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
Plica
Treatment

Cortisone injection may help
 Surgery may be required for excision of
the thickened band of tissue
Plica
Synovial
plica
Patella
Plica
Trochlea
groove
Anterior Cruciate Ligament
Injuries

Incidence is 0.3-0.38 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
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
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
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

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
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
Tibial Spine Avulsion
Fractures
Treatment
Type I – usually casting
 Type II – closed reduction/cast
 Type III – ORIF with
screw/wire/sutures

Mensical Injuries
Symptoms






Pain
Effusion
Snapping
Giving way
Intermittent locking
Locked knee
Meniscal Injuries
Outcomes

Complete meniscectomies results are
very poor
 60% unsatisfactory at 7 years
 Preservation is critical
 80-90% have favorable outcomes with
repair
Meniscal Injuries
Blood
supply to
meniscus
Repairable zone
Meniscal
tear
Patellar Dislocation
Patellar Dislocation

Twisting injury
 Collision
 May not know patella dislocated
 Immediate swelling
 Can’t play
Patellar Dislocation
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
Patellar Dislocation
 Predisposing
factors to recurrenceligamentous laxity, increased genu
valgum, torsional malalignment
 Consider surgical treatment for
recurrent dislocation/subluxation if fail
extensive rehabilitation/exercises
Other LE Injuries

Bone Bruise
 Shin Splints
 Stress Fractures
 Nerve Entrapements
 Severe’s Disease
 Subungual Hematoma’s
Bone bruise
Collision
Fall
Non-contact twist
Xrays usually normal
dx by mri
Tx rest,nwb time
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
Shin Pain
Differential Diagnosis

Shin Splints
 Chronic Exertional
Compartment Syndrome
 Nerve Entrapment Syndromes
 Stress Fractures
Shin Splints
Treatment

Ice massage
 NSAID’s
 Decrease running and jumping
 Correct training errors
 Strengthening
 Continue with cardio/vascular training
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
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)]
Stress Fractures
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
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
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
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
Sever’s Disease
Increased density
and partial
fragmentation of
the calcaneal
apophysis
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
Subungual Hematoma
Think open fracture
Injuries About The Shoulder
 Little
Leaguer’s Shoulder
 Shoulder instability
 Recurrent dislocations
 Clavicle fractures
 A-C separations
Little Leaguer’s
Shoulder

Pain due to a stress fracture
of the humeral physis
 Overuse injury
 Rest usually takes care
of the problem
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)
Little Leaguer’s
Shoulder
May help to limit the amount of pitching
in the game but doesn’t control practice
or at home
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
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

Shoulder Instability
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
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
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- 25-50%
– 90% of young athletes have associated
Bankart lesions (avulsion of labrumligament complex)
Recurrent Dislocations
Treatment
 Surgical
– Open
– Arthroscopically- higher
failure rate for athletes
under 20-years of age?