17
Bone-Up on Orthopedics Paul D. Giles, DO, MS
Bone-Up on Orthopedics Paul D Giles DO MS
912015
1
Paul D Giles DO MS Primary Care Sports Medicine
Johns Hopkins Community Physicians Bowie MD
2013 Team USA Deaf Olympics ndash Team Physician
To review high volume musculoskeletal injuries seen by family physicians
To review the proper diagnostic tests including physical exam and radiologic test as well as treatment of these injuries
To discuss information found within question stems and assign meaning found therein
912015
2
Diagnosis
HPI No injury
Intermittent sharp pain lat and ant shoulder
Overhead
Sleeping on side
Work (carpenter)
No numbting
OTC NSAIDs without relief
No ho prior injury
PMH PSH Meds All Soc hx ROS nc
PE Active ROM 180180
Pain in all planes
IR L shoulder to T6
Pain with resisted ER
+Empty Can Impingement signs
Neg Crossover OrsquoBriens Speedrsquos
+TTP ant shoulder
Rad-4 view x-ray Normal
Rotator Cuff TendonosisImpingement Syn Can be from chronic microtrauma or acute
macrotrauma co pain weakness and loss of motion
Difficulty reaching behind and overhead
Painful laying on affected side
Physical Exam + Empty can test Hawkinrsquos test Neerrsquos Test
+Speedrsquos Test=Biceps Tendonosis
+OrsquoBriens Test=SLAP Lesion
Treatment Rest NSAIDs PT Corticosteroid inj
Surgery for complete tears
Rotator
Cuff
Interval
912015
3
Diagnosis
HPI Started after raking leaves
in fall
Constant lat forearmelbow ache
Grippinglifting
Computer
No swellingnumbting
Ibuprofen with some relief
No ho sig injury
PMH PSH Meds All Soc hx ROS nc
PE No effusionecchymosis
erythema TTP lat epicondyle Full painless PROM at
elbow flexextprosup 55 mm strength
Pain with elbow ext forearm pro wrist ext grip
Neg valgusvarus stress Neg Tinels ulnar groove
X-ray 3 view elbow Neg
Lateral Epicondylitis (Tennis Elbow) Overload of tendon-bone junction Present with pain and tenderness over lateral
epicondyle Physical exam
Tender over lateral epicondyle
Pain with resisted wrist extension and extension of middle finger
Treatment PT bracing (wrist or counterforce) NSAIDs cort inj
Medial Epicondylitis (Golferrsquos Elbow) Pain with resisted wrist flexion
912015
4
Extensors
Flexors
Lateral Epicondyle
Medial Epicondyle
Diagnosis
HPI Fell Backward during
Basket Ball Game
Landed on pronated wrist with locked elbow
Treatments Tried
Rest
Ice
Aggravating Factors Weight Bearing
Wrist Extension
PMH PSH Meds All Soc hx ROS nc
PE No Ecchymosis
Full AROM with pain
Minimal swelling
TTP over Radial Wrist
ldquoAnatomical Snuff Boxrdquo
Special Tests
Neg Tinelrsquos
Neg Finkelsteinrsquos
Neg Phalenrsquos
X-ray Wrist (APLatObl) Neg
912015
5
Wrist
Scaphoid fracture 70 of true wrist fractures
Risk of nonunion or AVN
Pain in anatomical snuff box
May not be seen on initial x-rays
Long arm vs short arm cast
Can take up to 4 months to heal
Diagnosis
HPI No injury
Offensive lineman football
Intermittent ache middle of low back
Wt lifting
Playing football
Running
No numbting
Chiropractor x6 moswithout relief
No meds
No prev inj
PMH PSH Meds All Soc hx ROS nc
PE TTP bl paraspinals L4-5
Pain with ext
+Stork bl
55 mm strength bl LE
Sensation intact
DTRs 2+4
Neg straight leg raise
Normal gait
X-ray 4 view (APLatObl) Neg
912015
6
Spondylolysis-defect in pars interarticularis Caused by repeated hyperextension of the lumbar spine History-Adolescents
Strenuous athletic participation LBP often without radiation Insidious onset progresses to chronic dull midline LS pain
PE Tenderness to palpation over defect
Can have step-off with spondylolisthesis ROM Stork test-key PE test for diagnosis
Dx X-rays-oblique view will show chronic defect Bone Scan vs CT Scan vs MRI
TX Rest vs Brace
spondyloLISTHESIS
912015
7
Diagnosis
HPI Heard pop in knee landing
from jump in basketball Immediate swelling
ER-x-rays neg
Knee immobilizer NSAIDs
Constant pain Any WB
Using crutches (giving out)
+swelling
-ecchymosiserythema
No prev inj
PMH PSH Meds All Soc hx ROS nc
PE Large effusion TTP medlat jt line Ext to 10flex to 90
Sig guarding laxity on ant
drawerLachmanrsquos test
Neg valgusvarus stress
Unable to do McMurrayrsquos
Antalgic gait X-ray 4 view wt
bearing (APLatTunnel Sunrise)-neg
ACL injury Primary stabilizer of knee
Prevents anterior translation of tibia on femur
Can be contact or noncontact
Increased incidence in adolescent females
Will often hear pop followed by immediate effusion
+ Lachman test Pivot Shift and Anterior Drawer Tests
Surgery based on associated injuries and patient preference
912015
8
Diagnosis
HPI Rolled ankle playing soccer
Immediate swellbruise
Unable to cont playing
Urg care-x-rays neg
Stirrup bracecrutches
Inter sharp pain lat ankle Worse walking
+ limp
+ swellbruise
NSAIDs with some relief
ho 3 ankle sprains-no tx
PMH PSH Meds All Soc hx ROS nc
PE +swelling
Ecchymosis lat ankle
TTP ATFLCFL No medial TTP
Dec ROM due to stiffnesspain
Weak IRER with pain
-ant drawer +Talar tilt -EREversion test -syndesmosis squeeze -Thompsonrsquos test
X-ray 3 view wt bearing (APOblLat) Neg
Lateral ankle sprain 80-85 of all ankle sprains Inversion + plantarflexion of ankle 3 ligaments stabilize the lateral ankle
Injured in order based on severity ATFLCFLPTFL Present with swelling ecchymosis and variable weight-
bearing tolerance Anterior Drawer Test for ATFTalar Tilt Test for CF
Ottawa ankle rules guide need for x-ray Treatment
1 rule is control swelling RICE Crutches if limping Aggressive PT to regain strength and stability Bracing can be used as an adjunct to rehab and to prevent
future injury Associated Injury Fracture to the base of the 5th Metatarsal
912015
9
Dislocation Complete dissociation of humeral head from glenoid
fossa Subluxation is a transient displacement without complete
dissociation 95 are anterior dislocations Treatment
Stabilize arm multiple relocation techniques Surgery vs Nonsurgical management 90 of young athletes will re-dislocate
Associated injuries Joint capsule Labrum tear-Bankart Lesion Humeral fracture-Hill Sachs Deformity Axillary nerve or artery
AC joint separation (separated shoulder) Multiple ligaments and mm stabilize joint
Fall on top of shoulder
Graded I-VI (I-III most common)
Evaluation
Tender over AC Joint
+ Crossover Test
Treatment
Grades I-III Ice sling for comfort PT to regain ROM
Grades IV-VI Refer for surgery
I II IV V VI
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and upper
back most likely sprainstrain
Radicular symptoms include pain numbnesstingling and weakness into shoulder and arm to the hand
+ Spurlings sign = radiculopathy
Imaging
X-ray MRI EMG
Tx
NSAIDs muscle relaxers and PT
Epidural inj
Surgery
912015
10
Fall on outstretched arm
Limited flexext and pronationsupination Tenderness over lateral elbow
Swelling may or may not be present
Often missed on initial x-ray Important to re-xray after 2-3 wks
Treatment Sling for 3-7 days
Early ROM
Surgery rarely necessary
Little leaguerrsquos elbow Spectrum of injuries to elbow
Also overuse and poor mechanics
Caused by medial stress or lateral compression
Pitch counts
Treatment is rest followed by strength exercises
Focus on correcting mechanics
Progressive throwing program
Distal radius fracture Very common-17 of all fractures in ER
Treatment based on multiple anatomical factors
Cast up to 6wks
Scaphoid fracture 70 of true wrist fractures
Risk of nonunion or AVN
Pain in anatomical snuff box
May not be seen on initial x-rays
Long arm vs short arm cast
Can take up to 4 months to heal
912015
11
Carpal Tunnel Syndrome numbting and pain in radial 3 digits (+) Tinel and Phalen tests Confirmed by EMG with NCV Treatment
Cock-up Splint NSAIDS PT Surgery gt3 mos conservative care or worsening neurological
symptoms
DeQuervainrsquos Tenosynovitis APL amp EPB-1st dorsal compartment Tenderness and swelling over radial styloid (+) Finkelsteinrsquos Test Treatment
Thumb spica splint NSAIDs PT Corticosteroid inj Surgical release of 1st dorsal compartment
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and
upper back of sprainstrain Radicular symptoms include pain
numbnesstingling and weakness into buttock and leg to the foot
+ Straight Leg Raise = radiculopathy Imaging
X-ray MRI EMG
Tx NSAIDs muscle relaxers and PT
Epidural inj
Surgery
Meniscus Traumatic or degenerative
Caused by weight-bearing + rotational forces
co knee pain delayed swelling locking and catching
Effusion and joint line tenderness on exam
+McMurray and Thessaly (ldquoTwist amp Shoutrdquo) tests
Treatment
RICE NSAIDs
Functional symptoms require surgical evaluation
912015
12
Osgood-Schlatter Disease Osteochondritis of the tibial tuberosity Most commonly seen in 13-14 yo boys 11-12 yo girls
Most common in jumping sports History
Recent growth spurt Anterior knee pain
Physical Exam Tender over prominent tibial tuberosity
Tx Ice NSAIDs StretchStrengthen
quads and hams
OK to play to pain tolerance Self-limited condition
Legg-Calve-Perthes Disease Interruption of blood supply to femoral
epiphysis Average age is 4-9 yo Present with deep hip groin or thigh pain
May radiate to knee Walk with limp dec IR of hip Dx with x-ray
MRIBone scan if early Tx-Refer to ortho
Slipped Capital Femoral Epiphysis Due to shearing forces during growth spurts Avg age 8-15 yo Early dx is key-insidious onset of
hipgrointhighknee pain Dec IR on PE X-rays-ice cream scoop slipping off cone
Refer to Ortho
L-C-P
SCFE
OA
GROIN PAIN = HIP JOINT Pain can radiate to knee or low back so make
sure to check hip
Tx with NSAIDs PT Cort inj Surgery
Trochanteric Bursitis Paintenderness over greater trochanter
Worse with hip flexext
Multiple underlying factors
Tx with PT NSAIDs rest cort inj
912015
13
Patella femoral pain syndrome Abnormal tracking of patella in groove between condyles
of femur
Chronic in nature
co anterior knee pain Theater sign
Pain going down stairs
Increased Q angle on PE
Treatment Strength balance and flexibility
exercises
Foot orthotics
Bracingtaping in season
Surgery-rare
Medial Ankle Sprain Dorsiflexion + eversion of foot Injury to deltoid ligament
Fracture of tibia more common than ligament tear
Can extend proximally to cause fibular fracture
Similar presentation as a lateral ankle sprain X-rays required to assess joint stability Treatment
Same as lateral ankle sprain unless extension into syndesmosis or distal fibula Surgery if joint is unstable
Longer healing time than lateral ankle sprains
Plantar Fasciitis Irritation of the calcaneal attachment of the plantar
fascia
Not caused by heel spur
Insidious onset of pain radiating into arch
Painful 1st steps in AM
Tenderness of anterior-medial calcaneus
Often tight achilles tendon
Treatment
NSAIDs rest PT w massage orthotics night splints
Surgical release is last resort
912015
14
Sever Disease Apophysitis of posterior calcaneus
Epiphysis fuses at 12-15 yo
History
Insidious onset of heal pain
Boys 10-12 yo Girls 8-10 yo
Physical Exam
Tenderness over insertion of achilles tendon
Decrease passive ankle dorsiflexion
Treatment
Ice NSAIDs heel lifts stretchstrengthen heel cords
1 McKeag MD Douglas and James Moeller MD ACSMrsquos Primary Care Sports Medicine 2nd
Edition Philadelphia Lippincott Williams amp Wilkins 2007
2 Eiff MD M Patrice Robert Hatch MD and Walter Calmbach MD Fracture Management for Primary Care Philadelphia Saunders Elsevier 2003
3 DeLee MD Jesse David Drez Jr MD Mark Miller MD Orthopedic Sports Medicine Philadelphia Saunders Elsevier 2010
4 Magee PhD David Ortohpedic Physical Assessment 4th Edition Philadelphia Saunders Elsevier 2002
Shoulder Anatomy Greyrsquos -httpcommonswikimediaorgwikiFileShoulder_joint_anatomy_quizjpg
Forearm Extensors Greyrsquos -httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtSuperficialGrayBB418gif
Forearm Flexors Greyrsquos -
httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtDeepGrayBB415gif
Offensive Line US Navy Football -httpscommonswikimediaorgwikiFileUS_Navy_071201-N-6463B-447_Navy_Quarter_Back_Kaipo-Noa_Haheaku-Enhada_(10)_drops_back_to_pass_while_receiving_maximum_protection_from_his_offensive_line_at_the_108th_annual_Army_vs_Navy_football_game_at_M5ET_Bank_Stadium_in_Baljpg
Gymnast ndash httppixabaycomengymnastics-gymnast-sports-graceful-89608
Figure Skater - httpfreetemsnetfiledance-on-ice-460
Volleyball Court Serve - httpwwwnationmastercomencyclopediaVolleyball
Volleyball Spike US Airforce -
httpd1staticdvidshubnetmediathumbsphotos1305933304450x300_q75jpgis
Tennis Serve - httpcommonswikimediaorgwikiFileMarat_safin_1jpg
Ankle Anatomy Greyrsquos -httpwwwfpnotebookcom_mediaorthoLegFootLateralLigamentsGrayBB355gif
912015
15
AC Separation Grade I -httpcommonswikimediaorgwikiFileClassification_type_1_of_AC_separationpng
AC Separation Grade II -httpcommonswikimediaorgwikiFileClassification_type_2_of_AC_separationpng
AC Separation Grade IV -
httpcommonswikimediaorgwikiFileClassification_type_4_of_AC_separationpng
AC Separation Grade V -httpcommonswikimediaorgwikiFileClassification_type_5_of_AC_separationpng
AC Separation Grade VI -httpcommonswikimediaorgwikiFileClassification_type_6_of_AC_separationpng
Little League elbow - httpwwwpublicdomainpicturesnetview-imagephpimage=2144amppicture=throw-boy
Osgood-Schllater MRI - httpuploadwikimediaorgwikipediacommons999MBq_Osgood-Schlatterjpg
Osgood-Schlatter XR - httpuploadwikimediaorgwikipediacommonsdd9Osgood_Schlater_1JPG
Legg-Calve-Perthes - httpcommonswikimediaorgwikiFileLeggCalvePerthes1jpg
SCFE - httpuploadwikimediaorgwikipediacommons448SCFE_FROG_B26Wjpg
Knee Sunrise X-ray - httpscommonswikimediaorgwikiFileMedical_X-Ray_imaging_CFK03_nevitjpg
Severrsquos Disease - httpcommonswikimediaorgwikiFileMedical_X-Ray_imaging_TKL07_nevitjpg
Shoulder Forearms Ankle Greyrsquos Anatomy - This faithful reproduction of a lithograph plate from Grays Anatomy a two-
dimensional work of art is not copyrightable in the US as per Bridgeman Art Library v Corel Corp the same is also true in many other countries including Germany Unless stated otherwise it is from the 20th US edition of Grays Anatomy of the Human Body originally published in 1918 and therefore lapsed into the public domain Other copies of Grays Anatomy can be found on Bartleby and also on Yahoo
This image is in the public domain because its copyright has expired This applies worldwide
Offensive Line ndash US Navy Football - This file is a work of a sailor or employee of the US Navy taken or made as part of that persons
official duties As a work of the US federal government the image is in the public domain
Gymnast - The person who associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the
work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial purposes all without asking permission
Figure Skater - License Public Domain CC0 (absolutely free) File type jpg | file size 1478 kB Add date 2012-08-27 212949
Volleyball Court Serve - This file is licensed under the Creative Commons Attribution ShareAlike license versions 25 20 and10
US Air Force Volleyball Spike - This work 2013 United States Armed Forces Volleyball Championship [Image 11 of 28] by A1C Justyn
Freeman identified by DVIDS is free of known copyright restrictions under US copyright law
Tennis Serve - The copyright holder of this work released this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [they] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
AC Separation Grading - This file is made available under the Creative Commons CC0 10 Universal Public Domain DedicationThe person who
associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial
purposes all without asking permission
Little League Elbow - Royalty free stock photos All pictures are free for commercial and personal use
Osgood-Schlatter MR ampXray - The copyright holder of this work release this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [They] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
Legg-Calve-Perthes - This file is licensed under the Creative Commons Attribution 30 Unported license
SCFE - This work has been released into the public domain by its author Mikir at the wikipedia project This applies worldwide
Knee Sunrise X-ray - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the
terms of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
Severrsquos Disease - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the terms
of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
912015
1
Paul D Giles DO MS Primary Care Sports Medicine
Johns Hopkins Community Physicians Bowie MD
2013 Team USA Deaf Olympics ndash Team Physician
To review high volume musculoskeletal injuries seen by family physicians
To review the proper diagnostic tests including physical exam and radiologic test as well as treatment of these injuries
To discuss information found within question stems and assign meaning found therein
912015
2
Diagnosis
HPI No injury
Intermittent sharp pain lat and ant shoulder
Overhead
Sleeping on side
Work (carpenter)
No numbting
OTC NSAIDs without relief
No ho prior injury
PMH PSH Meds All Soc hx ROS nc
PE Active ROM 180180
Pain in all planes
IR L shoulder to T6
Pain with resisted ER
+Empty Can Impingement signs
Neg Crossover OrsquoBriens Speedrsquos
+TTP ant shoulder
Rad-4 view x-ray Normal
Rotator Cuff TendonosisImpingement Syn Can be from chronic microtrauma or acute
macrotrauma co pain weakness and loss of motion
Difficulty reaching behind and overhead
Painful laying on affected side
Physical Exam + Empty can test Hawkinrsquos test Neerrsquos Test
+Speedrsquos Test=Biceps Tendonosis
+OrsquoBriens Test=SLAP Lesion
Treatment Rest NSAIDs PT Corticosteroid inj
Surgery for complete tears
Rotator
Cuff
Interval
912015
3
Diagnosis
HPI Started after raking leaves
in fall
Constant lat forearmelbow ache
Grippinglifting
Computer
No swellingnumbting
Ibuprofen with some relief
No ho sig injury
PMH PSH Meds All Soc hx ROS nc
PE No effusionecchymosis
erythema TTP lat epicondyle Full painless PROM at
elbow flexextprosup 55 mm strength
Pain with elbow ext forearm pro wrist ext grip
Neg valgusvarus stress Neg Tinels ulnar groove
X-ray 3 view elbow Neg
Lateral Epicondylitis (Tennis Elbow) Overload of tendon-bone junction Present with pain and tenderness over lateral
epicondyle Physical exam
Tender over lateral epicondyle
Pain with resisted wrist extension and extension of middle finger
Treatment PT bracing (wrist or counterforce) NSAIDs cort inj
Medial Epicondylitis (Golferrsquos Elbow) Pain with resisted wrist flexion
912015
4
Extensors
Flexors
Lateral Epicondyle
Medial Epicondyle
Diagnosis
HPI Fell Backward during
Basket Ball Game
Landed on pronated wrist with locked elbow
Treatments Tried
Rest
Ice
Aggravating Factors Weight Bearing
Wrist Extension
PMH PSH Meds All Soc hx ROS nc
PE No Ecchymosis
Full AROM with pain
Minimal swelling
TTP over Radial Wrist
ldquoAnatomical Snuff Boxrdquo
Special Tests
Neg Tinelrsquos
Neg Finkelsteinrsquos
Neg Phalenrsquos
X-ray Wrist (APLatObl) Neg
912015
5
Wrist
Scaphoid fracture 70 of true wrist fractures
Risk of nonunion or AVN
Pain in anatomical snuff box
May not be seen on initial x-rays
Long arm vs short arm cast
Can take up to 4 months to heal
Diagnosis
HPI No injury
Offensive lineman football
Intermittent ache middle of low back
Wt lifting
Playing football
Running
No numbting
Chiropractor x6 moswithout relief
No meds
No prev inj
PMH PSH Meds All Soc hx ROS nc
PE TTP bl paraspinals L4-5
Pain with ext
+Stork bl
55 mm strength bl LE
Sensation intact
DTRs 2+4
Neg straight leg raise
Normal gait
X-ray 4 view (APLatObl) Neg
912015
6
Spondylolysis-defect in pars interarticularis Caused by repeated hyperextension of the lumbar spine History-Adolescents
Strenuous athletic participation LBP often without radiation Insidious onset progresses to chronic dull midline LS pain
PE Tenderness to palpation over defect
Can have step-off with spondylolisthesis ROM Stork test-key PE test for diagnosis
Dx X-rays-oblique view will show chronic defect Bone Scan vs CT Scan vs MRI
TX Rest vs Brace
spondyloLISTHESIS
912015
7
Diagnosis
HPI Heard pop in knee landing
from jump in basketball Immediate swelling
ER-x-rays neg
Knee immobilizer NSAIDs
Constant pain Any WB
Using crutches (giving out)
+swelling
-ecchymosiserythema
No prev inj
PMH PSH Meds All Soc hx ROS nc
PE Large effusion TTP medlat jt line Ext to 10flex to 90
Sig guarding laxity on ant
drawerLachmanrsquos test
Neg valgusvarus stress
Unable to do McMurrayrsquos
Antalgic gait X-ray 4 view wt
bearing (APLatTunnel Sunrise)-neg
ACL injury Primary stabilizer of knee
Prevents anterior translation of tibia on femur
Can be contact or noncontact
Increased incidence in adolescent females
Will often hear pop followed by immediate effusion
+ Lachman test Pivot Shift and Anterior Drawer Tests
Surgery based on associated injuries and patient preference
912015
8
Diagnosis
HPI Rolled ankle playing soccer
Immediate swellbruise
Unable to cont playing
Urg care-x-rays neg
Stirrup bracecrutches
Inter sharp pain lat ankle Worse walking
+ limp
+ swellbruise
NSAIDs with some relief
ho 3 ankle sprains-no tx
PMH PSH Meds All Soc hx ROS nc
PE +swelling
Ecchymosis lat ankle
TTP ATFLCFL No medial TTP
Dec ROM due to stiffnesspain
Weak IRER with pain
-ant drawer +Talar tilt -EREversion test -syndesmosis squeeze -Thompsonrsquos test
X-ray 3 view wt bearing (APOblLat) Neg
Lateral ankle sprain 80-85 of all ankle sprains Inversion + plantarflexion of ankle 3 ligaments stabilize the lateral ankle
Injured in order based on severity ATFLCFLPTFL Present with swelling ecchymosis and variable weight-
bearing tolerance Anterior Drawer Test for ATFTalar Tilt Test for CF
Ottawa ankle rules guide need for x-ray Treatment
1 rule is control swelling RICE Crutches if limping Aggressive PT to regain strength and stability Bracing can be used as an adjunct to rehab and to prevent
future injury Associated Injury Fracture to the base of the 5th Metatarsal
912015
9
Dislocation Complete dissociation of humeral head from glenoid
fossa Subluxation is a transient displacement without complete
dissociation 95 are anterior dislocations Treatment
Stabilize arm multiple relocation techniques Surgery vs Nonsurgical management 90 of young athletes will re-dislocate
Associated injuries Joint capsule Labrum tear-Bankart Lesion Humeral fracture-Hill Sachs Deformity Axillary nerve or artery
AC joint separation (separated shoulder) Multiple ligaments and mm stabilize joint
Fall on top of shoulder
Graded I-VI (I-III most common)
Evaluation
Tender over AC Joint
+ Crossover Test
Treatment
Grades I-III Ice sling for comfort PT to regain ROM
Grades IV-VI Refer for surgery
I II IV V VI
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and upper
back most likely sprainstrain
Radicular symptoms include pain numbnesstingling and weakness into shoulder and arm to the hand
+ Spurlings sign = radiculopathy
Imaging
X-ray MRI EMG
Tx
NSAIDs muscle relaxers and PT
Epidural inj
Surgery
912015
10
Fall on outstretched arm
Limited flexext and pronationsupination Tenderness over lateral elbow
Swelling may or may not be present
Often missed on initial x-ray Important to re-xray after 2-3 wks
Treatment Sling for 3-7 days
Early ROM
Surgery rarely necessary
Little leaguerrsquos elbow Spectrum of injuries to elbow
Also overuse and poor mechanics
Caused by medial stress or lateral compression
Pitch counts
Treatment is rest followed by strength exercises
Focus on correcting mechanics
Progressive throwing program
Distal radius fracture Very common-17 of all fractures in ER
Treatment based on multiple anatomical factors
Cast up to 6wks
Scaphoid fracture 70 of true wrist fractures
Risk of nonunion or AVN
Pain in anatomical snuff box
May not be seen on initial x-rays
Long arm vs short arm cast
Can take up to 4 months to heal
912015
11
Carpal Tunnel Syndrome numbting and pain in radial 3 digits (+) Tinel and Phalen tests Confirmed by EMG with NCV Treatment
Cock-up Splint NSAIDS PT Surgery gt3 mos conservative care or worsening neurological
symptoms
DeQuervainrsquos Tenosynovitis APL amp EPB-1st dorsal compartment Tenderness and swelling over radial styloid (+) Finkelsteinrsquos Test Treatment
Thumb spica splint NSAIDs PT Corticosteroid inj Surgical release of 1st dorsal compartment
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and
upper back of sprainstrain Radicular symptoms include pain
numbnesstingling and weakness into buttock and leg to the foot
+ Straight Leg Raise = radiculopathy Imaging
X-ray MRI EMG
Tx NSAIDs muscle relaxers and PT
Epidural inj
Surgery
Meniscus Traumatic or degenerative
Caused by weight-bearing + rotational forces
co knee pain delayed swelling locking and catching
Effusion and joint line tenderness on exam
+McMurray and Thessaly (ldquoTwist amp Shoutrdquo) tests
Treatment
RICE NSAIDs
Functional symptoms require surgical evaluation
912015
12
Osgood-Schlatter Disease Osteochondritis of the tibial tuberosity Most commonly seen in 13-14 yo boys 11-12 yo girls
Most common in jumping sports History
Recent growth spurt Anterior knee pain
Physical Exam Tender over prominent tibial tuberosity
Tx Ice NSAIDs StretchStrengthen
quads and hams
OK to play to pain tolerance Self-limited condition
Legg-Calve-Perthes Disease Interruption of blood supply to femoral
epiphysis Average age is 4-9 yo Present with deep hip groin or thigh pain
May radiate to knee Walk with limp dec IR of hip Dx with x-ray
MRIBone scan if early Tx-Refer to ortho
Slipped Capital Femoral Epiphysis Due to shearing forces during growth spurts Avg age 8-15 yo Early dx is key-insidious onset of
hipgrointhighknee pain Dec IR on PE X-rays-ice cream scoop slipping off cone
Refer to Ortho
L-C-P
SCFE
OA
GROIN PAIN = HIP JOINT Pain can radiate to knee or low back so make
sure to check hip
Tx with NSAIDs PT Cort inj Surgery
Trochanteric Bursitis Paintenderness over greater trochanter
Worse with hip flexext
Multiple underlying factors
Tx with PT NSAIDs rest cort inj
912015
13
Patella femoral pain syndrome Abnormal tracking of patella in groove between condyles
of femur
Chronic in nature
co anterior knee pain Theater sign
Pain going down stairs
Increased Q angle on PE
Treatment Strength balance and flexibility
exercises
Foot orthotics
Bracingtaping in season
Surgery-rare
Medial Ankle Sprain Dorsiflexion + eversion of foot Injury to deltoid ligament
Fracture of tibia more common than ligament tear
Can extend proximally to cause fibular fracture
Similar presentation as a lateral ankle sprain X-rays required to assess joint stability Treatment
Same as lateral ankle sprain unless extension into syndesmosis or distal fibula Surgery if joint is unstable
Longer healing time than lateral ankle sprains
Plantar Fasciitis Irritation of the calcaneal attachment of the plantar
fascia
Not caused by heel spur
Insidious onset of pain radiating into arch
Painful 1st steps in AM
Tenderness of anterior-medial calcaneus
Often tight achilles tendon
Treatment
NSAIDs rest PT w massage orthotics night splints
Surgical release is last resort
912015
14
Sever Disease Apophysitis of posterior calcaneus
Epiphysis fuses at 12-15 yo
History
Insidious onset of heal pain
Boys 10-12 yo Girls 8-10 yo
Physical Exam
Tenderness over insertion of achilles tendon
Decrease passive ankle dorsiflexion
Treatment
Ice NSAIDs heel lifts stretchstrengthen heel cords
1 McKeag MD Douglas and James Moeller MD ACSMrsquos Primary Care Sports Medicine 2nd
Edition Philadelphia Lippincott Williams amp Wilkins 2007
2 Eiff MD M Patrice Robert Hatch MD and Walter Calmbach MD Fracture Management for Primary Care Philadelphia Saunders Elsevier 2003
3 DeLee MD Jesse David Drez Jr MD Mark Miller MD Orthopedic Sports Medicine Philadelphia Saunders Elsevier 2010
4 Magee PhD David Ortohpedic Physical Assessment 4th Edition Philadelphia Saunders Elsevier 2002
Shoulder Anatomy Greyrsquos -httpcommonswikimediaorgwikiFileShoulder_joint_anatomy_quizjpg
Forearm Extensors Greyrsquos -httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtSuperficialGrayBB418gif
Forearm Flexors Greyrsquos -
httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtDeepGrayBB415gif
Offensive Line US Navy Football -httpscommonswikimediaorgwikiFileUS_Navy_071201-N-6463B-447_Navy_Quarter_Back_Kaipo-Noa_Haheaku-Enhada_(10)_drops_back_to_pass_while_receiving_maximum_protection_from_his_offensive_line_at_the_108th_annual_Army_vs_Navy_football_game_at_M5ET_Bank_Stadium_in_Baljpg
Gymnast ndash httppixabaycomengymnastics-gymnast-sports-graceful-89608
Figure Skater - httpfreetemsnetfiledance-on-ice-460
Volleyball Court Serve - httpwwwnationmastercomencyclopediaVolleyball
Volleyball Spike US Airforce -
httpd1staticdvidshubnetmediathumbsphotos1305933304450x300_q75jpgis
Tennis Serve - httpcommonswikimediaorgwikiFileMarat_safin_1jpg
Ankle Anatomy Greyrsquos -httpwwwfpnotebookcom_mediaorthoLegFootLateralLigamentsGrayBB355gif
912015
15
AC Separation Grade I -httpcommonswikimediaorgwikiFileClassification_type_1_of_AC_separationpng
AC Separation Grade II -httpcommonswikimediaorgwikiFileClassification_type_2_of_AC_separationpng
AC Separation Grade IV -
httpcommonswikimediaorgwikiFileClassification_type_4_of_AC_separationpng
AC Separation Grade V -httpcommonswikimediaorgwikiFileClassification_type_5_of_AC_separationpng
AC Separation Grade VI -httpcommonswikimediaorgwikiFileClassification_type_6_of_AC_separationpng
Little League elbow - httpwwwpublicdomainpicturesnetview-imagephpimage=2144amppicture=throw-boy
Osgood-Schllater MRI - httpuploadwikimediaorgwikipediacommons999MBq_Osgood-Schlatterjpg
Osgood-Schlatter XR - httpuploadwikimediaorgwikipediacommonsdd9Osgood_Schlater_1JPG
Legg-Calve-Perthes - httpcommonswikimediaorgwikiFileLeggCalvePerthes1jpg
SCFE - httpuploadwikimediaorgwikipediacommons448SCFE_FROG_B26Wjpg
Knee Sunrise X-ray - httpscommonswikimediaorgwikiFileMedical_X-Ray_imaging_CFK03_nevitjpg
Severrsquos Disease - httpcommonswikimediaorgwikiFileMedical_X-Ray_imaging_TKL07_nevitjpg
Shoulder Forearms Ankle Greyrsquos Anatomy - This faithful reproduction of a lithograph plate from Grays Anatomy a two-
dimensional work of art is not copyrightable in the US as per Bridgeman Art Library v Corel Corp the same is also true in many other countries including Germany Unless stated otherwise it is from the 20th US edition of Grays Anatomy of the Human Body originally published in 1918 and therefore lapsed into the public domain Other copies of Grays Anatomy can be found on Bartleby and also on Yahoo
This image is in the public domain because its copyright has expired This applies worldwide
Offensive Line ndash US Navy Football - This file is a work of a sailor or employee of the US Navy taken or made as part of that persons
official duties As a work of the US federal government the image is in the public domain
Gymnast - The person who associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the
work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial purposes all without asking permission
Figure Skater - License Public Domain CC0 (absolutely free) File type jpg | file size 1478 kB Add date 2012-08-27 212949
Volleyball Court Serve - This file is licensed under the Creative Commons Attribution ShareAlike license versions 25 20 and10
US Air Force Volleyball Spike - This work 2013 United States Armed Forces Volleyball Championship [Image 11 of 28] by A1C Justyn
Freeman identified by DVIDS is free of known copyright restrictions under US copyright law
Tennis Serve - The copyright holder of this work released this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [they] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
AC Separation Grading - This file is made available under the Creative Commons CC0 10 Universal Public Domain DedicationThe person who
associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial
purposes all without asking permission
Little League Elbow - Royalty free stock photos All pictures are free for commercial and personal use
Osgood-Schlatter MR ampXray - The copyright holder of this work release this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [They] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
Legg-Calve-Perthes - This file is licensed under the Creative Commons Attribution 30 Unported license
SCFE - This work has been released into the public domain by its author Mikir at the wikipedia project This applies worldwide
Knee Sunrise X-ray - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the
terms of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
Severrsquos Disease - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the terms
of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
912015
2
Diagnosis
HPI No injury
Intermittent sharp pain lat and ant shoulder
Overhead
Sleeping on side
Work (carpenter)
No numbting
OTC NSAIDs without relief
No ho prior injury
PMH PSH Meds All Soc hx ROS nc
PE Active ROM 180180
Pain in all planes
IR L shoulder to T6
Pain with resisted ER
+Empty Can Impingement signs
Neg Crossover OrsquoBriens Speedrsquos
+TTP ant shoulder
Rad-4 view x-ray Normal
Rotator Cuff TendonosisImpingement Syn Can be from chronic microtrauma or acute
macrotrauma co pain weakness and loss of motion
Difficulty reaching behind and overhead
Painful laying on affected side
Physical Exam + Empty can test Hawkinrsquos test Neerrsquos Test
+Speedrsquos Test=Biceps Tendonosis
+OrsquoBriens Test=SLAP Lesion
Treatment Rest NSAIDs PT Corticosteroid inj
Surgery for complete tears
Rotator
Cuff
Interval
912015
3
Diagnosis
HPI Started after raking leaves
in fall
Constant lat forearmelbow ache
Grippinglifting
Computer
No swellingnumbting
Ibuprofen with some relief
No ho sig injury
PMH PSH Meds All Soc hx ROS nc
PE No effusionecchymosis
erythema TTP lat epicondyle Full painless PROM at
elbow flexextprosup 55 mm strength
Pain with elbow ext forearm pro wrist ext grip
Neg valgusvarus stress Neg Tinels ulnar groove
X-ray 3 view elbow Neg
Lateral Epicondylitis (Tennis Elbow) Overload of tendon-bone junction Present with pain and tenderness over lateral
epicondyle Physical exam
Tender over lateral epicondyle
Pain with resisted wrist extension and extension of middle finger
Treatment PT bracing (wrist or counterforce) NSAIDs cort inj
Medial Epicondylitis (Golferrsquos Elbow) Pain with resisted wrist flexion
912015
4
Extensors
Flexors
Lateral Epicondyle
Medial Epicondyle
Diagnosis
HPI Fell Backward during
Basket Ball Game
Landed on pronated wrist with locked elbow
Treatments Tried
Rest
Ice
Aggravating Factors Weight Bearing
Wrist Extension
PMH PSH Meds All Soc hx ROS nc
PE No Ecchymosis
Full AROM with pain
Minimal swelling
TTP over Radial Wrist
ldquoAnatomical Snuff Boxrdquo
Special Tests
Neg Tinelrsquos
Neg Finkelsteinrsquos
Neg Phalenrsquos
X-ray Wrist (APLatObl) Neg
912015
5
Wrist
Scaphoid fracture 70 of true wrist fractures
Risk of nonunion or AVN
Pain in anatomical snuff box
May not be seen on initial x-rays
Long arm vs short arm cast
Can take up to 4 months to heal
Diagnosis
HPI No injury
Offensive lineman football
Intermittent ache middle of low back
Wt lifting
Playing football
Running
No numbting
Chiropractor x6 moswithout relief
No meds
No prev inj
PMH PSH Meds All Soc hx ROS nc
PE TTP bl paraspinals L4-5
Pain with ext
+Stork bl
55 mm strength bl LE
Sensation intact
DTRs 2+4
Neg straight leg raise
Normal gait
X-ray 4 view (APLatObl) Neg
912015
6
Spondylolysis-defect in pars interarticularis Caused by repeated hyperextension of the lumbar spine History-Adolescents
Strenuous athletic participation LBP often without radiation Insidious onset progresses to chronic dull midline LS pain
PE Tenderness to palpation over defect
Can have step-off with spondylolisthesis ROM Stork test-key PE test for diagnosis
Dx X-rays-oblique view will show chronic defect Bone Scan vs CT Scan vs MRI
TX Rest vs Brace
spondyloLISTHESIS
912015
7
Diagnosis
HPI Heard pop in knee landing
from jump in basketball Immediate swelling
ER-x-rays neg
Knee immobilizer NSAIDs
Constant pain Any WB
Using crutches (giving out)
+swelling
-ecchymosiserythema
No prev inj
PMH PSH Meds All Soc hx ROS nc
PE Large effusion TTP medlat jt line Ext to 10flex to 90
Sig guarding laxity on ant
drawerLachmanrsquos test
Neg valgusvarus stress
Unable to do McMurrayrsquos
Antalgic gait X-ray 4 view wt
bearing (APLatTunnel Sunrise)-neg
ACL injury Primary stabilizer of knee
Prevents anterior translation of tibia on femur
Can be contact or noncontact
Increased incidence in adolescent females
Will often hear pop followed by immediate effusion
+ Lachman test Pivot Shift and Anterior Drawer Tests
Surgery based on associated injuries and patient preference
912015
8
Diagnosis
HPI Rolled ankle playing soccer
Immediate swellbruise
Unable to cont playing
Urg care-x-rays neg
Stirrup bracecrutches
Inter sharp pain lat ankle Worse walking
+ limp
+ swellbruise
NSAIDs with some relief
ho 3 ankle sprains-no tx
PMH PSH Meds All Soc hx ROS nc
PE +swelling
Ecchymosis lat ankle
TTP ATFLCFL No medial TTP
Dec ROM due to stiffnesspain
Weak IRER with pain
-ant drawer +Talar tilt -EREversion test -syndesmosis squeeze -Thompsonrsquos test
X-ray 3 view wt bearing (APOblLat) Neg
Lateral ankle sprain 80-85 of all ankle sprains Inversion + plantarflexion of ankle 3 ligaments stabilize the lateral ankle
Injured in order based on severity ATFLCFLPTFL Present with swelling ecchymosis and variable weight-
bearing tolerance Anterior Drawer Test for ATFTalar Tilt Test for CF
Ottawa ankle rules guide need for x-ray Treatment
1 rule is control swelling RICE Crutches if limping Aggressive PT to regain strength and stability Bracing can be used as an adjunct to rehab and to prevent
future injury Associated Injury Fracture to the base of the 5th Metatarsal
912015
9
Dislocation Complete dissociation of humeral head from glenoid
fossa Subluxation is a transient displacement without complete
dissociation 95 are anterior dislocations Treatment
Stabilize arm multiple relocation techniques Surgery vs Nonsurgical management 90 of young athletes will re-dislocate
Associated injuries Joint capsule Labrum tear-Bankart Lesion Humeral fracture-Hill Sachs Deformity Axillary nerve or artery
AC joint separation (separated shoulder) Multiple ligaments and mm stabilize joint
Fall on top of shoulder
Graded I-VI (I-III most common)
Evaluation
Tender over AC Joint
+ Crossover Test
Treatment
Grades I-III Ice sling for comfort PT to regain ROM
Grades IV-VI Refer for surgery
I II IV V VI
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and upper
back most likely sprainstrain
Radicular symptoms include pain numbnesstingling and weakness into shoulder and arm to the hand
+ Spurlings sign = radiculopathy
Imaging
X-ray MRI EMG
Tx
NSAIDs muscle relaxers and PT
Epidural inj
Surgery
912015
10
Fall on outstretched arm
Limited flexext and pronationsupination Tenderness over lateral elbow
Swelling may or may not be present
Often missed on initial x-ray Important to re-xray after 2-3 wks
Treatment Sling for 3-7 days
Early ROM
Surgery rarely necessary
Little leaguerrsquos elbow Spectrum of injuries to elbow
Also overuse and poor mechanics
Caused by medial stress or lateral compression
Pitch counts
Treatment is rest followed by strength exercises
Focus on correcting mechanics
Progressive throwing program
Distal radius fracture Very common-17 of all fractures in ER
Treatment based on multiple anatomical factors
Cast up to 6wks
Scaphoid fracture 70 of true wrist fractures
Risk of nonunion or AVN
Pain in anatomical snuff box
May not be seen on initial x-rays
Long arm vs short arm cast
Can take up to 4 months to heal
912015
11
Carpal Tunnel Syndrome numbting and pain in radial 3 digits (+) Tinel and Phalen tests Confirmed by EMG with NCV Treatment
Cock-up Splint NSAIDS PT Surgery gt3 mos conservative care or worsening neurological
symptoms
DeQuervainrsquos Tenosynovitis APL amp EPB-1st dorsal compartment Tenderness and swelling over radial styloid (+) Finkelsteinrsquos Test Treatment
Thumb spica splint NSAIDs PT Corticosteroid inj Surgical release of 1st dorsal compartment
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and
upper back of sprainstrain Radicular symptoms include pain
numbnesstingling and weakness into buttock and leg to the foot
+ Straight Leg Raise = radiculopathy Imaging
X-ray MRI EMG
Tx NSAIDs muscle relaxers and PT
Epidural inj
Surgery
Meniscus Traumatic or degenerative
Caused by weight-bearing + rotational forces
co knee pain delayed swelling locking and catching
Effusion and joint line tenderness on exam
+McMurray and Thessaly (ldquoTwist amp Shoutrdquo) tests
Treatment
RICE NSAIDs
Functional symptoms require surgical evaluation
912015
12
Osgood-Schlatter Disease Osteochondritis of the tibial tuberosity Most commonly seen in 13-14 yo boys 11-12 yo girls
Most common in jumping sports History
Recent growth spurt Anterior knee pain
Physical Exam Tender over prominent tibial tuberosity
Tx Ice NSAIDs StretchStrengthen
quads and hams
OK to play to pain tolerance Self-limited condition
Legg-Calve-Perthes Disease Interruption of blood supply to femoral
epiphysis Average age is 4-9 yo Present with deep hip groin or thigh pain
May radiate to knee Walk with limp dec IR of hip Dx with x-ray
MRIBone scan if early Tx-Refer to ortho
Slipped Capital Femoral Epiphysis Due to shearing forces during growth spurts Avg age 8-15 yo Early dx is key-insidious onset of
hipgrointhighknee pain Dec IR on PE X-rays-ice cream scoop slipping off cone
Refer to Ortho
L-C-P
SCFE
OA
GROIN PAIN = HIP JOINT Pain can radiate to knee or low back so make
sure to check hip
Tx with NSAIDs PT Cort inj Surgery
Trochanteric Bursitis Paintenderness over greater trochanter
Worse with hip flexext
Multiple underlying factors
Tx with PT NSAIDs rest cort inj
912015
13
Patella femoral pain syndrome Abnormal tracking of patella in groove between condyles
of femur
Chronic in nature
co anterior knee pain Theater sign
Pain going down stairs
Increased Q angle on PE
Treatment Strength balance and flexibility
exercises
Foot orthotics
Bracingtaping in season
Surgery-rare
Medial Ankle Sprain Dorsiflexion + eversion of foot Injury to deltoid ligament
Fracture of tibia more common than ligament tear
Can extend proximally to cause fibular fracture
Similar presentation as a lateral ankle sprain X-rays required to assess joint stability Treatment
Same as lateral ankle sprain unless extension into syndesmosis or distal fibula Surgery if joint is unstable
Longer healing time than lateral ankle sprains
Plantar Fasciitis Irritation of the calcaneal attachment of the plantar
fascia
Not caused by heel spur
Insidious onset of pain radiating into arch
Painful 1st steps in AM
Tenderness of anterior-medial calcaneus
Often tight achilles tendon
Treatment
NSAIDs rest PT w massage orthotics night splints
Surgical release is last resort
912015
14
Sever Disease Apophysitis of posterior calcaneus
Epiphysis fuses at 12-15 yo
History
Insidious onset of heal pain
Boys 10-12 yo Girls 8-10 yo
Physical Exam
Tenderness over insertion of achilles tendon
Decrease passive ankle dorsiflexion
Treatment
Ice NSAIDs heel lifts stretchstrengthen heel cords
1 McKeag MD Douglas and James Moeller MD ACSMrsquos Primary Care Sports Medicine 2nd
Edition Philadelphia Lippincott Williams amp Wilkins 2007
2 Eiff MD M Patrice Robert Hatch MD and Walter Calmbach MD Fracture Management for Primary Care Philadelphia Saunders Elsevier 2003
3 DeLee MD Jesse David Drez Jr MD Mark Miller MD Orthopedic Sports Medicine Philadelphia Saunders Elsevier 2010
4 Magee PhD David Ortohpedic Physical Assessment 4th Edition Philadelphia Saunders Elsevier 2002
Shoulder Anatomy Greyrsquos -httpcommonswikimediaorgwikiFileShoulder_joint_anatomy_quizjpg
Forearm Extensors Greyrsquos -httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtSuperficialGrayBB418gif
Forearm Flexors Greyrsquos -
httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtDeepGrayBB415gif
Offensive Line US Navy Football -httpscommonswikimediaorgwikiFileUS_Navy_071201-N-6463B-447_Navy_Quarter_Back_Kaipo-Noa_Haheaku-Enhada_(10)_drops_back_to_pass_while_receiving_maximum_protection_from_his_offensive_line_at_the_108th_annual_Army_vs_Navy_football_game_at_M5ET_Bank_Stadium_in_Baljpg
Gymnast ndash httppixabaycomengymnastics-gymnast-sports-graceful-89608
Figure Skater - httpfreetemsnetfiledance-on-ice-460
Volleyball Court Serve - httpwwwnationmastercomencyclopediaVolleyball
Volleyball Spike US Airforce -
httpd1staticdvidshubnetmediathumbsphotos1305933304450x300_q75jpgis
Tennis Serve - httpcommonswikimediaorgwikiFileMarat_safin_1jpg
Ankle Anatomy Greyrsquos -httpwwwfpnotebookcom_mediaorthoLegFootLateralLigamentsGrayBB355gif
912015
15
AC Separation Grade I -httpcommonswikimediaorgwikiFileClassification_type_1_of_AC_separationpng
AC Separation Grade II -httpcommonswikimediaorgwikiFileClassification_type_2_of_AC_separationpng
AC Separation Grade IV -
httpcommonswikimediaorgwikiFileClassification_type_4_of_AC_separationpng
AC Separation Grade V -httpcommonswikimediaorgwikiFileClassification_type_5_of_AC_separationpng
AC Separation Grade VI -httpcommonswikimediaorgwikiFileClassification_type_6_of_AC_separationpng
Little League elbow - httpwwwpublicdomainpicturesnetview-imagephpimage=2144amppicture=throw-boy
Osgood-Schllater MRI - httpuploadwikimediaorgwikipediacommons999MBq_Osgood-Schlatterjpg
Osgood-Schlatter XR - httpuploadwikimediaorgwikipediacommonsdd9Osgood_Schlater_1JPG
Legg-Calve-Perthes - httpcommonswikimediaorgwikiFileLeggCalvePerthes1jpg
SCFE - httpuploadwikimediaorgwikipediacommons448SCFE_FROG_B26Wjpg
Knee Sunrise X-ray - httpscommonswikimediaorgwikiFileMedical_X-Ray_imaging_CFK03_nevitjpg
Severrsquos Disease - httpcommonswikimediaorgwikiFileMedical_X-Ray_imaging_TKL07_nevitjpg
Shoulder Forearms Ankle Greyrsquos Anatomy - This faithful reproduction of a lithograph plate from Grays Anatomy a two-
dimensional work of art is not copyrightable in the US as per Bridgeman Art Library v Corel Corp the same is also true in many other countries including Germany Unless stated otherwise it is from the 20th US edition of Grays Anatomy of the Human Body originally published in 1918 and therefore lapsed into the public domain Other copies of Grays Anatomy can be found on Bartleby and also on Yahoo
This image is in the public domain because its copyright has expired This applies worldwide
Offensive Line ndash US Navy Football - This file is a work of a sailor or employee of the US Navy taken or made as part of that persons
official duties As a work of the US federal government the image is in the public domain
Gymnast - The person who associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the
work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial purposes all without asking permission
Figure Skater - License Public Domain CC0 (absolutely free) File type jpg | file size 1478 kB Add date 2012-08-27 212949
Volleyball Court Serve - This file is licensed under the Creative Commons Attribution ShareAlike license versions 25 20 and10
US Air Force Volleyball Spike - This work 2013 United States Armed Forces Volleyball Championship [Image 11 of 28] by A1C Justyn
Freeman identified by DVIDS is free of known copyright restrictions under US copyright law
Tennis Serve - The copyright holder of this work released this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [they] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
AC Separation Grading - This file is made available under the Creative Commons CC0 10 Universal Public Domain DedicationThe person who
associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial
purposes all without asking permission
Little League Elbow - Royalty free stock photos All pictures are free for commercial and personal use
Osgood-Schlatter MR ampXray - The copyright holder of this work release this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [They] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
Legg-Calve-Perthes - This file is licensed under the Creative Commons Attribution 30 Unported license
SCFE - This work has been released into the public domain by its author Mikir at the wikipedia project This applies worldwide
Knee Sunrise X-ray - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the
terms of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
Severrsquos Disease - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the terms
of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
912015
3
Diagnosis
HPI Started after raking leaves
in fall
Constant lat forearmelbow ache
Grippinglifting
Computer
No swellingnumbting
Ibuprofen with some relief
No ho sig injury
PMH PSH Meds All Soc hx ROS nc
PE No effusionecchymosis
erythema TTP lat epicondyle Full painless PROM at
elbow flexextprosup 55 mm strength
Pain with elbow ext forearm pro wrist ext grip
Neg valgusvarus stress Neg Tinels ulnar groove
X-ray 3 view elbow Neg
Lateral Epicondylitis (Tennis Elbow) Overload of tendon-bone junction Present with pain and tenderness over lateral
epicondyle Physical exam
Tender over lateral epicondyle
Pain with resisted wrist extension and extension of middle finger
Treatment PT bracing (wrist or counterforce) NSAIDs cort inj
Medial Epicondylitis (Golferrsquos Elbow) Pain with resisted wrist flexion
912015
4
Extensors
Flexors
Lateral Epicondyle
Medial Epicondyle
Diagnosis
HPI Fell Backward during
Basket Ball Game
Landed on pronated wrist with locked elbow
Treatments Tried
Rest
Ice
Aggravating Factors Weight Bearing
Wrist Extension
PMH PSH Meds All Soc hx ROS nc
PE No Ecchymosis
Full AROM with pain
Minimal swelling
TTP over Radial Wrist
ldquoAnatomical Snuff Boxrdquo
Special Tests
Neg Tinelrsquos
Neg Finkelsteinrsquos
Neg Phalenrsquos
X-ray Wrist (APLatObl) Neg
912015
5
Wrist
Scaphoid fracture 70 of true wrist fractures
Risk of nonunion or AVN
Pain in anatomical snuff box
May not be seen on initial x-rays
Long arm vs short arm cast
Can take up to 4 months to heal
Diagnosis
HPI No injury
Offensive lineman football
Intermittent ache middle of low back
Wt lifting
Playing football
Running
No numbting
Chiropractor x6 moswithout relief
No meds
No prev inj
PMH PSH Meds All Soc hx ROS nc
PE TTP bl paraspinals L4-5
Pain with ext
+Stork bl
55 mm strength bl LE
Sensation intact
DTRs 2+4
Neg straight leg raise
Normal gait
X-ray 4 view (APLatObl) Neg
912015
6
Spondylolysis-defect in pars interarticularis Caused by repeated hyperextension of the lumbar spine History-Adolescents
Strenuous athletic participation LBP often without radiation Insidious onset progresses to chronic dull midline LS pain
PE Tenderness to palpation over defect
Can have step-off with spondylolisthesis ROM Stork test-key PE test for diagnosis
Dx X-rays-oblique view will show chronic defect Bone Scan vs CT Scan vs MRI
TX Rest vs Brace
spondyloLISTHESIS
912015
7
Diagnosis
HPI Heard pop in knee landing
from jump in basketball Immediate swelling
ER-x-rays neg
Knee immobilizer NSAIDs
Constant pain Any WB
Using crutches (giving out)
+swelling
-ecchymosiserythema
No prev inj
PMH PSH Meds All Soc hx ROS nc
PE Large effusion TTP medlat jt line Ext to 10flex to 90
Sig guarding laxity on ant
drawerLachmanrsquos test
Neg valgusvarus stress
Unable to do McMurrayrsquos
Antalgic gait X-ray 4 view wt
bearing (APLatTunnel Sunrise)-neg
ACL injury Primary stabilizer of knee
Prevents anterior translation of tibia on femur
Can be contact or noncontact
Increased incidence in adolescent females
Will often hear pop followed by immediate effusion
+ Lachman test Pivot Shift and Anterior Drawer Tests
Surgery based on associated injuries and patient preference
912015
8
Diagnosis
HPI Rolled ankle playing soccer
Immediate swellbruise
Unable to cont playing
Urg care-x-rays neg
Stirrup bracecrutches
Inter sharp pain lat ankle Worse walking
+ limp
+ swellbruise
NSAIDs with some relief
ho 3 ankle sprains-no tx
PMH PSH Meds All Soc hx ROS nc
PE +swelling
Ecchymosis lat ankle
TTP ATFLCFL No medial TTP
Dec ROM due to stiffnesspain
Weak IRER with pain
-ant drawer +Talar tilt -EREversion test -syndesmosis squeeze -Thompsonrsquos test
X-ray 3 view wt bearing (APOblLat) Neg
Lateral ankle sprain 80-85 of all ankle sprains Inversion + plantarflexion of ankle 3 ligaments stabilize the lateral ankle
Injured in order based on severity ATFLCFLPTFL Present with swelling ecchymosis and variable weight-
bearing tolerance Anterior Drawer Test for ATFTalar Tilt Test for CF
Ottawa ankle rules guide need for x-ray Treatment
1 rule is control swelling RICE Crutches if limping Aggressive PT to regain strength and stability Bracing can be used as an adjunct to rehab and to prevent
future injury Associated Injury Fracture to the base of the 5th Metatarsal
912015
9
Dislocation Complete dissociation of humeral head from glenoid
fossa Subluxation is a transient displacement without complete
dissociation 95 are anterior dislocations Treatment
Stabilize arm multiple relocation techniques Surgery vs Nonsurgical management 90 of young athletes will re-dislocate
Associated injuries Joint capsule Labrum tear-Bankart Lesion Humeral fracture-Hill Sachs Deformity Axillary nerve or artery
AC joint separation (separated shoulder) Multiple ligaments and mm stabilize joint
Fall on top of shoulder
Graded I-VI (I-III most common)
Evaluation
Tender over AC Joint
+ Crossover Test
Treatment
Grades I-III Ice sling for comfort PT to regain ROM
Grades IV-VI Refer for surgery
I II IV V VI
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and upper
back most likely sprainstrain
Radicular symptoms include pain numbnesstingling and weakness into shoulder and arm to the hand
+ Spurlings sign = radiculopathy
Imaging
X-ray MRI EMG
Tx
NSAIDs muscle relaxers and PT
Epidural inj
Surgery
912015
10
Fall on outstretched arm
Limited flexext and pronationsupination Tenderness over lateral elbow
Swelling may or may not be present
Often missed on initial x-ray Important to re-xray after 2-3 wks
Treatment Sling for 3-7 days
Early ROM
Surgery rarely necessary
Little leaguerrsquos elbow Spectrum of injuries to elbow
Also overuse and poor mechanics
Caused by medial stress or lateral compression
Pitch counts
Treatment is rest followed by strength exercises
Focus on correcting mechanics
Progressive throwing program
Distal radius fracture Very common-17 of all fractures in ER
Treatment based on multiple anatomical factors
Cast up to 6wks
Scaphoid fracture 70 of true wrist fractures
Risk of nonunion or AVN
Pain in anatomical snuff box
May not be seen on initial x-rays
Long arm vs short arm cast
Can take up to 4 months to heal
912015
11
Carpal Tunnel Syndrome numbting and pain in radial 3 digits (+) Tinel and Phalen tests Confirmed by EMG with NCV Treatment
Cock-up Splint NSAIDS PT Surgery gt3 mos conservative care or worsening neurological
symptoms
DeQuervainrsquos Tenosynovitis APL amp EPB-1st dorsal compartment Tenderness and swelling over radial styloid (+) Finkelsteinrsquos Test Treatment
Thumb spica splint NSAIDs PT Corticosteroid inj Surgical release of 1st dorsal compartment
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and
upper back of sprainstrain Radicular symptoms include pain
numbnesstingling and weakness into buttock and leg to the foot
+ Straight Leg Raise = radiculopathy Imaging
X-ray MRI EMG
Tx NSAIDs muscle relaxers and PT
Epidural inj
Surgery
Meniscus Traumatic or degenerative
Caused by weight-bearing + rotational forces
co knee pain delayed swelling locking and catching
Effusion and joint line tenderness on exam
+McMurray and Thessaly (ldquoTwist amp Shoutrdquo) tests
Treatment
RICE NSAIDs
Functional symptoms require surgical evaluation
912015
12
Osgood-Schlatter Disease Osteochondritis of the tibial tuberosity Most commonly seen in 13-14 yo boys 11-12 yo girls
Most common in jumping sports History
Recent growth spurt Anterior knee pain
Physical Exam Tender over prominent tibial tuberosity
Tx Ice NSAIDs StretchStrengthen
quads and hams
OK to play to pain tolerance Self-limited condition
Legg-Calve-Perthes Disease Interruption of blood supply to femoral
epiphysis Average age is 4-9 yo Present with deep hip groin or thigh pain
May radiate to knee Walk with limp dec IR of hip Dx with x-ray
MRIBone scan if early Tx-Refer to ortho
Slipped Capital Femoral Epiphysis Due to shearing forces during growth spurts Avg age 8-15 yo Early dx is key-insidious onset of
hipgrointhighknee pain Dec IR on PE X-rays-ice cream scoop slipping off cone
Refer to Ortho
L-C-P
SCFE
OA
GROIN PAIN = HIP JOINT Pain can radiate to knee or low back so make
sure to check hip
Tx with NSAIDs PT Cort inj Surgery
Trochanteric Bursitis Paintenderness over greater trochanter
Worse with hip flexext
Multiple underlying factors
Tx with PT NSAIDs rest cort inj
912015
13
Patella femoral pain syndrome Abnormal tracking of patella in groove between condyles
of femur
Chronic in nature
co anterior knee pain Theater sign
Pain going down stairs
Increased Q angle on PE
Treatment Strength balance and flexibility
exercises
Foot orthotics
Bracingtaping in season
Surgery-rare
Medial Ankle Sprain Dorsiflexion + eversion of foot Injury to deltoid ligament
Fracture of tibia more common than ligament tear
Can extend proximally to cause fibular fracture
Similar presentation as a lateral ankle sprain X-rays required to assess joint stability Treatment
Same as lateral ankle sprain unless extension into syndesmosis or distal fibula Surgery if joint is unstable
Longer healing time than lateral ankle sprains
Plantar Fasciitis Irritation of the calcaneal attachment of the plantar
fascia
Not caused by heel spur
Insidious onset of pain radiating into arch
Painful 1st steps in AM
Tenderness of anterior-medial calcaneus
Often tight achilles tendon
Treatment
NSAIDs rest PT w massage orthotics night splints
Surgical release is last resort
912015
14
Sever Disease Apophysitis of posterior calcaneus
Epiphysis fuses at 12-15 yo
History
Insidious onset of heal pain
Boys 10-12 yo Girls 8-10 yo
Physical Exam
Tenderness over insertion of achilles tendon
Decrease passive ankle dorsiflexion
Treatment
Ice NSAIDs heel lifts stretchstrengthen heel cords
1 McKeag MD Douglas and James Moeller MD ACSMrsquos Primary Care Sports Medicine 2nd
Edition Philadelphia Lippincott Williams amp Wilkins 2007
2 Eiff MD M Patrice Robert Hatch MD and Walter Calmbach MD Fracture Management for Primary Care Philadelphia Saunders Elsevier 2003
3 DeLee MD Jesse David Drez Jr MD Mark Miller MD Orthopedic Sports Medicine Philadelphia Saunders Elsevier 2010
4 Magee PhD David Ortohpedic Physical Assessment 4th Edition Philadelphia Saunders Elsevier 2002
Shoulder Anatomy Greyrsquos -httpcommonswikimediaorgwikiFileShoulder_joint_anatomy_quizjpg
Forearm Extensors Greyrsquos -httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtSuperficialGrayBB418gif
Forearm Flexors Greyrsquos -
httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtDeepGrayBB415gif
Offensive Line US Navy Football -httpscommonswikimediaorgwikiFileUS_Navy_071201-N-6463B-447_Navy_Quarter_Back_Kaipo-Noa_Haheaku-Enhada_(10)_drops_back_to_pass_while_receiving_maximum_protection_from_his_offensive_line_at_the_108th_annual_Army_vs_Navy_football_game_at_M5ET_Bank_Stadium_in_Baljpg
Gymnast ndash httppixabaycomengymnastics-gymnast-sports-graceful-89608
Figure Skater - httpfreetemsnetfiledance-on-ice-460
Volleyball Court Serve - httpwwwnationmastercomencyclopediaVolleyball
Volleyball Spike US Airforce -
httpd1staticdvidshubnetmediathumbsphotos1305933304450x300_q75jpgis
Tennis Serve - httpcommonswikimediaorgwikiFileMarat_safin_1jpg
Ankle Anatomy Greyrsquos -httpwwwfpnotebookcom_mediaorthoLegFootLateralLigamentsGrayBB355gif
912015
15
AC Separation Grade I -httpcommonswikimediaorgwikiFileClassification_type_1_of_AC_separationpng
AC Separation Grade II -httpcommonswikimediaorgwikiFileClassification_type_2_of_AC_separationpng
AC Separation Grade IV -
httpcommonswikimediaorgwikiFileClassification_type_4_of_AC_separationpng
AC Separation Grade V -httpcommonswikimediaorgwikiFileClassification_type_5_of_AC_separationpng
AC Separation Grade VI -httpcommonswikimediaorgwikiFileClassification_type_6_of_AC_separationpng
Little League elbow - httpwwwpublicdomainpicturesnetview-imagephpimage=2144amppicture=throw-boy
Osgood-Schllater MRI - httpuploadwikimediaorgwikipediacommons999MBq_Osgood-Schlatterjpg
Osgood-Schlatter XR - httpuploadwikimediaorgwikipediacommonsdd9Osgood_Schlater_1JPG
Legg-Calve-Perthes - httpcommonswikimediaorgwikiFileLeggCalvePerthes1jpg
SCFE - httpuploadwikimediaorgwikipediacommons448SCFE_FROG_B26Wjpg
Knee Sunrise X-ray - httpscommonswikimediaorgwikiFileMedical_X-Ray_imaging_CFK03_nevitjpg
Severrsquos Disease - httpcommonswikimediaorgwikiFileMedical_X-Ray_imaging_TKL07_nevitjpg
Shoulder Forearms Ankle Greyrsquos Anatomy - This faithful reproduction of a lithograph plate from Grays Anatomy a two-
dimensional work of art is not copyrightable in the US as per Bridgeman Art Library v Corel Corp the same is also true in many other countries including Germany Unless stated otherwise it is from the 20th US edition of Grays Anatomy of the Human Body originally published in 1918 and therefore lapsed into the public domain Other copies of Grays Anatomy can be found on Bartleby and also on Yahoo
This image is in the public domain because its copyright has expired This applies worldwide
Offensive Line ndash US Navy Football - This file is a work of a sailor or employee of the US Navy taken or made as part of that persons
official duties As a work of the US federal government the image is in the public domain
Gymnast - The person who associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the
work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial purposes all without asking permission
Figure Skater - License Public Domain CC0 (absolutely free) File type jpg | file size 1478 kB Add date 2012-08-27 212949
Volleyball Court Serve - This file is licensed under the Creative Commons Attribution ShareAlike license versions 25 20 and10
US Air Force Volleyball Spike - This work 2013 United States Armed Forces Volleyball Championship [Image 11 of 28] by A1C Justyn
Freeman identified by DVIDS is free of known copyright restrictions under US copyright law
Tennis Serve - The copyright holder of this work released this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [they] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
AC Separation Grading - This file is made available under the Creative Commons CC0 10 Universal Public Domain DedicationThe person who
associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial
purposes all without asking permission
Little League Elbow - Royalty free stock photos All pictures are free for commercial and personal use
Osgood-Schlatter MR ampXray - The copyright holder of this work release this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [They] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
Legg-Calve-Perthes - This file is licensed under the Creative Commons Attribution 30 Unported license
SCFE - This work has been released into the public domain by its author Mikir at the wikipedia project This applies worldwide
Knee Sunrise X-ray - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the
terms of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
Severrsquos Disease - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the terms
of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
912015
4
Extensors
Flexors
Lateral Epicondyle
Medial Epicondyle
Diagnosis
HPI Fell Backward during
Basket Ball Game
Landed on pronated wrist with locked elbow
Treatments Tried
Rest
Ice
Aggravating Factors Weight Bearing
Wrist Extension
PMH PSH Meds All Soc hx ROS nc
PE No Ecchymosis
Full AROM with pain
Minimal swelling
TTP over Radial Wrist
ldquoAnatomical Snuff Boxrdquo
Special Tests
Neg Tinelrsquos
Neg Finkelsteinrsquos
Neg Phalenrsquos
X-ray Wrist (APLatObl) Neg
912015
5
Wrist
Scaphoid fracture 70 of true wrist fractures
Risk of nonunion or AVN
Pain in anatomical snuff box
May not be seen on initial x-rays
Long arm vs short arm cast
Can take up to 4 months to heal
Diagnosis
HPI No injury
Offensive lineman football
Intermittent ache middle of low back
Wt lifting
Playing football
Running
No numbting
Chiropractor x6 moswithout relief
No meds
No prev inj
PMH PSH Meds All Soc hx ROS nc
PE TTP bl paraspinals L4-5
Pain with ext
+Stork bl
55 mm strength bl LE
Sensation intact
DTRs 2+4
Neg straight leg raise
Normal gait
X-ray 4 view (APLatObl) Neg
912015
6
Spondylolysis-defect in pars interarticularis Caused by repeated hyperextension of the lumbar spine History-Adolescents
Strenuous athletic participation LBP often without radiation Insidious onset progresses to chronic dull midline LS pain
PE Tenderness to palpation over defect
Can have step-off with spondylolisthesis ROM Stork test-key PE test for diagnosis
Dx X-rays-oblique view will show chronic defect Bone Scan vs CT Scan vs MRI
TX Rest vs Brace
spondyloLISTHESIS
912015
7
Diagnosis
HPI Heard pop in knee landing
from jump in basketball Immediate swelling
ER-x-rays neg
Knee immobilizer NSAIDs
Constant pain Any WB
Using crutches (giving out)
+swelling
-ecchymosiserythema
No prev inj
PMH PSH Meds All Soc hx ROS nc
PE Large effusion TTP medlat jt line Ext to 10flex to 90
Sig guarding laxity on ant
drawerLachmanrsquos test
Neg valgusvarus stress
Unable to do McMurrayrsquos
Antalgic gait X-ray 4 view wt
bearing (APLatTunnel Sunrise)-neg
ACL injury Primary stabilizer of knee
Prevents anterior translation of tibia on femur
Can be contact or noncontact
Increased incidence in adolescent females
Will often hear pop followed by immediate effusion
+ Lachman test Pivot Shift and Anterior Drawer Tests
Surgery based on associated injuries and patient preference
912015
8
Diagnosis
HPI Rolled ankle playing soccer
Immediate swellbruise
Unable to cont playing
Urg care-x-rays neg
Stirrup bracecrutches
Inter sharp pain lat ankle Worse walking
+ limp
+ swellbruise
NSAIDs with some relief
ho 3 ankle sprains-no tx
PMH PSH Meds All Soc hx ROS nc
PE +swelling
Ecchymosis lat ankle
TTP ATFLCFL No medial TTP
Dec ROM due to stiffnesspain
Weak IRER with pain
-ant drawer +Talar tilt -EREversion test -syndesmosis squeeze -Thompsonrsquos test
X-ray 3 view wt bearing (APOblLat) Neg
Lateral ankle sprain 80-85 of all ankle sprains Inversion + plantarflexion of ankle 3 ligaments stabilize the lateral ankle
Injured in order based on severity ATFLCFLPTFL Present with swelling ecchymosis and variable weight-
bearing tolerance Anterior Drawer Test for ATFTalar Tilt Test for CF
Ottawa ankle rules guide need for x-ray Treatment
1 rule is control swelling RICE Crutches if limping Aggressive PT to regain strength and stability Bracing can be used as an adjunct to rehab and to prevent
future injury Associated Injury Fracture to the base of the 5th Metatarsal
912015
9
Dislocation Complete dissociation of humeral head from glenoid
fossa Subluxation is a transient displacement without complete
dissociation 95 are anterior dislocations Treatment
Stabilize arm multiple relocation techniques Surgery vs Nonsurgical management 90 of young athletes will re-dislocate
Associated injuries Joint capsule Labrum tear-Bankart Lesion Humeral fracture-Hill Sachs Deformity Axillary nerve or artery
AC joint separation (separated shoulder) Multiple ligaments and mm stabilize joint
Fall on top of shoulder
Graded I-VI (I-III most common)
Evaluation
Tender over AC Joint
+ Crossover Test
Treatment
Grades I-III Ice sling for comfort PT to regain ROM
Grades IV-VI Refer for surgery
I II IV V VI
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and upper
back most likely sprainstrain
Radicular symptoms include pain numbnesstingling and weakness into shoulder and arm to the hand
+ Spurlings sign = radiculopathy
Imaging
X-ray MRI EMG
Tx
NSAIDs muscle relaxers and PT
Epidural inj
Surgery
912015
10
Fall on outstretched arm
Limited flexext and pronationsupination Tenderness over lateral elbow
Swelling may or may not be present
Often missed on initial x-ray Important to re-xray after 2-3 wks
Treatment Sling for 3-7 days
Early ROM
Surgery rarely necessary
Little leaguerrsquos elbow Spectrum of injuries to elbow
Also overuse and poor mechanics
Caused by medial stress or lateral compression
Pitch counts
Treatment is rest followed by strength exercises
Focus on correcting mechanics
Progressive throwing program
Distal radius fracture Very common-17 of all fractures in ER
Treatment based on multiple anatomical factors
Cast up to 6wks
Scaphoid fracture 70 of true wrist fractures
Risk of nonunion or AVN
Pain in anatomical snuff box
May not be seen on initial x-rays
Long arm vs short arm cast
Can take up to 4 months to heal
912015
11
Carpal Tunnel Syndrome numbting and pain in radial 3 digits (+) Tinel and Phalen tests Confirmed by EMG with NCV Treatment
Cock-up Splint NSAIDS PT Surgery gt3 mos conservative care or worsening neurological
symptoms
DeQuervainrsquos Tenosynovitis APL amp EPB-1st dorsal compartment Tenderness and swelling over radial styloid (+) Finkelsteinrsquos Test Treatment
Thumb spica splint NSAIDs PT Corticosteroid inj Surgical release of 1st dorsal compartment
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and
upper back of sprainstrain Radicular symptoms include pain
numbnesstingling and weakness into buttock and leg to the foot
+ Straight Leg Raise = radiculopathy Imaging
X-ray MRI EMG
Tx NSAIDs muscle relaxers and PT
Epidural inj
Surgery
Meniscus Traumatic or degenerative
Caused by weight-bearing + rotational forces
co knee pain delayed swelling locking and catching
Effusion and joint line tenderness on exam
+McMurray and Thessaly (ldquoTwist amp Shoutrdquo) tests
Treatment
RICE NSAIDs
Functional symptoms require surgical evaluation
912015
12
Osgood-Schlatter Disease Osteochondritis of the tibial tuberosity Most commonly seen in 13-14 yo boys 11-12 yo girls
Most common in jumping sports History
Recent growth spurt Anterior knee pain
Physical Exam Tender over prominent tibial tuberosity
Tx Ice NSAIDs StretchStrengthen
quads and hams
OK to play to pain tolerance Self-limited condition
Legg-Calve-Perthes Disease Interruption of blood supply to femoral
epiphysis Average age is 4-9 yo Present with deep hip groin or thigh pain
May radiate to knee Walk with limp dec IR of hip Dx with x-ray
MRIBone scan if early Tx-Refer to ortho
Slipped Capital Femoral Epiphysis Due to shearing forces during growth spurts Avg age 8-15 yo Early dx is key-insidious onset of
hipgrointhighknee pain Dec IR on PE X-rays-ice cream scoop slipping off cone
Refer to Ortho
L-C-P
SCFE
OA
GROIN PAIN = HIP JOINT Pain can radiate to knee or low back so make
sure to check hip
Tx with NSAIDs PT Cort inj Surgery
Trochanteric Bursitis Paintenderness over greater trochanter
Worse with hip flexext
Multiple underlying factors
Tx with PT NSAIDs rest cort inj
912015
13
Patella femoral pain syndrome Abnormal tracking of patella in groove between condyles
of femur
Chronic in nature
co anterior knee pain Theater sign
Pain going down stairs
Increased Q angle on PE
Treatment Strength balance and flexibility
exercises
Foot orthotics
Bracingtaping in season
Surgery-rare
Medial Ankle Sprain Dorsiflexion + eversion of foot Injury to deltoid ligament
Fracture of tibia more common than ligament tear
Can extend proximally to cause fibular fracture
Similar presentation as a lateral ankle sprain X-rays required to assess joint stability Treatment
Same as lateral ankle sprain unless extension into syndesmosis or distal fibula Surgery if joint is unstable
Longer healing time than lateral ankle sprains
Plantar Fasciitis Irritation of the calcaneal attachment of the plantar
fascia
Not caused by heel spur
Insidious onset of pain radiating into arch
Painful 1st steps in AM
Tenderness of anterior-medial calcaneus
Often tight achilles tendon
Treatment
NSAIDs rest PT w massage orthotics night splints
Surgical release is last resort
912015
14
Sever Disease Apophysitis of posterior calcaneus
Epiphysis fuses at 12-15 yo
History
Insidious onset of heal pain
Boys 10-12 yo Girls 8-10 yo
Physical Exam
Tenderness over insertion of achilles tendon
Decrease passive ankle dorsiflexion
Treatment
Ice NSAIDs heel lifts stretchstrengthen heel cords
1 McKeag MD Douglas and James Moeller MD ACSMrsquos Primary Care Sports Medicine 2nd
Edition Philadelphia Lippincott Williams amp Wilkins 2007
2 Eiff MD M Patrice Robert Hatch MD and Walter Calmbach MD Fracture Management for Primary Care Philadelphia Saunders Elsevier 2003
3 DeLee MD Jesse David Drez Jr MD Mark Miller MD Orthopedic Sports Medicine Philadelphia Saunders Elsevier 2010
4 Magee PhD David Ortohpedic Physical Assessment 4th Edition Philadelphia Saunders Elsevier 2002
Shoulder Anatomy Greyrsquos -httpcommonswikimediaorgwikiFileShoulder_joint_anatomy_quizjpg
Forearm Extensors Greyrsquos -httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtSuperficialGrayBB418gif
Forearm Flexors Greyrsquos -
httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtDeepGrayBB415gif
Offensive Line US Navy Football -httpscommonswikimediaorgwikiFileUS_Navy_071201-N-6463B-447_Navy_Quarter_Back_Kaipo-Noa_Haheaku-Enhada_(10)_drops_back_to_pass_while_receiving_maximum_protection_from_his_offensive_line_at_the_108th_annual_Army_vs_Navy_football_game_at_M5ET_Bank_Stadium_in_Baljpg
Gymnast ndash httppixabaycomengymnastics-gymnast-sports-graceful-89608
Figure Skater - httpfreetemsnetfiledance-on-ice-460
Volleyball Court Serve - httpwwwnationmastercomencyclopediaVolleyball
Volleyball Spike US Airforce -
httpd1staticdvidshubnetmediathumbsphotos1305933304450x300_q75jpgis
Tennis Serve - httpcommonswikimediaorgwikiFileMarat_safin_1jpg
Ankle Anatomy Greyrsquos -httpwwwfpnotebookcom_mediaorthoLegFootLateralLigamentsGrayBB355gif
912015
15
AC Separation Grade I -httpcommonswikimediaorgwikiFileClassification_type_1_of_AC_separationpng
AC Separation Grade II -httpcommonswikimediaorgwikiFileClassification_type_2_of_AC_separationpng
AC Separation Grade IV -
httpcommonswikimediaorgwikiFileClassification_type_4_of_AC_separationpng
AC Separation Grade V -httpcommonswikimediaorgwikiFileClassification_type_5_of_AC_separationpng
AC Separation Grade VI -httpcommonswikimediaorgwikiFileClassification_type_6_of_AC_separationpng
Little League elbow - httpwwwpublicdomainpicturesnetview-imagephpimage=2144amppicture=throw-boy
Osgood-Schllater MRI - httpuploadwikimediaorgwikipediacommons999MBq_Osgood-Schlatterjpg
Osgood-Schlatter XR - httpuploadwikimediaorgwikipediacommonsdd9Osgood_Schlater_1JPG
Legg-Calve-Perthes - httpcommonswikimediaorgwikiFileLeggCalvePerthes1jpg
SCFE - httpuploadwikimediaorgwikipediacommons448SCFE_FROG_B26Wjpg
Knee Sunrise X-ray - httpscommonswikimediaorgwikiFileMedical_X-Ray_imaging_CFK03_nevitjpg
Severrsquos Disease - httpcommonswikimediaorgwikiFileMedical_X-Ray_imaging_TKL07_nevitjpg
Shoulder Forearms Ankle Greyrsquos Anatomy - This faithful reproduction of a lithograph plate from Grays Anatomy a two-
dimensional work of art is not copyrightable in the US as per Bridgeman Art Library v Corel Corp the same is also true in many other countries including Germany Unless stated otherwise it is from the 20th US edition of Grays Anatomy of the Human Body originally published in 1918 and therefore lapsed into the public domain Other copies of Grays Anatomy can be found on Bartleby and also on Yahoo
This image is in the public domain because its copyright has expired This applies worldwide
Offensive Line ndash US Navy Football - This file is a work of a sailor or employee of the US Navy taken or made as part of that persons
official duties As a work of the US federal government the image is in the public domain
Gymnast - The person who associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the
work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial purposes all without asking permission
Figure Skater - License Public Domain CC0 (absolutely free) File type jpg | file size 1478 kB Add date 2012-08-27 212949
Volleyball Court Serve - This file is licensed under the Creative Commons Attribution ShareAlike license versions 25 20 and10
US Air Force Volleyball Spike - This work 2013 United States Armed Forces Volleyball Championship [Image 11 of 28] by A1C Justyn
Freeman identified by DVIDS is free of known copyright restrictions under US copyright law
Tennis Serve - The copyright holder of this work released this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [they] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
AC Separation Grading - This file is made available under the Creative Commons CC0 10 Universal Public Domain DedicationThe person who
associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial
purposes all without asking permission
Little League Elbow - Royalty free stock photos All pictures are free for commercial and personal use
Osgood-Schlatter MR ampXray - The copyright holder of this work release this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [They] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
Legg-Calve-Perthes - This file is licensed under the Creative Commons Attribution 30 Unported license
SCFE - This work has been released into the public domain by its author Mikir at the wikipedia project This applies worldwide
Knee Sunrise X-ray - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the
terms of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
Severrsquos Disease - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the terms
of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
912015
5
Wrist
Scaphoid fracture 70 of true wrist fractures
Risk of nonunion or AVN
Pain in anatomical snuff box
May not be seen on initial x-rays
Long arm vs short arm cast
Can take up to 4 months to heal
Diagnosis
HPI No injury
Offensive lineman football
Intermittent ache middle of low back
Wt lifting
Playing football
Running
No numbting
Chiropractor x6 moswithout relief
No meds
No prev inj
PMH PSH Meds All Soc hx ROS nc
PE TTP bl paraspinals L4-5
Pain with ext
+Stork bl
55 mm strength bl LE
Sensation intact
DTRs 2+4
Neg straight leg raise
Normal gait
X-ray 4 view (APLatObl) Neg
912015
6
Spondylolysis-defect in pars interarticularis Caused by repeated hyperextension of the lumbar spine History-Adolescents
Strenuous athletic participation LBP often without radiation Insidious onset progresses to chronic dull midline LS pain
PE Tenderness to palpation over defect
Can have step-off with spondylolisthesis ROM Stork test-key PE test for diagnosis
Dx X-rays-oblique view will show chronic defect Bone Scan vs CT Scan vs MRI
TX Rest vs Brace
spondyloLISTHESIS
912015
7
Diagnosis
HPI Heard pop in knee landing
from jump in basketball Immediate swelling
ER-x-rays neg
Knee immobilizer NSAIDs
Constant pain Any WB
Using crutches (giving out)
+swelling
-ecchymosiserythema
No prev inj
PMH PSH Meds All Soc hx ROS nc
PE Large effusion TTP medlat jt line Ext to 10flex to 90
Sig guarding laxity on ant
drawerLachmanrsquos test
Neg valgusvarus stress
Unable to do McMurrayrsquos
Antalgic gait X-ray 4 view wt
bearing (APLatTunnel Sunrise)-neg
ACL injury Primary stabilizer of knee
Prevents anterior translation of tibia on femur
Can be contact or noncontact
Increased incidence in adolescent females
Will often hear pop followed by immediate effusion
+ Lachman test Pivot Shift and Anterior Drawer Tests
Surgery based on associated injuries and patient preference
912015
8
Diagnosis
HPI Rolled ankle playing soccer
Immediate swellbruise
Unable to cont playing
Urg care-x-rays neg
Stirrup bracecrutches
Inter sharp pain lat ankle Worse walking
+ limp
+ swellbruise
NSAIDs with some relief
ho 3 ankle sprains-no tx
PMH PSH Meds All Soc hx ROS nc
PE +swelling
Ecchymosis lat ankle
TTP ATFLCFL No medial TTP
Dec ROM due to stiffnesspain
Weak IRER with pain
-ant drawer +Talar tilt -EREversion test -syndesmosis squeeze -Thompsonrsquos test
X-ray 3 view wt bearing (APOblLat) Neg
Lateral ankle sprain 80-85 of all ankle sprains Inversion + plantarflexion of ankle 3 ligaments stabilize the lateral ankle
Injured in order based on severity ATFLCFLPTFL Present with swelling ecchymosis and variable weight-
bearing tolerance Anterior Drawer Test for ATFTalar Tilt Test for CF
Ottawa ankle rules guide need for x-ray Treatment
1 rule is control swelling RICE Crutches if limping Aggressive PT to regain strength and stability Bracing can be used as an adjunct to rehab and to prevent
future injury Associated Injury Fracture to the base of the 5th Metatarsal
912015
9
Dislocation Complete dissociation of humeral head from glenoid
fossa Subluxation is a transient displacement without complete
dissociation 95 are anterior dislocations Treatment
Stabilize arm multiple relocation techniques Surgery vs Nonsurgical management 90 of young athletes will re-dislocate
Associated injuries Joint capsule Labrum tear-Bankart Lesion Humeral fracture-Hill Sachs Deformity Axillary nerve or artery
AC joint separation (separated shoulder) Multiple ligaments and mm stabilize joint
Fall on top of shoulder
Graded I-VI (I-III most common)
Evaluation
Tender over AC Joint
+ Crossover Test
Treatment
Grades I-III Ice sling for comfort PT to regain ROM
Grades IV-VI Refer for surgery
I II IV V VI
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and upper
back most likely sprainstrain
Radicular symptoms include pain numbnesstingling and weakness into shoulder and arm to the hand
+ Spurlings sign = radiculopathy
Imaging
X-ray MRI EMG
Tx
NSAIDs muscle relaxers and PT
Epidural inj
Surgery
912015
10
Fall on outstretched arm
Limited flexext and pronationsupination Tenderness over lateral elbow
Swelling may or may not be present
Often missed on initial x-ray Important to re-xray after 2-3 wks
Treatment Sling for 3-7 days
Early ROM
Surgery rarely necessary
Little leaguerrsquos elbow Spectrum of injuries to elbow
Also overuse and poor mechanics
Caused by medial stress or lateral compression
Pitch counts
Treatment is rest followed by strength exercises
Focus on correcting mechanics
Progressive throwing program
Distal radius fracture Very common-17 of all fractures in ER
Treatment based on multiple anatomical factors
Cast up to 6wks
Scaphoid fracture 70 of true wrist fractures
Risk of nonunion or AVN
Pain in anatomical snuff box
May not be seen on initial x-rays
Long arm vs short arm cast
Can take up to 4 months to heal
912015
11
Carpal Tunnel Syndrome numbting and pain in radial 3 digits (+) Tinel and Phalen tests Confirmed by EMG with NCV Treatment
Cock-up Splint NSAIDS PT Surgery gt3 mos conservative care or worsening neurological
symptoms
DeQuervainrsquos Tenosynovitis APL amp EPB-1st dorsal compartment Tenderness and swelling over radial styloid (+) Finkelsteinrsquos Test Treatment
Thumb spica splint NSAIDs PT Corticosteroid inj Surgical release of 1st dorsal compartment
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and
upper back of sprainstrain Radicular symptoms include pain
numbnesstingling and weakness into buttock and leg to the foot
+ Straight Leg Raise = radiculopathy Imaging
X-ray MRI EMG
Tx NSAIDs muscle relaxers and PT
Epidural inj
Surgery
Meniscus Traumatic or degenerative
Caused by weight-bearing + rotational forces
co knee pain delayed swelling locking and catching
Effusion and joint line tenderness on exam
+McMurray and Thessaly (ldquoTwist amp Shoutrdquo) tests
Treatment
RICE NSAIDs
Functional symptoms require surgical evaluation
912015
12
Osgood-Schlatter Disease Osteochondritis of the tibial tuberosity Most commonly seen in 13-14 yo boys 11-12 yo girls
Most common in jumping sports History
Recent growth spurt Anterior knee pain
Physical Exam Tender over prominent tibial tuberosity
Tx Ice NSAIDs StretchStrengthen
quads and hams
OK to play to pain tolerance Self-limited condition
Legg-Calve-Perthes Disease Interruption of blood supply to femoral
epiphysis Average age is 4-9 yo Present with deep hip groin or thigh pain
May radiate to knee Walk with limp dec IR of hip Dx with x-ray
MRIBone scan if early Tx-Refer to ortho
Slipped Capital Femoral Epiphysis Due to shearing forces during growth spurts Avg age 8-15 yo Early dx is key-insidious onset of
hipgrointhighknee pain Dec IR on PE X-rays-ice cream scoop slipping off cone
Refer to Ortho
L-C-P
SCFE
OA
GROIN PAIN = HIP JOINT Pain can radiate to knee or low back so make
sure to check hip
Tx with NSAIDs PT Cort inj Surgery
Trochanteric Bursitis Paintenderness over greater trochanter
Worse with hip flexext
Multiple underlying factors
Tx with PT NSAIDs rest cort inj
912015
13
Patella femoral pain syndrome Abnormal tracking of patella in groove between condyles
of femur
Chronic in nature
co anterior knee pain Theater sign
Pain going down stairs
Increased Q angle on PE
Treatment Strength balance and flexibility
exercises
Foot orthotics
Bracingtaping in season
Surgery-rare
Medial Ankle Sprain Dorsiflexion + eversion of foot Injury to deltoid ligament
Fracture of tibia more common than ligament tear
Can extend proximally to cause fibular fracture
Similar presentation as a lateral ankle sprain X-rays required to assess joint stability Treatment
Same as lateral ankle sprain unless extension into syndesmosis or distal fibula Surgery if joint is unstable
Longer healing time than lateral ankle sprains
Plantar Fasciitis Irritation of the calcaneal attachment of the plantar
fascia
Not caused by heel spur
Insidious onset of pain radiating into arch
Painful 1st steps in AM
Tenderness of anterior-medial calcaneus
Often tight achilles tendon
Treatment
NSAIDs rest PT w massage orthotics night splints
Surgical release is last resort
912015
14
Sever Disease Apophysitis of posterior calcaneus
Epiphysis fuses at 12-15 yo
History
Insidious onset of heal pain
Boys 10-12 yo Girls 8-10 yo
Physical Exam
Tenderness over insertion of achilles tendon
Decrease passive ankle dorsiflexion
Treatment
Ice NSAIDs heel lifts stretchstrengthen heel cords
1 McKeag MD Douglas and James Moeller MD ACSMrsquos Primary Care Sports Medicine 2nd
Edition Philadelphia Lippincott Williams amp Wilkins 2007
2 Eiff MD M Patrice Robert Hatch MD and Walter Calmbach MD Fracture Management for Primary Care Philadelphia Saunders Elsevier 2003
3 DeLee MD Jesse David Drez Jr MD Mark Miller MD Orthopedic Sports Medicine Philadelphia Saunders Elsevier 2010
4 Magee PhD David Ortohpedic Physical Assessment 4th Edition Philadelphia Saunders Elsevier 2002
Shoulder Anatomy Greyrsquos -httpcommonswikimediaorgwikiFileShoulder_joint_anatomy_quizjpg
Forearm Extensors Greyrsquos -httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtSuperficialGrayBB418gif
Forearm Flexors Greyrsquos -
httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtDeepGrayBB415gif
Offensive Line US Navy Football -httpscommonswikimediaorgwikiFileUS_Navy_071201-N-6463B-447_Navy_Quarter_Back_Kaipo-Noa_Haheaku-Enhada_(10)_drops_back_to_pass_while_receiving_maximum_protection_from_his_offensive_line_at_the_108th_annual_Army_vs_Navy_football_game_at_M5ET_Bank_Stadium_in_Baljpg
Gymnast ndash httppixabaycomengymnastics-gymnast-sports-graceful-89608
Figure Skater - httpfreetemsnetfiledance-on-ice-460
Volleyball Court Serve - httpwwwnationmastercomencyclopediaVolleyball
Volleyball Spike US Airforce -
httpd1staticdvidshubnetmediathumbsphotos1305933304450x300_q75jpgis
Tennis Serve - httpcommonswikimediaorgwikiFileMarat_safin_1jpg
Ankle Anatomy Greyrsquos -httpwwwfpnotebookcom_mediaorthoLegFootLateralLigamentsGrayBB355gif
912015
15
AC Separation Grade I -httpcommonswikimediaorgwikiFileClassification_type_1_of_AC_separationpng
AC Separation Grade II -httpcommonswikimediaorgwikiFileClassification_type_2_of_AC_separationpng
AC Separation Grade IV -
httpcommonswikimediaorgwikiFileClassification_type_4_of_AC_separationpng
AC Separation Grade V -httpcommonswikimediaorgwikiFileClassification_type_5_of_AC_separationpng
AC Separation Grade VI -httpcommonswikimediaorgwikiFileClassification_type_6_of_AC_separationpng
Little League elbow - httpwwwpublicdomainpicturesnetview-imagephpimage=2144amppicture=throw-boy
Osgood-Schllater MRI - httpuploadwikimediaorgwikipediacommons999MBq_Osgood-Schlatterjpg
Osgood-Schlatter XR - httpuploadwikimediaorgwikipediacommonsdd9Osgood_Schlater_1JPG
Legg-Calve-Perthes - httpcommonswikimediaorgwikiFileLeggCalvePerthes1jpg
SCFE - httpuploadwikimediaorgwikipediacommons448SCFE_FROG_B26Wjpg
Knee Sunrise X-ray - httpscommonswikimediaorgwikiFileMedical_X-Ray_imaging_CFK03_nevitjpg
Severrsquos Disease - httpcommonswikimediaorgwikiFileMedical_X-Ray_imaging_TKL07_nevitjpg
Shoulder Forearms Ankle Greyrsquos Anatomy - This faithful reproduction of a lithograph plate from Grays Anatomy a two-
dimensional work of art is not copyrightable in the US as per Bridgeman Art Library v Corel Corp the same is also true in many other countries including Germany Unless stated otherwise it is from the 20th US edition of Grays Anatomy of the Human Body originally published in 1918 and therefore lapsed into the public domain Other copies of Grays Anatomy can be found on Bartleby and also on Yahoo
This image is in the public domain because its copyright has expired This applies worldwide
Offensive Line ndash US Navy Football - This file is a work of a sailor or employee of the US Navy taken or made as part of that persons
official duties As a work of the US federal government the image is in the public domain
Gymnast - The person who associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the
work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial purposes all without asking permission
Figure Skater - License Public Domain CC0 (absolutely free) File type jpg | file size 1478 kB Add date 2012-08-27 212949
Volleyball Court Serve - This file is licensed under the Creative Commons Attribution ShareAlike license versions 25 20 and10
US Air Force Volleyball Spike - This work 2013 United States Armed Forces Volleyball Championship [Image 11 of 28] by A1C Justyn
Freeman identified by DVIDS is free of known copyright restrictions under US copyright law
Tennis Serve - The copyright holder of this work released this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [they] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
AC Separation Grading - This file is made available under the Creative Commons CC0 10 Universal Public Domain DedicationThe person who
associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial
purposes all without asking permission
Little League Elbow - Royalty free stock photos All pictures are free for commercial and personal use
Osgood-Schlatter MR ampXray - The copyright holder of this work release this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [They] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
Legg-Calve-Perthes - This file is licensed under the Creative Commons Attribution 30 Unported license
SCFE - This work has been released into the public domain by its author Mikir at the wikipedia project This applies worldwide
Knee Sunrise X-ray - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the
terms of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
Severrsquos Disease - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the terms
of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
912015
6
Spondylolysis-defect in pars interarticularis Caused by repeated hyperextension of the lumbar spine History-Adolescents
Strenuous athletic participation LBP often without radiation Insidious onset progresses to chronic dull midline LS pain
PE Tenderness to palpation over defect
Can have step-off with spondylolisthesis ROM Stork test-key PE test for diagnosis
Dx X-rays-oblique view will show chronic defect Bone Scan vs CT Scan vs MRI
TX Rest vs Brace
spondyloLISTHESIS
912015
7
Diagnosis
HPI Heard pop in knee landing
from jump in basketball Immediate swelling
ER-x-rays neg
Knee immobilizer NSAIDs
Constant pain Any WB
Using crutches (giving out)
+swelling
-ecchymosiserythema
No prev inj
PMH PSH Meds All Soc hx ROS nc
PE Large effusion TTP medlat jt line Ext to 10flex to 90
Sig guarding laxity on ant
drawerLachmanrsquos test
Neg valgusvarus stress
Unable to do McMurrayrsquos
Antalgic gait X-ray 4 view wt
bearing (APLatTunnel Sunrise)-neg
ACL injury Primary stabilizer of knee
Prevents anterior translation of tibia on femur
Can be contact or noncontact
Increased incidence in adolescent females
Will often hear pop followed by immediate effusion
+ Lachman test Pivot Shift and Anterior Drawer Tests
Surgery based on associated injuries and patient preference
912015
8
Diagnosis
HPI Rolled ankle playing soccer
Immediate swellbruise
Unable to cont playing
Urg care-x-rays neg
Stirrup bracecrutches
Inter sharp pain lat ankle Worse walking
+ limp
+ swellbruise
NSAIDs with some relief
ho 3 ankle sprains-no tx
PMH PSH Meds All Soc hx ROS nc
PE +swelling
Ecchymosis lat ankle
TTP ATFLCFL No medial TTP
Dec ROM due to stiffnesspain
Weak IRER with pain
-ant drawer +Talar tilt -EREversion test -syndesmosis squeeze -Thompsonrsquos test
X-ray 3 view wt bearing (APOblLat) Neg
Lateral ankle sprain 80-85 of all ankle sprains Inversion + plantarflexion of ankle 3 ligaments stabilize the lateral ankle
Injured in order based on severity ATFLCFLPTFL Present with swelling ecchymosis and variable weight-
bearing tolerance Anterior Drawer Test for ATFTalar Tilt Test for CF
Ottawa ankle rules guide need for x-ray Treatment
1 rule is control swelling RICE Crutches if limping Aggressive PT to regain strength and stability Bracing can be used as an adjunct to rehab and to prevent
future injury Associated Injury Fracture to the base of the 5th Metatarsal
912015
9
Dislocation Complete dissociation of humeral head from glenoid
fossa Subluxation is a transient displacement without complete
dissociation 95 are anterior dislocations Treatment
Stabilize arm multiple relocation techniques Surgery vs Nonsurgical management 90 of young athletes will re-dislocate
Associated injuries Joint capsule Labrum tear-Bankart Lesion Humeral fracture-Hill Sachs Deformity Axillary nerve or artery
AC joint separation (separated shoulder) Multiple ligaments and mm stabilize joint
Fall on top of shoulder
Graded I-VI (I-III most common)
Evaluation
Tender over AC Joint
+ Crossover Test
Treatment
Grades I-III Ice sling for comfort PT to regain ROM
Grades IV-VI Refer for surgery
I II IV V VI
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and upper
back most likely sprainstrain
Radicular symptoms include pain numbnesstingling and weakness into shoulder and arm to the hand
+ Spurlings sign = radiculopathy
Imaging
X-ray MRI EMG
Tx
NSAIDs muscle relaxers and PT
Epidural inj
Surgery
912015
10
Fall on outstretched arm
Limited flexext and pronationsupination Tenderness over lateral elbow
Swelling may or may not be present
Often missed on initial x-ray Important to re-xray after 2-3 wks
Treatment Sling for 3-7 days
Early ROM
Surgery rarely necessary
Little leaguerrsquos elbow Spectrum of injuries to elbow
Also overuse and poor mechanics
Caused by medial stress or lateral compression
Pitch counts
Treatment is rest followed by strength exercises
Focus on correcting mechanics
Progressive throwing program
Distal radius fracture Very common-17 of all fractures in ER
Treatment based on multiple anatomical factors
Cast up to 6wks
Scaphoid fracture 70 of true wrist fractures
Risk of nonunion or AVN
Pain in anatomical snuff box
May not be seen on initial x-rays
Long arm vs short arm cast
Can take up to 4 months to heal
912015
11
Carpal Tunnel Syndrome numbting and pain in radial 3 digits (+) Tinel and Phalen tests Confirmed by EMG with NCV Treatment
Cock-up Splint NSAIDS PT Surgery gt3 mos conservative care or worsening neurological
symptoms
DeQuervainrsquos Tenosynovitis APL amp EPB-1st dorsal compartment Tenderness and swelling over radial styloid (+) Finkelsteinrsquos Test Treatment
Thumb spica splint NSAIDs PT Corticosteroid inj Surgical release of 1st dorsal compartment
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and
upper back of sprainstrain Radicular symptoms include pain
numbnesstingling and weakness into buttock and leg to the foot
+ Straight Leg Raise = radiculopathy Imaging
X-ray MRI EMG
Tx NSAIDs muscle relaxers and PT
Epidural inj
Surgery
Meniscus Traumatic or degenerative
Caused by weight-bearing + rotational forces
co knee pain delayed swelling locking and catching
Effusion and joint line tenderness on exam
+McMurray and Thessaly (ldquoTwist amp Shoutrdquo) tests
Treatment
RICE NSAIDs
Functional symptoms require surgical evaluation
912015
12
Osgood-Schlatter Disease Osteochondritis of the tibial tuberosity Most commonly seen in 13-14 yo boys 11-12 yo girls
Most common in jumping sports History
Recent growth spurt Anterior knee pain
Physical Exam Tender over prominent tibial tuberosity
Tx Ice NSAIDs StretchStrengthen
quads and hams
OK to play to pain tolerance Self-limited condition
Legg-Calve-Perthes Disease Interruption of blood supply to femoral
epiphysis Average age is 4-9 yo Present with deep hip groin or thigh pain
May radiate to knee Walk with limp dec IR of hip Dx with x-ray
MRIBone scan if early Tx-Refer to ortho
Slipped Capital Femoral Epiphysis Due to shearing forces during growth spurts Avg age 8-15 yo Early dx is key-insidious onset of
hipgrointhighknee pain Dec IR on PE X-rays-ice cream scoop slipping off cone
Refer to Ortho
L-C-P
SCFE
OA
GROIN PAIN = HIP JOINT Pain can radiate to knee or low back so make
sure to check hip
Tx with NSAIDs PT Cort inj Surgery
Trochanteric Bursitis Paintenderness over greater trochanter
Worse with hip flexext
Multiple underlying factors
Tx with PT NSAIDs rest cort inj
912015
13
Patella femoral pain syndrome Abnormal tracking of patella in groove between condyles
of femur
Chronic in nature
co anterior knee pain Theater sign
Pain going down stairs
Increased Q angle on PE
Treatment Strength balance and flexibility
exercises
Foot orthotics
Bracingtaping in season
Surgery-rare
Medial Ankle Sprain Dorsiflexion + eversion of foot Injury to deltoid ligament
Fracture of tibia more common than ligament tear
Can extend proximally to cause fibular fracture
Similar presentation as a lateral ankle sprain X-rays required to assess joint stability Treatment
Same as lateral ankle sprain unless extension into syndesmosis or distal fibula Surgery if joint is unstable
Longer healing time than lateral ankle sprains
Plantar Fasciitis Irritation of the calcaneal attachment of the plantar
fascia
Not caused by heel spur
Insidious onset of pain radiating into arch
Painful 1st steps in AM
Tenderness of anterior-medial calcaneus
Often tight achilles tendon
Treatment
NSAIDs rest PT w massage orthotics night splints
Surgical release is last resort
912015
14
Sever Disease Apophysitis of posterior calcaneus
Epiphysis fuses at 12-15 yo
History
Insidious onset of heal pain
Boys 10-12 yo Girls 8-10 yo
Physical Exam
Tenderness over insertion of achilles tendon
Decrease passive ankle dorsiflexion
Treatment
Ice NSAIDs heel lifts stretchstrengthen heel cords
1 McKeag MD Douglas and James Moeller MD ACSMrsquos Primary Care Sports Medicine 2nd
Edition Philadelphia Lippincott Williams amp Wilkins 2007
2 Eiff MD M Patrice Robert Hatch MD and Walter Calmbach MD Fracture Management for Primary Care Philadelphia Saunders Elsevier 2003
3 DeLee MD Jesse David Drez Jr MD Mark Miller MD Orthopedic Sports Medicine Philadelphia Saunders Elsevier 2010
4 Magee PhD David Ortohpedic Physical Assessment 4th Edition Philadelphia Saunders Elsevier 2002
Shoulder Anatomy Greyrsquos -httpcommonswikimediaorgwikiFileShoulder_joint_anatomy_quizjpg
Forearm Extensors Greyrsquos -httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtSuperficialGrayBB418gif
Forearm Flexors Greyrsquos -
httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtDeepGrayBB415gif
Offensive Line US Navy Football -httpscommonswikimediaorgwikiFileUS_Navy_071201-N-6463B-447_Navy_Quarter_Back_Kaipo-Noa_Haheaku-Enhada_(10)_drops_back_to_pass_while_receiving_maximum_protection_from_his_offensive_line_at_the_108th_annual_Army_vs_Navy_football_game_at_M5ET_Bank_Stadium_in_Baljpg
Gymnast ndash httppixabaycomengymnastics-gymnast-sports-graceful-89608
Figure Skater - httpfreetemsnetfiledance-on-ice-460
Volleyball Court Serve - httpwwwnationmastercomencyclopediaVolleyball
Volleyball Spike US Airforce -
httpd1staticdvidshubnetmediathumbsphotos1305933304450x300_q75jpgis
Tennis Serve - httpcommonswikimediaorgwikiFileMarat_safin_1jpg
Ankle Anatomy Greyrsquos -httpwwwfpnotebookcom_mediaorthoLegFootLateralLigamentsGrayBB355gif
912015
15
AC Separation Grade I -httpcommonswikimediaorgwikiFileClassification_type_1_of_AC_separationpng
AC Separation Grade II -httpcommonswikimediaorgwikiFileClassification_type_2_of_AC_separationpng
AC Separation Grade IV -
httpcommonswikimediaorgwikiFileClassification_type_4_of_AC_separationpng
AC Separation Grade V -httpcommonswikimediaorgwikiFileClassification_type_5_of_AC_separationpng
AC Separation Grade VI -httpcommonswikimediaorgwikiFileClassification_type_6_of_AC_separationpng
Little League elbow - httpwwwpublicdomainpicturesnetview-imagephpimage=2144amppicture=throw-boy
Osgood-Schllater MRI - httpuploadwikimediaorgwikipediacommons999MBq_Osgood-Schlatterjpg
Osgood-Schlatter XR - httpuploadwikimediaorgwikipediacommonsdd9Osgood_Schlater_1JPG
Legg-Calve-Perthes - httpcommonswikimediaorgwikiFileLeggCalvePerthes1jpg
SCFE - httpuploadwikimediaorgwikipediacommons448SCFE_FROG_B26Wjpg
Knee Sunrise X-ray - httpscommonswikimediaorgwikiFileMedical_X-Ray_imaging_CFK03_nevitjpg
Severrsquos Disease - httpcommonswikimediaorgwikiFileMedical_X-Ray_imaging_TKL07_nevitjpg
Shoulder Forearms Ankle Greyrsquos Anatomy - This faithful reproduction of a lithograph plate from Grays Anatomy a two-
dimensional work of art is not copyrightable in the US as per Bridgeman Art Library v Corel Corp the same is also true in many other countries including Germany Unless stated otherwise it is from the 20th US edition of Grays Anatomy of the Human Body originally published in 1918 and therefore lapsed into the public domain Other copies of Grays Anatomy can be found on Bartleby and also on Yahoo
This image is in the public domain because its copyright has expired This applies worldwide
Offensive Line ndash US Navy Football - This file is a work of a sailor or employee of the US Navy taken or made as part of that persons
official duties As a work of the US federal government the image is in the public domain
Gymnast - The person who associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the
work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial purposes all without asking permission
Figure Skater - License Public Domain CC0 (absolutely free) File type jpg | file size 1478 kB Add date 2012-08-27 212949
Volleyball Court Serve - This file is licensed under the Creative Commons Attribution ShareAlike license versions 25 20 and10
US Air Force Volleyball Spike - This work 2013 United States Armed Forces Volleyball Championship [Image 11 of 28] by A1C Justyn
Freeman identified by DVIDS is free of known copyright restrictions under US copyright law
Tennis Serve - The copyright holder of this work released this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [they] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
AC Separation Grading - This file is made available under the Creative Commons CC0 10 Universal Public Domain DedicationThe person who
associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial
purposes all without asking permission
Little League Elbow - Royalty free stock photos All pictures are free for commercial and personal use
Osgood-Schlatter MR ampXray - The copyright holder of this work release this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [They] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
Legg-Calve-Perthes - This file is licensed under the Creative Commons Attribution 30 Unported license
SCFE - This work has been released into the public domain by its author Mikir at the wikipedia project This applies worldwide
Knee Sunrise X-ray - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the
terms of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
Severrsquos Disease - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the terms
of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
912015
7
Diagnosis
HPI Heard pop in knee landing
from jump in basketball Immediate swelling
ER-x-rays neg
Knee immobilizer NSAIDs
Constant pain Any WB
Using crutches (giving out)
+swelling
-ecchymosiserythema
No prev inj
PMH PSH Meds All Soc hx ROS nc
PE Large effusion TTP medlat jt line Ext to 10flex to 90
Sig guarding laxity on ant
drawerLachmanrsquos test
Neg valgusvarus stress
Unable to do McMurrayrsquos
Antalgic gait X-ray 4 view wt
bearing (APLatTunnel Sunrise)-neg
ACL injury Primary stabilizer of knee
Prevents anterior translation of tibia on femur
Can be contact or noncontact
Increased incidence in adolescent females
Will often hear pop followed by immediate effusion
+ Lachman test Pivot Shift and Anterior Drawer Tests
Surgery based on associated injuries and patient preference
912015
8
Diagnosis
HPI Rolled ankle playing soccer
Immediate swellbruise
Unable to cont playing
Urg care-x-rays neg
Stirrup bracecrutches
Inter sharp pain lat ankle Worse walking
+ limp
+ swellbruise
NSAIDs with some relief
ho 3 ankle sprains-no tx
PMH PSH Meds All Soc hx ROS nc
PE +swelling
Ecchymosis lat ankle
TTP ATFLCFL No medial TTP
Dec ROM due to stiffnesspain
Weak IRER with pain
-ant drawer +Talar tilt -EREversion test -syndesmosis squeeze -Thompsonrsquos test
X-ray 3 view wt bearing (APOblLat) Neg
Lateral ankle sprain 80-85 of all ankle sprains Inversion + plantarflexion of ankle 3 ligaments stabilize the lateral ankle
Injured in order based on severity ATFLCFLPTFL Present with swelling ecchymosis and variable weight-
bearing tolerance Anterior Drawer Test for ATFTalar Tilt Test for CF
Ottawa ankle rules guide need for x-ray Treatment
1 rule is control swelling RICE Crutches if limping Aggressive PT to regain strength and stability Bracing can be used as an adjunct to rehab and to prevent
future injury Associated Injury Fracture to the base of the 5th Metatarsal
912015
9
Dislocation Complete dissociation of humeral head from glenoid
fossa Subluxation is a transient displacement without complete
dissociation 95 are anterior dislocations Treatment
Stabilize arm multiple relocation techniques Surgery vs Nonsurgical management 90 of young athletes will re-dislocate
Associated injuries Joint capsule Labrum tear-Bankart Lesion Humeral fracture-Hill Sachs Deformity Axillary nerve or artery
AC joint separation (separated shoulder) Multiple ligaments and mm stabilize joint
Fall on top of shoulder
Graded I-VI (I-III most common)
Evaluation
Tender over AC Joint
+ Crossover Test
Treatment
Grades I-III Ice sling for comfort PT to regain ROM
Grades IV-VI Refer for surgery
I II IV V VI
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and upper
back most likely sprainstrain
Radicular symptoms include pain numbnesstingling and weakness into shoulder and arm to the hand
+ Spurlings sign = radiculopathy
Imaging
X-ray MRI EMG
Tx
NSAIDs muscle relaxers and PT
Epidural inj
Surgery
912015
10
Fall on outstretched arm
Limited flexext and pronationsupination Tenderness over lateral elbow
Swelling may or may not be present
Often missed on initial x-ray Important to re-xray after 2-3 wks
Treatment Sling for 3-7 days
Early ROM
Surgery rarely necessary
Little leaguerrsquos elbow Spectrum of injuries to elbow
Also overuse and poor mechanics
Caused by medial stress or lateral compression
Pitch counts
Treatment is rest followed by strength exercises
Focus on correcting mechanics
Progressive throwing program
Distal radius fracture Very common-17 of all fractures in ER
Treatment based on multiple anatomical factors
Cast up to 6wks
Scaphoid fracture 70 of true wrist fractures
Risk of nonunion or AVN
Pain in anatomical snuff box
May not be seen on initial x-rays
Long arm vs short arm cast
Can take up to 4 months to heal
912015
11
Carpal Tunnel Syndrome numbting and pain in radial 3 digits (+) Tinel and Phalen tests Confirmed by EMG with NCV Treatment
Cock-up Splint NSAIDS PT Surgery gt3 mos conservative care or worsening neurological
symptoms
DeQuervainrsquos Tenosynovitis APL amp EPB-1st dorsal compartment Tenderness and swelling over radial styloid (+) Finkelsteinrsquos Test Treatment
Thumb spica splint NSAIDs PT Corticosteroid inj Surgical release of 1st dorsal compartment
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and
upper back of sprainstrain Radicular symptoms include pain
numbnesstingling and weakness into buttock and leg to the foot
+ Straight Leg Raise = radiculopathy Imaging
X-ray MRI EMG
Tx NSAIDs muscle relaxers and PT
Epidural inj
Surgery
Meniscus Traumatic or degenerative
Caused by weight-bearing + rotational forces
co knee pain delayed swelling locking and catching
Effusion and joint line tenderness on exam
+McMurray and Thessaly (ldquoTwist amp Shoutrdquo) tests
Treatment
RICE NSAIDs
Functional symptoms require surgical evaluation
912015
12
Osgood-Schlatter Disease Osteochondritis of the tibial tuberosity Most commonly seen in 13-14 yo boys 11-12 yo girls
Most common in jumping sports History
Recent growth spurt Anterior knee pain
Physical Exam Tender over prominent tibial tuberosity
Tx Ice NSAIDs StretchStrengthen
quads and hams
OK to play to pain tolerance Self-limited condition
Legg-Calve-Perthes Disease Interruption of blood supply to femoral
epiphysis Average age is 4-9 yo Present with deep hip groin or thigh pain
May radiate to knee Walk with limp dec IR of hip Dx with x-ray
MRIBone scan if early Tx-Refer to ortho
Slipped Capital Femoral Epiphysis Due to shearing forces during growth spurts Avg age 8-15 yo Early dx is key-insidious onset of
hipgrointhighknee pain Dec IR on PE X-rays-ice cream scoop slipping off cone
Refer to Ortho
L-C-P
SCFE
OA
GROIN PAIN = HIP JOINT Pain can radiate to knee or low back so make
sure to check hip
Tx with NSAIDs PT Cort inj Surgery
Trochanteric Bursitis Paintenderness over greater trochanter
Worse with hip flexext
Multiple underlying factors
Tx with PT NSAIDs rest cort inj
912015
13
Patella femoral pain syndrome Abnormal tracking of patella in groove between condyles
of femur
Chronic in nature
co anterior knee pain Theater sign
Pain going down stairs
Increased Q angle on PE
Treatment Strength balance and flexibility
exercises
Foot orthotics
Bracingtaping in season
Surgery-rare
Medial Ankle Sprain Dorsiflexion + eversion of foot Injury to deltoid ligament
Fracture of tibia more common than ligament tear
Can extend proximally to cause fibular fracture
Similar presentation as a lateral ankle sprain X-rays required to assess joint stability Treatment
Same as lateral ankle sprain unless extension into syndesmosis or distal fibula Surgery if joint is unstable
Longer healing time than lateral ankle sprains
Plantar Fasciitis Irritation of the calcaneal attachment of the plantar
fascia
Not caused by heel spur
Insidious onset of pain radiating into arch
Painful 1st steps in AM
Tenderness of anterior-medial calcaneus
Often tight achilles tendon
Treatment
NSAIDs rest PT w massage orthotics night splints
Surgical release is last resort
912015
14
Sever Disease Apophysitis of posterior calcaneus
Epiphysis fuses at 12-15 yo
History
Insidious onset of heal pain
Boys 10-12 yo Girls 8-10 yo
Physical Exam
Tenderness over insertion of achilles tendon
Decrease passive ankle dorsiflexion
Treatment
Ice NSAIDs heel lifts stretchstrengthen heel cords
1 McKeag MD Douglas and James Moeller MD ACSMrsquos Primary Care Sports Medicine 2nd
Edition Philadelphia Lippincott Williams amp Wilkins 2007
2 Eiff MD M Patrice Robert Hatch MD and Walter Calmbach MD Fracture Management for Primary Care Philadelphia Saunders Elsevier 2003
3 DeLee MD Jesse David Drez Jr MD Mark Miller MD Orthopedic Sports Medicine Philadelphia Saunders Elsevier 2010
4 Magee PhD David Ortohpedic Physical Assessment 4th Edition Philadelphia Saunders Elsevier 2002
Shoulder Anatomy Greyrsquos -httpcommonswikimediaorgwikiFileShoulder_joint_anatomy_quizjpg
Forearm Extensors Greyrsquos -httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtSuperficialGrayBB418gif
Forearm Flexors Greyrsquos -
httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtDeepGrayBB415gif
Offensive Line US Navy Football -httpscommonswikimediaorgwikiFileUS_Navy_071201-N-6463B-447_Navy_Quarter_Back_Kaipo-Noa_Haheaku-Enhada_(10)_drops_back_to_pass_while_receiving_maximum_protection_from_his_offensive_line_at_the_108th_annual_Army_vs_Navy_football_game_at_M5ET_Bank_Stadium_in_Baljpg
Gymnast ndash httppixabaycomengymnastics-gymnast-sports-graceful-89608
Figure Skater - httpfreetemsnetfiledance-on-ice-460
Volleyball Court Serve - httpwwwnationmastercomencyclopediaVolleyball
Volleyball Spike US Airforce -
httpd1staticdvidshubnetmediathumbsphotos1305933304450x300_q75jpgis
Tennis Serve - httpcommonswikimediaorgwikiFileMarat_safin_1jpg
Ankle Anatomy Greyrsquos -httpwwwfpnotebookcom_mediaorthoLegFootLateralLigamentsGrayBB355gif
912015
15
AC Separation Grade I -httpcommonswikimediaorgwikiFileClassification_type_1_of_AC_separationpng
AC Separation Grade II -httpcommonswikimediaorgwikiFileClassification_type_2_of_AC_separationpng
AC Separation Grade IV -
httpcommonswikimediaorgwikiFileClassification_type_4_of_AC_separationpng
AC Separation Grade V -httpcommonswikimediaorgwikiFileClassification_type_5_of_AC_separationpng
AC Separation Grade VI -httpcommonswikimediaorgwikiFileClassification_type_6_of_AC_separationpng
Little League elbow - httpwwwpublicdomainpicturesnetview-imagephpimage=2144amppicture=throw-boy
Osgood-Schllater MRI - httpuploadwikimediaorgwikipediacommons999MBq_Osgood-Schlatterjpg
Osgood-Schlatter XR - httpuploadwikimediaorgwikipediacommonsdd9Osgood_Schlater_1JPG
Legg-Calve-Perthes - httpcommonswikimediaorgwikiFileLeggCalvePerthes1jpg
SCFE - httpuploadwikimediaorgwikipediacommons448SCFE_FROG_B26Wjpg
Knee Sunrise X-ray - httpscommonswikimediaorgwikiFileMedical_X-Ray_imaging_CFK03_nevitjpg
Severrsquos Disease - httpcommonswikimediaorgwikiFileMedical_X-Ray_imaging_TKL07_nevitjpg
Shoulder Forearms Ankle Greyrsquos Anatomy - This faithful reproduction of a lithograph plate from Grays Anatomy a two-
dimensional work of art is not copyrightable in the US as per Bridgeman Art Library v Corel Corp the same is also true in many other countries including Germany Unless stated otherwise it is from the 20th US edition of Grays Anatomy of the Human Body originally published in 1918 and therefore lapsed into the public domain Other copies of Grays Anatomy can be found on Bartleby and also on Yahoo
This image is in the public domain because its copyright has expired This applies worldwide
Offensive Line ndash US Navy Football - This file is a work of a sailor or employee of the US Navy taken or made as part of that persons
official duties As a work of the US federal government the image is in the public domain
Gymnast - The person who associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the
work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial purposes all without asking permission
Figure Skater - License Public Domain CC0 (absolutely free) File type jpg | file size 1478 kB Add date 2012-08-27 212949
Volleyball Court Serve - This file is licensed under the Creative Commons Attribution ShareAlike license versions 25 20 and10
US Air Force Volleyball Spike - This work 2013 United States Armed Forces Volleyball Championship [Image 11 of 28] by A1C Justyn
Freeman identified by DVIDS is free of known copyright restrictions under US copyright law
Tennis Serve - The copyright holder of this work released this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [they] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
AC Separation Grading - This file is made available under the Creative Commons CC0 10 Universal Public Domain DedicationThe person who
associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial
purposes all without asking permission
Little League Elbow - Royalty free stock photos All pictures are free for commercial and personal use
Osgood-Schlatter MR ampXray - The copyright holder of this work release this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [They] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
Legg-Calve-Perthes - This file is licensed under the Creative Commons Attribution 30 Unported license
SCFE - This work has been released into the public domain by its author Mikir at the wikipedia project This applies worldwide
Knee Sunrise X-ray - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the
terms of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
Severrsquos Disease - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the terms
of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
912015
8
Diagnosis
HPI Rolled ankle playing soccer
Immediate swellbruise
Unable to cont playing
Urg care-x-rays neg
Stirrup bracecrutches
Inter sharp pain lat ankle Worse walking
+ limp
+ swellbruise
NSAIDs with some relief
ho 3 ankle sprains-no tx
PMH PSH Meds All Soc hx ROS nc
PE +swelling
Ecchymosis lat ankle
TTP ATFLCFL No medial TTP
Dec ROM due to stiffnesspain
Weak IRER with pain
-ant drawer +Talar tilt -EREversion test -syndesmosis squeeze -Thompsonrsquos test
X-ray 3 view wt bearing (APOblLat) Neg
Lateral ankle sprain 80-85 of all ankle sprains Inversion + plantarflexion of ankle 3 ligaments stabilize the lateral ankle
Injured in order based on severity ATFLCFLPTFL Present with swelling ecchymosis and variable weight-
bearing tolerance Anterior Drawer Test for ATFTalar Tilt Test for CF
Ottawa ankle rules guide need for x-ray Treatment
1 rule is control swelling RICE Crutches if limping Aggressive PT to regain strength and stability Bracing can be used as an adjunct to rehab and to prevent
future injury Associated Injury Fracture to the base of the 5th Metatarsal
912015
9
Dislocation Complete dissociation of humeral head from glenoid
fossa Subluxation is a transient displacement without complete
dissociation 95 are anterior dislocations Treatment
Stabilize arm multiple relocation techniques Surgery vs Nonsurgical management 90 of young athletes will re-dislocate
Associated injuries Joint capsule Labrum tear-Bankart Lesion Humeral fracture-Hill Sachs Deformity Axillary nerve or artery
AC joint separation (separated shoulder) Multiple ligaments and mm stabilize joint
Fall on top of shoulder
Graded I-VI (I-III most common)
Evaluation
Tender over AC Joint
+ Crossover Test
Treatment
Grades I-III Ice sling for comfort PT to regain ROM
Grades IV-VI Refer for surgery
I II IV V VI
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and upper
back most likely sprainstrain
Radicular symptoms include pain numbnesstingling and weakness into shoulder and arm to the hand
+ Spurlings sign = radiculopathy
Imaging
X-ray MRI EMG
Tx
NSAIDs muscle relaxers and PT
Epidural inj
Surgery
912015
10
Fall on outstretched arm
Limited flexext and pronationsupination Tenderness over lateral elbow
Swelling may or may not be present
Often missed on initial x-ray Important to re-xray after 2-3 wks
Treatment Sling for 3-7 days
Early ROM
Surgery rarely necessary
Little leaguerrsquos elbow Spectrum of injuries to elbow
Also overuse and poor mechanics
Caused by medial stress or lateral compression
Pitch counts
Treatment is rest followed by strength exercises
Focus on correcting mechanics
Progressive throwing program
Distal radius fracture Very common-17 of all fractures in ER
Treatment based on multiple anatomical factors
Cast up to 6wks
Scaphoid fracture 70 of true wrist fractures
Risk of nonunion or AVN
Pain in anatomical snuff box
May not be seen on initial x-rays
Long arm vs short arm cast
Can take up to 4 months to heal
912015
11
Carpal Tunnel Syndrome numbting and pain in radial 3 digits (+) Tinel and Phalen tests Confirmed by EMG with NCV Treatment
Cock-up Splint NSAIDS PT Surgery gt3 mos conservative care or worsening neurological
symptoms
DeQuervainrsquos Tenosynovitis APL amp EPB-1st dorsal compartment Tenderness and swelling over radial styloid (+) Finkelsteinrsquos Test Treatment
Thumb spica splint NSAIDs PT Corticosteroid inj Surgical release of 1st dorsal compartment
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and
upper back of sprainstrain Radicular symptoms include pain
numbnesstingling and weakness into buttock and leg to the foot
+ Straight Leg Raise = radiculopathy Imaging
X-ray MRI EMG
Tx NSAIDs muscle relaxers and PT
Epidural inj
Surgery
Meniscus Traumatic or degenerative
Caused by weight-bearing + rotational forces
co knee pain delayed swelling locking and catching
Effusion and joint line tenderness on exam
+McMurray and Thessaly (ldquoTwist amp Shoutrdquo) tests
Treatment
RICE NSAIDs
Functional symptoms require surgical evaluation
912015
12
Osgood-Schlatter Disease Osteochondritis of the tibial tuberosity Most commonly seen in 13-14 yo boys 11-12 yo girls
Most common in jumping sports History
Recent growth spurt Anterior knee pain
Physical Exam Tender over prominent tibial tuberosity
Tx Ice NSAIDs StretchStrengthen
quads and hams
OK to play to pain tolerance Self-limited condition
Legg-Calve-Perthes Disease Interruption of blood supply to femoral
epiphysis Average age is 4-9 yo Present with deep hip groin or thigh pain
May radiate to knee Walk with limp dec IR of hip Dx with x-ray
MRIBone scan if early Tx-Refer to ortho
Slipped Capital Femoral Epiphysis Due to shearing forces during growth spurts Avg age 8-15 yo Early dx is key-insidious onset of
hipgrointhighknee pain Dec IR on PE X-rays-ice cream scoop slipping off cone
Refer to Ortho
L-C-P
SCFE
OA
GROIN PAIN = HIP JOINT Pain can radiate to knee or low back so make
sure to check hip
Tx with NSAIDs PT Cort inj Surgery
Trochanteric Bursitis Paintenderness over greater trochanter
Worse with hip flexext
Multiple underlying factors
Tx with PT NSAIDs rest cort inj
912015
13
Patella femoral pain syndrome Abnormal tracking of patella in groove between condyles
of femur
Chronic in nature
co anterior knee pain Theater sign
Pain going down stairs
Increased Q angle on PE
Treatment Strength balance and flexibility
exercises
Foot orthotics
Bracingtaping in season
Surgery-rare
Medial Ankle Sprain Dorsiflexion + eversion of foot Injury to deltoid ligament
Fracture of tibia more common than ligament tear
Can extend proximally to cause fibular fracture
Similar presentation as a lateral ankle sprain X-rays required to assess joint stability Treatment
Same as lateral ankle sprain unless extension into syndesmosis or distal fibula Surgery if joint is unstable
Longer healing time than lateral ankle sprains
Plantar Fasciitis Irritation of the calcaneal attachment of the plantar
fascia
Not caused by heel spur
Insidious onset of pain radiating into arch
Painful 1st steps in AM
Tenderness of anterior-medial calcaneus
Often tight achilles tendon
Treatment
NSAIDs rest PT w massage orthotics night splints
Surgical release is last resort
912015
14
Sever Disease Apophysitis of posterior calcaneus
Epiphysis fuses at 12-15 yo
History
Insidious onset of heal pain
Boys 10-12 yo Girls 8-10 yo
Physical Exam
Tenderness over insertion of achilles tendon
Decrease passive ankle dorsiflexion
Treatment
Ice NSAIDs heel lifts stretchstrengthen heel cords
1 McKeag MD Douglas and James Moeller MD ACSMrsquos Primary Care Sports Medicine 2nd
Edition Philadelphia Lippincott Williams amp Wilkins 2007
2 Eiff MD M Patrice Robert Hatch MD and Walter Calmbach MD Fracture Management for Primary Care Philadelphia Saunders Elsevier 2003
3 DeLee MD Jesse David Drez Jr MD Mark Miller MD Orthopedic Sports Medicine Philadelphia Saunders Elsevier 2010
4 Magee PhD David Ortohpedic Physical Assessment 4th Edition Philadelphia Saunders Elsevier 2002
Shoulder Anatomy Greyrsquos -httpcommonswikimediaorgwikiFileShoulder_joint_anatomy_quizjpg
Forearm Extensors Greyrsquos -httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtSuperficialGrayBB418gif
Forearm Flexors Greyrsquos -
httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtDeepGrayBB415gif
Offensive Line US Navy Football -httpscommonswikimediaorgwikiFileUS_Navy_071201-N-6463B-447_Navy_Quarter_Back_Kaipo-Noa_Haheaku-Enhada_(10)_drops_back_to_pass_while_receiving_maximum_protection_from_his_offensive_line_at_the_108th_annual_Army_vs_Navy_football_game_at_M5ET_Bank_Stadium_in_Baljpg
Gymnast ndash httppixabaycomengymnastics-gymnast-sports-graceful-89608
Figure Skater - httpfreetemsnetfiledance-on-ice-460
Volleyball Court Serve - httpwwwnationmastercomencyclopediaVolleyball
Volleyball Spike US Airforce -
httpd1staticdvidshubnetmediathumbsphotos1305933304450x300_q75jpgis
Tennis Serve - httpcommonswikimediaorgwikiFileMarat_safin_1jpg
Ankle Anatomy Greyrsquos -httpwwwfpnotebookcom_mediaorthoLegFootLateralLigamentsGrayBB355gif
912015
15
AC Separation Grade I -httpcommonswikimediaorgwikiFileClassification_type_1_of_AC_separationpng
AC Separation Grade II -httpcommonswikimediaorgwikiFileClassification_type_2_of_AC_separationpng
AC Separation Grade IV -
httpcommonswikimediaorgwikiFileClassification_type_4_of_AC_separationpng
AC Separation Grade V -httpcommonswikimediaorgwikiFileClassification_type_5_of_AC_separationpng
AC Separation Grade VI -httpcommonswikimediaorgwikiFileClassification_type_6_of_AC_separationpng
Little League elbow - httpwwwpublicdomainpicturesnetview-imagephpimage=2144amppicture=throw-boy
Osgood-Schllater MRI - httpuploadwikimediaorgwikipediacommons999MBq_Osgood-Schlatterjpg
Osgood-Schlatter XR - httpuploadwikimediaorgwikipediacommonsdd9Osgood_Schlater_1JPG
Legg-Calve-Perthes - httpcommonswikimediaorgwikiFileLeggCalvePerthes1jpg
SCFE - httpuploadwikimediaorgwikipediacommons448SCFE_FROG_B26Wjpg
Knee Sunrise X-ray - httpscommonswikimediaorgwikiFileMedical_X-Ray_imaging_CFK03_nevitjpg
Severrsquos Disease - httpcommonswikimediaorgwikiFileMedical_X-Ray_imaging_TKL07_nevitjpg
Shoulder Forearms Ankle Greyrsquos Anatomy - This faithful reproduction of a lithograph plate from Grays Anatomy a two-
dimensional work of art is not copyrightable in the US as per Bridgeman Art Library v Corel Corp the same is also true in many other countries including Germany Unless stated otherwise it is from the 20th US edition of Grays Anatomy of the Human Body originally published in 1918 and therefore lapsed into the public domain Other copies of Grays Anatomy can be found on Bartleby and also on Yahoo
This image is in the public domain because its copyright has expired This applies worldwide
Offensive Line ndash US Navy Football - This file is a work of a sailor or employee of the US Navy taken or made as part of that persons
official duties As a work of the US federal government the image is in the public domain
Gymnast - The person who associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the
work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial purposes all without asking permission
Figure Skater - License Public Domain CC0 (absolutely free) File type jpg | file size 1478 kB Add date 2012-08-27 212949
Volleyball Court Serve - This file is licensed under the Creative Commons Attribution ShareAlike license versions 25 20 and10
US Air Force Volleyball Spike - This work 2013 United States Armed Forces Volleyball Championship [Image 11 of 28] by A1C Justyn
Freeman identified by DVIDS is free of known copyright restrictions under US copyright law
Tennis Serve - The copyright holder of this work released this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [they] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
AC Separation Grading - This file is made available under the Creative Commons CC0 10 Universal Public Domain DedicationThe person who
associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial
purposes all without asking permission
Little League Elbow - Royalty free stock photos All pictures are free for commercial and personal use
Osgood-Schlatter MR ampXray - The copyright holder of this work release this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [They] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
Legg-Calve-Perthes - This file is licensed under the Creative Commons Attribution 30 Unported license
SCFE - This work has been released into the public domain by its author Mikir at the wikipedia project This applies worldwide
Knee Sunrise X-ray - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the
terms of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
Severrsquos Disease - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the terms
of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
912015
9
Dislocation Complete dissociation of humeral head from glenoid
fossa Subluxation is a transient displacement without complete
dissociation 95 are anterior dislocations Treatment
Stabilize arm multiple relocation techniques Surgery vs Nonsurgical management 90 of young athletes will re-dislocate
Associated injuries Joint capsule Labrum tear-Bankart Lesion Humeral fracture-Hill Sachs Deformity Axillary nerve or artery
AC joint separation (separated shoulder) Multiple ligaments and mm stabilize joint
Fall on top of shoulder
Graded I-VI (I-III most common)
Evaluation
Tender over AC Joint
+ Crossover Test
Treatment
Grades I-III Ice sling for comfort PT to regain ROM
Grades IV-VI Refer for surgery
I II IV V VI
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and upper
back most likely sprainstrain
Radicular symptoms include pain numbnesstingling and weakness into shoulder and arm to the hand
+ Spurlings sign = radiculopathy
Imaging
X-ray MRI EMG
Tx
NSAIDs muscle relaxers and PT
Epidural inj
Surgery
912015
10
Fall on outstretched arm
Limited flexext and pronationsupination Tenderness over lateral elbow
Swelling may or may not be present
Often missed on initial x-ray Important to re-xray after 2-3 wks
Treatment Sling for 3-7 days
Early ROM
Surgery rarely necessary
Little leaguerrsquos elbow Spectrum of injuries to elbow
Also overuse and poor mechanics
Caused by medial stress or lateral compression
Pitch counts
Treatment is rest followed by strength exercises
Focus on correcting mechanics
Progressive throwing program
Distal radius fracture Very common-17 of all fractures in ER
Treatment based on multiple anatomical factors
Cast up to 6wks
Scaphoid fracture 70 of true wrist fractures
Risk of nonunion or AVN
Pain in anatomical snuff box
May not be seen on initial x-rays
Long arm vs short arm cast
Can take up to 4 months to heal
912015
11
Carpal Tunnel Syndrome numbting and pain in radial 3 digits (+) Tinel and Phalen tests Confirmed by EMG with NCV Treatment
Cock-up Splint NSAIDS PT Surgery gt3 mos conservative care or worsening neurological
symptoms
DeQuervainrsquos Tenosynovitis APL amp EPB-1st dorsal compartment Tenderness and swelling over radial styloid (+) Finkelsteinrsquos Test Treatment
Thumb spica splint NSAIDs PT Corticosteroid inj Surgical release of 1st dorsal compartment
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and
upper back of sprainstrain Radicular symptoms include pain
numbnesstingling and weakness into buttock and leg to the foot
+ Straight Leg Raise = radiculopathy Imaging
X-ray MRI EMG
Tx NSAIDs muscle relaxers and PT
Epidural inj
Surgery
Meniscus Traumatic or degenerative
Caused by weight-bearing + rotational forces
co knee pain delayed swelling locking and catching
Effusion and joint line tenderness on exam
+McMurray and Thessaly (ldquoTwist amp Shoutrdquo) tests
Treatment
RICE NSAIDs
Functional symptoms require surgical evaluation
912015
12
Osgood-Schlatter Disease Osteochondritis of the tibial tuberosity Most commonly seen in 13-14 yo boys 11-12 yo girls
Most common in jumping sports History
Recent growth spurt Anterior knee pain
Physical Exam Tender over prominent tibial tuberosity
Tx Ice NSAIDs StretchStrengthen
quads and hams
OK to play to pain tolerance Self-limited condition
Legg-Calve-Perthes Disease Interruption of blood supply to femoral
epiphysis Average age is 4-9 yo Present with deep hip groin or thigh pain
May radiate to knee Walk with limp dec IR of hip Dx with x-ray
MRIBone scan if early Tx-Refer to ortho
Slipped Capital Femoral Epiphysis Due to shearing forces during growth spurts Avg age 8-15 yo Early dx is key-insidious onset of
hipgrointhighknee pain Dec IR on PE X-rays-ice cream scoop slipping off cone
Refer to Ortho
L-C-P
SCFE
OA
GROIN PAIN = HIP JOINT Pain can radiate to knee or low back so make
sure to check hip
Tx with NSAIDs PT Cort inj Surgery
Trochanteric Bursitis Paintenderness over greater trochanter
Worse with hip flexext
Multiple underlying factors
Tx with PT NSAIDs rest cort inj
912015
13
Patella femoral pain syndrome Abnormal tracking of patella in groove between condyles
of femur
Chronic in nature
co anterior knee pain Theater sign
Pain going down stairs
Increased Q angle on PE
Treatment Strength balance and flexibility
exercises
Foot orthotics
Bracingtaping in season
Surgery-rare
Medial Ankle Sprain Dorsiflexion + eversion of foot Injury to deltoid ligament
Fracture of tibia more common than ligament tear
Can extend proximally to cause fibular fracture
Similar presentation as a lateral ankle sprain X-rays required to assess joint stability Treatment
Same as lateral ankle sprain unless extension into syndesmosis or distal fibula Surgery if joint is unstable
Longer healing time than lateral ankle sprains
Plantar Fasciitis Irritation of the calcaneal attachment of the plantar
fascia
Not caused by heel spur
Insidious onset of pain radiating into arch
Painful 1st steps in AM
Tenderness of anterior-medial calcaneus
Often tight achilles tendon
Treatment
NSAIDs rest PT w massage orthotics night splints
Surgical release is last resort
912015
14
Sever Disease Apophysitis of posterior calcaneus
Epiphysis fuses at 12-15 yo
History
Insidious onset of heal pain
Boys 10-12 yo Girls 8-10 yo
Physical Exam
Tenderness over insertion of achilles tendon
Decrease passive ankle dorsiflexion
Treatment
Ice NSAIDs heel lifts stretchstrengthen heel cords
1 McKeag MD Douglas and James Moeller MD ACSMrsquos Primary Care Sports Medicine 2nd
Edition Philadelphia Lippincott Williams amp Wilkins 2007
2 Eiff MD M Patrice Robert Hatch MD and Walter Calmbach MD Fracture Management for Primary Care Philadelphia Saunders Elsevier 2003
3 DeLee MD Jesse David Drez Jr MD Mark Miller MD Orthopedic Sports Medicine Philadelphia Saunders Elsevier 2010
4 Magee PhD David Ortohpedic Physical Assessment 4th Edition Philadelphia Saunders Elsevier 2002
Shoulder Anatomy Greyrsquos -httpcommonswikimediaorgwikiFileShoulder_joint_anatomy_quizjpg
Forearm Extensors Greyrsquos -httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtSuperficialGrayBB418gif
Forearm Flexors Greyrsquos -
httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtDeepGrayBB415gif
Offensive Line US Navy Football -httpscommonswikimediaorgwikiFileUS_Navy_071201-N-6463B-447_Navy_Quarter_Back_Kaipo-Noa_Haheaku-Enhada_(10)_drops_back_to_pass_while_receiving_maximum_protection_from_his_offensive_line_at_the_108th_annual_Army_vs_Navy_football_game_at_M5ET_Bank_Stadium_in_Baljpg
Gymnast ndash httppixabaycomengymnastics-gymnast-sports-graceful-89608
Figure Skater - httpfreetemsnetfiledance-on-ice-460
Volleyball Court Serve - httpwwwnationmastercomencyclopediaVolleyball
Volleyball Spike US Airforce -
httpd1staticdvidshubnetmediathumbsphotos1305933304450x300_q75jpgis
Tennis Serve - httpcommonswikimediaorgwikiFileMarat_safin_1jpg
Ankle Anatomy Greyrsquos -httpwwwfpnotebookcom_mediaorthoLegFootLateralLigamentsGrayBB355gif
912015
15
AC Separation Grade I -httpcommonswikimediaorgwikiFileClassification_type_1_of_AC_separationpng
AC Separation Grade II -httpcommonswikimediaorgwikiFileClassification_type_2_of_AC_separationpng
AC Separation Grade IV -
httpcommonswikimediaorgwikiFileClassification_type_4_of_AC_separationpng
AC Separation Grade V -httpcommonswikimediaorgwikiFileClassification_type_5_of_AC_separationpng
AC Separation Grade VI -httpcommonswikimediaorgwikiFileClassification_type_6_of_AC_separationpng
Little League elbow - httpwwwpublicdomainpicturesnetview-imagephpimage=2144amppicture=throw-boy
Osgood-Schllater MRI - httpuploadwikimediaorgwikipediacommons999MBq_Osgood-Schlatterjpg
Osgood-Schlatter XR - httpuploadwikimediaorgwikipediacommonsdd9Osgood_Schlater_1JPG
Legg-Calve-Perthes - httpcommonswikimediaorgwikiFileLeggCalvePerthes1jpg
SCFE - httpuploadwikimediaorgwikipediacommons448SCFE_FROG_B26Wjpg
Knee Sunrise X-ray - httpscommonswikimediaorgwikiFileMedical_X-Ray_imaging_CFK03_nevitjpg
Severrsquos Disease - httpcommonswikimediaorgwikiFileMedical_X-Ray_imaging_TKL07_nevitjpg
Shoulder Forearms Ankle Greyrsquos Anatomy - This faithful reproduction of a lithograph plate from Grays Anatomy a two-
dimensional work of art is not copyrightable in the US as per Bridgeman Art Library v Corel Corp the same is also true in many other countries including Germany Unless stated otherwise it is from the 20th US edition of Grays Anatomy of the Human Body originally published in 1918 and therefore lapsed into the public domain Other copies of Grays Anatomy can be found on Bartleby and also on Yahoo
This image is in the public domain because its copyright has expired This applies worldwide
Offensive Line ndash US Navy Football - This file is a work of a sailor or employee of the US Navy taken or made as part of that persons
official duties As a work of the US federal government the image is in the public domain
Gymnast - The person who associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the
work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial purposes all without asking permission
Figure Skater - License Public Domain CC0 (absolutely free) File type jpg | file size 1478 kB Add date 2012-08-27 212949
Volleyball Court Serve - This file is licensed under the Creative Commons Attribution ShareAlike license versions 25 20 and10
US Air Force Volleyball Spike - This work 2013 United States Armed Forces Volleyball Championship [Image 11 of 28] by A1C Justyn
Freeman identified by DVIDS is free of known copyright restrictions under US copyright law
Tennis Serve - The copyright holder of this work released this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [they] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
AC Separation Grading - This file is made available under the Creative Commons CC0 10 Universal Public Domain DedicationThe person who
associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial
purposes all without asking permission
Little League Elbow - Royalty free stock photos All pictures are free for commercial and personal use
Osgood-Schlatter MR ampXray - The copyright holder of this work release this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [They] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
Legg-Calve-Perthes - This file is licensed under the Creative Commons Attribution 30 Unported license
SCFE - This work has been released into the public domain by its author Mikir at the wikipedia project This applies worldwide
Knee Sunrise X-ray - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the
terms of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
Severrsquos Disease - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the terms
of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
912015
10
Fall on outstretched arm
Limited flexext and pronationsupination Tenderness over lateral elbow
Swelling may or may not be present
Often missed on initial x-ray Important to re-xray after 2-3 wks
Treatment Sling for 3-7 days
Early ROM
Surgery rarely necessary
Little leaguerrsquos elbow Spectrum of injuries to elbow
Also overuse and poor mechanics
Caused by medial stress or lateral compression
Pitch counts
Treatment is rest followed by strength exercises
Focus on correcting mechanics
Progressive throwing program
Distal radius fracture Very common-17 of all fractures in ER
Treatment based on multiple anatomical factors
Cast up to 6wks
Scaphoid fracture 70 of true wrist fractures
Risk of nonunion or AVN
Pain in anatomical snuff box
May not be seen on initial x-rays
Long arm vs short arm cast
Can take up to 4 months to heal
912015
11
Carpal Tunnel Syndrome numbting and pain in radial 3 digits (+) Tinel and Phalen tests Confirmed by EMG with NCV Treatment
Cock-up Splint NSAIDS PT Surgery gt3 mos conservative care or worsening neurological
symptoms
DeQuervainrsquos Tenosynovitis APL amp EPB-1st dorsal compartment Tenderness and swelling over radial styloid (+) Finkelsteinrsquos Test Treatment
Thumb spica splint NSAIDs PT Corticosteroid inj Surgical release of 1st dorsal compartment
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and
upper back of sprainstrain Radicular symptoms include pain
numbnesstingling and weakness into buttock and leg to the foot
+ Straight Leg Raise = radiculopathy Imaging
X-ray MRI EMG
Tx NSAIDs muscle relaxers and PT
Epidural inj
Surgery
Meniscus Traumatic or degenerative
Caused by weight-bearing + rotational forces
co knee pain delayed swelling locking and catching
Effusion and joint line tenderness on exam
+McMurray and Thessaly (ldquoTwist amp Shoutrdquo) tests
Treatment
RICE NSAIDs
Functional symptoms require surgical evaluation
912015
12
Osgood-Schlatter Disease Osteochondritis of the tibial tuberosity Most commonly seen in 13-14 yo boys 11-12 yo girls
Most common in jumping sports History
Recent growth spurt Anterior knee pain
Physical Exam Tender over prominent tibial tuberosity
Tx Ice NSAIDs StretchStrengthen
quads and hams
OK to play to pain tolerance Self-limited condition
Legg-Calve-Perthes Disease Interruption of blood supply to femoral
epiphysis Average age is 4-9 yo Present with deep hip groin or thigh pain
May radiate to knee Walk with limp dec IR of hip Dx with x-ray
MRIBone scan if early Tx-Refer to ortho
Slipped Capital Femoral Epiphysis Due to shearing forces during growth spurts Avg age 8-15 yo Early dx is key-insidious onset of
hipgrointhighknee pain Dec IR on PE X-rays-ice cream scoop slipping off cone
Refer to Ortho
L-C-P
SCFE
OA
GROIN PAIN = HIP JOINT Pain can radiate to knee or low back so make
sure to check hip
Tx with NSAIDs PT Cort inj Surgery
Trochanteric Bursitis Paintenderness over greater trochanter
Worse with hip flexext
Multiple underlying factors
Tx with PT NSAIDs rest cort inj
912015
13
Patella femoral pain syndrome Abnormal tracking of patella in groove between condyles
of femur
Chronic in nature
co anterior knee pain Theater sign
Pain going down stairs
Increased Q angle on PE
Treatment Strength balance and flexibility
exercises
Foot orthotics
Bracingtaping in season
Surgery-rare
Medial Ankle Sprain Dorsiflexion + eversion of foot Injury to deltoid ligament
Fracture of tibia more common than ligament tear
Can extend proximally to cause fibular fracture
Similar presentation as a lateral ankle sprain X-rays required to assess joint stability Treatment
Same as lateral ankle sprain unless extension into syndesmosis or distal fibula Surgery if joint is unstable
Longer healing time than lateral ankle sprains
Plantar Fasciitis Irritation of the calcaneal attachment of the plantar
fascia
Not caused by heel spur
Insidious onset of pain radiating into arch
Painful 1st steps in AM
Tenderness of anterior-medial calcaneus
Often tight achilles tendon
Treatment
NSAIDs rest PT w massage orthotics night splints
Surgical release is last resort
912015
14
Sever Disease Apophysitis of posterior calcaneus
Epiphysis fuses at 12-15 yo
History
Insidious onset of heal pain
Boys 10-12 yo Girls 8-10 yo
Physical Exam
Tenderness over insertion of achilles tendon
Decrease passive ankle dorsiflexion
Treatment
Ice NSAIDs heel lifts stretchstrengthen heel cords
1 McKeag MD Douglas and James Moeller MD ACSMrsquos Primary Care Sports Medicine 2nd
Edition Philadelphia Lippincott Williams amp Wilkins 2007
2 Eiff MD M Patrice Robert Hatch MD and Walter Calmbach MD Fracture Management for Primary Care Philadelphia Saunders Elsevier 2003
3 DeLee MD Jesse David Drez Jr MD Mark Miller MD Orthopedic Sports Medicine Philadelphia Saunders Elsevier 2010
4 Magee PhD David Ortohpedic Physical Assessment 4th Edition Philadelphia Saunders Elsevier 2002
Shoulder Anatomy Greyrsquos -httpcommonswikimediaorgwikiFileShoulder_joint_anatomy_quizjpg
Forearm Extensors Greyrsquos -httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtSuperficialGrayBB418gif
Forearm Flexors Greyrsquos -
httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtDeepGrayBB415gif
Offensive Line US Navy Football -httpscommonswikimediaorgwikiFileUS_Navy_071201-N-6463B-447_Navy_Quarter_Back_Kaipo-Noa_Haheaku-Enhada_(10)_drops_back_to_pass_while_receiving_maximum_protection_from_his_offensive_line_at_the_108th_annual_Army_vs_Navy_football_game_at_M5ET_Bank_Stadium_in_Baljpg
Gymnast ndash httppixabaycomengymnastics-gymnast-sports-graceful-89608
Figure Skater - httpfreetemsnetfiledance-on-ice-460
Volleyball Court Serve - httpwwwnationmastercomencyclopediaVolleyball
Volleyball Spike US Airforce -
httpd1staticdvidshubnetmediathumbsphotos1305933304450x300_q75jpgis
Tennis Serve - httpcommonswikimediaorgwikiFileMarat_safin_1jpg
Ankle Anatomy Greyrsquos -httpwwwfpnotebookcom_mediaorthoLegFootLateralLigamentsGrayBB355gif
912015
15
AC Separation Grade I -httpcommonswikimediaorgwikiFileClassification_type_1_of_AC_separationpng
AC Separation Grade II -httpcommonswikimediaorgwikiFileClassification_type_2_of_AC_separationpng
AC Separation Grade IV -
httpcommonswikimediaorgwikiFileClassification_type_4_of_AC_separationpng
AC Separation Grade V -httpcommonswikimediaorgwikiFileClassification_type_5_of_AC_separationpng
AC Separation Grade VI -httpcommonswikimediaorgwikiFileClassification_type_6_of_AC_separationpng
Little League elbow - httpwwwpublicdomainpicturesnetview-imagephpimage=2144amppicture=throw-boy
Osgood-Schllater MRI - httpuploadwikimediaorgwikipediacommons999MBq_Osgood-Schlatterjpg
Osgood-Schlatter XR - httpuploadwikimediaorgwikipediacommonsdd9Osgood_Schlater_1JPG
Legg-Calve-Perthes - httpcommonswikimediaorgwikiFileLeggCalvePerthes1jpg
SCFE - httpuploadwikimediaorgwikipediacommons448SCFE_FROG_B26Wjpg
Knee Sunrise X-ray - httpscommonswikimediaorgwikiFileMedical_X-Ray_imaging_CFK03_nevitjpg
Severrsquos Disease - httpcommonswikimediaorgwikiFileMedical_X-Ray_imaging_TKL07_nevitjpg
Shoulder Forearms Ankle Greyrsquos Anatomy - This faithful reproduction of a lithograph plate from Grays Anatomy a two-
dimensional work of art is not copyrightable in the US as per Bridgeman Art Library v Corel Corp the same is also true in many other countries including Germany Unless stated otherwise it is from the 20th US edition of Grays Anatomy of the Human Body originally published in 1918 and therefore lapsed into the public domain Other copies of Grays Anatomy can be found on Bartleby and also on Yahoo
This image is in the public domain because its copyright has expired This applies worldwide
Offensive Line ndash US Navy Football - This file is a work of a sailor or employee of the US Navy taken or made as part of that persons
official duties As a work of the US federal government the image is in the public domain
Gymnast - The person who associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the
work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial purposes all without asking permission
Figure Skater - License Public Domain CC0 (absolutely free) File type jpg | file size 1478 kB Add date 2012-08-27 212949
Volleyball Court Serve - This file is licensed under the Creative Commons Attribution ShareAlike license versions 25 20 and10
US Air Force Volleyball Spike - This work 2013 United States Armed Forces Volleyball Championship [Image 11 of 28] by A1C Justyn
Freeman identified by DVIDS is free of known copyright restrictions under US copyright law
Tennis Serve - The copyright holder of this work released this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [they] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
AC Separation Grading - This file is made available under the Creative Commons CC0 10 Universal Public Domain DedicationThe person who
associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial
purposes all without asking permission
Little League Elbow - Royalty free stock photos All pictures are free for commercial and personal use
Osgood-Schlatter MR ampXray - The copyright holder of this work release this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [They] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
Legg-Calve-Perthes - This file is licensed under the Creative Commons Attribution 30 Unported license
SCFE - This work has been released into the public domain by its author Mikir at the wikipedia project This applies worldwide
Knee Sunrise X-ray - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the
terms of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
Severrsquos Disease - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the terms
of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
912015
11
Carpal Tunnel Syndrome numbting and pain in radial 3 digits (+) Tinel and Phalen tests Confirmed by EMG with NCV Treatment
Cock-up Splint NSAIDS PT Surgery gt3 mos conservative care or worsening neurological
symptoms
DeQuervainrsquos Tenosynovitis APL amp EPB-1st dorsal compartment Tenderness and swelling over radial styloid (+) Finkelsteinrsquos Test Treatment
Thumb spica splint NSAIDs PT Corticosteroid inj Surgical release of 1st dorsal compartment
SprainStrain vs Radiculopathy Presentation of painstiffness limited to neck and
upper back of sprainstrain Radicular symptoms include pain
numbnesstingling and weakness into buttock and leg to the foot
+ Straight Leg Raise = radiculopathy Imaging
X-ray MRI EMG
Tx NSAIDs muscle relaxers and PT
Epidural inj
Surgery
Meniscus Traumatic or degenerative
Caused by weight-bearing + rotational forces
co knee pain delayed swelling locking and catching
Effusion and joint line tenderness on exam
+McMurray and Thessaly (ldquoTwist amp Shoutrdquo) tests
Treatment
RICE NSAIDs
Functional symptoms require surgical evaluation
912015
12
Osgood-Schlatter Disease Osteochondritis of the tibial tuberosity Most commonly seen in 13-14 yo boys 11-12 yo girls
Most common in jumping sports History
Recent growth spurt Anterior knee pain
Physical Exam Tender over prominent tibial tuberosity
Tx Ice NSAIDs StretchStrengthen
quads and hams
OK to play to pain tolerance Self-limited condition
Legg-Calve-Perthes Disease Interruption of blood supply to femoral
epiphysis Average age is 4-9 yo Present with deep hip groin or thigh pain
May radiate to knee Walk with limp dec IR of hip Dx with x-ray
MRIBone scan if early Tx-Refer to ortho
Slipped Capital Femoral Epiphysis Due to shearing forces during growth spurts Avg age 8-15 yo Early dx is key-insidious onset of
hipgrointhighknee pain Dec IR on PE X-rays-ice cream scoop slipping off cone
Refer to Ortho
L-C-P
SCFE
OA
GROIN PAIN = HIP JOINT Pain can radiate to knee or low back so make
sure to check hip
Tx with NSAIDs PT Cort inj Surgery
Trochanteric Bursitis Paintenderness over greater trochanter
Worse with hip flexext
Multiple underlying factors
Tx with PT NSAIDs rest cort inj
912015
13
Patella femoral pain syndrome Abnormal tracking of patella in groove between condyles
of femur
Chronic in nature
co anterior knee pain Theater sign
Pain going down stairs
Increased Q angle on PE
Treatment Strength balance and flexibility
exercises
Foot orthotics
Bracingtaping in season
Surgery-rare
Medial Ankle Sprain Dorsiflexion + eversion of foot Injury to deltoid ligament
Fracture of tibia more common than ligament tear
Can extend proximally to cause fibular fracture
Similar presentation as a lateral ankle sprain X-rays required to assess joint stability Treatment
Same as lateral ankle sprain unless extension into syndesmosis or distal fibula Surgery if joint is unstable
Longer healing time than lateral ankle sprains
Plantar Fasciitis Irritation of the calcaneal attachment of the plantar
fascia
Not caused by heel spur
Insidious onset of pain radiating into arch
Painful 1st steps in AM
Tenderness of anterior-medial calcaneus
Often tight achilles tendon
Treatment
NSAIDs rest PT w massage orthotics night splints
Surgical release is last resort
912015
14
Sever Disease Apophysitis of posterior calcaneus
Epiphysis fuses at 12-15 yo
History
Insidious onset of heal pain
Boys 10-12 yo Girls 8-10 yo
Physical Exam
Tenderness over insertion of achilles tendon
Decrease passive ankle dorsiflexion
Treatment
Ice NSAIDs heel lifts stretchstrengthen heel cords
1 McKeag MD Douglas and James Moeller MD ACSMrsquos Primary Care Sports Medicine 2nd
Edition Philadelphia Lippincott Williams amp Wilkins 2007
2 Eiff MD M Patrice Robert Hatch MD and Walter Calmbach MD Fracture Management for Primary Care Philadelphia Saunders Elsevier 2003
3 DeLee MD Jesse David Drez Jr MD Mark Miller MD Orthopedic Sports Medicine Philadelphia Saunders Elsevier 2010
4 Magee PhD David Ortohpedic Physical Assessment 4th Edition Philadelphia Saunders Elsevier 2002
Shoulder Anatomy Greyrsquos -httpcommonswikimediaorgwikiFileShoulder_joint_anatomy_quizjpg
Forearm Extensors Greyrsquos -httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtSuperficialGrayBB418gif
Forearm Flexors Greyrsquos -
httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtDeepGrayBB415gif
Offensive Line US Navy Football -httpscommonswikimediaorgwikiFileUS_Navy_071201-N-6463B-447_Navy_Quarter_Back_Kaipo-Noa_Haheaku-Enhada_(10)_drops_back_to_pass_while_receiving_maximum_protection_from_his_offensive_line_at_the_108th_annual_Army_vs_Navy_football_game_at_M5ET_Bank_Stadium_in_Baljpg
Gymnast ndash httppixabaycomengymnastics-gymnast-sports-graceful-89608
Figure Skater - httpfreetemsnetfiledance-on-ice-460
Volleyball Court Serve - httpwwwnationmastercomencyclopediaVolleyball
Volleyball Spike US Airforce -
httpd1staticdvidshubnetmediathumbsphotos1305933304450x300_q75jpgis
Tennis Serve - httpcommonswikimediaorgwikiFileMarat_safin_1jpg
Ankle Anatomy Greyrsquos -httpwwwfpnotebookcom_mediaorthoLegFootLateralLigamentsGrayBB355gif
912015
15
AC Separation Grade I -httpcommonswikimediaorgwikiFileClassification_type_1_of_AC_separationpng
AC Separation Grade II -httpcommonswikimediaorgwikiFileClassification_type_2_of_AC_separationpng
AC Separation Grade IV -
httpcommonswikimediaorgwikiFileClassification_type_4_of_AC_separationpng
AC Separation Grade V -httpcommonswikimediaorgwikiFileClassification_type_5_of_AC_separationpng
AC Separation Grade VI -httpcommonswikimediaorgwikiFileClassification_type_6_of_AC_separationpng
Little League elbow - httpwwwpublicdomainpicturesnetview-imagephpimage=2144amppicture=throw-boy
Osgood-Schllater MRI - httpuploadwikimediaorgwikipediacommons999MBq_Osgood-Schlatterjpg
Osgood-Schlatter XR - httpuploadwikimediaorgwikipediacommonsdd9Osgood_Schlater_1JPG
Legg-Calve-Perthes - httpcommonswikimediaorgwikiFileLeggCalvePerthes1jpg
SCFE - httpuploadwikimediaorgwikipediacommons448SCFE_FROG_B26Wjpg
Knee Sunrise X-ray - httpscommonswikimediaorgwikiFileMedical_X-Ray_imaging_CFK03_nevitjpg
Severrsquos Disease - httpcommonswikimediaorgwikiFileMedical_X-Ray_imaging_TKL07_nevitjpg
Shoulder Forearms Ankle Greyrsquos Anatomy - This faithful reproduction of a lithograph plate from Grays Anatomy a two-
dimensional work of art is not copyrightable in the US as per Bridgeman Art Library v Corel Corp the same is also true in many other countries including Germany Unless stated otherwise it is from the 20th US edition of Grays Anatomy of the Human Body originally published in 1918 and therefore lapsed into the public domain Other copies of Grays Anatomy can be found on Bartleby and also on Yahoo
This image is in the public domain because its copyright has expired This applies worldwide
Offensive Line ndash US Navy Football - This file is a work of a sailor or employee of the US Navy taken or made as part of that persons
official duties As a work of the US federal government the image is in the public domain
Gymnast - The person who associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the
work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial purposes all without asking permission
Figure Skater - License Public Domain CC0 (absolutely free) File type jpg | file size 1478 kB Add date 2012-08-27 212949
Volleyball Court Serve - This file is licensed under the Creative Commons Attribution ShareAlike license versions 25 20 and10
US Air Force Volleyball Spike - This work 2013 United States Armed Forces Volleyball Championship [Image 11 of 28] by A1C Justyn
Freeman identified by DVIDS is free of known copyright restrictions under US copyright law
Tennis Serve - The copyright holder of this work released this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [they] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
AC Separation Grading - This file is made available under the Creative Commons CC0 10 Universal Public Domain DedicationThe person who
associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial
purposes all without asking permission
Little League Elbow - Royalty free stock photos All pictures are free for commercial and personal use
Osgood-Schlatter MR ampXray - The copyright holder of this work release this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [They] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
Legg-Calve-Perthes - This file is licensed under the Creative Commons Attribution 30 Unported license
SCFE - This work has been released into the public domain by its author Mikir at the wikipedia project This applies worldwide
Knee Sunrise X-ray - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the
terms of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
Severrsquos Disease - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the terms
of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
912015
12
Osgood-Schlatter Disease Osteochondritis of the tibial tuberosity Most commonly seen in 13-14 yo boys 11-12 yo girls
Most common in jumping sports History
Recent growth spurt Anterior knee pain
Physical Exam Tender over prominent tibial tuberosity
Tx Ice NSAIDs StretchStrengthen
quads and hams
OK to play to pain tolerance Self-limited condition
Legg-Calve-Perthes Disease Interruption of blood supply to femoral
epiphysis Average age is 4-9 yo Present with deep hip groin or thigh pain
May radiate to knee Walk with limp dec IR of hip Dx with x-ray
MRIBone scan if early Tx-Refer to ortho
Slipped Capital Femoral Epiphysis Due to shearing forces during growth spurts Avg age 8-15 yo Early dx is key-insidious onset of
hipgrointhighknee pain Dec IR on PE X-rays-ice cream scoop slipping off cone
Refer to Ortho
L-C-P
SCFE
OA
GROIN PAIN = HIP JOINT Pain can radiate to knee or low back so make
sure to check hip
Tx with NSAIDs PT Cort inj Surgery
Trochanteric Bursitis Paintenderness over greater trochanter
Worse with hip flexext
Multiple underlying factors
Tx with PT NSAIDs rest cort inj
912015
13
Patella femoral pain syndrome Abnormal tracking of patella in groove between condyles
of femur
Chronic in nature
co anterior knee pain Theater sign
Pain going down stairs
Increased Q angle on PE
Treatment Strength balance and flexibility
exercises
Foot orthotics
Bracingtaping in season
Surgery-rare
Medial Ankle Sprain Dorsiflexion + eversion of foot Injury to deltoid ligament
Fracture of tibia more common than ligament tear
Can extend proximally to cause fibular fracture
Similar presentation as a lateral ankle sprain X-rays required to assess joint stability Treatment
Same as lateral ankle sprain unless extension into syndesmosis or distal fibula Surgery if joint is unstable
Longer healing time than lateral ankle sprains
Plantar Fasciitis Irritation of the calcaneal attachment of the plantar
fascia
Not caused by heel spur
Insidious onset of pain radiating into arch
Painful 1st steps in AM
Tenderness of anterior-medial calcaneus
Often tight achilles tendon
Treatment
NSAIDs rest PT w massage orthotics night splints
Surgical release is last resort
912015
14
Sever Disease Apophysitis of posterior calcaneus
Epiphysis fuses at 12-15 yo
History
Insidious onset of heal pain
Boys 10-12 yo Girls 8-10 yo
Physical Exam
Tenderness over insertion of achilles tendon
Decrease passive ankle dorsiflexion
Treatment
Ice NSAIDs heel lifts stretchstrengthen heel cords
1 McKeag MD Douglas and James Moeller MD ACSMrsquos Primary Care Sports Medicine 2nd
Edition Philadelphia Lippincott Williams amp Wilkins 2007
2 Eiff MD M Patrice Robert Hatch MD and Walter Calmbach MD Fracture Management for Primary Care Philadelphia Saunders Elsevier 2003
3 DeLee MD Jesse David Drez Jr MD Mark Miller MD Orthopedic Sports Medicine Philadelphia Saunders Elsevier 2010
4 Magee PhD David Ortohpedic Physical Assessment 4th Edition Philadelphia Saunders Elsevier 2002
Shoulder Anatomy Greyrsquos -httpcommonswikimediaorgwikiFileShoulder_joint_anatomy_quizjpg
Forearm Extensors Greyrsquos -httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtSuperficialGrayBB418gif
Forearm Flexors Greyrsquos -
httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtDeepGrayBB415gif
Offensive Line US Navy Football -httpscommonswikimediaorgwikiFileUS_Navy_071201-N-6463B-447_Navy_Quarter_Back_Kaipo-Noa_Haheaku-Enhada_(10)_drops_back_to_pass_while_receiving_maximum_protection_from_his_offensive_line_at_the_108th_annual_Army_vs_Navy_football_game_at_M5ET_Bank_Stadium_in_Baljpg
Gymnast ndash httppixabaycomengymnastics-gymnast-sports-graceful-89608
Figure Skater - httpfreetemsnetfiledance-on-ice-460
Volleyball Court Serve - httpwwwnationmastercomencyclopediaVolleyball
Volleyball Spike US Airforce -
httpd1staticdvidshubnetmediathumbsphotos1305933304450x300_q75jpgis
Tennis Serve - httpcommonswikimediaorgwikiFileMarat_safin_1jpg
Ankle Anatomy Greyrsquos -httpwwwfpnotebookcom_mediaorthoLegFootLateralLigamentsGrayBB355gif
912015
15
AC Separation Grade I -httpcommonswikimediaorgwikiFileClassification_type_1_of_AC_separationpng
AC Separation Grade II -httpcommonswikimediaorgwikiFileClassification_type_2_of_AC_separationpng
AC Separation Grade IV -
httpcommonswikimediaorgwikiFileClassification_type_4_of_AC_separationpng
AC Separation Grade V -httpcommonswikimediaorgwikiFileClassification_type_5_of_AC_separationpng
AC Separation Grade VI -httpcommonswikimediaorgwikiFileClassification_type_6_of_AC_separationpng
Little League elbow - httpwwwpublicdomainpicturesnetview-imagephpimage=2144amppicture=throw-boy
Osgood-Schllater MRI - httpuploadwikimediaorgwikipediacommons999MBq_Osgood-Schlatterjpg
Osgood-Schlatter XR - httpuploadwikimediaorgwikipediacommonsdd9Osgood_Schlater_1JPG
Legg-Calve-Perthes - httpcommonswikimediaorgwikiFileLeggCalvePerthes1jpg
SCFE - httpuploadwikimediaorgwikipediacommons448SCFE_FROG_B26Wjpg
Knee Sunrise X-ray - httpscommonswikimediaorgwikiFileMedical_X-Ray_imaging_CFK03_nevitjpg
Severrsquos Disease - httpcommonswikimediaorgwikiFileMedical_X-Ray_imaging_TKL07_nevitjpg
Shoulder Forearms Ankle Greyrsquos Anatomy - This faithful reproduction of a lithograph plate from Grays Anatomy a two-
dimensional work of art is not copyrightable in the US as per Bridgeman Art Library v Corel Corp the same is also true in many other countries including Germany Unless stated otherwise it is from the 20th US edition of Grays Anatomy of the Human Body originally published in 1918 and therefore lapsed into the public domain Other copies of Grays Anatomy can be found on Bartleby and also on Yahoo
This image is in the public domain because its copyright has expired This applies worldwide
Offensive Line ndash US Navy Football - This file is a work of a sailor or employee of the US Navy taken or made as part of that persons
official duties As a work of the US federal government the image is in the public domain
Gymnast - The person who associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the
work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial purposes all without asking permission
Figure Skater - License Public Domain CC0 (absolutely free) File type jpg | file size 1478 kB Add date 2012-08-27 212949
Volleyball Court Serve - This file is licensed under the Creative Commons Attribution ShareAlike license versions 25 20 and10
US Air Force Volleyball Spike - This work 2013 United States Armed Forces Volleyball Championship [Image 11 of 28] by A1C Justyn
Freeman identified by DVIDS is free of known copyright restrictions under US copyright law
Tennis Serve - The copyright holder of this work released this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [they] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
AC Separation Grading - This file is made available under the Creative Commons CC0 10 Universal Public Domain DedicationThe person who
associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial
purposes all without asking permission
Little League Elbow - Royalty free stock photos All pictures are free for commercial and personal use
Osgood-Schlatter MR ampXray - The copyright holder of this work release this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [They] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
Legg-Calve-Perthes - This file is licensed under the Creative Commons Attribution 30 Unported license
SCFE - This work has been released into the public domain by its author Mikir at the wikipedia project This applies worldwide
Knee Sunrise X-ray - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the
terms of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
Severrsquos Disease - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the terms
of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
912015
13
Patella femoral pain syndrome Abnormal tracking of patella in groove between condyles
of femur
Chronic in nature
co anterior knee pain Theater sign
Pain going down stairs
Increased Q angle on PE
Treatment Strength balance and flexibility
exercises
Foot orthotics
Bracingtaping in season
Surgery-rare
Medial Ankle Sprain Dorsiflexion + eversion of foot Injury to deltoid ligament
Fracture of tibia more common than ligament tear
Can extend proximally to cause fibular fracture
Similar presentation as a lateral ankle sprain X-rays required to assess joint stability Treatment
Same as lateral ankle sprain unless extension into syndesmosis or distal fibula Surgery if joint is unstable
Longer healing time than lateral ankle sprains
Plantar Fasciitis Irritation of the calcaneal attachment of the plantar
fascia
Not caused by heel spur
Insidious onset of pain radiating into arch
Painful 1st steps in AM
Tenderness of anterior-medial calcaneus
Often tight achilles tendon
Treatment
NSAIDs rest PT w massage orthotics night splints
Surgical release is last resort
912015
14
Sever Disease Apophysitis of posterior calcaneus
Epiphysis fuses at 12-15 yo
History
Insidious onset of heal pain
Boys 10-12 yo Girls 8-10 yo
Physical Exam
Tenderness over insertion of achilles tendon
Decrease passive ankle dorsiflexion
Treatment
Ice NSAIDs heel lifts stretchstrengthen heel cords
1 McKeag MD Douglas and James Moeller MD ACSMrsquos Primary Care Sports Medicine 2nd
Edition Philadelphia Lippincott Williams amp Wilkins 2007
2 Eiff MD M Patrice Robert Hatch MD and Walter Calmbach MD Fracture Management for Primary Care Philadelphia Saunders Elsevier 2003
3 DeLee MD Jesse David Drez Jr MD Mark Miller MD Orthopedic Sports Medicine Philadelphia Saunders Elsevier 2010
4 Magee PhD David Ortohpedic Physical Assessment 4th Edition Philadelphia Saunders Elsevier 2002
Shoulder Anatomy Greyrsquos -httpcommonswikimediaorgwikiFileShoulder_joint_anatomy_quizjpg
Forearm Extensors Greyrsquos -httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtSuperficialGrayBB418gif
Forearm Flexors Greyrsquos -
httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtDeepGrayBB415gif
Offensive Line US Navy Football -httpscommonswikimediaorgwikiFileUS_Navy_071201-N-6463B-447_Navy_Quarter_Back_Kaipo-Noa_Haheaku-Enhada_(10)_drops_back_to_pass_while_receiving_maximum_protection_from_his_offensive_line_at_the_108th_annual_Army_vs_Navy_football_game_at_M5ET_Bank_Stadium_in_Baljpg
Gymnast ndash httppixabaycomengymnastics-gymnast-sports-graceful-89608
Figure Skater - httpfreetemsnetfiledance-on-ice-460
Volleyball Court Serve - httpwwwnationmastercomencyclopediaVolleyball
Volleyball Spike US Airforce -
httpd1staticdvidshubnetmediathumbsphotos1305933304450x300_q75jpgis
Tennis Serve - httpcommonswikimediaorgwikiFileMarat_safin_1jpg
Ankle Anatomy Greyrsquos -httpwwwfpnotebookcom_mediaorthoLegFootLateralLigamentsGrayBB355gif
912015
15
AC Separation Grade I -httpcommonswikimediaorgwikiFileClassification_type_1_of_AC_separationpng
AC Separation Grade II -httpcommonswikimediaorgwikiFileClassification_type_2_of_AC_separationpng
AC Separation Grade IV -
httpcommonswikimediaorgwikiFileClassification_type_4_of_AC_separationpng
AC Separation Grade V -httpcommonswikimediaorgwikiFileClassification_type_5_of_AC_separationpng
AC Separation Grade VI -httpcommonswikimediaorgwikiFileClassification_type_6_of_AC_separationpng
Little League elbow - httpwwwpublicdomainpicturesnetview-imagephpimage=2144amppicture=throw-boy
Osgood-Schllater MRI - httpuploadwikimediaorgwikipediacommons999MBq_Osgood-Schlatterjpg
Osgood-Schlatter XR - httpuploadwikimediaorgwikipediacommonsdd9Osgood_Schlater_1JPG
Legg-Calve-Perthes - httpcommonswikimediaorgwikiFileLeggCalvePerthes1jpg
SCFE - httpuploadwikimediaorgwikipediacommons448SCFE_FROG_B26Wjpg
Knee Sunrise X-ray - httpscommonswikimediaorgwikiFileMedical_X-Ray_imaging_CFK03_nevitjpg
Severrsquos Disease - httpcommonswikimediaorgwikiFileMedical_X-Ray_imaging_TKL07_nevitjpg
Shoulder Forearms Ankle Greyrsquos Anatomy - This faithful reproduction of a lithograph plate from Grays Anatomy a two-
dimensional work of art is not copyrightable in the US as per Bridgeman Art Library v Corel Corp the same is also true in many other countries including Germany Unless stated otherwise it is from the 20th US edition of Grays Anatomy of the Human Body originally published in 1918 and therefore lapsed into the public domain Other copies of Grays Anatomy can be found on Bartleby and also on Yahoo
This image is in the public domain because its copyright has expired This applies worldwide
Offensive Line ndash US Navy Football - This file is a work of a sailor or employee of the US Navy taken or made as part of that persons
official duties As a work of the US federal government the image is in the public domain
Gymnast - The person who associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the
work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial purposes all without asking permission
Figure Skater - License Public Domain CC0 (absolutely free) File type jpg | file size 1478 kB Add date 2012-08-27 212949
Volleyball Court Serve - This file is licensed under the Creative Commons Attribution ShareAlike license versions 25 20 and10
US Air Force Volleyball Spike - This work 2013 United States Armed Forces Volleyball Championship [Image 11 of 28] by A1C Justyn
Freeman identified by DVIDS is free of known copyright restrictions under US copyright law
Tennis Serve - The copyright holder of this work released this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [they] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
AC Separation Grading - This file is made available under the Creative Commons CC0 10 Universal Public Domain DedicationThe person who
associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial
purposes all without asking permission
Little League Elbow - Royalty free stock photos All pictures are free for commercial and personal use
Osgood-Schlatter MR ampXray - The copyright holder of this work release this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [They] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
Legg-Calve-Perthes - This file is licensed under the Creative Commons Attribution 30 Unported license
SCFE - This work has been released into the public domain by its author Mikir at the wikipedia project This applies worldwide
Knee Sunrise X-ray - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the
terms of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
Severrsquos Disease - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the terms
of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
912015
14
Sever Disease Apophysitis of posterior calcaneus
Epiphysis fuses at 12-15 yo
History
Insidious onset of heal pain
Boys 10-12 yo Girls 8-10 yo
Physical Exam
Tenderness over insertion of achilles tendon
Decrease passive ankle dorsiflexion
Treatment
Ice NSAIDs heel lifts stretchstrengthen heel cords
1 McKeag MD Douglas and James Moeller MD ACSMrsquos Primary Care Sports Medicine 2nd
Edition Philadelphia Lippincott Williams amp Wilkins 2007
2 Eiff MD M Patrice Robert Hatch MD and Walter Calmbach MD Fracture Management for Primary Care Philadelphia Saunders Elsevier 2003
3 DeLee MD Jesse David Drez Jr MD Mark Miller MD Orthopedic Sports Medicine Philadelphia Saunders Elsevier 2010
4 Magee PhD David Ortohpedic Physical Assessment 4th Edition Philadelphia Saunders Elsevier 2002
Shoulder Anatomy Greyrsquos -httpcommonswikimediaorgwikiFileShoulder_joint_anatomy_quizjpg
Forearm Extensors Greyrsquos -httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtSuperficialGrayBB418gif
Forearm Flexors Greyrsquos -
httpwwwfpnotebookcom_mediaorthoArmForearmMusclesLtDeepGrayBB415gif
Offensive Line US Navy Football -httpscommonswikimediaorgwikiFileUS_Navy_071201-N-6463B-447_Navy_Quarter_Back_Kaipo-Noa_Haheaku-Enhada_(10)_drops_back_to_pass_while_receiving_maximum_protection_from_his_offensive_line_at_the_108th_annual_Army_vs_Navy_football_game_at_M5ET_Bank_Stadium_in_Baljpg
Gymnast ndash httppixabaycomengymnastics-gymnast-sports-graceful-89608
Figure Skater - httpfreetemsnetfiledance-on-ice-460
Volleyball Court Serve - httpwwwnationmastercomencyclopediaVolleyball
Volleyball Spike US Airforce -
httpd1staticdvidshubnetmediathumbsphotos1305933304450x300_q75jpgis
Tennis Serve - httpcommonswikimediaorgwikiFileMarat_safin_1jpg
Ankle Anatomy Greyrsquos -httpwwwfpnotebookcom_mediaorthoLegFootLateralLigamentsGrayBB355gif
912015
15
AC Separation Grade I -httpcommonswikimediaorgwikiFileClassification_type_1_of_AC_separationpng
AC Separation Grade II -httpcommonswikimediaorgwikiFileClassification_type_2_of_AC_separationpng
AC Separation Grade IV -
httpcommonswikimediaorgwikiFileClassification_type_4_of_AC_separationpng
AC Separation Grade V -httpcommonswikimediaorgwikiFileClassification_type_5_of_AC_separationpng
AC Separation Grade VI -httpcommonswikimediaorgwikiFileClassification_type_6_of_AC_separationpng
Little League elbow - httpwwwpublicdomainpicturesnetview-imagephpimage=2144amppicture=throw-boy
Osgood-Schllater MRI - httpuploadwikimediaorgwikipediacommons999MBq_Osgood-Schlatterjpg
Osgood-Schlatter XR - httpuploadwikimediaorgwikipediacommonsdd9Osgood_Schlater_1JPG
Legg-Calve-Perthes - httpcommonswikimediaorgwikiFileLeggCalvePerthes1jpg
SCFE - httpuploadwikimediaorgwikipediacommons448SCFE_FROG_B26Wjpg
Knee Sunrise X-ray - httpscommonswikimediaorgwikiFileMedical_X-Ray_imaging_CFK03_nevitjpg
Severrsquos Disease - httpcommonswikimediaorgwikiFileMedical_X-Ray_imaging_TKL07_nevitjpg
Shoulder Forearms Ankle Greyrsquos Anatomy - This faithful reproduction of a lithograph plate from Grays Anatomy a two-
dimensional work of art is not copyrightable in the US as per Bridgeman Art Library v Corel Corp the same is also true in many other countries including Germany Unless stated otherwise it is from the 20th US edition of Grays Anatomy of the Human Body originally published in 1918 and therefore lapsed into the public domain Other copies of Grays Anatomy can be found on Bartleby and also on Yahoo
This image is in the public domain because its copyright has expired This applies worldwide
Offensive Line ndash US Navy Football - This file is a work of a sailor or employee of the US Navy taken or made as part of that persons
official duties As a work of the US federal government the image is in the public domain
Gymnast - The person who associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the
work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial purposes all without asking permission
Figure Skater - License Public Domain CC0 (absolutely free) File type jpg | file size 1478 kB Add date 2012-08-27 212949
Volleyball Court Serve - This file is licensed under the Creative Commons Attribution ShareAlike license versions 25 20 and10
US Air Force Volleyball Spike - This work 2013 United States Armed Forces Volleyball Championship [Image 11 of 28] by A1C Justyn
Freeman identified by DVIDS is free of known copyright restrictions under US copyright law
Tennis Serve - The copyright holder of this work released this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [they] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
AC Separation Grading - This file is made available under the Creative Commons CC0 10 Universal Public Domain DedicationThe person who
associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial
purposes all without asking permission
Little League Elbow - Royalty free stock photos All pictures are free for commercial and personal use
Osgood-Schlatter MR ampXray - The copyright holder of this work release this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [They] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
Legg-Calve-Perthes - This file is licensed under the Creative Commons Attribution 30 Unported license
SCFE - This work has been released into the public domain by its author Mikir at the wikipedia project This applies worldwide
Knee Sunrise X-ray - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the
terms of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
Severrsquos Disease - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the terms
of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
912015
15
AC Separation Grade I -httpcommonswikimediaorgwikiFileClassification_type_1_of_AC_separationpng
AC Separation Grade II -httpcommonswikimediaorgwikiFileClassification_type_2_of_AC_separationpng
AC Separation Grade IV -
httpcommonswikimediaorgwikiFileClassification_type_4_of_AC_separationpng
AC Separation Grade V -httpcommonswikimediaorgwikiFileClassification_type_5_of_AC_separationpng
AC Separation Grade VI -httpcommonswikimediaorgwikiFileClassification_type_6_of_AC_separationpng
Little League elbow - httpwwwpublicdomainpicturesnetview-imagephpimage=2144amppicture=throw-boy
Osgood-Schllater MRI - httpuploadwikimediaorgwikipediacommons999MBq_Osgood-Schlatterjpg
Osgood-Schlatter XR - httpuploadwikimediaorgwikipediacommonsdd9Osgood_Schlater_1JPG
Legg-Calve-Perthes - httpcommonswikimediaorgwikiFileLeggCalvePerthes1jpg
SCFE - httpuploadwikimediaorgwikipediacommons448SCFE_FROG_B26Wjpg
Knee Sunrise X-ray - httpscommonswikimediaorgwikiFileMedical_X-Ray_imaging_CFK03_nevitjpg
Severrsquos Disease - httpcommonswikimediaorgwikiFileMedical_X-Ray_imaging_TKL07_nevitjpg
Shoulder Forearms Ankle Greyrsquos Anatomy - This faithful reproduction of a lithograph plate from Grays Anatomy a two-
dimensional work of art is not copyrightable in the US as per Bridgeman Art Library v Corel Corp the same is also true in many other countries including Germany Unless stated otherwise it is from the 20th US edition of Grays Anatomy of the Human Body originally published in 1918 and therefore lapsed into the public domain Other copies of Grays Anatomy can be found on Bartleby and also on Yahoo
This image is in the public domain because its copyright has expired This applies worldwide
Offensive Line ndash US Navy Football - This file is a work of a sailor or employee of the US Navy taken or made as part of that persons
official duties As a work of the US federal government the image is in the public domain
Gymnast - The person who associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the
work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial purposes all without asking permission
Figure Skater - License Public Domain CC0 (absolutely free) File type jpg | file size 1478 kB Add date 2012-08-27 212949
Volleyball Court Serve - This file is licensed under the Creative Commons Attribution ShareAlike license versions 25 20 and10
US Air Force Volleyball Spike - This work 2013 United States Armed Forces Volleyball Championship [Image 11 of 28] by A1C Justyn
Freeman identified by DVIDS is free of known copyright restrictions under US copyright law
Tennis Serve - The copyright holder of this work released this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [they] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
AC Separation Grading - This file is made available under the Creative Commons CC0 10 Universal Public Domain DedicationThe person who
associated a work with this deed has dedicated the work to the public domain by waiving all of his or her rights to the work worldwide under copyright law including all related and neighboring rights to the extent allowed by law You can copy modify distribute and perform the work even for commercial
purposes all without asking permission
Little League Elbow - Royalty free stock photos All pictures are free for commercial and personal use
Osgood-Schlatter MR ampXray - The copyright holder of this work release this work into the public domain This applies worldwide
In some countries this may not be legally possible if so [They] grant anyone the right to use this work for any purpose without any conditions unless such conditions are required by law
Legg-Calve-Perthes - This file is licensed under the Creative Commons Attribution 30 Unported license
SCFE - This work has been released into the public domain by its author Mikir at the wikipedia project This applies worldwide
Knee Sunrise X-ray - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the
terms of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
Severrsquos Disease - This image is free but not public domain some rights are reserved Please do not copy this image illegally by ignoring the terms
of the license In order to be able to use the image you are required to attribute image to copy Nevit Dilmen in a visible form
