HISTORY: 27 year old right hand dominant male professional soccer player presented for a right thumb injury after a forceful strike from a soccer ball approximately 5 meters away to this right thumb leading to a hyperextension injury. He noted significant swelling and pain. He did not recall a specific dislocation event. PHYSICAL EXAM: Evaluation of the right hand and wrist noted soft tissue swelling about the thumb metacarpophalangeal joint. He had limited range of motion of the thumb with intact flexor pollicis longus and extensor pollicis longus function. He did not have any evidence of metacarpophalangeal hyperextension. His thumb metacarpophalangeal joint was stable to both radial and ulnar-directed stress at both 0 and 30 degrees. DIFFERENTIAL DIAGNOSIS: 1. Metacarpophalangeal joint fracture.2. Volar plate Injury.3. Ulnar collateral ligament tear. TESTS AND RESULTS: Right Thumb Plain Radiographs - Comminuted ulnar sesamoid fracture. No evidence of thumb metacarpophalangeal joint dislocation. No hyperextension of the thumb metacarpophalangeal joint. MRI Right Hand - Comminuted fracture involving the ulnar sesamoid of the right thumb with intact radial and ulnar collateral ligaments. There was a small increased signal within the adductor pollicis muscle belly. FINAL/WORKING DIAGNOSIS: Right Thumb Ulnar Sesamoid Fracture. TREATMENT AND OUTCOME: Imaging was reviewed, and non-operative management was recommended. The patient was given a customized dorsal block splint for immobilization of the metacarpophalangeal joint of his right thumb to prevent hyperextension for game play. A custom hand-based thumb spica splint was given for daily use. At the two week follow up he noted improvement in his swelling and range of motion but had continued discomfort. At five weeks from injury, repeat x-rays were obtained and demonstrated a stable comminuted ulnar sesamoid fracture. His pain and range of motion continued to improve. He was transitioned to a softer brace for daily use. At his final follow up two and a half months from injury, he had resolution of pain and full range of motion. His radiographs revealed some resorption of the fracture fragments. At this visit he was cleared for full activity without bracing. He has since returned to full activity without any functional limitations or pain.

HISTORY:A 29 year-old Male Semi-pro boxer presented with pain in the distal 3rd metacarpal bone that had been on-going for 3 weeks. He believes this injury was caused while sparring with a partner. He noted he didn’t have immediate pain but developed pain and swelling the following day. The area remained painful and worsened when he was punching. He denies radiation of pain. There was no numbness, tingling, or weakness. PHYSICAL EXAMINATION: Examination of his right hand shows soft tissue swelling around the 3rd metacarpophalangeal joint. There is tenderness along the radial aspect of the 3rd MCP joint with ulnar subluxation of the extensor mechanism. Resisted flexion of the 3rd finger caused pain. There is no clicking or locking. DIFFERENTIAL DIAGNOSIS: 1. 3rd metacarpal occult fracture 2. Joint capsule sprain of the 3rd MCP 3. Digital Collateral ligament injury 4. Junctura Tendinum disruption 5. Congenital sagittal band deficiency TEST AND RESULTS: Right Hand anterior-posterior and lateral radiographs:-no osseous abnormalities MRI of the right hand: -Radial sagittal Band tear of the 3rd MCP Joint -mild sprain of the 3rd ulnar collateral ligament -mild bone marrow edema of the 2nd Metacarpal base FINAL/WORKING DIAGNOSIS: Rupture of the radial sagittal fibers of the 3rd MCP joint (Boxer Knuckle) TREATMENT AND OUTCOMES: 1. Patient was referred to a hand specialist and underwent surgical repair of the radial sagittal band2. 3rd MCP was immobilized with a splint for 4 weeks 3. Range of motion and strengthening was started 4 weeks post-surgical repair with gradual return to full activities 4. He currently continues to work on a return to full activities

Objective Assess how treatment with the viscosupplement hylan G-F 20 relates to opioid prescriptions and intraarticular corticosteroid injections (IACS) in patients with osteoarthritis of the knee (OAK). Design Case-crossover; adult patients with OAK identified in a claims database were treated with hylan G-F 20 from July 1, 2007, to June 29, 2017. Opioid or IACS prescriptions in the 6 months before treatment were compared to the 6 months after. Patients with comorbid conditions requiring pain medications were excluded, resulting in a 29,395-patient cohort. Four subgroups were investigated: patients with (1) opioids before hylan G-F 20 (OB; n = 6,609); (2) opioids before and after hylan G-F 20 (OBF; n = 3,320); (3) IACS before hylan G-F 20 (CB; n = 11,162); and (4) IACS before and after hylan G-F 20 (CBF; n = 2,810). All opioids were converted to morphine milligram equivalents (MME). Results OB subgroup patients had a significant decrease (P < 0.01) in total MME (-14.0%), MME per day (-14.2%) and opioid prescription days (-12.6%) after treatment versus before. Only 50.2% of patients prescribed opioids before hylan G-F 20 were prescribed an opioid after treatment. OBF subgroup patients had a significant increase (P < 0.01) in opioid prescription days (7.8%) before versus after treatment. There was a significant decrease (P < 0.01) in the number of IACS after versus before treatment for the Total Cohort (-56.1%), and subgroups CB (-72.6%) and CBF (-4.1%). A total of 74.8% of patients receiving an IACS before treatment did not receive an IACS after treatment. Conclusions Hylan G-F 20 is associated with a reduction in opioid prescriptions and IACS in OAK patients.

HISTORY: A 20 year old Division III collegiate football kicker was diagnosed with COVID-19 in September 2020. His symptoms included cough, body aches, and fatigue that resolved after 6 days. After completing his time in isolation, he presented to the sports cardiology office per current guidelines for evaluation in order to be cleared for return to play. He denied any significant past medical history and reported social alcohol use and vaping. He had not returned to exercise. He denied chest pain, palpitations, and shortness of breath. PHYSICAL EXAMINATION: Examination in the office revealed him to be well appearing and in no apparent distress. On cardiac examination, he had a regular rate and rhythm and no murmurs were appreciated. His lungs were clear to auscultation bilaterally without any wheezing, rales, and/or rhonchi. His neurologic exam was grossly intact and his extremities were warm and well perfused. DIFFERENTIAL DIAGNOSIS: 1. Resolved viral illness 2. Post-viral pulmonary process 3. Post-viral myocarditis TEST AND RESULTS: EKG - normal; Troponin - not detected; Echocardiogram - Left ventricular ejection fraction of 40% with global hypokinesia; Cardiac MRI - inflamed myocardium suggestive of myocarditis. FINAL WORKING DIAGNOSIS: Post-viral Myocarditis TREATMENT AND OUTCOMES: 1. Denied clearance for return to play for at least 3 months. 2. Instructed to refrain from exercise and any strenuous activities 3. Will repeat echocardiogram and cMRI in 3 months and will return to play if all prior changes have normalized.

HISTORY: A 53-year-old male with history of knee osteoarthritis presented with worsening right knee pain 2.5 months following MVA. He also noted a mobile mass over the superior lateral knee. There was no relief with NSAIDs or rest. PHYSICAL EXAMINATION: Antalgic gait with crutches. Right knee with moderate effusion, limited range of motion to 100 degrees flexion and 10 degrees extension with crepitus, tenderness to palpation over the lateral joint line with a palpable mass superior to the lateral femoral condyle. Positive McMurray’s test. DIFFERENTIAL DIAGNOSIS: 1. Osteoarthritis flare2. Meniscal tear3. Avulsion fracture of the femur4. Crystalline arthropathy5. Synovial osteochondromatosis TEST AND RESULTS: Right Knee X-Ray: Linear bony density along the medial femoral condyle, suspicious for an acute to subacute avulsion fracture. Stable findings of synovial osteochondromatosis. Synovial Fluid Analysis: No organisms or crystals identified. Right Knee MRI without contrast: Tricompartmental osteoarthritis with secondary synovial osteochondromatosis with large calcified intra-articular body within the suprapatellar recess measuring 4.7 cm. Moderate joint effusion. Moderate synovitis. Medial and lateral complex meniscal tears. Pellegrini-Stieda lesion, compatible with sequela of prior MCL injury without periligamentous edema. FINAL WORKING DIAGNOSIS: Synovial osteochondromatosis with a large loose body with underlying osteoarthritis and medial and lateral complex meniscal tears. TREATMENT AND OUTCOMES: Aspiration was performed for 47 cc serous synovial fluid followed by intra-articular corticosteroid injection. At 3 week follow-up visit, the patient noted 50% improvement in pain, but recurrent effusion and increased buckling. Case was discussed with an orthopedic surgeon and recommendation was made for loose body excision and possible total knee arthroplasty. After discussion, the patient preferred to avoid surgery and continue conservative care with bracing and physical therapy.

Objective This literature review summarizes evidence on the safety and efficacy of intraarticular hyaluronic acid (IAHA) preparations approved in the United States for the treatment of osteoarthritis of the knee. Design A systematic literature search was performed in PubMed, Ovid MEDLINE, and SCOPUS databases. Only studies in which clinical outcomes of individual IAHA preparations alone could be assessed when compared to placebo, no treatment, other standard knee osteoarthritis treatments, and IAHA head-to-head studies were selected. Results One hundred nine articles meeting our inclusion criteria were identified, including 59 randomized and 50 observational studies. Hylan G-F 20 has been the most extensively studied preparation, with consistent results confirming efficacy in placebo-controlled studies. Efficacy is also consistently reported for Supartz, Monovisc, and Euflexxa, but not for Hyalgan, Orthovisc, and Durolane. In the head-to-head trials, high-molecular-weight (MW) Hylan G-F 20 was consistently superior to low MW sodium hyaluronate preparations (Hyalgan, Supartz) up to 20 weeks, whereas one study reported that Durolane was noninferior to Supartz. Head-to-head trials comparing high versus medium MW preparations all used Hylan G-F 20 as the high MW preparation. Of the IAHA preparations with strong evidence of efficacy in placebo-controlled studies, Euflexxa was found to be noninferior to Hylan G-F 20. There are no direct comparisons to Monovisc. One additional IAHA preparation (ie, Synovial), which has not been assessed in placebo-controlled studies, was also noninferior to Hylan G-F 20. Conclusion IAHA efficacy varies widely across preparations. High-quality studies are required to assess and compare the safety and efficacy of IAHA preparations.

TITLE: Tunneling Away Lateral Ankle Pain AUTHORS: Geoffrey M. Dreher, DO; David Webner, MD; Kevin DuPrey, DO ACSM Sponsor (if you accept): Thomas Kaminski, PhD, ATC ([email protected]) HISTORY: 60-year-old boilermaker presented with 2-month insidious onset left lateral ankle pain, localized to the lateral malleolus, described as achy and throbbing, 7/10, worse with walking, stairs and climbing ladders. No relief with Acetaminophen or NSAIDs. PHYSICAL EXAMINATION: Left ankle: no edema or ecchymosis, full range of motion with pain in active dorsiflexion and plantarflexion. Strength 5/5, gross sensation intact and 2+ dorsalis pedis and posterior tibial pulses. Tenderness to palpation along the lateral malleolus extending distally approximately 5 cm along lateral ankle. DIFFERENTIAL DIAGNOSIS: 1. Chronic lateral ankle instability 2. Peroneal tendinosis with subluxation 3. Lateral malleolar stress fracture 4. Ankle osteoarthritis 5. Talar osteochondral lesion TEST AND RESULTS: •Left ankle 3 view x-ray: Normal. •Left ankle MRI: Anatomic variant involving conjoined peroneus brevis and longus tendons, located along the anterolateral aspect of distal fibula. Deficient/absent peroneal groove along posterior fibula, which also suggests congenital abnormality. Mild conjoined tendinosis, without surrounding edema. •Left lateral ankle ultrasound: Intact peroneal tendon overlying the lateral maleolus with trace fluid in sheath. The peroneal tendons split just before brevis insertion onto base of 5th metatarsal. FINAL/WORKING DIAGNOSIS: 1. Conjoined left peroneal tendon subluxation with tenosynovitis and absence of fibular groove. TREATMENT AND OUTCOMES: 1. Physical therapy for 6 weeks led to improved balance and walking mechanics, but no change in pain. 2. Immobilization in CAM boot for 6 weeks caused no improvement in pain or swelling out of boot. 3. Corticosteroid injection to peroneal tendons at level of lateral malleolus lead to no improvement. 4. Podiatry referral and surgery including tubularization of peroneal tendons, creation of 6mm fibular groove and repair of peroneal retinaculum. 3 months post-operatively, the patient was full weight bearing pain free with daily activities in lace-up ankle brace.

HISTORY: An 18-Year-Old Male Division III quarterback presented to the office with left knee swelling and pain. He was playing in a game 10 days prior in which he was sacked twice, each time landing on his left knee and medial thigh. Right after the game, he noted swelling over the superior aspect of the patella and pain with direct pressure and full flexion. He described the pain as sharp and fiery, non-radiating, 3/10, waxing and waning. He has been wearing a compression sleeve and icing his knee. PHYSICAL EXAMINATION: Examination of the patient’s Left knee revealed decreased ROM with flexion and extension to 120/0 degrees. Large, 4+, suprapatellar effusion. Strength intact. Negative patellar compression test for pain and crepitus. No patellar instability. No ligamentous laxity to anterior, posterior, varus and valgus (30°) stress testing. Negative Lachman’s testing. Negative anterior and posterior drawer testing. No joint line tenderness. Negative McMurray’s testing. No patellar tendon tenderness. No pes anserine bursa tenderness. The patient was otherwise neurovascularly intact. DIFFERENTIAL DIAGNOSIS: 1. Suprapatellar Bursitis 2. Prepatellar Bursitis 3. Patella Fracture 4. Intraarticular Injury with knee effusion 5. Morel-Lavallée lesion TEST AND RESULTS: Ultrasound exam revealed large collection of fluid in the suprapatellar and medial thigh region. X-ray showed no fracture and moderate soft tissue swelling anterior to the left patella. FINAL WORKING DIAGNOSIS: Morel-Lavallée lesion TREATMENT AND OUTCOMES: 1. Under US guidance 75 cc of serosanguinous fluid was aspirated from the suprapatellar bursa on the left knee on the first visit. Compression wrap applied. 2. 75 cc of serosanguinous fluid was aspirated 3 days later. Compression continued. 3. 50 cc of serosanguinous fluid was aspirated 4 day later, 7 days after the initial visit 4. 1 week later there was only mild accumulation of fluid. No aspiration was required. He had near full ROM and no pain with activity. He was cleared to return to football at that visit and successfully returned with no issues.

Background: Sensitive and specific screening methods are needed to identify athletes at risk of prolonged recovery after sport-related concussion (SRC). Convergence insufficiency (CI) is a common finding in concussed athletes. Purpose: To assess the relationship between CI and recovery after SRC at the initial office visit. Study Design: Case-control study; Level of evidence, 3. Methods: In this retrospective cohort study, 270 athletes (147 male, 123 female), mean ± SD age 14.7 ± 2.0 years (range, 10-21 years), with the diagnosis of SRC who presented for initial office visit between January 2014 and January 2016 were evaluated for near point of convergence (NPC). The athletes were categorized into 2 groups: normal near point of convergence (NPC ≤6 cm), and convergence insufficiency (NPC >6 cm). These athletes were then followed to determine recovery time. Results: Athletes presented for initial office visit at a mean of 5.2 ± 4.2 days (range, 1-21 days) after SRC. Half of the athletes had CI after SRC (50.4%; n = 136). Athletes with CI (NPC 12.3 ± 4.7 cm) took significantly longer to recover after SRC, requiring 51.6 ± 53.9 days, compared with athletes with normal NPC (4.1 ± 1.3 cm), who required 19.2 ± 14.7 days (P < .001). After controlling for potential confounding variables, CI significantly increased the odds of prolonged recovery (≥28 days from injury) by 12.3-fold (P < .001; 95% confidence interval, 6.6-23.0). CI screening correctly classified 75.2% of our sample with 84.2% sensitivity and 70.0% specificity. The positive predictive value for CI and prolonged recovery was 62.5%, and the negative predictive value was 88.1%. Conclusion: CI at the initial office visit identified athletes at increased risk of prolonged recovery after SCR. Clinicians should consider measuring NPC in concussed athletes as a quick and inexpensive prognostic screening method.

OBJECTIVE:To examine publicly-available information on all identified cases of suicide in active or former American professional football players between 1920 and the spring of 2015.DESIGN:Retrospective cohort study.SETTING:Professional American Football in the US.PARTICIPANTS:A cohort of 26 702 athletes who had died, retired or were currently playing in the NFL from nfl.com since 1920 was identified.MAIN OUTCOME MEASURES:Internet queries identifying 26 professional football players who completed suicide. Obituaries and news reports were reviewed. The primary outcome measures included mortality, demographic characteristics and life circumstances in professional American football players completing suicide.RESULTS:From 1920-2015, the median age of the 26 men who completed suicide was 39.5 years (range = 23-85). The median number of years after retirement was 6.5 (range = 0-63). Most of the deaths since 1920 have occurred in the past 15 years (58.7%) and a large percentage have occurred since 2009 (42.3%). Most of the men suffered from multiple life stressors prior to their deaths, such as retirement from sport, loss of steady income, divorce, failed business ventures, estrangement from family members and medical, psychiatric and/or substance abuse problems.CONCLUSIONS:A disproportionate number of completed suicides in current and former professional football players have occurred since 2009 (42.3%). It is well established in the literature that the causes of depression and suicidality are diverse, often multifactorial and treatable. Providing at-risk retired athletes with mental health treatment will likely reduce their suffering and improve their quality-of-life.

BACKGROUND:There is a need for successful screening methods to identify athletes at increased risk of anterior cruciate ligament (ACL) injury. Previous research showed that collegiate athletes with ACL tears demonstrated slower time to stabilization during jump landing after reconstruction.HYPOTHESIS:Collegiate athletes with baseline deficiencies in time to stabilization are at increased risk of subsequent ACL rupture.STUDY DESIGN:Case-control study; Level of evidence, 3.METHODS:A total of 278 National Collegiate Athletic Association Division I college athletes (166 men, 112 women; mean age, 18.5 years; height, 178.8 cm; mass, 79.9 kg) in the high-risk sports of men's football; women's volleyball and field hockey; and men's and women's lacrosse, basketball, and soccer were measured to obtain baseline time to stabilization for backward, forward, medial, and lateral single-legged jump landing tasks. Athletes were followed for ACL rupture over a 4-year period. Independent t tests were used to evaluate differences in time to stabilization for each jump landing task between athletes with subsequent ACL rupture and uninjured athletes. Logistic regression models were used to assess time to stabilization as a predictor for ACL rupture.RESULTS:Nine athletes sustained noncontact ACL ruptures (5 men, 4 women). These 9 athletes took significantly longer to stabilize compared with uninjured athletes during baseline backward jump landing (1.58 ± 0.39 and 1.09 ± 0.52 seconds, respectively; P = .0052). The odds of ACL rupture increased 3-fold (odds ratio, 2.95; 95% CI, 1.28-6.77) for every second increase in backward time to stabilization observed between injured and uninjured athletes.CONCLUSION:Collegiate athletes with slower baseline backward time to stabilization were at increased risk of ACL rupture.

HISTORY: A 12-year old male presented with right groin pain that started immediately after a quick cut during basketball. He felt a pop with immediate pain, localized to the proximal adductor. Pain improved after a week of rest but increased with return to basketball. Pain was worse with hip flexion and better with rest. PHYSICAL EXAMINATION: Right hip: There was moderate tenderness along the proximal adductor muscle extending to the lesser trochanter but no tenderness over the ASIS, AIIS, greater trochanter or pubic symphysis. There was pain with active flexion, adduction and abduction and full passive ROM with flexion, internal rotation and external rotation. Strength was 5/5, except for 4+/5 with abduction. Log roll was negative. There was anterior pain with FABER and FADIR testing. DIFFERENTIAL DIAGNOSIS: 1.Adductor strain 2.Avulsion fracture of the lesser trochanter 3.Slipped capital femoral epiphysis 4.Acetabular labral tear 5.Athletic pubalgia 6.Avascular necrosis of the femoral head/Legg-Calvé-Perthes Disease 7.Femoral neck stress fracture 8.Iliopsoas bursitis TEST AND RESULTS: Right Hip Ultrasound: •Small area of hypoechogenicity in the proximal adductor musculotendinous unit Right Hip/Pelvis X-ray: •Sclerosis of medial intertrochanteric region of the right femur •Ill-defined lucent lesions within the right ischium and right proximal femoral diaphysis, no bony expansion or periosteal reaction Whole Body Nuclear Bone Scan: •Increased uptake in the bilateral long bones MRI Right Hip •Multifocal regions of intramedullary signal abnormality involving bilateral proximal femurs •Lobulated fluid signal lesion within the right posterior acetabular column/ischium •No bone marrow edema, stress fracture or reaction, or soft tissue injury FINAL/WORKING DIAGNOSIS: Right Proximal Adductor Strain with underlying Polyostotic Fibrous Dysplasia TREATMENT AND OUTCOMES: 1.Labs showed elevated Alkaline Phosphatase, normal PTH and Calcium 2.Referral to Orthopedic Oncology 3.Biopsy confirmed Polyostotic Fibrous Dysplasia 4.MRI with and without contrast to evaluate cystic lesion 5.Endocrinology evaluation 6.Physical Therapy Outcome - Five weeks after initial visit, patient was pain free and cleared to return to sport with Orthopedic Oncology and Endocrinology follow up.

HISTORY: A 21 year old skill-position division I college football player presented for sideline evaluation during a game after feeling a pop in his LEFT knee while running (earlier in the game he had been struck in the left knee but had then been able to continue playing). Roughly 1 month prior to this injury, he had sustained a grade 2 PCL injury to the RIGHT knee that occurred during a practice when he landed awkwardly striking his knee into the turf for which he was treated non-operatively with PCL bracing and rehab and had passed functional testing. PHYSICAL EXAMINATION: Physical exam of the LEFT knee was significant for positive posterior drawer with negative Lachman, negative anterior drawer, symmetrical dial test, negative tenderness, and preserved ROM. Left knee PCL laxity was less than that of the right knee. After several weeks of rehab subsequent exam showed the initially injured knee (RIGHT) had increased excursion as compared to the left and had increased translation with external rotation. DIFFERENTIAL DIAGNOSIS: PCL full tear PCL partial tear Partial ACL tear Collateral ligament tear Meniscal injury Plantaris rupture Posterior capsule injury Posterolateral corner injury TEST AND RESULTS: MRI R knee: - Abnormal signal and morphology of the PCL consistent with rupture. No other major pathology. MRI L knee: - Partial tear of PCL midportion with intact proximal and distal attachments - Mild contusion of the medial meniscus posterior horn inferior portion - Moderate posterior capsular strain FINAL WORKING DIAGNOSIS: Bilateral PCL partial tear (right higher grade than left) TREATMENT AND OUTCOMES: He began conservative treatment of the left knee with an immobilizer brace with progression to activity. He was unable to regain explosiveness and sprint speed due to the sense of bilateral knee laxity with mild left knee pain occurring at speed. Isokinetic dynamometer testing revealed left knee flexor strength of 90% compared to the right with equal knee extensor strength. His inability to fully progress was likely attributable to bilateral PCL injury: with one normal leg he was able to compensate for unilateral PCL laxity, whereas bilateral PCL laxity functionally eliminated his compensatory mechanism. He consequently underwent season-ending right PCL reconstruction after maximized rehab did not allow return of function.

HISTORY: A 13-year-old right handed quarterback presented with a one month history of progressive right medial elbow pain that occurred two weeks into training camp. There was no traumatic event to explain his symptoms. He plays quarterback for two teams and was noted to have good throwing mechanics by his coaches. His pain worsened with throwing and had become so severe he experienced pain at rest.He denied any clicking, popping, bruising, weakness or paresthesias but noted swelling of the inner elbow. PHYSICAL EXAMINATION: Examination of the right elbow revealed normal carrying angles. There was noticeable swelling over the medial epicondyle. Active and passive range of motion in flexion was 100 degrees and 20 degrees in extension, and 80 degrees in supination/pronation. He was exquisitely tender at the medial epicondyle.There was no laxity with varus and valgus stress at 0 and 30 degrees, but pain was reproduced with valgus stress. There was pain on resisted wrist flexion and pronation. Of note, shoulder examination demonstrated gleno-humeral internal rotation deficit of 25 degrees on the right. DIFFERENTIAL DIAGNOSIS: 1.Medial epicondylitis 2.Osteochondral defect 3.Ulnar nerve entrapment 4.Medial epicondylar apophysitis 5.Fracture/stress-fracture 6.Neoplasm 7.Panner’s Disease TEST AND RESULTS: AP/Lateral X-ray of Right and Left Elbow: -Showed a minimally displaced avulsion fracture of the medial epicondyle with physeal widening compared with unaffected side and joint effusion. MRI of right elbow: - Medial epicondyle apophysitis and mild avulsion with a pronator teres strain. Ulnar collateral ligament intact FINAL WORKING DIAGNOSIS: Severe Little Leaguer’s Elbow (medial epicondyle apophysitis) in a football player TREATMENT AND OUTCOMES: 1.Wore a sling for 5-7 days 2.Avoided throwing related activity for minimum of 6 weeks 3.Sent to physical therapy to work on gentle range of motion exercises in flexion and extension, shoulder stretching for gleno-humeral internal rotation deficit and scapular strengthening as well as core strengthening exercises. 4.Repeated X-ray at 3 weeks and 6 weeks which documented healing 5. To date the patient is pain free and our plan was to begin a graduated throwing program

Background: Few studies have examined acute injuries in track and field in both elite and subelite athletes. Purpose: To observe the absolute number and relative rates of injury in track and field athletes across a wide range of competition levels and ages during 3 years of the Penn Relays Carnival to assist with future medical coverage planning and injury prevention strategies. Study Design: Descriptive epidemiology study. Methods: Over a 3-year period, all injuries treated by the medical staff were recorded on a standardized injury report form. Absolute number of injuries and relative injury rates (number of injuries per 1000 competing athletes) were determined and odds ratios (ORs) of injury rates were calculated between sexes, competition levels, and events. Injuries were also broken down into major or minor medical or orthopaedic injuries. Results: Throughout the study period, 48,473 competing athletes participated in the Penn Relays Carnival, and 436 injuries were sustained. For medical coverage purposes, the relative rate of injury subtypes was greatest for minor orthopaedic injuries (5.71 injuries per 1000 participants), followed by minor medical injuries (3.42 injuries per 1000 participants), major medical injuries (0.69 injuries per 1000 participants), and major orthopaedic injuries (0.18 injuries per 1000 participants). College/elite athletes displayed the lowest relative injury rate (7.99 injuries per 1000 participants), which was significantly less than that of high school (9.87 injuries per 1000 participants) and masters athletes (16.33 injuries per 1000 participants). Male athletes displayed a greater likelihood of having a minor orthopaedic injury compared with female athletes (OR, 1.36 [95% CI, 1.06-1.75]; χ 2 = 5.73; P = .017) but were less likely to sustain a major medical injury (OR, 0.33 [95% CI, 0.15-0.75]; χ 2 = 7.75; P = .005). Of the 3 most heavily participated in events, the 4 × 400-m relay displayed the greatest relative injury rate (13.6 injuries per 1000 participants) compared with the 4 × 100-m and 4 × 200-m relays. Conclusion: Medical coverage teams for future large-scale track and field events need to plan for at least 2 major orthopaedic and 7 major medical injuries per 10,000 participants. Male track and field athletes, particularly masters male athletes, are at greater risk of injury compared with other sexes and competition levels.

HISTORY: A 49-year-old female healthcare administrator presented with left wrist and thumb pain and stiffness for 4 months. She described an intermittent pain along the radial aspect of her wrist, with sharp pain when moving her thumb and wrist. She denied any numbness, tingling or shooting pains. She tried NSAIDs with minimal pain relief, but warm heat wraps and bracing at night improved her morning wrist stiffness. Recently, she began having the same pain in the right wrist. PHYSICAL EXAMINATION: Examination of the patient’s left wrist revealed no swelling, deformities, or muscular atrophy. She had pain with wrist extension, ulnar deviation, and thumb abduction and extension, but none with wrist flexion and radial deviation. She had a positive Finkelstein’s test and tenderness over the radial styloid. Resisted strength testing was 4-/5 for thumb abduction and extension, and 5/5 for wrist flexion, extension, supination and pronation. She had normal sensation and a negative Tinel’s sign. DIFFERENTIAL DIAGNOSIS: 1.de Quervain Tenosynovitis 2.Osteoarthritis of the first carpo-metacarpal joint 3.Intersection Syndrome 4.Dorsal ganglion at the wrist 5.Degenerative arthritis at the radioscaphoid joint WORKING DIAGNOSIS: Based on history and physical examination, the working diagnosis was de Quervain Tenosynovitis. TESTS AND RESULTS: An ultrasound examination of the left wrist and injection of 1ml of dexamethasone into the tendon sheath of abductor pollicus longus and extensor pollicis brevis tendon was performed. The patient experienced some symptom improvement post-injection. A complete wrist X-ray was obtained later that day, and showed a possible Madelung deformity and a positive ulnar variance measuring 4mm. TREATMENT AND OUTCOMES: Originally, physical therapy and a thumb spica splint were prescribed for de Quervain Tenosynovitis. After X-ray was performed, the patient was informed of the Madelung deformity and was referred to an orthopedic hand surgeon for consultation. Upon follow up, she had not made an appointment with the hand surgeon, or physical therapy, but was using the brace. She continued to have mild-to-moderate bilateral wrist pain, but was managing with bracing and warm massage.