Faculty Bibliography

Groin pain is a common complaint in athletes that use themusculature of the lower abdomen and proximal thigh. Thecomplex anatomy of the groin region and broad differentialdiagnosis presents the sports medicine specialist with uniquediagnostic and treatment challenges. Sports hernia, osteitispubis, and adductor dysfunction are common extra-articularmusculoskeletal causes of groin pain in athletes. The currentpaper reviews the pathogenesis, history and physicalexamination, imaging, non-operative treatment, surgicaltechniques, and outcomes for these conditions. Treatmentalgorithms are presented for management of patients withsports hernia, osteitis pubis, and adductor dysfunction.

Cyclops lesion was previously described as a fibrous lesion with a granulation tissue core originating from the tibial insertion of the anterior cruciate ligament (ACL) graft. 1 Recently, two case reports described inverted cyclops le - sions, which originated from the femoral aspect of the ACL. 2,3 Both cyclops and inverted cyclops lesions are usually associated with a block to knee extension. Here we present a case of an 18-year-old female who developed a painful inverted cyclops lesion originating from the femoral notch above hamstring autograft without restriction to knee range of motion 20 months after arthroscopically assisted ACL reconstruction. The case is followed by literature review on presentation, diagnosis, and treatment of cyclops and inverted cyclops lesions.

Ice hockey is a fast paced sport with unique injury potential. There are no studies in the literature that examine the shoulder strength and range of motion in this population. Players on a single professional ice hockey team underwent a comprehensive examination of shoulder motion and strength. Shoulder motion and strength between right and left extremities were compared within athletes. Comparisons were made between right and left handed players, players that shoot right versus left handed, and by position. Within individual athletes, there was no difference in motion or strength between right and left shoulders. There was no difference in motion or strength between the dominant and non-dominant shoulder and players that shoot right versus left handed. Defensemen had a statistically significant increase in external rotation with the arm at the side for the left shoulder (66 degrees versus 55 degrees , p = 0.02) and a trend towards increased external rotation with the arm at the side for the right shoulder (65 degrees versus 56 degrees , p = 0.07). In professional ice hockey players, there is no difference in shoulder motion and strength between the right and left upper extremity. Ice hockey defensemen may have more external rotation with the arm at the side than forward.

Achilles tendon pathology is common and affects athletes and nonathletes alike. The cause is multifactorial and controversial, involving biological, anatomical, and mechanical factors. A variety of conditions characterized by Achilles tendon inflammation and/or degeneration can be clinically and histologically differentiated. These include insertional Achilles tendinopathy, retrocalcaneal bursitis, Achilles paratenonitis, Achilles tendinosis, and Achilles paratenonitis with tendinosis. The mainstay of treatment for all of these diagnoses is nonoperative. There is a large body of evidence addressing treatment of acute and chronic Achilles tendon ruptures; however, controversy remains.

OBJECTIVE: The objectives of the article are to improve the radiologist's understanding of shoulder arthroscopy and see how it correlates with MRI. We review the basic principles of arthroscopy followed by a comparison of its strengths and weaknesses relative to MRI. This discussion is supplemented by a series of cases that show the relationship between arthroscopy and MRI in terms of the visualization of normal and abnormal anatomy in the diagnosis of common shoulder abnormalities. CONCLUSION: By understanding what our orthopedic colleagues are seeing (and not seeing) during arthroscopic shoulder surgery, we can better understand the strengths and weaknesses of MRI, which provides us the opportunity to improve our imaging interpretations and produce valuable management-guiding diagnostic reports.

BACKGROUND: Injury to subchondral bone is associated with knee pain and osteoarthritis (OA). A percutaneous calcium phosphate injection is a novel approach in which subchondral bone marrow edema lesions are percutaneously injected with calcium phosphate. In theory, calcium phosphate provides structural support while it is gradually replaced by bone. However, little clinical evidence supports the efficacy of percutaneous calcium phosphate injections. QUESTIONS/PURPOSES: We asked: (1) Does percutaneous calcium phosphate injection improve validated patient-reported outcome measures? (2) What proportion of patients experience failure of treatment (defined as a low score on the Tegner Lysholm Knee Scoring Scale)? (3) Is there a relationship between outcome and age, sex, BMI, and preoperative grade of OA? METHODS: Between September 2012 and January 2014, we treated 33 patients with percutaneous calcium phosphate injections. Twenty-five satisfied our study inclusion criteria; of those, three patients were lost to followup and 22 (88%; 13 men, nine women) with a median age of 53.5 years (range, 38-70 years) were available for retrospective chart review and telephone evaluation at a minimum of 6 months (median, 12 months; range, 6-24 months). Our general indications for this procedure were the presence of subchondral bone marrow edema lesions observed on MR images involving weightbearing regions of the knee associated with localized pain on weightbearing and palpation and failure to respond to conservative therapy (> 3 months). Patients with pain secondary to extensive nondegenerative meniscal tears with a flipped displaced component at the level of bone marrow edema lesions, or with mechanical axis deviation greater than 8 degrees were excluded. All patients had Grades III or IV chondral lesions (modified Outerbridge grading system for chondromalacia) overlying MRI-identified subchondral bone marrow edema lesions. Percutaneous calcium phosphate injection was performed on the medial tibial condyle (15 patients), the medial femoral condyle (five patients), and the lateral femoral condyle (two patients). Concomitant partial meniscectomy was performed in 18 patients. Preoperative and postoperative scores from the Knee Injury and Arthritis Outcome Score (KOOS) and the Tegner Lysholm Knee Scoring Scale were analyzed. RESULTS: For patients available for followup, the outcome scores improved after treatment. The KOOS improved from a mean of 39.5 +/- 21.8 to 71.3 +/- 23 (95% CI, 18.6-45.2; p < 0.001) and the Tegner and Lysholm score from 48 +/- 15.1 to 77.5 +/- 20.6 (95% CI, 18.8-40.2; p < 0.001). However, seven of the 22 patients had poor clinical outcomes as assessed by the Tegner Lysholm Knee Scoring Scale, whereas three had fair results, five had good results, and seven had excellent results. The postoperative Tegner Lysholm score was inversely related to the preoperative Kellgren-Lawrence OA grade (R2 = 0.292; F (1.20) = 9.645; p = 0.006). We found no relationship between outcome scores and age, sex, or BMI. CONCLUSIONS: In a study that would have been expected to present a best-case analysis (short-term followup, loss to followup of patients with potentially unsatisfactory results, and use of invasive cotreatments including arthroscopic debridements), we found that percutaneous calcium phosphate injection in patients with symptomatic bone marrow edema lesions of the knee and advanced OA yielded poor results in a concerning proportion of our patients. Based on these results, we advise against the use of percutaneous calcium phosphate injections for patients with advanced osteoarthritic changes. LEVEL OF EVIDENCE: Level IV, therapeutic study.

The management of meniscal pathology continues to evolve as researchers gain a better understanding of the role of the meniscus in normal knee kinematics. Evidence now supports retention or transplantation of meniscal tissue to maintain homeostatic knee mechanisms because the removal of meniscal tissue changes the contact stresses and leads to structural and biomechanical changes in the articular cartilage and the subchondral plate that predisposes the knee to the development of degenerative arthritis. Advances in repair techniques, biologic adjuvants, and progressive tissue-engineering strategies are rapidly adding to the surgeon's armamentarium when dealing with meniscal injury and insufficiency. Early clinical data support many of these advanced techniques. It is helpful to explore meniscal function, pathology, and current treatment modalities, with a focus on meniscal repair and transplantation as well as adjuvants to biologic healing and future directions in this field.