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Plica Redundant fold in synovial lining of the knee Redundant fold in synovial lining of the knee Palpable over medial or lateral retinaculum Palpable over medial or lateral retinaculum Gradual onset of pain increased with sitting or prolonged knee flexion and aggravated by arising Gradual onset of pain increased with sitting or prolonged knee flexion and aggravated by arising Can cause snapping and can be entrapped in the patellofemoral joint Can cause snapping and can be entrapped in the patellofemoral joint

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Plica Treatment Cortisone injection may help Cortisone injection may help Surgery may be required for excision of the thickened band of tissue Surgery may be required for excision of the thickened band of tissue

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Plica Plica Trochlea groove Patella Synovial plica

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Anterior Cruciate Ligament Injuries Incidence is 0.3-0.38 per 1000 per year and increasing Incidence is 0.3-0.38 per 1000 per year and increasing Usually sports related (football, soccer, skiing) Usually sports related (football, soccer, skiing) Estimated 3 in 100,000 have tibial spine avulsions Estimated 3 in 100,000 have tibial spine avulsions Skeletally immature patients account for 3-4% of all ACL injuries Skeletally immature patients account for 3-4% of all ACL injuries

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Anterior Cruciate Ligament Injuries Bony avulsion of tibial spine insertion occurs more commonly found in preadolescent children Bony avulsion of tibial spine insertion occurs more commonly found in preadolescent children Intrasubstance tears are more commonly seen in adolescents Intrasubstance tears are more commonly seen in adolescents MOI is usually hyperextension, sudden deceleration, or a valgus rotational force with a stationary foot MOI is usually hyperextension, sudden deceleration, or a valgus rotational force with a stationary foot

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Isolated ACL Tears Preadolescent children best treated with activity modification and observation Preadolescent children best treated with activity modification and observation Repair of ligament has high failure rate Repair of ligament has high failure rate Recommendation for children with > 1year left of growth remaining not to have bone tunnels for reconstruction (some controversy) Recommendation for children with > 1year left of growth remaining not to have bone tunnels for reconstruction (some controversy) Adolescents are treated as adults Adolescents are treated as adults

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Anterior Cruciate Ligament Injuries Natural History Preadolescent not well known due to low #s Preadolescent not well known due to low #s Adolescents- similar to young adults Adolescents- similar to young adults 33-86% reports episodes of giving way when treated nonoperatively 33-86% reports episodes of giving way when treated nonoperatively

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Anterior Cruciate Ligament Injuries Natural History Activity, not age is primary factor Activity, not age is primary factor Adolescents are usually very active and they will have a higher rate of failure with conservative treatment Adolescents are usually very active and they will have a higher rate of failure with conservative treatment Increase risk of meniscal damage if treated conservatively Increase risk of meniscal damage if treated conservatively

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Tibial Spine Avulsion Fractures Type I-minimally displaced Type I-minimally displaced Type II-posterior hinge but still attached to the tibial epiphysis Type II-posterior hinge but still attached to the tibial epiphysis Type III- fx is displaced Type III- fx is displaced Type I Type II Type III

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Tibial Spine Avulsion Fractures Treatment Treatment Type I usually casting Type I usually casting Type II closed reduction/cast Type II closed reduction/cast Type III ORIF with screw/wire/sutures Type III ORIF with screw/wire/sutures

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Mensical Injuries Symptoms Pain Pain Effusion Effusion Snapping Snapping Giving way Giving way Intermittent locking Intermittent locking Locked knee Locked knee

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Meniscal Injuries Outcomes Complete meniscectomies results are very poor Complete meniscectomies results are very poor 60% unsatisfactory at 7 years 60% unsatisfactory at 7 years Preservation is critical Preservation is critical 80-90% have favorable outcomes with repair 80-90% have favorable outcomes with repair

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Meniscal Injuries Meniscal tear Repairable zone Blood supply to meniscus

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Patellar Dislocation

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Twisting injury Collision May not know patella dislocated Immediate swelling Cant play

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Patellar Dislocation

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Almost always lateral Younger age at initial dislocation, increased risk of recurrent dislocation Often reduce spontaneously with knee extension and present with hemarthrosis Immobilize in extension for 4 weeks

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Patellar Dislocation Predisposing factors to recurrence- ligamentous laxity, increased genu valgum, torsional malalignment Consider surgical treatment for recurrent dislocation/subluxation if fail extensive rehabilitation/exercises

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Other LE Injuries Bone Bruise Shin Splints Stress Fractures Nerve Entrapements Severes Disease Subungual Hematomas

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Bone bruise Collision Fall Non-contact twist Xrays usually normal dx by mri Tx rest,nwb time

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Shin Splints Exercise induced pain along the anteriomedial tibia Exercise induced pain along the anteriomedial tibia Encompasses a spectrum of disorders- posterior tibial tendonitis, periostitis, and can lead to a stress fracture Encompasses a spectrum of disorders- posterior tibial tendonitis, periostitis, and can lead to a stress fracture Usually a result of training errors or change in quality and quantity of running Usually a result of training errors or change in quality and quantity of running

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Shin Pain Differential Diagnosis Shin Splints Shin Splints Chronic Exertional Chronic Exertional Compartment Syndrome Compartment Syndrome Nerve Entrapment Syndromes Nerve Entrapment Syndromes Stress Fractures Stress Fractures

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Shin Splints Treatment Ice massage Ice massage NSAIDs NSAIDs Decrease running and jumping Decrease running and jumping Correct training errors Correct training errors Strengthening Strengthening Continue with cardio/vascular training Continue with cardio/vascular training

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Stress Fractures Most commonly results from training errors (change in surfaces or shoes) Most commonly results from training errors (change in surfaces or shoes) Need high index of suspicion Need high index of suspicion Difficult clinically to distinguish from overuse type syndromes Difficult clinically to distinguish from overuse type syndromes May be seen on plain X-rays but Tc-99m bone scan may be needed May be seen on plain X-rays but Tc-99m bone scan may be needed MRI MRI

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Stress Fractures Increasingly more frequent in recreational and competitive athletes Increasingly more frequent in recreational and competitive athletes About 10% of sport injuries About 10% of sport injuries Common with preexisting conditions with decreased bone mass, bone mineralization [nutritional disorders (rickets), systemic disorders (DM, RA)] Common with preexisting conditions with decreased bone mass, bone mineralization [nutritional disorders (rickets), systemic disorders (DM, RA)]

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Stress Fractures

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Treatment Activity modification [you need to keep these athletes in shape (swim, bike, weight train, etc.)] Activity modification [you need to keep these athletes in shape (swim, bike, weight train, etc.)] Rest- (it takes time) Rest- (it takes time) Immobilization rarely needed Immobilization rarely needed

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Nerve Entrapment Syndromes Occur secondarily to problems such as lower extremity edema, compression syndrome, bone impingement and joint instability Occur secondarily to problems such as lower extremity edema, compression syndrome, bone impingement and joint instability Nerve problems are mostly functional: that is the nerve is entrapped only during athletic activity Nerve problems are mostly functional: that is the nerve is entrapped only during athletic activity

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Nerve Entrapment Syndromes Superficial peroneal n.-pain and numbness over distal calf & dorsum of foot & ankle Superficial peroneal n.-pain and numbness over distal calf & dorsum of foot & ankle Deep peroneal n.- pain at dorsum of foot with pain and numbness at 1 st web Deep peroneal n.- pain at dorsum of foot with pain and numbness at 1 st web Sural n.-numbness at lateral heel and foot Sural n.-numbness at lateral heel and foot Posterior tibial n.-tarsal tunnel symptoms Posterior tibial n.-tarsal tunnel symptoms

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Severs Disease Self limiting apohysitis of the os calcis at the insertion site of the Achilles tendon Self limiting apohysitis of the os calcis at the insertion site of the Achilles tendon Pain over post. os calcis Pain over post. os calcis Aggravated by activity Aggravated by activity Recent growth spurt Recent growth spurt

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Severs Disease Increased density and partial fragmentation of the calcaneal apophysis Increased density and partial fragmentation of the calcaneal apophysis

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Severs Disease Most commonly seen in 6 to 10 year old males Most commonly seen in 6 to 10 year old males Treatment is symptomatic Treatment is symptomatic Mild restriction of activities Ice Heel lifts Achilles stretches Arch supports

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Subungual Hematoma Think open fracture

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Injuries About The Shoulder Little Leaguers Shoulder Little Leaguers Shoulder Shoulder instability Shoulder instability Recurrent dislocations Recurrent dislocations Clavicle fractures Clavicle fractures A-C separations A-C separations

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Little Leaguers Shoulder Pain due to a stress fracture Pain due to a stress fracture of the humeral physis of the humeral physis Overuse injury Overuse injury Rest usually takes care Rest usually takes care of the problem of the problem

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Little Leaguers Shoulder Treatment is PREVENTION Treatment is PREVENTION Restrict # of pitches and innings pitched Mandatory days of rest Show proper technique ( no side arm) and do not attempt techniques beyond the current skeletal maturity (curve balls)

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Little Leaguers Shoulder May help to limit the amount of pitching in the game but doesnt control practice or at home May help to limit the amount of pitching in the game but doesnt control practice or at home

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Shoulder Instability Commonly seen in young swimmers and throwing athletes (also volleyball & tennis) Commonly seen in young swimmers and throwing athletes (also volleyball & tennis) Overuse syndrome Overuse syndrome Pain is exacerbated by repetitive overhead activities that cause a stretching of the anterior capsule and musculature of the shoulder Pain is exacerbated by repetitive overhead activities that cause a stretching of the anterior capsule and musculature of the shoulder

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Shoulder Instability Commonly loose jointed Commonly loose jointed Multiple-joint laxity check the knees, elbows, MCP joints, thumb to flexor surface of forearm Multiple-joint laxity check the knees, elbows, MCP joints, thumb to flexor surface of forearm Check skin hyperelasticity (Marfans?) Check skin hyperelasticity (Marfans?) Usually atraumatic instability Usually atraumatic instability Voluntary instability can be associated with psychologic instability Voluntary instability can be associated with psychologic instability

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Shoulder Instability

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Physical exam may also show rotator cuff and scapular weakness and apprehension Multifactorial causes Motor imbalance Scapular weakness Capsular laxity RARELY IS THIS ROTATOR CUFF DISEASE RARELY IS THIS ROTATOR CUFF DISEASE

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Shoulder Instability Treatment Physical therapy- includes stretching posterior capsule and strengthening anterior musculature, rotator cuff, and the muscles of the scapula ( usually up to 6 months) Physical therapy- includes stretching posterior capsule and strengthening anterior musculature, rotator cuff, and the muscles of the scapula ( usually up to 6 months) Surgical - capsular shrinking has promise for failures at therapy, capsular plication Surgical - capsular shrinking has promise for failures at therapy, capsular plication

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Recurrent Dislocations Initial traumatic dislocation Initial traumatic dislocation Can lead to long term disability Can lead to long term disability Age is important fact for recurrent dislocations Age is important fact for recurrent dislocations Over 50 years of age very few Children and adolescents- 25-50% 90% of young athletes have associated Bankart lesions (avulsion of labrum- ligament complex)

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Recurrent Dislocations Treatment Surgical Surgical Open Arthroscopically- higher failure rate for athletes failure rate for athletes under 20-years of age? under 20-years of age?