1. Plica Redundant fold in synovial lining of the knee
Palpable over medial or lateral retinaculum
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

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

3. Plica
Synovial plica
Patella
Plica
Trochlea groove

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

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

6. Isolated ACL Tears
Preadolescent children best treated with activity modification and observation
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)
Adolescents are treated as adults

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

8. Anterior Cruciate Ligament Injuries
Natural History
Activity, not age is primary factor
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

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

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

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

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

13. Meniscal Injuries Blood supply to meniscus Repairable zone
Meniscal tear

14. Patellar Dislocation

15. Patellar Dislocation Twisting injury Collision
May not know patella dislocated
Immediate swelling
Can’t play

16. Patellar Dislocation

17. Patellar Dislocation 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

18. 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

19. Other LE Injuries Bone Bruise Shin Splints Stress Fractures
Nerve Entrapements
Severe’s Disease
Subungual Hematoma’s

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

21. Shin Splints Exercise induced pain along the anteriomedial tibia
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

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

23. Shin Splints Treatment Ice massage NSAID’s
Decrease running and jumping
Correct training errors
Strengthening
Continue with cardio/vascular training

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

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

26. Stress Fractures

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

28. Nerve Entrapment Syndromes
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

29. Nerve Entrapment Syndromes
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 1st web
Sural n.-numbness at lateral heel and foot
Posterior tibial n.-tarsal tunnel symptoms

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

31. Sever’s Disease
Increased density and partial fragmentation of the calcaneal apophysis

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

33. Subungual Hematoma
Think open fracture

34. Injuries About The Shoulder
Little Leaguer’s Shoulder
Shoulder instability
Recurrent dislocations
Clavicle fractures
A-C separations

35. Little Leaguer’s Shoulder
Pain due to a stress fracture
of the humeral physis
Overuse injury
Rest usually takes care
of the problem

36. Little Leaguer’s Shoulder
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)

37. Little Leaguer’s Shoulder
May help to limit the amount of pitching in the game but doesn’t control practice or at home

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

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

40. Shoulder Instability

41. Shoulder Instability
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

42. 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)
Surgical - capsular shrinking has promise for failures at therapy , capsular plication

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

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