade. This program ofinstruction and exercise demonstrationmay be initiated and carried out eitherby the doctor, certified athletic trainer ora skilled physical therapist. Occasionally,an injection of cortisone may be helpfulin treating this condition.

Is surgery necessary?Surgery is not necessary in mostcases of shoulder impingement. Butif symptoms persist despite adequatenonsurgical treatment, surgicalintervention may be beneficial.Surgery involves debriding, or surgicallyremoving, tissue that is irritating therotator cuff. This may be done witheither open or arthroscopic techniques.Outcome is favorable in about90 percent of the cases.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

SHOULDERINSTABILITY/DISLOCATIONS

EXPERT CONSULTANT | Daniel J. Solomon, MD

SPORTS MEDICINE | Shoulder Instability/Dislocations 24

The shoulder is the most mobile jointin the body. It allows one to lift the arm,rotate it, and reach up over head. It isable to turn in many directions. Thisgreater range of motion, however,results in less stability.

How do shoulder dislocationshappen?Shoulder instability occurs when thehead of humerus (the upper arm bone)is forced out of the shoulder socket.This usually occurs as a result ofa sudden traumatic injury.

Once a shoulder has dislocated, it isvulnerable to repeat episodes. Whenthe shoulder is loose and slips out ofplace repeatedly, it is called chronicshoulder instability.

The shoulder is made up of threebones: humerus (upper arm bone),scapula (shoulder blade), andclavicle (collarbone).

Shoulder dislocations can be partial,with the ball of the upper arm comingjust partially out of the socket. Thisis called a subluxation. A completedislocation means the ball comesall the way out of the socket.

What are the symptomsof shoulder instability?Common symptoms of chronic shoulderinstability include:

� Pain caused by shoulder injury

� Repeated shoulder dislocations

� Repeated instances of the shouldergiving out

� A persistent sensation of the shoulderfeeling loose, slipping in and outof the joint, or just “hanging there”

How is shoulder instabilitydiagnosed?There are specific tests that help assessinstability in the shoulder, includinggeneral looseness in ligaments. A doctormay order imaging tests, includingX-rays, CT Scan or MRI to helpconfirm a diagnosis and identifyany other problems.

How is shoulder instabilitytreated and how long isrecovery?Chronic shoulder instability is oftenfirst treated with nonsurgical options.If these options do not relieve the painand instability, surgery may be needed.

Statistics� 70,000 shoulder dislocationsoccur each year.

Athletes who have suffereda shoulder dislocation:� Lance Armstrong,Professional Cyclist

� Drew Brees, New Orleans SaintsQuarterback

Clavicle(Collarbone)

RotatorCuff Tendon

Humerus(Upper Arm)

Biceps Tendon

Scapula(Shoulder Blade)Glenoid

Nonsurgical Treatment

It often takes several months of nonsurgical treatmentbefore an assessment of success can be made.Nonsurgical treatment typically includes:

� Activity modification

� Non-steroidal anti-inflammatory medication.

� Physical therapy

Surgical Treatment

Surgery is often necessary to repair torn or stretchedligaments so that they are better able to hold theshoulder joint in place.

Bankhart lesions (tearing of the front labrum fromthe socket) can be surgically repaired by using sutureanchors to reattach the ligament to the bone.

Arthroscopy — Soft tissues in the shoulder can berepaired using tiny instruments and small incisions.This is a same-day or outpatient procedure.Arthroscopy is minimally invasive surgery. A surgeonwill look inside the shoulder with a tiny cameraand perform the surgery with special instruments.

Open Surgery — Some patients may need an opensurgical procedure. This involves making a largerincision over the shoulder and performing the repairunder direct visualization.

RehabilitationAfter surgery, the shoulder may be immobilizedtemporarily with a sling.

When the sling is removed, exercises to rehabilitatethe ligaments will be started. These will improvethe range of motion in the shoulder and preventscarring as the ligaments heal. Exercises tostrengthen a shoulder will gradually be addedto a rehabilitation plan.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

SHOULDER INSTABILITY/DISLOCATIONS

SPORTS MEDICINE | Shoulder Instability/Dislocations 25

Dislocated shoulder and shoulder realigned

SLAP TEARSEXPERT CONSULTANT | Robert A. Gallo, MD

SPORTS MEDICINE | SLAP Tears 26

What is a SLAP tear?SLAP is an acronym that stands forsuperior labrum anterior to posterior.The labrum is a rim of tissue thatadds depth to the bony socket ofthe shoulder. The superior or “top”portion of the labrum is importantand frequently injured becausethe biceps attaches to this region.

How do SLAP tears happen?SLAP tears occur as a result of traumaor chronic overhead activity. A fallon an outstretched hand with the armoverhead and a fall directly onto theshoulder are thought to be the mostcommon mechanism of injury. Chronictears are often seen in overheadathletes, such as baseball pitchersand tennis players. Experts believethat SLAP tears can be the end resultof imbalances in the shoulder.

How are SLAP tearsdiagnosed?Because of overlap among differentshoulder problems, SLAP tears arerarely diagnosed on physical examinationalone. MRIs with or without contrast arethe diagnosis tool of choice. However,differentiating a SLAP tear from normalvariations of the labrum’s attachmentto the socket can be difficult.

How are SLAP tears treated?A trial of non-operative treatment is thepreferred initial step for a SLAP tear.While the SLAP tear likely will not heal,a recent study confirmed that many haveimprovement of symptoms and function.If non-operative treatments, such asphysical therapy, are not successful,then surgery may be considered.

Surgery is usually performedarthroscopically and involvesreattaching the torn labrum backto the top of the socket. Usuallybone anchors loaded with suturesare inserted into the top of the socket.The sutures are passed through thetorn area of the labrum. The sutures aretied with knots, which reapproximatesthe torn labrum back to the bone.

How can SLAP tearsbe prevented?While acute SLAP tears are difficultto prevent, chronic tears, especiallyamong overhead athletes, can beprevented by maintaining balancewithin the shoulder. Exercises thatstrengthen the muscles around theshoulder blade and stretches thatfocus on preventing a tight posteriorshoulder are thought to be importantin minimizing the chance of a chronicSLAP tear.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

Statistics� SLAP repair procedure only hasa 33–66% success rate in puttingathletes back on the field.

� SLAP tears have been reported inup to one of four people undergoinga shoulder arthroscopy.

� Among active populations, SLAPtears may be even more common:according to one study, nearly 40%of military personnel had a SLAPtear at the time of arthroscopy.

Athlete who had a SLAP tear� Jameer Nelson, Orlando Magic,basketball player

STEROIDSEXPERT CONSULTANT | Edward McDevitt, MD

SPORTS MEDICINE | Anabolic Steroids 27

The newspapers are full of articlesrevealing the use of anabolic steroids,a performance enhancing drug, in theOlympics and professional sports, butthese dangerous drugs are also beingused by children in college, high school,and even middle school!

What are anabolic steroids?Anabolic steroids are synthetic derivativesof the male sex hormone testosterone.The steroids help with the constructionof new proteins and increase musclesize and strength. This is somethingthat already takes place in the body,but the steroids simulate or increase thisnormal biologic activity. Performanceenhancing drugs are easily availablein communities, weight rooms, or evenvia the Internet.

Steroids can either be taken orally orby an injection. Anabolic steroids in andof themselves are not effective. However,when used in conjunction with strengthtraining they may cause gains in sizeand strength, along with dangerousside effects.

What are the side effectsof anabolic steroids?Performance enhancing drugs do havethe ability to make athletes bigger andstronger but users face potentially deadlyhealth risks. Many of the side effects ofperformance enhancing drugs continueeven after stopping the drugs. Users also

are likelier to engage in risky behavior,such as taking other illegal drugs, orengaging in dangerous sexual practices.

Signs of anabolic steroid use include:

� Acne, often severe, and seenon the back and face

� Severe mood swings, extremeaggression, and even suicidal behavior

� Premature balding, irreversiblebreast enlargement, and smallertesticles in boys

� Deeper voice, shrinking breasts,and clitoral enlargement in girls

� Dangerous enlargement of the heart,that may increase bad cholesteroland blood pressure

� Often irreversible liver damage

� In children, premature closureof the growth plates, stoppingnormal growth of bones.

Is there ever a reason to takeanabolic steroids?Anabolic steroids are invaluable to peoplewho have lost testicular function, suchas men with testicular tumors. Anabolicsteroids are also used in some types ofanemia to stimulate the bone marrow.

How can we prevent childrenfrom using anabolic steroids?Do not think that performance enhancingdrugs are only a problem of the eliteathletes. Children are exposed to these

drugs on a daily basis. Get involved.Ask kids about what they know aboutthese drugs. Ask them if they know ifany of their classmates are using thesedrugs. Ask them if they know thepotential dangers of performanceenhancing drugs.

If you think your child may beexperimenting with these drugs,talk to your doctor.

It is also important to talk with thecoaches and ask if yearly physicalsare required by the league or school forathletic participants. A pre-participationphysical by a physician is an invaluableway to screen for potential performanceenhancing drug use in athletes. Askthe coaches if they know if any of theirathletes have experimented withperformance enhancing drugs.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

Statistics� As many as four million Americanchildren and teens are usingperformance enhancing drugssuch as anabolic steroids.

What is a stress fracture?A stress fracture is an overuse injury.Each day, the body produces new boneto replace the bone that is broken downby the stress of everyday living. Usually,this process is balanced, with the bodyreplacing the amount of bone lost.However, this balance may becomeupset with excessive physical training.The body, due to several factors, maynot produce sufficient bone. As a result,micro cracks, called “stress fractures,”can occur in the bone.

The most common cause of stressfractures is an abrupt increase in theduration, intensity or frequency ofphysical activity without adequateperiods of rest. In addition to mechanicalinfluences, systemic factors (suchas hormonal imbalances), nutritionaldeficiencies, sleep deprivation andmetabolic bone disorders may contributeto the development of stress fractures.Furthermore, some female athleteswho train competitively develop eatingdisorders and/or amenorrhea (infrequentmenstrual periods). Both conditionsmay lead to a low estrogen state withresultant decreased bone mineral densityand an increased risk of stress fractures.

Stress fractures are frequently seen inmilitary recruits and athletes, especiallyrunners. For every mile a runner runs,more than 110 tons of force must beabsorbed by the legs. Bones are notmade to withstand so much energy

on their own and the muscles act asshock absorbers. As muscles becometired and stop absorbing, all forces aretransferred to the bones. Although stressfractures have been described in nearlyevery bone of the human body, they aremore common in the lower extremityweight-bearing bones. The mostcommon area for a stress fractureis in the tibia. Stress fractures maybe associated with a specific sportsuch as the elbow in throwing sports,the ribs in golfing and rowing, thespine in gymnastics, the lower extremityin running activities and the footin gymnastics and basketball.

How are stress fracturesdiagnosed?Stress fractures produce pain in alimited area directly over the point of thebone where the fracture has occurred.The pain is exacerbated by activity andis relieved with rest. Bone tendernessis the most obvious finding on physicalexamination.

X-rays may not be helpful in diagnosingan early stress fracture because thebone often appears normal and themicro cracks are not visible. Afterseveral weeks of rest, the bone beginsto repair itself and often demonstratesa healing reaction or callus on X-ray.

The diagnosis of an early stress fracturecan usually be confirmed by a bone scanor magnetic resonance imaging (MRI).

How is a stress fracturetreated?Stress fractures may be broadlyclassified as either low-risk injuries (lesslikely to become more serious fractures)or high-risk injuries (more likely tobecome serious fractures). Low-risk

STRESSFRACTURES

EXPERT CONSULTANT | Barry P. Boden, MD, Michael Leddy, MD, Matthew J. Matava, MD

SPORTS MEDICINE | Stress Fractures 28

Statistics� The annual incidence of stressfractures in athletes and militaryrecruits ranges from 5% to 30%,depending on the sport andother risk factors.

� Stress fractures occur lessfrequently in those of black Africandescent than in Caucasians, dueto a generally higher BMD (bonemineral density) in the former.

� Women and highly activeindividuals are also at a higherrisk. The incidence probablyalso increases with age dueto age-related reductions in BMD.

� Children may also be at riskbecause their bones have yet toreach full density and strength.

� The female athlete triad also canput women at risk, as disorderedeating and osteoporosis can causethe bones to be severely weakened.

Athletes who had stress fractures� Yao Ming, NBA basketball player

� Deena Kastor, Olympic distancerunner

� Jerry Hairston Jr., San Diego Padres

� Julio Jones, Alabama WR

� Paul Stastny, Avalanche NHL player

stress fractures infrequently require expensive imagingmodalities such as bone scans or MRIs. A rest periodof one to six weeks of limited weight bearing activityprogressing to full weight bearing may be necessary.Return to activity should be a gradual process.Low-impact activities, such as swimming or biking,can be performed to maintain cardiovascularconditioning once the pain subsides. When thepatient can comfortably perform low-impact activitiesfor prolonged periods without pain, high-impactexercises may be initiated. Typically, the athletegradually increases jogging mileage and eventuallyreturns to sport-specific activities.

High-risk stress fractures, involving areas such as thehip, have a predilection for progressing to completefracture; therefore, they require a more aggressiveapproach. In athletes who have chronic pain andnormal findings on initial X-rays, a bone scan or MRIis recommended. Because of the high complicationrate, high-risk stress fractures should be treated liketraumatic fractures — often with a cast andoccasionally with surgery when necessary.

How are stress fractures prevented?Here are some tips developed by AAOS to helpprevent stress fractures:

� When participating in any new sports activity, setincremental goals. For example, do not immediatelyset out to run five miles a day; instead, graduallybuild up your mileage on a weekly basis.

� Cross-training — alternating activities thataccomplish the same fitness goals — can helpto prevent injuries like stress fractures. Insteadof running every day to meet cardiovascular goals,run on even days and bike on odd days. Addsome strength training and flexibility exercisesto the mix for the most benefit.

� Maintain a healthy diet. Make sure to incorporatecalcium and vitamin D rich foods in your meals.

� Use the proper equipment. Do not wear oldor worn running shoes.

� If pain or swelling occurs, immediately stop theactivity and rest for a few days. If continued painpersists, see an orthopaedic surgeon.

� It is important to recognize the symptoms earlyand treat them appropriately to return to sportsat a normal playing level.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

STRESS FRACTURES

SPORTS MEDICINE | Stress Fractures 29

SUDDEN CARDIACDEATH IN ATHLETES

EXPERT CONSULTANT | Kenneth Fine, MD

SPORTS MEDICINE | Sudden Cardiac Death in Athletes 30

Sudden cardiac death (SCD) in athletes,although extremely rare, is a potentiallycatastrophic complication of sports.The most common cause of cardiacdeath related to sports is hypertrophiccardiomyopathy, an abnormalenlargement of cardiac muscle. Thisis a rare genetic condition of the heartthat predisposes an individual to SCDwith physical exertion. Another rarecause of sudden cardiac death iscommotio cordis, where direct traumato the chest at a specific moment inthe cardiac cycle initiates a dangerousarrhythmia (abnormal rhythm) in theheart’s electrical system. Commotiocordis usually occurs in sports wherea blunt projectile, such as a baseballor hockey puck, hits the athlete’s chest.

How are sudden cardiacevents treated?Life-threatening cardiac arrhythmiasthat occur in young athletes are verydifficult to treat. Immediate use of anAED (automated external defibrillator)may provide some benefit.

How can SCD be prevented?Unfortunately, the only way to preventdeath from hypertrophic cardiomyopathyis recognition of the condition andcounseling the athlete to avoid strenuousactivity. This condition can be diagnosedby cardiac ultrasound. Some expertshave advocated screening athleteswith ultrasound or electrocardiograms

(EKGs), although this screening iscontroversial due to the high costs andrelative rarity of the condition. However,any athlete with cardiac symptoms,such as dizziness, fatigue, shortness ofbreath out of proportion to the physicalactivity, palpitations, seizures, andespecially syncope (passing out) shouldbe taken out of competition andthoroughly tested. Further, a familyhistory of cardiac abnormalities,especially a known relative withhypertrophic cardiomyopathy ora history of unexplained suddendeath in a family member, warrantsa complete cardiac evaluation.

Various forms of chest protection andpads have been tried in order to preventcommotio cordis, but unfortunatelyno method has been shown to preventthis tragic event. Rule changes insome sports may be of some benefit toprevent commotio cordis. For example,limiting the use of aluminum bats inbaseball and softball may protect thepitcher by decreasing the speed thatthe ball comes off the bat. Softer ballsand teaching players to turn their chestsaway from a batted ball may alsoreduce the risk of commotio cordis.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

Statistics� Fortunately, SCD is extremely rarein sports. For most, the cardiacbenefits of activity and sportsparticipation far outweigh the risks.

� According to recent estimates,the incidence of sports related SCDmay be as high as 1:75,000 per yearin high school and college athletes.

� Studies have shown the incidenceof SCD in U.S. military recruitsto be 1:9,000 per year.

� The most common causein young athletes, hypertrophiccardiomyopathy, accounts for25–30% of these cases andcommotio cordis accounts for 20%.

� Coronary artery abnormalities arethe cause of 14% of SCD in athletes.

Athletes who had a sudden cardiacevent� Hank Gathers, a basketball playerat Loyola Marymount University

� Reggie Lewis, Boston Celtics

� Marc-Vivian Foé, a Camerooniansoccer star, died during a matchin 2003

THROWINGINJURIESIN CHILDREN

SPORTS MEDICINE | Throwing Injuries in Children 31

What causes throwing injuries?With the start of the baseball seasoneach spring, doctors frequently seean increase in elbow problems in youngbaseball players. A common elbowproblem in these children is medialapophysitis, commonly referred to as“Little Leaguer or Youth Pitching elbow.”

The elbow joint is made up of threebones: upper arm bone (humerus) andthe two bones in the forearm (radiusand ulna). Muscles, ligaments, andtendons hold the elbow joint together.

“Little Leaguer Elbow”This injury occurs when repetitivethrowing creates an excessively strongpull on the tendons and ligaments of theelbow. The young player feels pain at theprominence on the inside of the elbow.

“Pitcher’s elbow” can be serious if itbecomes aggravated. Repeated pullingcan tear ligaments and tendons awayfrom the bone. The tearing may pulltiny bone fragments with it in the sameway a plant takes soil with it whenit is uprooted. This can disrupt normalbone growth, resulting in deformity.

What are the symptoms?“Pitcher’s elbow” may cause pain onthe inside of the elbow. A child shouldstop throwing if any of the followingsymptoms appear:� Elbow pain� Restricted range of motion� Locking or catching in the elbow joint

How is the condition treated?Left untreated, throwing injuries inthe elbow can become complicatedconditions.

Nonsurgical Treatment

Younger children tend to respond betterto nonsurgical treatments.

� Rest. Continuing to throw may leadto major complications and jeopardizea child’s ability to remain activein a sport that requires throwing.

� Apply ice packs to bring downany swelling.

� If pain persists after a few days ofcomplete rest of the affected area,or if pain recurs when throwingis resumed, stop the activity againuntil the child gets treatment.

� Refine throwing technique.

What is the recovery time?Recovery depends on the athlete’s ageand severity of injury. If identified earlyand activity modification is started,it could be only a short duration untilthe athlete is back to sport. On theother hand, if the athlete continues toplay despite pain and other symptoms,the damage could take monthsto resolve or could be permanent.

Surgical Treatment

Surgery is occasionally necessaryfor severe problems, especially in girlsolder than 12 years and boys olderthan 14 years.

Depending upon a child’s injury,surgery may involve removing loosebone fragments, bone grafting, orreattaching a ligament back to the bone.

How can the injury beprevented?The general guideline for how manypitches a child can safely throw eachweek is 75 for 8–10 year olds, 100 for11–12 year olds, and 125 for 13–14year olds. This includes both practice andcompetitive play. To prevent throwinginjuries, young pitchers should onlyplay three to four innings each game.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

Statistics� The percentage of ulnar collateralreconstructions on high schoolpitchers compared to college levelor above pitchers has increasedfrom 8% between 1995 and 1998,to 24% between 2003 and 2006.(Andrews et al, AJSM, 2008)

� The overall risk of a youth pitchersustaining a serious throwing injurywithin 10 years was 5%. Thoseathletes who pitched more than100 innings in a year were 3.5 timesmore likely to be injured than thosewho pitched less than 100 innings.(Lyman et al, AJSM, 2002)

EXPERT CONSULTANT | Robert Gallo, MD

TREATMENT OFTENDON/LIGAMENTDISORDERS WITHPLATELET-RICH PLASMA

EXPERT CONSULTANT | Grant Jones, MD

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

What is platelet-rich plasma?Multiple treatments have been developedto try to speed up the healing rate oftendon injuries with mixed successes.One recent development is the useof platelet-rich plasma or “PRP” tostimulate healing. PRP is made byseparating out the platelets from therest of athlete’s blood and putting theminto a concentrated form. The PRP isthen injected around the repair site inacutely, torn surgically repaired tendonsor ligaments or injected with a needleinto the degenerative tendon in thenon-surgically treated overuse conditions.Platelets contain growth factors thatstimulate healing, and laboratorystudies have shown that PRP mayimprove tendon and ligament healing.

What are the results of PRPin athletes?Studies on the use of PRP in athleteshave shown mixed results. A fewstudies on patients with “tennis elbow”and “jumper’s knee” have demonstratedsome potential benefit from PRP interms of decreased pain and returnto activity while other studies have notshown any benefit for these conditions.Studies on patients undergoing Achillestendon repair, anterior cruciate ligamentreconstruction, and rotator cuff repairshave shown potential for decreasedpain levels in the early stages andearlier tendon or ligament healing, butno differences in the long-term outcome.

Is it legal to use PRP inathletes to aid recovery?In 2009, the World Anti-Doping agencydetermined that PRP is prohibited whengiven as an injection into muscle andthat injections into tendons to aid in thehealing from injury require a declarationof its use that is in compliance with theInternational Standard for TherapeuticUse Exemptions (TUEs). Similarly,the U.S. Anti-doping Agency issuedan “athlete’s advisory” in 2009 thata PRP injection is equivalent to aninjection of growth factors and thatan athlete needs a TUE if a medicalprofessional determines that a PRPinjection is necessary. In U.S.professional sports leagues, however,PRP is not addressed in their listsof banned substances.

Athletes who have hadPRP injectionsThe most publicized case of the useof PRP in athletes involved Hines Wardof the Pittsburgh Steelers. He receiveda PRP injection into his medial collateralligament after sustaining an acute injuryprior to the 2009 Super Bowl. Hisrecovery was reported to be quickerthan anticipated, and he was ableto play in the Super Bowl.

Additional Informationwww.sportsmed.orgwww.orthoinfo.orgwww.STOPSportsInjuries.org

SOURCES

SPORTS MEDICINE 33

Concussion

American Orthopaedic Society of Sports Medicine ConcussionWorkshop Chicago 1997

Collins, Gioia, Langlios 2007 Concussion ManagementGuidelines CDC Physician ToolKit

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Heat Illness

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www.mayoclinic.com/health/mrsa/DS00735

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Slap Tears

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Stress Fractures

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Treatment of Tendon/Ligament Disorderswith Platelet-Rich Plasma

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www.sportsmed.org www.orthoinfo.org