26 Sports Medicine

26.1 General Approach to the MSK Exam

  1. History
    • Mechanism, chronicity, exposures, associated symptoms
    • Red flags: B symptoms, major trauma
  2. Inspection: Compare to contralateral side. Make sure to EXPOSE for best exam.
    • Look for asymmetry, atrophy, deformity, ecchymosis, erythema, scars
    • Red flags: Erythema (sign of infxn), deformity concerning for major trauma
  3. Palpation
    • Feel for anatomic points of interest
    • Red flags: Warmth (sign of infxn), diminished sensation (sign of neurologic deficit)
  4. Range of motion (ROM): Active first, then passive
    • Look for pain w/ motion, limited ROM (and distinguish whether due to pain, effusion, mechanical problem)
  5. Strength
    • Graded from 0-5 out of 5:
      • 5/5 = full strength
      • 4/5 = movement against some resistance
      • 3/5 = movement against gravity
      • 2/5 = movement but not against gravity
      • 1/5 = muscle flicker
      • 0/5 = no contraction
    • Red flags: Diminished strength if not due to pain (sign of neurologic deficit)
  6. Special testing is joint specific - see relevant sections below

26.2 Fractures

26.2.1 Salter-Harris Classification for Physeal Fractures

Type I Type II Type III Type IV Type V
Lesion
Details Often involves growth plate Most common! Growth plate + metaphysis Growth plate + epiphysis + joint space Metaphysis + growth plate + epiphysis + joint space Compression of growth plate
Implications Good prognosis Good prognosis Threatens growth and articular integrity Threatens growth and articular integrity Very high risk for growth arrest
Management - Dx: Usually clinical dx (XR negative unless displaced); contralateral XR may be useful
- Immobilization (cast vs. splint) for > 3 wks		 Immobilization (cast vs. splint) for > 3 wks - Immediate Ortho consult
- Likely reduction (anatomic vs. surgical)		 - Immediate Ortho consult
- Likely reduction (anatomic vs. surgical)		 - Immediate Ortho consult
- Likely reduction (anatomic vs. surgical)

26.3 Pre-Participation Physical

26.3.0.1 History

  • Goal: Elucidate conditions that might preclude or limit sports participation
  • Cardiac history
  • Dyspnea on exertion → consider exercise induced asthma or vocal cord dysfunction
  • History of head trauma
  • History of “burners” or “stingers” (from transient brachial plexus compression/stretching) → if recurrent, may need C-spine XR
  • Disordered eating (esp/ in sports w/ weight requirements)
  • Substance abuse
  • Family history: Sudden death, congenital heart disease, arrhythmias, Marfan syndrome

26.3.0.2 Physical Exam

Special attention to CV, resp, and MSK (assess ROM, symmetry, stability)

26.3.0.3 Cardiac Testing

  • e.g. EKG, echo, exercise testing
  • ONLY if clinically indicated, though highly controversial and recommendations worldwide differ. Current AHA/AAP PPE guidelines currently do not recommend global EKG/echo.

26.3.0.4 Clearance

  • Increased risk of injury?
  • Would treatment make athlete safe to participate?
  • Can limited participation be allowed while treatment is undergone?
  • Limitations for some or all sports?

26.4 Upper Extremity: Elbow, Forearm & Wrist

26.4.1 Anatomy

26.4.2 Exam Pearls

  • Rapid elbow/forearm neurovascular exam:
    • Brachial artery: Brachial + radial pulses, perfusion check
    • Median nerve: Sensation over palmar side of digits 1-3
    • Anterior interosseous nerve (motor-only branch of median nerve): “OK” sign 👌, grip strength
    • Radial nerve: Wrist extension, thumbs-up sign 👍
    • Ulnar nerve: Spread fingers against resistance

26.4.3 Supracondylar Fracture

26.4.3.1 Description/Mechanism

Usually fall on outstretched hand (FOOSH) with elbow hyperextension

26.4.3.2 Diagnosis

  • Exam: Gross deformity, limited active elbow motion
  • Imaging: AP + lateral XR. Findings may be subtle (posterior fat pad sign on lateral film)

26.4.3.3 Management

  • Ortho consult
  • Usually surgical fixation for displaced fractures

26.4.4 Nursemaid’s Elbow (Subluxation of Radial Head)

26.4.4.1 Description/Mechanism

Traction on arm with extended elbow (e.g. swinging child through the air)

26.4.4.2 Diagnosis

  • Exam: No deformity, elbow held in passive pronation with slight flexion, refusing to use arm
  • Imaging: Unnecessary unless suspect fracture based on H&P, or if reduction unsuccessful

26.4.4.3 Management

Stabilize elbow w/ one hand → supinate forearm and flex elbow (will usually feel/hear click)

26.4.5 Distal Radius Fracture

26.4.5.1 Description/Mechanism

  • FOOSH
  • Most common pediatric fracture

26.4.5.2 Diagnosis

  • Exam: Pain, ecchymosis, swelling
  • Imaging: AP + lateral XR of wrist and forearm; consider AP + lateral of elbow if tender or if diaphyseal fractures present

26.4.5.3 Management

  • Ortho consult
  • Depending on severity, may require anything from immobilization to ORIF

26.5 Upper Extremity: Shoulder

26.5.1 Anatomy

  • Rotator cuff muscles (mnemonic: SITS → AEEI)
    • Supraspinatus → Abduction
    • Infraspinatus and Teres Minor → External rotation x2
    • Subscapularis → Internal rotation

26.5.2 Exam Pearls & Special Tests

  • Empty can test: Strength in internal rotation/thumb down position. Tests supraspinatus.
  • Scarf test: Pain w/ cross arm adduction. Tests AC joint.
  • Lift-off test: Strength in lifting dorsum of hand off back. Tests subscapularis.
  • Impingement test: Pain w/ passive internal rotation/forward flexion. Tests subacromial impingement.

26.5.2.1 Common Associations

  • Scapular winging i/s/o recent trauma or viral illness → likely serratus anterior or trapezius dysfunction
  • Inability to passively/actively rotate affected arm externally s/p seizure → likely posterior shoulder dislocation
  • Supraspinatus/infraspinatus wasting → likely rotator cuff tear or suprascapular nerve entrapment
  • Decreased cervical ROM w/ pain radiating below elbow → likely cervical disc disease
  • Shoulder pain in a throwing athlete w/ anterior glenohumeral joint pain/impingement → likely glenohumeral joint instability
  • Pain or “clunking” sound w/ overhead motion → likely labral disorder

26.5.3 Proximal Humeral Fracture

26.5.3.1 Description/Mechanism

  • FOOSH
  • Direct blow to lateral shoulder

26.5.3.2 Signs & Symptoms

History of trauma, severe shoulder pain, pain w/ arm movement

26.5.3.3 Diagnosis

  • Exam: tenderness, swelling, shoulder asymmetry, arm shortened and held in extension
  • Imaging: AP + axillary XR of humerus
    • Also get scapular “Y” view if concerned for shoulder injury
    • Suspect Salter-Harris I if negative XR + tenderness at physis

26.5.3.4 Management

  • Immobilization
  • Likely Ortho consult, esp. if more severe (a/w shoulder dislocation, neurovascular compromise, etc.)

26.5.4 Dislocation

26.5.4.1 Description/Mechanism

  • Majority of dislocations are anterior
  • Blow to abducted/externally rotated/extended arm
  • FOOSH
  • Forceful forward swinging of arm

26.5.4.2 Diagnosis

  • Exam: Arm abducted and externally rotated w/ resistance to all movement, loss of rounded appearance of shoulder. Evaluate for sensory loss over lateral deltoid (2/2 axillary nerve dysfunction).
  • Imaging: AP + scapular “Y” + axillary XR to confirm dx and exclude fractures (can be repeated post-reduction if unsure of success)

26.5.4.3 Management

Reduction (variety of techniques exist) → immobilization and referral to Sports Med/Ortho for prevention of recurrent dislocation

26.5.5 Rotator Cuff Injury

26.5.5.1 Description/Mechanism

  • Includes impingement (inflammation & pinching of rotator cuff tendons) and rotator cuff tears
    • Impingement very common, tears very uncommon in youth athletes
  • Overuse or acute injury, usually involving throwing or overhead activities

26.5.5.2 Signs & Symptoms

Pain in upper arm, worse w/ overhead activity or lying on affected side

26.5.5.3 Diagnosis

  • Exam: Pain/weakness w/ testing of rotator cuff muscles; positive empty can, lift off, Hawkins, and/or impingement tests (see above)
  • Imaging: XR only if bony pathology suspected; MRI best

26.5.5.4 Management

  • Can start w/ conservative management (NSAIDs, PT)
  • Chronic, symptomatic tears → consider surgical intervention

26.5.6 Little Leage Shoulder (Proximal Humeral Epiphysiolysis)

26.5.6.1 Description/Mechanism

  • Overuse injury from throwing causing microfractures in humeral epiphysis
  • Most common in 11-16yo athletes

26.5.6.2 Signs & Symptoms

Progressive shoulder pain w/ throwing, localized to proximal humerus, usually lateral

26.5.6.3 Diagnosis

  • Exam: TTP at proximal lateral humerus over deltoid
  • Imaging: AP XR of both arms in external and internal rotation; can get MRI if dx unclear

26.5.6.4 Management

  • Rest x3 mos (minimum) + PT, then gradual progression to throwing
  • Can still bat and play positions that do not require a lot of throwing

26.5.7 Acromioclavicular (AC) Joint Injury

26.5.7.1 Description/Mechanism

  • Ranges from sprain of AC ligaments to full ligamentous rupture w/ clavicular displacement
  • Usually fall onto or direct blow to shoulder

26.5.7.2 Diagnosis

  • Exam: Tenderness, swelling, asymmetry at AC joint, prominent distal clavicle; + scarf test
  • Imaging: XR (abnormal in more severe injury, may be normal if joint space not widened)

26.5.7.3 Management

  • Less severe injury (no separation of joint capsule) → sling 1-2 wks, ice, NSAIDs → early motion as able, including flexion/extension at elbow
  • More severe injury → likely surgical intervention

26.5.8 Clavicular Fracture

26.5.8.1 Description/Mechanism

Classified by location: most common is midshaft fracture > distal third > proximal third

26.5.8.2 Diagnosis

  • Exam: Arm held adducted close to body, often supported w/ opposite hand; point tenderness, crepitus
    • Neurovascular and respiratory exam crucial due to risk of brachial plexus and lung injury
  • Imaging: XR

26.5.8.3 Management

  • Most heal well w/ sling, but indications for surgery are controversial
  • Any sign of neurovascular compromise → acute reduction needed

26.6 Lower Extremity: Hip

26.6.1 Anatomy

26.6.2 Exam Pearls & Special Tests

  • Hip pain can refer to groin, thigh, or knee, or can present as limp/refusal to walk w/o complaint of pain
    • Pain from intra-articular pathology often localizes to groin
  • Barlow/Ortolani: Remember to apply gentle anterior pressure to the trochanter during abduction (Ortolani test)
  • Trendelenburg test: Positive when patient stands on one leg and the contralateral hip drops, indicative of gluteals/hip abductor weakness
  • FABER (Flexion, Abduction, External Rotation): Test for hip or SI joint pathology
  • FADIR (Flexion, Adduction, Internal Rotation): Test for hip impingement
  • Log roll test: Patient on back w/ leg fully extended and relaxed, examiner passively rotates leg and hip internally and externally. Pain should yield high suspicion for intra-articular pathology.

26.6.3 Legg-Calve-Parthes Disease

26.6.3.1 Description/Mechanism

  • Avascular necrosis (AVN) of the hip
  • Most common age 5-7yo, M > F, bilateral in 10-20%

26.6.3.2 Signs & Symptoms

Activity-related hip pain and/or limp (acute or chronic)

26.6.3.3 Diagnosis

  • Exam: Trendelenburg gait, decreased hip abduction and internal rotation
  • Imaging: XR often normal early in course, bone scan or MRI more suggestive of dx

26.6.3.4 Management

  • Non-weight bearing and restoration of motion (crutches), NSAIDS, PT, aquatherapy
  • Severe cases may require spica casting or surgery

26.6.4 Slipped Capital Femoral Epiphysis (SCFE)

26.6.4.1 Description/Mechanism

  • Displacement of the capital femoral epiphysis from the femoral neck through the physeal plate
  • Commonly ages 10-16yo, M > F, bilateral in 20-40%

26.6.4.2 Signs & Symptoms

Groin pain, knee pain, limp

26.6.4.3 Diagnosis

  • Exam: Decreased hip ROM, hip externally rotated at rest, leg length discrepancy
  • Imaging: AP + frog leg lateral hip XR. Look for “ice cream scoop falling off the cone, S-sign (frog leg) + Klein’s Line (AP) for subtle cases.

26.6.5 Developmental Dysplasia of the Hip (DDH)

26.6.5.1 Description/Mechanism

  • Abnormal development of shallow acetabulum causing hip joint instability
  • F > M

26.6.5.2 Diagnosis

  • Exam: Positive Barlow/Ortolani (only reliable in ages <3mo). Limitation of hip abduction or positive Galeazzi (asymmetric knee heights when hips & knees flexed) in ages >3mo.
  • Imaging: US until age 4-6mos, AP XR pelvis w/ hip in 20-30 degree flexion after age 4-6mos

26.6.5.3 Management

  • Ortho referral
  • Depending on age at diagnosis/referral and severity, may be treated w/ anything from observation to harness to operative management

26.6.6 Femoroacetabular Impingement (FAI)

26.6.6.1 Description/Mechanism

  • Trapping of femoral neck against anterior acetabulum
  • Acetabular overcoverage (Pincer impingement) vs decreased head-neck offset (CAM impingement) vs both
  • Common in athletes
  • Difficult to differentiate from hip flexor tendinitis

26.6.6.2 Diagnosis

  • Exam: Pain on hip flexion passively or against resistance, impact/running, deep flexion; pain is usually anterior or into groin.
  • Imaging: XR AP Pelvis and Dunn laterals bilaterally
    • Can have skeletal setup and still not be their pain cause

26.6.6.3 Management

Safe to start with PT unless having mechanical/catch/lock symptoms or difficulty weight bearing (in which case, refer to Sports Med/Ortho)

26.7 Lower Extremity: Knee

26.7.1 Anatomy

26.7.2 Exam Pearls & Special Tests

  • Ober test: Positive if superior leg doesn’t drop towards table when released. Tests IT band.
  • Anterior drawer test: Anterior translation (keep foot stabilized) compared to contralateral knee. Tests ACL.
  • Valgus/varus stress test: Laxity/pain w/ valgus/varus at 0° and 30°. Tests MCL/LCL (respectively).
  • McMurray test: Pain/click w/ knee extension w/ tibia internally/externally rotated. Tests lateral/medial meniscus (respectively).

26.7.3 Osgood-Schlatter Disease

26.7.3.1 Description/Mechanism

  • Traction apophysitis of tibial tubercle at patellar tendon insertion
  • Often children who play jumping sports and/or are undergoing rapid growth spurt
  • Corollary process at inferior patellar pole = Sinding-Larsen-Johansson Syndrome

26.7.3.2 Signs & Symptoms

  • Gradually worsening anterior knee pain, exacerbated by kneeling, jumping, stairs, walking uphill
  • Can be asymmetric or bilateral
  • Pain relieved by rest

26.7.3.3 Diagnosis

  • Exam: Prominence of and TTP at the tibial tubercle, pain w/ resisted knee extension or squatting
  • Imaging: Not routinely indicated unless to rule out other dx

26.7.3.4 Management

  • Usually conservative: Pain management, PT for strengthening
  • Continuation of activity, as long as not prolonged squatting/kneeling (e.g. playing)

26.7.4 Patellofemoral Pain Syndrome (PFPS)

26.7.4.1 Description/Mechanism

Abnormal tracking of patella causes anterior knee pain w/o intra-articular pathology

26.7.4.2 Signs & Symptoms

  • Anterior knee pain worsened w/ prolonged sitting (theater sign) or descending stairs
  • Pain w/ running/impact activity (aka Runner’s knee)

26.7.4.3 Diagnosis

  • Exam: Positive J-sign (lateral patellar tracking during terminal knee extension), positive patella mobility test (medial glide < ¼ or > ¾ patella width suggesting hypo- or hypermobility)
  • Imaging: Not routinely indicated unless to exclude other dx

26.7.4.4 Management

  • Conservative treatment, PT for strengthening
  • Avoid long-term NSAID use

26.7.5 Anterior Cruciate Ligament (ACL) Injuries

26.7.5.1 Description/Mechanism

  • Cutting/pivoting motion causing valgus stress on knee, can be due to direct blow causing hyperextension/valgus deformation
  • Medial meniscus and MCL often injured at same time (Unhappy Triad)

26.7.5.2 Signs & Symptoms

“Pop” at time of injury, swelling, feeling of knee “giving out”

26.7.5.3 Diagnosis

  • Exam: Joint effusion, positive anterior drawer test
  • Imaging: MRI > XR, but can get XR to evaluate for associated injury/fracture

26.7.5.4 Management

  • Ortho/Sports Med referral
  • Operative management in majority of cases, ideally w/ period of pre-operative rehabilitation to optimize outcomes

26.7.6 Meniscus Injuries

26.7.6.1 Description/Mechanism

  • Direction change w/ knee rotation, planted foot, and flexed knee
  • Commonly in sports w/ lots of deceleration and direction change

26.7.6.2 Signs & Symptoms

  • Often insidious onset of pain/swelling in 24h after injury
  • Pain worse w/ twisting/pivoting
  • Can have locking/popping/catching sensation

26.7.6.3 Diagnosis

  • Exam: Joint line tenderness, inability to fully extend/squat/kneel, positive McMurray test
  • Imaging: MRI > XR (plain films often negative)

26.7.6.4 Management

  • Ortho/Sports Med referral
  • Management varies from conservative to operative (usually arthroscopic)

26.7.7 Iliotibial (IT) Band Syndrome

26.7.7.1 Description/Mechanism

Tight IT band sliding over lateral femoral epicondyle

26.7.7.2 Signs & Symptoms

Diffuse lateral knee pain, worsened w/ activity or w/ prolonged sitting w/ knee in flexed position

26.7.7.3 Diagnosis

  • Exam: TTP in lateral knee, positive Ober test
  • Imaging: Not routinely indicated

26.7.7.4 Management

  • Activity modification
  • NSAIDs
  • Stretching/strengthening regimen

26.7.8 Osteochondritis Dissecans

26.7.8.1 Description/Mechanism

  • Acquired subchondral bone lesion which can progress to involve cartilage causing separation from underlying bone; most common in knee
  • Mechanism unknown; proposed to be due to repetitive trauma vs. inflammation
  • Can lead to osteoarthritis if not recognized/treated

26.7.8.2 Signs & Symptoms

  • May be incidental finding on imaging vs. non-specific activity related knee pain
  • May have swelling or symptoms of catching/locking if lesions are unstable

26.7.8.3 Diagnosis

  • Exam: No specific findings
  • Imaging: 4-view XR (AP, lateral, sunrise, tunnel) of knee, MRI to further delineate known OCD lesion and determine management (or if XR negative but high clinical suspicion)

26.7.8.4 Management

  • Referral to Ortho/Sports Med
  • May be treated conservatively (non-weight-bearing or activity limitation) vs. operatively (if lesions are unstable or unresponsive to conservative treatment)

26.8 Lower Extremity: Ankle/Foot

26.8.1 Anatomy

26.8.2 Exam Pearls & Special Tests

  • Mid-calf squeeze: Positive if generates pain in ankle. Tests tibiofibular syndesmosis.
  • Anterior drawer test: Anterior translation comapred to contralateral ankle. Tests ATFL.
  • Talar tilt: Range of inversion compared to contralateral ankle. Tests CFL.
  • Ottawa ankle rules (when to get XR of ankle/foot, validated for >18yo):
    • Ankle: Pain in malleolar zone + EITHER of:
      • Bony tenderness at posterior edge of lateral/medial malleolus
      • Inability to bear weight both immediately after injury + at time of exam
    • Foot: Pain in midfoot zone + EITHER of:
      • Bony tenderness at base of 5th metatarsal or navicular bone
      • Inability to bear weight both immediately after injury + at time of exam

26.8.3 Ankle Sprain

26.8.3.1 Description/Mechanism

  • Ligamentous stretching/tearing
  • Lateral: Inversion of plantar-flexed foot; injuries ATFL most commonly
  • Medial: Eversion or abduction/ external

26.8.3.2 Signs & Symptoms

Pain, swelling (diffuse or localized), +/- inability to bear weight

26.8.3.3 Diagnosis

  • Exam: Swelling, TTP, positive anterior drawer/talar tilt (lateral sprain), positive mid-calf squeeze (high sprain), squeeze test for syndesmotic injury
  • Imaging: Not routinely indicated unless concern for fracture (see Ottawa rules above) or clinical uncertainty

26.8.3.4 Management

  • Short period of complete immobilization (longer depending on severity), supportive device (lace-up brace or elastic bandage)
  • ROM/strength exercises (can be w/ formal PT, esp. in case of recurrent ankle sprains) are critical to restoring function and proprioception
  • For HIGH ankle sprains, consult Ortho/Sports Med (may need acute surgical stabilization if severe)

26.8.4 Sever’s Disease

26.8.4.1 Description/Mechanism

  • Traction apophysitis of calcaneal growth plate at site of Achilles insertion; often children who play sports w/ jumping/heel striking and/or are undergoing rapid growth spurt
  • Essentially Osgood-Schlatter at the calcaneus

26.8.4.2 Signs & Symptoms

Chronic heel pain w/ insidious onset, worse w/ activity or wearing non-supportive footwear

26.8.4.3 Diagnosis

  • Exam: TTP at calcaneal apophysis or w/ “calcaneal compression test”
  • Imaging: Not routinely indicated unless diagnosis unclear or to rule out fracture

26.8.4.4 Management

Painful activity → gradual return to play, use of heel cup for support, ice and stretching

26.8.5 Spiral/Oblique Fracture

26.8.5.1 Description/Mechanism

  • “Toddler’s fracture” in 9mo-3yo
  • Rotation around fixed foot → distal tibial fracture; often minimal trauma in toddlers, higher impact injury in older children
  • ~30% of tibial fractures have associated fibular fracture
  • Spiral fractures in NON-ambulatory child → concern for NAT

26.8.5.2 Signs & Symptoms

Limp, refusal to bear weight

26.8.5.3 Diagnosis

  • Exam: Point tenderness over distal ⅓ of tibia
  • Imaging: AP + lateral XR of the tibia and fibula; fractures may be occult (not seen on imaging)

26.8.5.4 Management

  • Immobilization in long leg posterior splint/cast
  • Ortho referral

26.8.6 Congenital Clubfoot

26.8.6.1 Description/Mechanism

  • Idiopathic vs. due to intrinsic (e.g. neurologic) or extrinsic (e.g. fibroids) factors
  • 1:1000 live births, M > F

26.8.6.2 Diagnosis

  • Exam: Fixed (e.g. not correctable) deformity of the foot w/ plantar flexion and inversion + rotation, calf atrophy
  • Imaging: Usually dx on prenatal US, XR minimally useful initially

26.8.6.3 Management

  • Ortho referral (usually done in nursery prior to d/c)
  • Serial casting → Achilles tenotomy → bracing

26.9 Spine

26.9.1 Anatomy

26.9.2 Exam Pearls & Special Tests

  • Straight leg raise: Patient lying supine → flex at hip w/ knee straight (best if cervical spine flexed and ankle dorsiflexed) → assess for sciatic pain (sign of herniated disc)

26.9.3 Scoliosis

26.9.3.1 Description/Mechanism

  • Lateral curvature of the spine > 10°
  • Idiopathic (80%) vs. congenital vs. neuromuscular

26.9.3.2 Diagnosis

  • Exam: Adam’s forward bend test + inclinometer. Shoulder/torso asymmetry, rib prominence, paraspinal muscle prominence.
  • Imaging: XR w/ Cobb Angle > 10°

26.9.3.3 Management

  • Less than 25° → observation
  • 25-45° + skeletal immaturity → bracing
  • Greater than 45° → consider surgical intervention

26.9.4 Spondylolysis & Spondylolisthesis

26.9.4.1 Description/Mechanism

  • Spondylolysis: Bony defect in pars interarticularis (usually L4 and L5)
  • Spondylolisthesis: Displacement of vertebral body relative to inferior vertebral body
  • Caused by repetitive microtrauma
  • Most common causes of back pain in children >10yo; often in athletes engaged in sports w/ repetitive extension, flexion, and rotation

26.9.4.2 Signs & Symptoms

  • Low back pain that worsens w/ activity, improves w/ rest
  • Spondylolisthesis: May have radicular or cauda equina symptoms

26.9.4.3 Diagnosis

  • Imaging:
    • MRI is now study of choice
    • XR: Poorly sensitive and do not assess acuity, but might be required prior to MRI
      • Standing AP, lateral, oblique views: Visualize defect
      • Flexion and extension views: Assess stability

26.9.4.4 Management

  • Spondylolysis and low-grade spondylolisthesis → conservative (rest from sports for > 3 mos, NSAIDs, PT, back bracing)
  • Higher-grade spondylolisthesis (or failure of conservative management) → consider surgical intervention

26.9.5 Spondyloarthropathies

26.9.5.1 Signs & Symptoms

  • Insidious onset
  • Often misdiagnosed w/ recurrent strains/sprains
  • Pain worse at night, improves w/ activity

26.10 Head

26.10.1 Mild Traumatic Brain Injury (TBI) (Concussion)

Including Graduated Return-to-Sport Program

See ED chapter for Mild TBI section