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OITE 2005 - Sports

OITE 2005 - Sports. Megan Cashin November 8, 2006. Question 9. Posterolateral rotatory instability of the knee is associated with what type of abnormal motion? Proximal fibula moves posterior to the posterolateral tibia

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OITE 2005 - Sports

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  1. OITE 2005 - Sports Megan Cashin November 8, 2006

  2. Question 9 Posterolateral rotatory instability of the knee is associated with what type of abnormal motion? • Proximal fibula moves posterior to the posterolateral tibia • Lateral tibial plateau moves posterior to the lateral femoral condyle • Lateral femoral condyle moves posterior to the lateral tibial plateau • Entire tibia moves posterior and lateral to the femur • Posterior aspect of the patella moves lateral to the lateral femoral condyle

  3. Question 9 • Proximal fibula moves posterior to the posterolateral tibia • Lateral tibial plateau moves posterior to the lateral femoral condyle • Lateral femoral condyle moves posterior to the lateral tibial plateau • Entire tibia moves posterior and lateral to the femur • Posterior aspect of the patella moves lateral to the lateral femoral condyle

  4. DeLee JC, Drez D Jr, Miller MD: Orthopaedic Sports Medicine: Principles and Practice, ed. 2. Philadelphia, PA, WB Saunders, 2003, pp 1577-2154.Snider RK (ed) : Essentials of Musculoskeletal Care. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1997, pp. 304-366.Garrick JG (ed): Orthopaedic Knowledge Update: Sports Medicine 3. Rosemont, IL, American Academy of Orhtopaedic Surgeons, 2004, pp. 183-197. The posterolateral corner can be tested with the anterior drawer at 90° with internal tibial rotation. AS with the posteromedial capsule, when the posterolateral capsule is torn, the drawer with internal rotation will show an increase in translation when compared with the neutral test. The tibia will also tend to “internally rotate” as the anterior drawer test is being done. The hyperextension recurvatum sign also correlates with injury to the posterolateral corner. With the patient lying supine and relaxed, both legs are help up at extension by the examiner standing at the end of the table. In patients with a PCL and posterolateral capsule injury, the knee hyperextends and the tibia rotates externally because of incompetent of the posterolateral structures. The reverse pivot-shift test should also be done with the tibia rotated externally and the knee flexed. As the knee is extended, the tibia reduces with a palpable clunk, indicating that the posterolateral capsule is injured.

  5. Biomechanics • What role do posterolateral structures play in the knee? • Resist varus, ER, posterior translation and coupled ER • Excessive ER at 30 deg means what? • Injury to PLC • Excessive ER at 30 and 90 means what? • PCL and PLC injury

  6. Posterolateral Corner Injury • What is the result of PCL injury? • Increased posterior translation of tibia which increases with knee flexion • What is best test for PCL injury • Posterior drawer test • At what angle of knee is LCL injury best assessed? • 30 deg

  7. Question 19 The proposed mechanism of the injury in athletic pubalgia is hip • Flexion-abduction • Flexion-adduction • Extension • Extension-adduction • Extension-abduction

  8. Question 19 The proposed mechanism of the injury in athletic pubalgia is hip • Flexion-abduction • Flexion-adduction • Extension • Extension-adduction • Extension-abduction

  9. Meyers WC, Foley DP, Garret WE, et al: Management of severe lower abdominal or inguinal pain in high-performance athletes. Am J Sports Med 2000; 28:2-8. The purpose of this study was to gain insight into the pathophysiologic processes of severe lower-abdominal or inguinal pain in high-performance athletes. We evaluated 276 patients; 175 underwent pelvic floor repairs. Of the 157 athletes who had not undergone previous surgery, 124 (79%) participated at a professional or other highly competitive level, and 138 patients (88%) had adductor pain that accompanied the lower-abdominal or inguinal pain. More patients underwent related adductor releases during the later operative period in the series. Evaluation revealed 38 other abnormalities, including severe hip problems and malignancies. There were 152 athletes (97%) who returned to previous levels of performance. The syndrome was uncommon in women and the results were less predictable in nonathletes. A distinct syndrome of lower-abdominal/adductor pain in male athletes appears correctable by a procedure designed to strengthen the anterior pelvic floor. The location and pattern of pain and the operative success suggest the cause to be a combination of abdominal hyperextension and thigh hyperabduction, with the pivot point being the pubic symphysis. Diagnosis of "athletic pubalgia" and surgery should be limited to a select group of high-performance athletes. The consideration of other causes of groin pain in the patient is critical.

  10. Question 28 Which of the following rehabilitation exercises places the most stress on the anterior cruciate ligament? • Resisted non-weight bearing knee extension between 0º - 30º • Vertical squat to 60º • Leg press • Stair climbing machine • Stationary bike with high seat placement

  11. Question 28 Which of the following rehabilitation exercises places the most stress on the anterior cruciate ligament? • Resisted non-weight bearing knee extension between 0º - 30º • Vertical squat to 60º • Leg press • Stair climbing machine • Stationary bike with high seat placement

  12. Wilk KE, Escamilla RF, Fleisig GS, et al: A comparison of tibiofemoral joint forces and electromyographic activity during open and closed kinetic chain exercises. Am J Sports Med 1996; 24; 518-527. We chose to investigate tibiofemoral joint kinetics (compressive force, anteroposterior shear force, and extension torque) and electromyographic activity of the quadriceps, hamstring, and gastrocnemius muscles during open kinetic chain knee extension and closed kinetic chain leg press and squat. Ten uninjured male subjects performed 4 isotonic repetitions with a 12 repetition maximal weight for each exercise. Tibiofemoral forces were calculated using electromyographic, kinematic, and kinetic data. During the squat, the maximal compressive force was 6139 +/- 1708 N, occurring at 91 degrees of knee flexion; whereas the maximal compressive force for the knee extension exercise was 4598 +/- 2546 N (at 90 degrees knee flexion). During the closed kinetic chain exercises, a posterior shear force (posterior cruciate ligament stress) occurred throughout the range of motion, with the peak occurring from 85 degrees to 105 degrees of knee flexion. An anterior shear force (anterior cruciate ligament stress) was noted during open kinetic chain knee extension from 40 degrees to full extension; a peak force of 248 +/- 259 N was noted at 14 degrees of knee flexion. Electromyographic data indicated greater hamstring and quadriceps muscle co-contraction during the squat compared with the other two exercises. During the leg press, the quadriceps muscle electromyographic activity was approximately 39% to 52% of maximal velocity isometric contraction; whereas hamstring muscle activity was minimal (12% maximal velocity isometric contraction). This study demonstrated significant differences in tibiofemoral forces and muscle activity between the two closed kinetic chain exercises, and between the open and closed kinetic chain exercises.

  13. Beynnon BD, Johnson RJ, Fleming BC: The science of anterior cruciate ligament rehabilitation. Clin Orthop 2002; 402:9-20. This review of the literature assessed what is known about the biomechanics of the normal anterior cruciate ligament during rehabilitation exercises, the biomechanical behavior of the anterior cruciate ligament graft during healing, and clinical studies of rehabilitation after anterior cruciate ligament replacement. After anterior cruciate replacement, immobilization of the knee, or restricted motion without muscle contraction, leads to undesired outcomes for the ligamentous, articular, and muscular structures that surround the joint. It is clear that rehabilitation that incorporates early joint motion is beneficial for reducing pain, minimizing capsular contractions, decreasing scar formation that can limit joint motion, and is beneficial for articular cartilage. There is evidence derived from randomized controlled trials that immediately after anterior cruciate ligament reconstruction, weightbearing is possible without producing an increase of anterior knee laxity and is beneficial because it lowers the incidence of patellofemoral pain. Rehabilitation with a closed kinetic chain program results in anteroposterior knee laxity values that are closer to normal, and earlier return to normal daily activities, compared with rehabilitation with an open kinetic chain program. This review revealed that more randomized, controlled trials of rehabilitation are needed. These should include the clinicians' and patients' perspective of the outcome, and biomarkers of articular cartilage metabolism.

  14. Question 40 An ACL graft that is tensioned at 30° with a femoral tunnel that is too anterior will result in what graft problem? • Tight in flexion and extension • Tight in flexion and lax in extension • Isometric if the graft is properly tensioned • Lax in flexion and tight in extension • Lax in flexion and extension 0

  15. Question 40 An ACL graft that is tensioned at 30° with a femoral tunnel that is too anterior will result in what graft problem? • Tight in flexion and extension • Tight in flexion and lax in extension • Isometric if the graft is properly tensioned • Lax in flexion and tight in extension • Lax in flexion and extension

  16. OKU 3- Sports Medicine Loss of knee flexion and increased anteriortranslation have resulted when the tibial tunnel is too vertical. This results in a femoral tunnel that overtensions the graft in flexion and may impinge the graft in extension Concerns with overtensioning the graft and “capturing the knee” dictate that the knee should be in full extension with no applied posterior translation ast the time of fixation.l Greater tension on the graft and pretensioning the graft are 2 accepted methods of increasing graft stiffness and tension. It is thought that the graft will not be overtensioned if the knee is in absolute full extension at fixation

  17. Azar FM: Revision anterior cruciate ligament reconstruction. Instr Course Lect 2002; 5:335-342DeLee JC, Drez D Jr, Miller MD: Orthopaedic Sports Medicine: Principles and Practice, ed. 2. Philadelphia, PA, WB Saunders, 2003, pp 1577-2154.

  18. Question 42 An 18 year-old football player undergoes shoulder arthroscopy that documents the lesion shown in Figure 11. What is the most common associate intra-articular finding at the time of surgery? • Superior labral tear • Hill-Sachs lesion • Rotator cuff tear • Buford complex • Multiple loose bodies

  19. Question 42 An 18 year-old football player undergoes shoulder arthroscopy that documents the lesion shown in Figure 11. What is the most common associate intra-articular finding at the time of surgery? • Superior labral tear • Hill-Sachs lesion • Rotator cuff tear • Buford complex Multiple loose bodies

  20. Kralinger FS, Golser K, Wischatta R, et al: Predicting recurrence after primary anterior shoulder dislocation. Am J Sports Med 2002; 30;116-120. We evaluated the factors influencing the recurrence rate after primary anterior traumatic shoulder dislocation, especially sports activity. A significant number of patients changed to athletic activities that produce less shoulder strain. The natural assumption would be that sports activity directly influences recurrence. However, age-adjusted logistic regression analysis revealed that the correlation between sports and recurrence rate was false. Our statistical findings also clearly showed that physical therapy and immobilization do not reduce the risk of recurrence. The only factor associated with recurrence was age between 21 and 30 years. Patients in this age group who participate in high-risk sports activities should undergo primary surgical stabilization because of the increased risk of recurrence.

  21. Question 56 Which of the following is considered the most cost-effective screening tool for cardiovascular abnormalities in young athletes prior to participation in organized high school and/or college sports? • ECG • Echocardiography • History and physical examination • Arteriography • Exercise stress test

  22. Question 56 Which of the following is considered the most cost-effective screening tool for cardiovascular abnormalities in young athletes prior to participation in organized high school and/or college sports? • ECG • Echocardiography • History and physical examination • Arteriography • Exercise stress test

  23. Maron BJ, Thompson PD, Puffer JC, et al: Cardiovascular preparticipation screening in competitive athletes. A statement for health professionals form the Sudden Death Committee (clinical cardiology) and Congenital Cardiac Defects Committee (cardiovascular disease in the young), American Heart Association. Circulation 1996; 94:850-856. Noninvasive testing can enhance the diagnostic power of the standard history and physical examination; however, it is not prudent to recommend routine use of such tests as 12-lead electrocardiography, echocardiography, or graded exercise testing for detection of cardiovascular disease in large populations of young or older athletes. This recommendation is based on both practical and cost-efficiency considerations, given the large number of competitive athletes in the United States, the relatively low frequency with which the cardiovascular lesions responsible for these deaths occur, and the low rate of sudden cardiac death in the athletic community. This viewpoint, however, is not intended to actively discourage all efforts at population screening that may be proposed by individual investigators. Nevertheless, there is concern that the widespread use of noninvasive testing in athletic populations could result in many false-positive test results, creating unnecessary anxiety among substantial numbers of athletes and their families, as well as unjustified exclusion from life insurance coverage and athletic competition. Indeed, in such a circumstance with a low incidence of disease in the community, a great likelihood exists that the number of false-positive results would exceed that of true-positive results.68

  24. Madden CC, Walsh WM, Mellion MB: The team physician: The preparticipation exam and on the field management, in DeLee JC, Drez D Jr, Miller MD: Orthopaedic Sports Medicine: Principles and Practice, ed. 2. Philadelphia, PA, WB Saunders, 2003, pp 737-768. Consequently, we conclude that a complete and careful personal and family history and physical examination designed to identify (or raise suspicion of) those cardiovascular lesions known to cause sudden death or disease progression in young athletes is the best available and most practical approach to screening populations of competitive sports participants, regardless of age. Such cardiovascular screening is an obtainable objective and should be mandatory for all athletes. We recommend that both a history and a physical examination be performed before participation in organized high school (grades 9 through 12) and collegiate sports. Screening should then be repeated every 2 years. In intervening years an interim history should be obtained. Indeed, this recommendation is consistent with procedures that are customary for most high school and collegiate athletes in the United States.

  25. Question 69 An intra-articular knee injection is most accurately administered in which of the following locations? • Medial middle to upper patella with the knee extended • Lateral middle to upper patella with the knee extended • Anterior medial at the joint line with knee flexed at 90° • Anterior lateral at the joint time with knee flexed at 90° • Posterior medial at the joint line with knee flexed at 90°

  26. Question 69 An intra-articular knee injection is most accurately administered in which of the following locations? • Medial middle to upper patella with the knee extended • Lateral middle to upper patella with the knee extended • Anterior medial at the joint line with knee flexed at 90° • Anterior lateral at the joint time with knee flexed at 90° • Posterior medial at the joint line with knee flexed at 90°

  27. Jackson DW, Evans NA, Thomas BM: Accuracy of needle placement into the intra-articular space of the knee. J Bone Joint Surg Am 2002; 84: 1522-1527. To achieve their potential therapeutic benefit, hyaluronic acid derivatives should be injected directly into the knee joint space and not into the anterior fat pad or the subsynovial tissues. In the absence of a knee effusion, reproducible needle placement into the intra-articular space presents a challenge to the clinician. METHODS: The accuracy of needle placement was assessed in a prospective series of 240 consecutive injections in patients without clinical knee effusion. The injections were performed by one orthopaedic surgeon using a 2.0-in (5.1-cm) 21-gauge needle through three commonly employed knee joint portals: anteromedial, anterolateral, and lateral midpatellar. Accuracy rates for needle placement were confirmed with fluoroscopic imaging to document the dispersion pattern of injected contrast material. RESULTS: Of eighty injections performed through an anterolateral portal, fifty-seven were confirmed to have been placed in the intra-articular space on the first attempt (an accuracy rate of 71%). Sixty of eighty injections performed through an anteromedial approach were intra-articular on the first attempt (75% accuracy rate), as were seventy-four of eighty injections performed through a lateral midpatellar portal (93% accuracy rate). CONCLUSIONS: Using real-time fluoroscopic imaging with contrast material, we demonstrated the difficulty of accurately placing a needle into the intra-articular space of the knee when an effusion is not present. This study revealed that a lateral midpatellar injection (an injection into the patellofemoral joint) was intra-articular 93% of the time and was more accurate than injections performed by the same orthopaedic surgeon using either of the other two portals. This study highlights the need for clinicians to refine injection techniques for delivering intra-articular therapeutic substances that are intended to coat the articular surfaces of the knee joint.

  28. Question 82 Which of the following compartment pressure measurements best describes chronic exertional compartment syndrome? • Resting pressure of 10 mm Hg • 15 mm Hg 1 minute post exercise • 25 mm Hg 1 minute post exercise • 15 mm Hg 5 minutes post exercise • 25 mm Hg 5 minutes post exercise

  29. Question 82 Which of the following compartment pressure measurements best describes chronic exertional compartment syndrome? • Resting pressure of 10 mm Hg • 15 mm Hg 1 minute post exercise • 25 mm Hg 1 minute post exercise • 15 mm Hg 5 minutes post exercise • 25 mm Hg 5 minutes post exercise

  30. Pedowitz RA, Hardens AR, Mubarak SJ, et al: Modified criteria for the objective diagnosis of chronic compartment syndrome of the leg. Am J Sports Med 1990; 18: 35-40. One hundred fifty-nine patients were referred to the authors for evaluation of chronic exertional leg pain from 1978 to 1987. The records of 131 patients were complete and available for retrospective review. Forty-five patients were diagnosed as having a chronic compartment syndrome (CCS) and seventy-five patients had the syndrome ruled out by intramuscular pressure recordings. The only significant difference found between the two groups on history and physical examination was a 45.9% incidence of muscle hernia in the patients with CCS, compared to a 12.9% incidence in those without the syndrome. One-third of the patients with the syndrome and over one-half of those without it reported persistent, moderate to severe pain at 6 month to 9 year followup. Modified, objective criteria were developed for the diagnosis of CCS. The criteria were based upon the intramuscular pressures recorded with the slit catheter before and after exercise in 210 muscle compartments without CCS. In the presence of appropriate clinical findings, we consider one or more of the following intramuscular pressure criteria to be diagnostic of chronic compartment syndrome of the leg: 1) a preexercise pressure greater than or equal to 15 mm Hg, 2) a 1 minute postexercise pressure of greater than or equal to 30 mm Hg, or 3) a 5 minute postexercise pressure greater than or equal to 20 mm Hg.

  31. Question 88 Which of the following physical examination tests is most useful in diagnosing a syndesmotic ankle sprain? • Talar tilt • Anterior drawer • Posterior drawer • Fibula translation • External rotation stress

  32. Question 88 Which of the following physical examination tests is most useful in diagnosing a syndesmotic ankle sprain? • Talar tilt • Anterior drawer • Posterior drawer • Fibula translation • External rotation stress

  33. Boytim MJ, Fischer DA, Neumann L: Syndesmotic ankle sprains. AM J Sports Med 1991; 19:294-298. In this study we reviewed ankle sprains in a professional football team over a 6 year period. Fifteen players who sustained syndesmotic ankle sprains were compared with 28 players who sustained significant lateral ankle sprains. Players with syndesmotic sprains missed significantly more games and practices and they received substantially more treatments than players with lateral ankle sprains. Physical examination findings, results of radiographic evaluations, and etiologic factors are discussed. The external rotation stress test, a clinical method for diagnosis of this type of sprain at the time of injury, is described. Results of this study clearly demonstrate a prolonged recovery time for syndesmotic ankle sprains. Physicians and trainers who are aware of this injury can differentially diagnose these two types of sprains in the early postinjury period by the method described.

  34. Question 96 Which of the following exercises generally is not allowed in the first 6 weeks of rehabilitation after reconstruction of the ACL? • Open chain extension • Open chain flexion • Closed chain extension • Closed chain flexion • Active-assisted range of motion

  35. Question 96 Which of the following exercises generally is not allowed in the first 6 weeks of rehabilitation after reconstruction of the ACL? • Open chain extension • Open chain flexion • Closed chain extension • Closed chain flexion • Active-assisted range of motion

  36. Ross MD, Denegar CR, Winzenried JA: Implementation of open and closed chain kinetic chain quadriceps strengthening exercises after anterior cruciate ligament reconstruction. J Strength Cond Res 2001; 15:466-473. exercise should be performed after ACL reconstruction to strengthen the quadriceps. We believe that a combination of OKC and CKC exercises can be used to effectively and safely strengthen the quadriceps after ACL reconstruction. The purposes of this review are to examine the scientific literature currently available for the effects of OKC and CKC exercise on ACL strain and patellofemoral joint stress, and to present a sound rationale for using a combination of OKC and CKC exercises for quadriceps strengthening after ACL reconstruction. On the basis of our review, both OKC and CKC exercises can be modified and implemented for quadriceps strengthening after ACL reconstruction without causing excessive ACL strain or patellofemoral joint stress.

  37. Beutler AI, Cooper LW, Kirkendall DT, et al: Electromyographic analysis of single-leg, closed chain exercises: Implications for rehabilitation after anterior cruciate ligament reconstruction. J Sthl Train 2002;37:13-18. Many knee rehabilitation studies have examined open and closed kinetic chain exercises. However, most studies focus on 2-legged, closed chain exercise. The purpose of our study was to characterize 1-legged, closed chain exercise in young, healthy subjects. SUBJECTS: Eighteen normal subjects (11 men, 7 women; age, 24.6 +/- 1.6 years) performed unsupported, 1-legged squats and step-ups to approximately tibial height. MEASUREMENTS: Knee angle data and surface electromyographic activity from the thigh muscles were recorded. RESULTS: The maximum angle of knee flexion was 111 +/- 23 degrees for squats and 101 +/- 16 degrees for step-ups. The peak quadriceps activation was 201 +/- 66% maximum voluntary isometric contraction, occurring at an angle of 96 +/- 16 degrees for squats. Peak quadriceps activation was 207 +/- 50% maximum voluntary isometric contraction and occurred at 83 +/- 12 degrees for step-ups. CONCLUSIONS: The high and sustained levels of quadriceps activation indicate that 1-legged squats and step-ups would be effective in muscle rehabilitation. As functional, closed chain activities, they may also be protective of anterior cruciate ligament grafts. Because these exercises involve no weights or training equipment, they may prove more cost effective than traditional modes of rehabilitation.

  38. Question 125 Figures 38a and 38b show the radiographs of a 14 year old boy who has had knee pain for the past 4 months. He does not recall a specific injury that initiated the pain. Examination reveals no abnormalities. What is the next most appropriate step in management? • Observation • Physical therapy • Examination of the hip • MRI of the knee • Diagnostic arthroscopy of the knee

  39. Question 125 Figures 38a and 38b show the radiographs of a 14 year old boy who has had knee pain for the past 4 months. He does not recall a specific injury that initiated the pain. Examination reveals no abnormalities. What is the next most appropriate step in management? • Observation • Physical therapy • Examination of the hip • MRI of the knee • Diagnostic arthroscopy of the knee

  40. Matava MJ, Patton CM, Luhmann S, et al: Knee pain as the initial symptom of SCFE: An analysis of initial presentation and treatment. J Pediatr Orthop 1999; 19:455-460. A retrospective review was performed of 106 patients to determine the effect of knee pain as the initial complaint of slipped capital femoral epiphysis (SCFE). Sixteen (15%) patients had a primary complaint of distal thigh or knee pain or both at initial presentation to our institution or to a referring physician. Ninety (85%) patients described primarily hip, groin, or proximal thigh discomfort. Of the 106 patients with SCFE, 65 patients received no operative treatment before being evaluated at our institution and were the subject of the remainder of the study. Of these, 15 (23%) patients had distal thigh or knee pain or both as their chief complaint (group I), and 50 (77%) patients had hip, groin, or proximal thigh pain (group II). There was no difference between the groups with respect to age, gender, or slip stability. Group I patients were more likely to receive a misdiagnosis (p < 0.05) and undergo unnecessary or uninformative radiographs (p < 0.05). Additionally, patients in group I were found to have slips of greater radiographic severity (p < 0.05). Although not statistically significant, there was a trend for group I patients to experience a longer delay to diagnosis and to require a proximal femoral osteotomy as treatment for their slips. We conclude that isolated distal thigh or knee pain or both is a common presentation of SCFE. Furthermore, this symptom complex, when compared with the more classic presentation of SCFE, leads to higher rates of unnecessary radiographs, misdiagnoses, and severe slips, potentially increasing long-term morbidity.

  41. Calmbach WL, Hutchens M: Evaluation of patients presenting with knee pain: Part II. Differential diagnosis. Am Fam Physician 2003;68:917-922. Knee pain is a common presenting complaint with many possible causes. An awareness of certain patterns can help the family physician identify the underlying cause more efficiently. Teenage girls and young women are more likely to have patellar tracking problems such as patellar subluxation and patellofemoral pain syndrome, whereas teenage boys and young men are more likely to have knee extensor mechanism problems such as tibial apophysitis (Osgood-Schlatter lesion) and patellar tendonitis. Referred pain resulting from hip joint pathology, such as slipped capital femoral epiphysis, also may cause knee pain. Active patients are more likely to have acute ligamentous sprains and overuse injuries such as pes anserine bursitis and medial plica syndrome. Trauma may result in acute ligamentous rupture or fracture, leading to acute knee joint swelling and hemarthrosis. Septic arthritis may develop in patients of any age, but crystal-induced inflammatory arthropathy is more likely in adults. Osteoarthritis of the knee joint is common in older adults.

  42. Question 139 A 19 year old tennis player rolled her ankle in a match 3 weeks ago and was unable to continue playing. Radiographs obtained at the time of injury were normal, and the ankle was stable to examination. Management consisted of immobilization in a walking boot for 10 days, followed by ROM and strengthening exercises. She now reports increased ankle swelling, allodynia and hyperpathia. Examination reveals that the skin is cool and shiny. What is the most likely diagnosis? • Subacute DVT • Grade 2 syndesmotic injury • Lisfranc injury • Complex regional pain syndrome • Lateral process of the talus fracture

  43. Question 139 A 19 year old tennis player rolled her ankle in a match 3 weeks ago and was unable to continue playing. Radiographs obtained at the time of injury were normal, and the ankle was stable to examination. Management consisted of immobilization in a walking boot for 10 days, followed by ROM and strengthening exercises. She now reports increased ankle swelling, allodynia and hyperpathia. Examination reveals that the skin is cool and shiny. What is the most likely diagnosis? • Subacute DVT • Grade 2 syndesmotic injury • Lisfranc injury • Complex regional pain syndrome • Lateral process of the talus fracture

  44. Mehta SA, Lendenfeld TN: Complex regional pain syndromes including RSD and causalgia, in DeLee JC, Drez D Jr, Miller MD: Orthopaedic Sports Medicine: Principles and Practice, ed. 2. Philadelphia, PA, WB Saunders, 2003, pp 441-460.Lindenfeld TN, Bach BR JR, Wojtys EM; Reflex sympathetic dystrophy and pain dysfunction in the lower extremity. Inst Course Lect 1997;46:261-268.

  45. Question 169 The female athlete triad refers to which of the following findings in woman athletes? • Increased of ACL tears associated with MCL and medial meniscus tears • Decreased notch width and ACL size, resulting in increased ACL injuries • Decreased muscle strength and aerobic capacity, resulting in decreased endurance performance • Hip and knee alignment that contributes to an increased rate of patellofemoral pain • Disordered eating and amenorrhea contributing to osteoporosis

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