Shoulder and elbow pathology in the female athlete: sex-specific considerations.

Unique biologic and biomechanical aspects of the female body make women more prone to certain orthopedic injuries. Sex differences are well understood with regard to certain orthopedic pathologies such as anterior cruciate ligament injury, hallux valgus, carpal tunnel, and carpometacarpal joint arthritis; however, sex differences are less commonly discussed with regard to shoulder and elbow pathology. The purpose of this review is to elucidate sex differences specific to sports-related shoulder and elbow injuries in the female athlete population.

Anterior cruciate ligament rupture: differences between males and females.

The rate of anterior cruciate ligament (ACL) rupture is three times higher in female athletes than in male athletes. Intrinsic factors such as increased quadriceps angle and increased posterior tibial slope may predispose girls and women to ACL injury. Compared with males, females have smaller notch widths and smaller ACL cross-sectional area; however, no conclusive correlation between ACL size and notch dimension exists, especially in relation to risk of ACL injury. Female athletes who land with the knees in inadequate flexion and in greater-than-normal valgus and external rotation are at increased risk of ACL injury. No conclusive link has been made between ACL injury and the menstrual cycle. Neuromuscular intervention protocols have been shown to reduce the rate of injury in girls and women. Females are more likely than males to have a narrow A-shaped intercondylar notch, and special surgical considerations are required in such cases. Following ACL reconstruction, female athletes are more likely than male athletes to rupture the contralateral ACL; however, males and females are equally likely to rupture the reconstructed knee. Although self-reported outcomes in the first 2 years following reconstruction are worse for females than for males, longer-term studies demonstrate no difference between males and females.

Assessing Gender Differences in Technical Skills and Confidence in Orthopaedic Surgery Residency Applicants.

INTRODUCTION: Variations in confidence for procedural skills have been demonstrated when comparing male and female medical students in surgical training. This study investigates whether differences in technical skill and self-reported confidence exist between male and female medical students applying to orthopaedic residency. METHODS: All medical students (2017 to 2020) invited to interview at a single orthopaedic residency program were prospectively evaluated on their technical skills and self-reported confidence. Objective evaluation of technical skill included scores for a suturing task as evaluated by faculty graders. Self-reported confidence in technical skills was assessed before and after completing the assigned task. Scores for male and female students were compared by age, self-identified race/ethnicity, number of publications at the time of application, athletic background, and US Medical Licensing Examination Step 1 score. RESULTS: Two hundred sixteen medical students were interviewed, of which 73% were male (n = 158). No gender differences were observed in suture task technical skill scores or mean difference in simultaneous visual task scores. The mean change from pre-task and post-task self-reported confidence scores was similar between sexes. Although female students trended toward lower post-task self-reported confidence scores compared with male students, this did not achieve statistical significance. Lower self-reported confidence was associated with a higher US Medical Licensing Examination score and with attending a private medical school. DISCUSSION: No difference in technical skill or confidence was found between male and female applicants to a single orthopaedic surgery residency program. Female applicants trended toward self-reporting lower confidence than male applicants in post-task evaluations. Differences in confidence have been shown previously in surgical trainees, which may suggest that differences in skill and confidence may develop during residency training.

Sports Medicine Considerations During the COVID-19 Pandemic.

The outbreak of the novel coronavirus (COVID-19) has resulted in upward of 14 million confirmed cases and >597,000 deaths worldwide as of July 19, 2020. The current disruption in sports activities caused by COVID-19 presents a challenge to physicians, coaches, and trainers in discerning best practices for a safe return to sport. There is a distinct need to develop and adopt consistent measures for resumption of sports activities, including training and competition, in a way that places the health and well-being of athletes at the forefront while also protecting coaches, allied staff, and spectators. This article provides an overview of the effects of COVID-19 in the athletic population and presents considerations for training during the pandemic, as well as guidelines for return to sports as restrictions are lifted.

Surgical treatment of distal biceps rupture.

Rupture of the distal biceps tendon accounts for 10% of all biceps brachii ruptures. Injuries typically occur in the dominant elbow of men aged 40 to 49 years during eccentric contraction of the biceps. Degenerative changes, decreased vascularity, and tendon impingement may precede rupture. Although nonsurgical management is an option, healthy, active persons with distal biceps tendon ruptures benefit from early surgical repair, gaining improved strength in forearm supination and, to a lesser degree, elbow flexion. Biomechanical studies have tested the strength and displacement of various repairs; the suspensory cortical button technique exhibits maximum peak load to failure in vitro, and suture anchor and interosseous screw techniques yield the least displacement. Surgical complications include sensory and motor neurapraxia, infection, and heterotopic ossification. Current trends in postoperative rehabilitation include an early return to motion and to activities of daily living.

Considerations for Return to Exercise Following Mild-to-Moderate COVID-19 in the Recreational Athlete.

The COVID-19 pandemic has resulted in significant morbidity and mortality around the world. The spectrum of COVID-19 is broad, from clinical disease requiring intensive medical care to less severe symptoms that are treated with supportive care. The majority of COVID-19 cases fall into the mild-to-moderate category, with symptoms lasting less than 6 weeks. Nevertheless, the morbidity from COVID-19 is significant and can affect multiple body systems, most frequently the cardiac, pulmonary, hematologic, musculoskeletal, and gastrointestinal systems. For patients who wish to return to exercise after mild-to-moderate COVID-19, the wide range of disease expression presents a challenge for clinicians seeking to offer counsel. This literature review on return to activity following mild to moderate COVID-19 in the recreational athlete includes evidence-based considerations and recommendations for clinicians in guiding the safest return to activity.

Popliteal Artery Entrapment Syndrome: Bilateral Lower Extremity Involvement.

Popliteal artery entrapment syndrome is a condition in which compression of the popliteal neurovascular structures results in symptoms of lower extremity claudication by way of a constricting anatomic structure or a hypertrophied surrounding musculature. This diagnosis is often missed or misdiagnosed because popliteal artery entrapment syndrome has a presentation similar to that of exertional compartment syndrome. Popliteal artery entrapment syndrome may result in persistent disability or unnecessary morbidity or prevent athletes' return to sport. A female collegiate athlete presented with bilateral popliteal artery entrapment syndrome. She had successful surgical treatment and returned to a high level of sport. This article describes popliteal artery entrapment syndrome, emphasizes the importance of a thorough history and physical examination to elucidate the diagnosis, and provides information that may lead to the identification of individuals who will benefit from surgical intervention. [Orthopedics. 2018; 41(2):e295-e298.].

Partial-thickness rotator cuff tears.

Partial-thickness rotator cuff tears are not a single entity; rather, they represent a spectrum of disease states. Although often asymptomatic, they can be significantly disabling. Overhead throwing athletes with partial-thickness rotator cuff tears differ with respect to etiology, goals, and treatment from older, nonathlete patients with degenerative tears. Pathogenesis of degenerative partial-thickness tears is multifactorial, with evidence of intrinsic and extrinsic factors playing key roles. Diagnosis of partial-thickness rotator cuff tears should be based on the patient's symptoms together with magnetic resonance imaging studies. Conservative treatment is successful in most patients. Surgery generally is considered for patients with symptoms of sufficient duration and intensity. The role of acromioplasty has not been clearly delineated, but it should be considered when there is evidence of extrinsic causation for the partial-thickness rotator cuff tear.

Shoulder Injuries in Men's Collegiate Lacrosse, 2004-2009.

BACKGROUND: Men's lacrosse has been one of the fastest growing team sports in the United States, at both the collegiate and high school levels. Uniquely, it combines both continuous overhead and contact activity. Thus, an understanding of its injury epidemiology and mechanisms is vital. Shoulder injuries have been shown to be common in the sport, but thus far there has been no dedicated analysis of these injuries with which to better inform injury prevention strategies. STUDY DESIGN: Descriptive epidemiology study. METHODS: All athlete exposures (AEs) and shoulder injuries reported to the National Collegiate Athletic Association (NCAA) Injury Surveillance System for intercollegiate men's lacrosse athletes from 2004-2005 through 2008-2009 were collected. Type of injury was documented and the injury incidence per 1000 AEs was calculated. Event type, injury mechanism, specific injury, outcome, and time lost were recorded. Statistical analysis was performed using 95% CIs, calculated based on a normal approximation to Poisson distribution. RESULTS: There were a total of 124 observed shoulder injuries during 229,591 monitored AEs. With weights, this estimates 1707 shoulder injuries over 2,873,973 AEs, for an incidence of 0.59 per 1000 AEs (95% CI, 0.56-0.62). The incidence of shoulder injury during competition was 1.89 per 1000 AEs (95% CI, 1.76-2.02), compared with 0.35 per 1000 AEs (95% CI, 0.33-0.38) during practice. Acromioclavicular joint injuries were most common (0.29 per 1000 AEs; 95% CI, 0.27-0.31). Labral injuries and instability events were also frequent (0.11 per 1000 AEs; 95% CI, 0.10-0.13). Player-to-player contact caused 57% of all shoulder injuries, with 25% due to contact with the playing surface. The average time lost was 11.0 days, with 41.9% of all shoulder injuries requiring ≥10 days. Clavicle fractures and posterior shoulder dislocation were particularly severe, with no athletes returning to play during the same season. CONCLUSION: Shoulder injuries are common in NCAA men's lacrosse and are an important source of lost playing time. Acromioclavicular injuries were the most frequent injury in this series, but labral and instability injuries were also common. In this increasingly popular contact sport, an understanding of the epidemiology and mechanism of shoulder injuries may be used to improve protective equipment and develop injury prevention.

Etiology, assessment, and management of aromatase inhibitor-related musculoskeletal symptoms.

Aromatase inhibitors (AIs) are recommended as adjuvant endocrine therapy for postmenopausal women with hormone-responsive breast cancer. With the widespread use of AI adjuvant endocrine therapy, a significant profile of musculoskeletal symptoms has emerged. Moderate to severe musculoskeletal symptoms have led some women to discontinue therapy, compromising the survival benefit. The etiology of AI-related musculoskeletal symptoms is poorly understood, which challenges development of effective management strategies. The purpose of this article is to describe AI-related musculoskeletal symptoms, review possible causes, provide assessment guidelines, and recommend management strategies based on the best available evidence. Little evidence exists for effective management strategies of AI-related musculoskeletal symptoms, and randomized clinical trials are needed to establish effective interventions. A thorough musculoskeletal assessment can help guide clinical decision making for the best individual management approach. Providers need to manage symptoms with the best available evidence to minimize symptom distress and maximize adherence to AI therapy.

In situ forces in the anteromedial and posterolateral bundles of the anterior cruciate ligament under simulated functional loading conditions.

BACKGROUND: The in situ forces of the anteromedial (AM) and posterolateral bundles (PL) of the anterior cruciate ligament (ACL) under simulated functional loads such as simulated muscle loads have not been reported. These data are instrumental for improvement of the anatomical double-bundle ACL reconstruction. HYPOTHESIS: The load-sharing patterns of the 2 bundles are complementary under simulated muscle loads. STUDY DESIGN: Descriptive laboratory study. METHODS: Eight cadaveric knees in this study were sequentially studied using a robotic testing system. Each knee was tested under 3 external loading conditions including (1) a 134-N anterior tibial load; (2) combined rotational loads of 10 N x m of valgus and 5 N x m internal tibial torques; and (3) a 400-N quadriceps muscle load with the knee at 0 degrees , 15 degrees , 30 degrees , 60 degrees , and 90 degrees of flexion. The in situ forces of the 2 bundles of ACL were determined using the principle of superposition. RESULTS: Under the anterior tibial load, the PL bundle carried peak loads at full extension and concurrently had significantly lower force than the AM bundle throughout the range of flexion (P <.05). Under the combined rotational loads, the PL bundle contributed to carrying the load between 0 degrees and 30 degrees , although less than the AM bundle. Under simulated muscle loads, both bundles carried loads between 0 degrees and 30 degrees . There was no significant difference between the 2 bundle forces at all flexion angles (P > .05). CONCLUSION: Under externally applied loads, in general, the AM bundle carried a greater portion of the load at all flexion angles, whereas the PL bundle only shared the load at low flexion angles. The bundles functioned in a complementary rather than a reciprocal manner to each other. CLINICAL RELEVANCE: The data appear to support the concept that both bundles function in a complementary manner. Thus, how to re-create the 2 bundle functions in an ACL reconstruction should be further investigated.

Cyclooxygenase-2 expression in chondrosarcoma.

OBJECTIVE: In recent years it has become evident that tissue cyclooxygenase-2 (COX-2) may play a role in carcinogenesis and tumor malignancy. There is now a mounting body of information that strongly implies that COX-2 inhibitors may be of some value in the management of patients with carcinomas, and most recently several similar reports have appeared relating to sarcomas. METHODS: The authors studied 32 samples of cartilage tumors from our tumor tissue bank for the presence of COX-2 by a Western blot technique. There were 29 patients from whom the samples were obtained, including 8 with enchondromas and 21 with chondrosarcomas. RESULTS: Thirteen of the 24 chondrosarcoma samples and none of the 8 enchondromas were positive for COX-2. An attempt was made to correlate these results with clinical data including age, gender, staging according to the Musculoskeletal Tumor Society, anatomical site, ploidic pattern, presence of metastases and death rate but no statistically valid correlation could be found. CONCLUSION: It is evident that COX-2 may play some role in chondrosarcoma but not in the benign enchondroma and that further studies with COX-2 inhibitors are warranted.

Complete cervical intervertebral disc extrusion with spinal cord injury in the absence of facet dislocation: a case report.

STUDY DESIGN: Complete cervical disc complex extrusion, defined as the extrusion of both cartilaginous end-plates, the entire nucleus pulposus, and portions of the anulus fibrosus, is rare. A case of complete cervical disc complex extrusion with spinal cord injury in the absence of facet dislocation or subluxation in an obtunded patient is reported. OBJECTIVE: To report an unusual presentation of spinal cord injury and the occurrence of complete traumatic cervical disc complex extrusion in the absence of facet dislocation and normal plain radiographic findings. SUMMARY OF BACKGROUND DATA: Traumatic cervical disc herniation occurs in 54% to 80% of patients with facet dislocation. A report of complete extrusion of a cervical intervertebral disc complex (cartilaginous endplate, anulus, and nucleus pulposus) with spinal cord injury in the absence of dislocation has not been described, to the best of the authors' knowledge. METHODS: A clinical and radiographic review of such a case of complete traumatic cervical disc complex herniation in the absence of dislocation was performed. RESULTS: Plain radiographic imaging did not show any injury. A nondisplaced fracture of the left inferior facet joint was evident on computed tomography. The diagnosis of C4-C5 intervertebral disc extrusion was made only after magnetic resonance imaging. The vacuum effect of complete disc extrusion created a "white-out" appearance to the disc space on the sagittal T2 magnetic resonance image. The patient underwent anterior cervical discectomy and fusion with additional posterior cervical fusion. He subsequently regained functional strength against gravity in two of four limbs. He remains completely paraparetic in the left upper extremity and partially paraparetic in the left lower extremity. CONCLUSION: The case report highlights the occurrence of complete traumatic cervical disc extrusion in the absence of facet dislocation with normal plain radiographic findings and consequent spinal cord injury, which can accompany such an injury.