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Brukner & Khan's Clinical Sports Medicine


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Brukner and Khan's Clinical Sports Medicine is the bible of sports medicine. The text explores all aspects of diagnosis and management of sports-related injuries and physical activity. Buy NOW and receive 12 months FREE access to the Clinical Sports Medicine website featuring over 4 hours of video clips on assessment, treatment and rehabilitation, plus interviews with leading experts.

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Brukner & Khan's Clinical Sports Medicine

  1. 1. sa m pl e pa ge s on ly
  2. 2. Brukner & Khan’s Clinical SportsMedicineFOURTH E DI TION ly on s ge pa e pl m sa
  3. 3. We dedicate this fourth edition to the Clinical Sports Medicine community—to each clinician, educator, and policy maker committed to improving health through the power of physical activity. ly on s ge pa e pl m sa
  4. 4. Brukner & Khan’s Clinical SportsMedicineFOURTH E DITION Brukner Bahr Blair Cook ly Crossley on McConnell McCrory s noakes ge khan pa e pl m sa
  5. 5. NoticeMedicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment anddrug therapy are required. The editors and the publisher of this work have checked with sources believed to be reliable in theirefforts to provide information that is complete and generally in accord with the standards accepted at the time of publication.However, in view of the possibility of human error or changes in medical sciences, neither the editors, nor the publisher, nor anyother party who has been involved in the preparation or publication of this work warrants that the information contained hereinis in every respect accurate or complete. Readers are encouraged to confirm the information contained herein with other sources.For example, and in particular, readers are advised to check the product information sheet included in the package of each drugthey plan to administer to be certain that the information contained in this book is accurate and that changes have not beenmade in the recommended dose or in the contraindications for administration. This recommendation is of particular importancein connection with new or infrequently used drugs.First published 1993Second edition 2001Revised second edition 2002Third edition 2006Revised third edition 2009Text © 2012 McGraw-Hill Australia Pty LtdAdditional owners of copyright are acknowledged in on-page credits.Every effort has been made to trace and acknowledge copyrighted material. The authors and publishers tender their apologiesshould any infringement have occurred.Reproduction and communication for educational purposesThe Australian Copyright Act 1968 (the Act) allows a maximum of one chapter or 10% of the pages of this work, whichever is thegreater, to be reproduced and/or communicated by any educational institution for its educational purposes provided that theinstitution (or the body that administers it) has sent a Statutory Educational notice to Copyright Agency Limited (CAL) and beengranted a licence. For details of statutory educational and other copyright licences contact: Copyright Agency Limited, Level 15,233 Castlereagh Street, Sydney NSW 2000. Telephone: (02) 9394 7600. Website: and communication for other purposesApart from any fair dealing for the purposes of study, research, criticism or review, as permitted under the Act, no part of thispublication may be reproduced, distributed or transmitted in any form or by any means, or stored in a database or retrieval system,without the written permission of McGraw-Hill Australia including, but not limited to, any network or other electronic storage.Enquiries should be made to the publisher via or marked for the attention of the permissions editor atthe address below. lyNational Library of Australia Cataloguing-in-Publication DataAuthor: Brukner, Peter.Title: Brukner & Khan’s Clinical Sports Medicine / Peter Brukner, on Karim Khan.Edition: 4th ed.ISBN: 9780070998131 (hbk.)Notes: Includes index. Previous ed.: Clinical Sports Medicine, 2007. sSubjects: Sports medicine. ge Sports injuries.Other Authors/Contributors: Khan, Karim.Dewey Number: 617.1027 paPublished in Australia byMcGraw-Hill Australia Pty LtdLevel 2, 82 Waterloo Road, North Ryde NSW 2113Publisher: Fiona Richardson eSenior production editor: Yani SilvanaProduction editor: Jess Ní Chuinn plPublishing and digital manager: Carolyn CrowtherEditorial coordinator: Fiona Collison mCopy editor: Jill PopeIllustrator: Vicky Earle (anatomical figures)Proofreader: Mary-Jo O’Rourke saIndexer: Russell BrooksCover design: Georgette HallInternal design: David RosenmeyerTypeset in 9/11.5 pt Scala by Midland Typesetters, AustraliaPrinted in China on 80gsm matt art by iBook Printing Ltd
  6. 6. Foreword to the first edition (1993)Sport in Australia is ingrained in the national consciousness more widely, deeply, and indelibly than almostanywhere else in the world. When a prominent sportsperson sustains a sporting injury, either traumaticallyor from overuse, becomes excessively fatigued, or fails to live up to expectations, this assumes national impor-tance. It is even more relevant nowadays with greater individual participation in sporting activities. The sametype of problems occur for recreational athletes, middle-aged people wanting to become fit, or older peoplewishing to sustain a higher level of activity in their later years. In Clinical Sports Medicine the authors take sport and exercise medicine out of the realm of the elite athleteand place it fairly and squarely where it belongs—as a subspecialty to serve everyone in the community whowishes to be active. The book is organized in a manner that is sensible and usable. The chapters are arranged according tothe anatomical region of the symptom rather than diagnostic categories. This results in a very usable text forthe sports physician, general/family practitioner, physiotherapist, masseur, or athletic trainer whose practicecontains many active individuals. Practical aspects of sports medicine are well covered—care of the sporting team and concerns that aclinician might have when traveling with a team. In all, this is an eminently usable text which is timely in itsproduction and will find an important place among clinicians involved in the care of active individuals.John R Sutton MD, FRACPProfessor of Medicine, Exercise Physiology and Sports MedicineFaculty of Health SciencesUniversity of SydneyPast President, American College of Sports Medicine lyThis foreword was written by the late Professor John Sutton before his untimely death in 1996; it is retained in this ontextbook out of profound respect for this champion of the integration of science, physical activity promotion, and multi-disciplinary patient care. s ge pa e pl m sa v
  7. 7. Foreword to the fourth editionHumans were not designed to sit at desks all day and in front of televisions all evening, and this physicalinactivity is related to a host of health-related issues. Increasing physical activity is one very powerful way tomitigate many of the health issues we face today, and programs such as the Healthy People 2020 initiative andthe Exercise is Medicine campaign encourage individuals to remain active throughout their lifetime. As people become more involved in sport and exercise, sports medicine becomes increasingly important,and Clinical Sports Medicine has understandably become what we in the US refer to as the “PDR” (Physicians’Desk Reference) of sports medicine. For my UK colleagues the translation is “BNF” (British National Formu-lary). This text is extremely comprehensive, covering fundamental principles of biomechanics, diagnosis andtreatment, regional musculoskeletal injuries, and medical problems. The text also addresses those practicalissues of sports medicine that are often missing from other texts, such as dealing with athletic teams, coveringendurance events, and working with the elite athlete. The organization of the text makes it remarkably easy to use, including such features as color-coded booksections, flow diagrams to reinforce concepts, and tables that clearly organize information. Vicky Earle’sanatomical drawings are truly among the best in the business. All these features put an astounding wealthof information at the reader’s fingertips. This information has been assembled by a group of over 100 expe-rienced and world-class physical therapists, physicians, and scientists. These co-authors provide up-to-datereferences when available, and clearly state when evidence is lacking. This updated, fourth edition includes 200 new photos/graphics and 13 new chapters on current topics,including Integrating evidence into clinical practice, Principles of activity promotion, and Medical emergen-cies in sport. The editors continue to add to the clinically relevant topics with one of my favorites being whatI call “How to manage the patient who has seen everyone and wants a cure from you!” (Chapter 41). An innovative and exciting addition to this edition is the integration of the Clinical Sports Medicine master- lyclasses that allow you, through videos and podcasts on the Clinical Sports Medicine website, to learn directlyfrom the experts. These masterclasses will be continually updated and they provide a remarkably dynamic oncomponent to the text. It is exciting to watch Clinical Sports Medicine evolve substantially with each edition. The editors’ focus ofthis text is to “help clinicians help patients” and they have clearly hit their mark. This book is an absolute must- shave for any sports medicine professional. geProfessor Irene Davis, PT, PhD, FACSM, FAPTA, FASB paDirector, Spaulding National Running CenterDepartment of Physical Medicine and RehabilitationHarvard Medical School eSpaulding-Cambridge Outpatient Center plCambridge, MA, USA m savi
  8. 8. Brief contents Part A Fundamental principles 1 Sports and exercise medicine: addressing the world’s greatest public health problem 2 2 Sports and exercise medicine: the team approach 6 3 Integrating evidence into clinical practice to make quality decisions 11 4 Sports injuries: acute 15 5 Sports injuries: overuse 25 6 Pain: why and how does it hurt? 41 7 Beware: conditions masquerading as sports injuries 54 8 Clinical aspects of biomechanics and sporting injuries 61 9 Principles of injury prevention 11310 Recovery 13811 Principles of diagnosis: clinical assessment 14512 Principles of diagnosis: investigations including imaging 15713 Treatments used for musculoskeletal conditions: more choices and more evidence 16414 Core stability 21015 Principles of rehabilitation 22716 Principles of physical activity promotion for clinicians 254 Part B Regional problems17 Sports concussion 27218 Headache 290 ly19 Facial injuries 30020 Neck pain 313 on21 Shoulder pain 34222 Elbow and arm pain 39023 Wrist pain 413 s24 Hand and finger injuries 435 ge25 Thoracic and chest pain 44926 Low back pain 463 pa27 Buttock pain 49228 Hip-related pain 51029 Groin pain 545 e30 Anterior thigh pain 579 pl31 Posterior thigh pain 59432 Acute knee injuries 626 m33 Anterior knee pain 684 sa34 Lateral, medial, and posterior knee pain 71535 Leg pain 73536 Calf pain 761 vii
  9. 9. Br ie f contents37 Pain in the Achilles region 77638 Acute ankle injuries 80639 Ankle pain 82840 Foot pain 84441 The patient with longstanding symptoms: clinical pearls 878 Part C Special groups of participants42 The younger athlete 88843 Women and activity-related issues across the lifespan 91044 The older person who exercises 93645 Military personnel 94346 The athlete with a disability 960 Part D Management of medical problems47 Medical emergencies in the sporting context 97248 Sudden cardiac death in sport 99649 Managing cardiovascular symptoms in sportspeople 102450 Respiratory symptoms during exercise 103851 Gastrointestinal symptoms during exercise 105652 Renal symptoms during exercise 106353 Diabetes mellitus 107054 Exercise to treat neurological diseases and improve mental health 108255 Joint-related symptoms without acute injury 109356 Common sports-related infections 110257 The tired athlete 111858 Exercise in the heat 113259 Exercise at the extremes of cold and altitude 1146 ly60 Quick exercise prescriptions for specific medical conditions 1158 on Part E Practical sports medicine61 The preparticipation physical evaluation 1176 s62 Screening the elite sportsperson 1185 ge63 Providing team care 120364 Traveling with a team 1208 pa65 Medical coverage of endurance events 122166 Drugs and the athlete 122867 Ethics and sports medicine 1261 e pl m saviii
  10. 10. ContentsForeword to the first edition v Co-authors xxxviForeword to the fourth edition vi Other contributors xliiPreface xxxi Acknowledgments xlivAbout the authors xxxiii Guided tour of your book xlvEditors xxxv PART Fundamental principles 4 Sports injuries: acute 15 A Bone 161 Sports and exercise medicine: Fracture 16addressing the world’s greatest public Periosteal injury 17health problem 2 Articular cartilage 17 Joint 18The burden of physical inactivity and sedentary Dislocation/subluxation 18behavior 2 Ligament 18 The one trillion dollar argument (US alone!) 2 Muscle 20Physical fitness—more health benefits than Strain/tear 20smoking cessation or weight loss 2 Contusion 21 The molecular mechanisms that explain the Myositis ossificans 21 health benefits of physical activity 2 Cramp 22Putting it all together—the economic imperative 4 Tendon 22 Practical challenges 4 Bursa 23 The darkest hour is just before the dawn 4 Nerve 23 ly Skin 232 Sports and exercise medicine: theteam approach on 6 5 Sports injuries: overuse 25The sports and exercise medicine team 6 Bone stress 25 Multiskilling 6 Mechanism 26 s The sports and exercise medicine model 7 Risk factors 26 geThe challenges of management 7 Skeletal sites 28 Diagnosis 8 Clinical diagnosis 28 pa Treatment 9 Imaging diagnosis 28 Meeting individual needs 9 Low-risk and high-risk stress fracture 29The coach, the athlete, and the clinician 9 General principles of stress fracture treatment 30 e“Love thy sport” (and physical activity!) 9 Osteitis and periostitis 31 pl Apophysitis 313 Integrating evidence into clinical Articular cartilage 31 mpractice to make quality decisions 11 Joint 31 saLife before evidence-based practice 12 Ligament 31Sackett and the McMaster contribution 12 Muscle 31This seems obvious—so what is the problem? 13 Focal tissue thickening/fibrosis 32 ix
  11. 11. Conte nts Chronic compartment syndrome 32 Bone and soft tissue tumors 54 Muscle soreness 32 Rheumatological conditions 56Tendon 33 Disorders of muscle 57 Tendon overuse injury (tendinopathy) 33 Endocrine disorders 57 A contemporary model of a continuum of Vascular disorders 58 tendon pathology 33 Genetic disorders 58 Other terms associated with overuse tendon Granulomatous diseases 59 injuries 36 Infection 59Bursa 37 Pain syndromes 59Nerve 37Skin 37 8 Clinical aspects of biomechanics Blisters 37 and sporting injuries 61 Infections 37 “Ideal” lower limb biomechanics—the basics 61 Dermatitis 38 Lower limb joint motion 61 Skin cancers 38 Ideal neutral stance position 64But it’s not that simple … 38 “Ideal” biomechanics with movement—running 65 Pain: where is it coming from? 38 Loading (heel strike to foot flat) 66 Masquerades 38 Midstance (foot flat to heel off ) 67 The kinetic chain 38 Propulsion (heel off to toe off ) 68 Initial swing 696 Pain: why and how does it hurt? 41 Terminal swing 69What is pain? 41 Angle and base of gait 69What is nociception? 42 Influence of gait velocity 69 State-dependent sensitivity of primary Comparing heel and forefoot strike patterns 70 nociceptors 43 Influence of fatigue on running biomechanics 71 State-dependent sensitivity of spinal Lower limb biomechanical assessment in the nociceptors 44 clinical setting 71 lyThe brain decides 45 Structural (“static”) biomechanicalThe brain corrects the spinal cord 45 assessment 73 onWhen pain persists, the brain changes 47 Functional lower limb tests—single-legTreating someone in pain—a complex system stance, heel raise, squat, and landing fromrequires a comprehensive approach 47 a jump 77 sClinical approach to referred pain—often Dynamic movement assessment geneglected in clinical teaching 48 (e.g. running biomechanics) 82 Radicular pain 49 Sport-specific assessment 83 pa Somatic pain 49 Summary of the lower limb biomechanical Clinical assessment of referred pain 51 assessment 83Clinical summary 52 Clinical assessment of footwear—the Footwear e Assessment Tool 83 pl7 Beware: conditions masquerading Fit 83as sports injuries 54 General structure 83 m Motion control properties 83How to recognize a condition masquerading sa Cushioning 85as a sports injury 54 Wear patterns 85Conditions masquerading as sports injuries 54x
  12. 12. ContentsConditions related to suboptimal lower limb Appropriate training 128biomechanics 85 Principles of training 128Management of lower limb biomechanical Training methods 130abnormalities 86 Adequate recovery 134 Foot orthoses 86 Taping 91 10 Recovery 138Biomechanics of cycling 92 Warm-down or active recovery 138 Set-up and positioning on the bike 92 Deep-water running 139 Bike set-up in other forms of cycling 96 Cold water immersion (ice baths) 139 Aerodynamics and wind resistance 97 Massage 139 Pedaling technique 97 Compression garments 140 Assessment 97 Lifestyle factors 140 Rehabilitation 98 Nutrition 140 Conclusion 99 Glycogen replacement 140Upper limb biomechanics 99 Protein replacement 141 The biomechanics of throwing 99 Co-ingestion of carbohydrate and protein 141 Normal biomechanics of the scapula in Rehydration 142 throwing 102 Psychology 142 Abnormal scapular biomechanics and The function of the autonomic nervous physiology 103 system 143 Clinical significance of scapular Effect of exercise on the autonomic nervous biomechanics in shoulder injuries 104 system 143 Changes in throwing arm with repeated Techniques that aid psychological recovery 143 pitching 104 Common biomechanical abnormalities 11 Principles of diagnosis: clinical specific to pitching 105 assessment 145 Biomechanics of swimming 105 Biomechanics of tennis 106 Making a diagnosis 145 ly Biomechanics of other overhead sports 107 History 146 on Allow enough time 1469 Principles of injury prevention 113 Be a good listener 146 Know the sport 146Systematic injury prevention 113 s Circumstances of the injury 146Warm-up 116 ge Obtain an accurate description ofTaping and bracing 121 symptoms 146 Taping 121 History of a previous similar injury 147 pa Bracing 122 Other injuries 147Protective equipment 122 General health 147Suitable equipment 123 e Work and leisure activities 147 Running shoes 123 Consider why the problem has occurred 147 pl Running spikes 124 Training history 147 Football boots 125 m Equipment 148 Ski boots 125 Technique 148 sa Tennis racquets 126 Overtraining 148Appropriate surfaces 127 Psychological factors 148 xi
  13. 13. Conte nts Nutritional factors 148 Cardiovascular investigations 161 History of exercise-induced anaphylaxis 148 Respiratory investigations 161 Determine the importance of the sport Pulmonary function tests 161 to the athlete 148 The diagnosis 162Examination 148 Develop a routine 148 13 Treatments used for musculoskeletal Where relevant, examine the other side 148 conditions: more choices and more Consider possible causes of the injury 148 evidence 164 Attempt to reproduce the patient’s symptoms 148 Evidence for treatment effectiveness is Assess local tissues 148 continually changing 164 Assess for referred pain 149 Acute management 165 Assess neural mechanosensitivity 149 Rest 165 Examine the spine 149 Ice 165 Biomechanical examination 149 Compression 166 Functional testing 149 Elevation 166 The examination routine 149 Immobilization and early mobilization 166 Protected mobilization 16712 Principles of diagnosis: Continuous passive motion 167investigations including imaging 157 Therapeutic drugs 167 Analgesics 167Investigations 157 Topical analgesics 168 1. Understand the meaning of test results 157 Nonsteroidal anti-inflammatory drugs 2. Know how soon changes can be (NSAIDs) 168 detected by investigations 157 Topical anti-inflammatory agents 174 3. Only order investigations that will Corticosteroids 174 influence management 157 Nitric oxide donor 176 4. Provide relevant clinical findings on Sclerosing therapy 177 ly the requisition 157 Prolotherapy 177 5. Do not accept a poor quality test 157 on Glucosamine sulfate and chondroitin 6. Develop a close working relationship sulfate 178 with investigators 157 Hyaluronic acid therapy (Hyalgan, Synvisc, 7. Explain the investigations to the patient 158 s Ostenil, Orthovisc) 178Radiological investigation 158 ge Antidepressants 179 Plain X-ray 158 Local anesthetic injections 179 Computed tomographic (CT) scanning 158 Traumeel 180 pa Magnetic resonance imaging (MRI) 158 Bisphosphonates 180 Ultrasound scan (for diagnosis) 159 Blood and blood products 180 Radioisotopic bone scan 160 e Autologous blood injections 180Neurological investigations 161 Platelet-rich plasma 180 pl Electromyography 161 Heat and cold 181 Nerve conduction studies 161 m Cryotherapy 181 Neuropsychological testing 161 Superficial heat 183 saMuscle assessment 161 Contrast therapy 184 Compartment pressure testing 161xii
  14. 14. ContentsElectrotherapy 185 Efficacy of core strengthening exercise 223 Ultrasound 186 Prevention of injury and performance TENS (Transcutaneous electrical nerve improvement 223 stimulation) 187 Treatment of low back pain 224 Interferential stimulation 188 Effectiveness in sports injuries 224 High-voltage galvanic stimulation 188 Conclusion 224 Low-voltage galvanic stimulation 188 Neuromuscular stimulators 188 15 Principles of rehabilitation 227 Point stimulators 189 Keys to a successful rehabilitation program 227 Laser 189 Explanation 228 Diathermy 189 Provide precise prescription 228 Magnetic therapy 189 Make the most of the available facilities 228Extracorporeal shock wave therapy 190 Begin as soon as possible 228Manual therapy 190 Components of exercise programs for Joint mobilization 191 rehabilitation 228 Joint manipulation 192 Muscle conditioning 228 Joint traction 193 Cardiovascular fitness 235 Soft tissue therapy 193 Flexibility 235 Muscle energy techniques 196 Proprioception 238 Neural stretching 197 Functional exercises 240Acupuncture 198 Sport skills 240Dry needling 198 Hydrotherapy 242Hyperbaric oxygen therapy 200 Deep-water running 242Surgery 200 Correction of biomechanical abnormalities 243 Arthroscopic surgery 200 Stages of rehabilitation 243 Open surgery 201 Initial stage 243 Intermediate preparticipation stage 24314 Core stability 210 ly Advanced stage 244Anatomy 212 Return to sport 245 on Osseous and ligamentous structures 212 Secondary prevention 246 The thoracolumbar fascia 212 Progression of rehabilitation 246 Paraspinals 212 Type of activity 246 s Quadratus lumborum 213 Duration of activity 246 ge Abdominals 213 Frequency 246 Hip girdle musculature 213 Intensity 246 pa Diaphragm and pelvic floor 213 Complexity of activity 246Assessment of core stability 213 Monitoring rehabilitation programs 246Exercise of the core musculature 215 Psychology 247 e Decreasing spinal and pelvic viscosity 215 Emotional responses to injury 247 pl Use of biofeedback and real-time Psychological strategies to facilitate ultrasound in retraining core control 216 recovery 247 m Stabilization exercises 216 Conclusion 250 sa Functional progression 219 Core strengthening for sports 223 xiii
  15. 15. Conte nts16 Principles of physical activity Migraine 293promotion for clinicians 254 Cluster headache 295 Cervical headache 295Who should receive exercise counseling? 255 Mechanism 295Are there medical contraindications to being Clinical features 296active? 255 Exercise-related causes of headache 297Executing the prescription 256 Primary exertional headache 297 Practical steps with the consultation 256 Exertional migraine 297Exercise guidelines 257 Post-traumatic headache 298 Aerobic activity 257 External compression headache 298 Defining intensity 258 High-altitude headache 298 Resistance training 259 Hypercapnia headache 299 Flexibility 267 Follow-up 267 19 Facial injuries 300An overlooked element of motivation 267Summary 268 Functional anatomy 300 Clinical assessment 300 Soft tissue injuries 301 PART Regional problems Nose 303 B Epistaxis (nosebleed) 303 Nasal fractures 30317 Sports concussion 272 Septal hematoma 303Definition of concussion 273 Ear 304Prevention of concussion 273 Auricular hematoma 304The initial impact: applied pathophysiology 274 Lacerations 304Management of the concussed athlete 274 Perforated eardrum 304 On-field management 274 Otitis externa 304 Determining when the player can return Eye 305 ly safely to competition 277 Assessment of the injured eye 305The risk of premature return to play and Corneal injuries: abrasions and foreign onconcussion sequelae 281 body 306 Risk of further injury 281 Subconjunctival hemorrhage 307 Eyelid injuries 307 s Second impact syndrome 281 Concussive convulsions 281 Hyphema 307 ge Prolongation of symptoms 281 Lens dislocation 307 Chronic traumatic encephalopathy 281 Vitreous hemorrhage 307 pa Mental health issues 282 Retinal hemorrhage 307Children and concussion in sport 282 Retinal detachment 308 Orbital injuries 308 e18 Headache 290 Prevention of eye injuries 308 pl Teeth 309Headache in sport 290 Prevention of dental injuries 309 mClinical approach to the patient with headache 291 Fractures of facial bones 309 History 292 sa Fractures of the zygomaticomaxillary Examination 293 complex 310Vascular headaches 293xiv
  16. 16. Contents Maxillary fractures 310 Glenoid labrum injuries 360 Mandibular fractures 311 Clinically relevant anatomy 360 Temporomandibular injuries 311 Making the diagnosis 360Prevention of facial injuries 312 Treatment 361 Dislocation of the glenohumeral joint 36220 Neck pain 313 Anterior dislocation 362 Posterior dislocation of the glenohumeralClinical perspective 313 joint 363Assessing patients with neck pain 315 Shoulder instability 364 History 315 Anterior instability 364 Physical examination 317 Posterior instability 367Treatment of neck pain 326 Multidirectional instability 367 Education 326 Adhesive capsulitis (“frozen shoulder”) 367 Posture 326 Treatment 367 Exercise therapy 328 Fracture of the clavicle 368 Manual therapy 331 Middle-third clavicular fracture 368 Soft tissue techniques 332 Distal clavicle fractures 368 Neural tissue mobilization 332 Acromioclavicular joint conditions 369 Dry needling 332 Acute acromioclavicular joint injuries 369 Stress management 332 Chronic acromioclavicular joint pain 371Neck pain syndromes 333 Referred pain 372 Acute wry neck 333 Less common causes of shoulder pain 373 Acceleration–deceleration injury 334 Biceps tendinopathy 373 Cervicogenic headache 334 Rupture of the long head of the biceps 373 Acute nerve root pain 334 Pectoralis major tears 373 Stingers or burners 335 Subscapularis muscle tears 373Conclusion 336 Nerve entrapments 373 Thoracic outlet syndrome 375 ly21 Shoulder pain 342 Axillary vein thrombosis (“effort” onFunctional anatomy—static and dynamic 342 thrombosis) 376 Static stabilizers 342 Fractures around the shoulder joint 376 Dynamic stabilizers 343 Principles for shoulder rehabilitation 377 s Scapulohumeral rhythm 343 Make a complete and accurate diagnosis 377 geClinical perspective 344 Early pain reduction 377 A practical approach to shoulder pain 344 Integration of the kinetic chain into History 345 pa rehabilitation 377 Examination 345 Scapular stabilization 378 Shoulder investigations 352 Early achievement of 90° of abduction eImpingement 353 and improved glenohumeral rotation 378 Primary external impingement 354 pl Closed chain rehabilitation 381 Secondary external impingement 354 Plyometric exercises 382 m Internal impingement 355 Rotator cuff exercises 383Rotator cuff injuries 357 Putting it all together—specific rehabilitation sa Rotator cuff tendinopathy 357 protocols 384 Rotator cuff tears 359 Acute phase 384 xv
  17. 17. Conte nts Recovery phase 385 Subacute onset and chronic wrist pain 426 Functional phase 386 History 426 Criteria for return to play 387 Examination 426 Extra-articular conditions 42722 Elbow and arm pain 390 Injuries to the distal radial epiphysis 430 Articular causes of subacute and chronicLateral elbow pain 390 wrist pain 431 Clinical assessment 391 Numbness and hand pain 431 Lateral elbow tendinopathy 393 Other causes of lateral elbow pain 400 24 Hand and finger injuries 435Medial elbow pain 401 Flexor/pronator tendinopathy 401 Clinical evaluation 435 Medial collateral ligament sprain 401 History 435 Ulnar neuritis 402 Examination 436Posterior elbow pain 403 Investigations 437 Olecranon bursitis 403 Principles of treatment of hand injuries 438 Triceps tendinopathy 404 Control of edema 438 Posterior impingement 404 Exercises 439Acute elbow injuries 404 Taping and splinting 439 Investigation 404 Fractures of the metacarpals 439 Fractures 405 Fracture of the base of the first metacarpal 439 Dislocations 406 Fractures of the other metacarpals 441 Acute rupture of the medial collateral Fractures of phalanges 442 ligament 407 Proximal phalanx fractures 442 Tendon ruptures 407 Middle phalanx fractures 442Forearm pain 407 Distal phalanx fractures 442 Fracture of the radius and ulna 407 Dislocation of the metacarpophalangeal joints 442 Stress fractures 408 Dislocations of the finger joints 443 ly Entrapment of the posterior interosseous Dislocations of the PIP joint 443 nerve (radial tunnel syndrome) 408 Dislocations of the DIP joint 443 on Forearm compartment pressure syndrome 409 Ligament and tendon injuries 443Upper arm pain 409 Sprain of the ulnar collateral ligament of Myofascial pain 409 the first MCP joint 443 s Stress reaction of the humerus 409 Injuries to the radial collateral ligament ge of the first MCP joint 44423 Wrist pain 413 Capsular sprain of the first MCP joint 444 pa PIP joint sprains 444Acute wrist injuries 413 Mallet finger 445 History 413 Boutonnière deformity 446 e Examination 415 Avulsion of the flexor digitorum Investigations 418 pl profundus tendon 447 Fracture of the distal radius and ulna 420 Lacerations and infections of the hand 447 m Fracture of the scaphoid 420 Overuse conditions of the hand and fingers 447 Fracture of the hook of hamate 423 sa Dislocation of the carpal bones 424 Scapholunate dissociation 425xvi
  18. 18. Contents25 Thoracic and chest pain 449 Treatment 480 Stress fracture of the pars interarticularis 480Thoracic pain 449 Clinical features 480 Assessment 449 Treatment 481 Thoracic intervertebral joint disorders 453 Spondylolisthesis 482 Costovertebral and costotransverse joint Clinical features 483 disorders 454 Treatment 483 Scheuermann’s disease 455 Lumbar hypermobility 484 Thoracic intervertebral disk prolapse 455 Structural lumbar instability 484 T4 syndrome 455 Sacroiliac joint disorders 484 Postural imbalance of the neck, shoulder Rehabilitation following low back pain 484 and upper thoracic spine 456 Posture 484Chest pain 456 Daily activities 485 Assessment 457 Sporting technique 485 Rib trauma 458 Core stability 485 Referred pain from the thoracic spine 458 Specific muscle tightness 487 Sternoclavicular joint problems 459 Conclusion 488 Costochondritis 460 Stress fracture of the ribs 460 27 Buttock pain 492 Side strain 461Conclusion 461 Clinical approach 492 History 49226 Low back pain 463 Examination 494 Investigations 496Epidemiology 463 Referred pain from the lumbar spine 497Clinical perspective 463 Sacroiliac joint disorders 498 Conditions causing low back pain in Functional anatomy 498 which a definitive diagnosis can be made 464 Clinical features 500 Somatic low back pain 465 ly Treatment 501 Functional (clinical) instability in low Iliolumbar ligament sprain 502 on back pain 467 Hamstring origin tendinopathy 503 History 468 Fibrous adhesions 503 Examination 468 Ischiogluteal bursitis 504 s Investigations 468 Myofascial pain 504 geSevere low back pain 472 Less common causes 504 Clinical features of severe acute low Quadratus femoris injury 504 pa back pain 472 Stress fracture of the sacrum 505 Management of severe acute low back Piriformis conditions 505 pain 472 Posterior thigh compartment syndrome 506 eMild-to-moderate low back pain 473 Proximal hamstring avulsion injuries 506 pl Clinical features 474 Apophysitis/avulsion fracture of the Treatment of mild-to-moderate low back ischial tuberosity 507 m pain 474 Conditions not to be missed 507 Chronic low back pain 477 saAcute nerve root compression 478 Clinical features 480 xvii
  19. 19. Conte nts28 Hip-related pain 510 Factors that increase local bone stress 550 Clinical approach 552Functional anatomy and biomechanics 510 History 552 Morphology 511 Examination 553 Acetabular labrum 511 Investigations 558 Ligaments of the hip 512 Acute adductor strains 559 Chondral surfaces 513 Recurrent adductor muscle strain 559 Joint stability and normal muscle function 513 Adductor-related groin pain 559Clinical perspective: making sense of a complex Early warning signs 560problem 516 Treatment 560 Femoroacetabular impingement (FAI) 516 Iliopsoas-related groin pain 565Factors that may contribute to the Epidemiology 566development of hip-related pain 518 Clinical concepts 566 Extrinsic factors 518 Treatment 567 Intrinsic factors 519 Abdominal wall–related groin pain 567Clinical assessment 521 Posterior inguinal wall weakness History 521 (sports hernia, sportsman’s hernia) 567 Examination 522 Gilmore’s groin 568 Investigations 525 Laparoscopic inguinal ligament release 568Labral tears 526 Tear of the external oblique aponeurosisLigamentum teres tears 527 (hockey groin) 568Synovitis 528 Inguinal hernia 569Chondropathy 529 Rectus abdominis injuries 569Rehabilitation of the injured hip 530 Pubic bone stress–related groin pain 569 Unloading and protecting damaged or Treatment 571 potentially vulnerable structures 530 Less common injuries 572 Restoration of normal dynamic and Obturator neuropathy 572 neuromotor control 530 Other nerve entrapments 572 ly Address other remote factors that may be Stress fractures of the neck of the femur 572 altering the function of the kinetic chain 534 on Stress fracture of the inferior pubic ramus 573Surgical management of the injured hip 534 Referred pain to the groin 574 Rehabilitation following hip arthroscopy 535Os acetabulare 536 s 30 Anterior thigh pain 579Lateral hip pain 538 ge Greater trochanter pain syndrome (GTPS) 538 Clinical approach 579 Gluteus medius tendon tears 540 History 579 pa Examination 58029 Groin pain 545 Investigations 581 Quadriceps contusion 582 eAnatomy 545 Treatment 583 plPrevalence 547 Acute compartment syndrome of the thigh 586Risk factors 547 Myositis ossificans 587 mClinical overview 548 Quadriceps muscle strain 587 Local overload causing failure of various sa Distal quadriceps muscle strain 588 structures 548 Proximal rectus femoris strains 589 What role does bone stress play? 549xviii
  20. 20. ContentsDifferentiating between a mild quadriceps Compartment syndrome of the posteriorstrain and a quadriceps contusion 590 thigh 621Less common causes 590 Vascular 621 Stress fracture of the femur 590 Lateral femoral cutaneous nerve injury 32 Acute knee injuries 626 (“meralgia paresthetica”) 591 Functional anatomy 626 Femoral nerve injury 592 Clinical perspective 627 Referred pain 592 Does this patient have a significant knee injury? 62731 Posterior thigh pain 594 History 627Functional anatomy 594 Examination 629Clinical reasoning 595 Investigations 633 History 596 Meniscal injuries 634 Examination 597 Clinical features 635 Investigations 599 Treatment 635 Integrating the clinical assessment and Rehabilitation after meniscal surgery 636 investigation to make a diagnosis 600 Medial collateral ligament (MCL) injury 638Acute hamstring muscle strains 600 Treatment 638 Epidemiology 600 Anterior cruciate ligament (ACL) tears 639 Types of acute hamstring strains 600 Clinical features 639 Management of hamstring injuries 603 Surgical or non-surgical treatment of theRisk factors for acute hamstring strain 615 torn ACL? 647 Intrinsic risk factors 615 Surgical treatment 650 Extrinsic risk factors 616 Combined injuries 652Prevention of hamstring strains 616 Rehabilitation after ACL injury 652 Nordic drops and other eccentric exercises 616 Problems encountered during ACL Balance exercises/proprioception training 616 rehabilitation 656 ly Soft tissue therapy 617 Outcomes after ACL treatment 657 A promising clinical approach for the Mechanism of ACL injury as a step toward on high-risk athlete 617 prevention 659Referred pain to posterior thigh 618 Posterior cruciate ligament (PCL) tears 668 Trigger points 618 Clinical features 668 s Lumbar spine 618 Treatment 669 ge Sacroiliac complex 619 Lateral collateral ligament (LCL) tears 669Other hamstring injuries 620 Articular cartilage damage 669 pa Avulsion of the hamstring from the Classification 669 ischial tuberosity 620 Treatment 671 Common conjoint tendon tear 620 Acute patellar trauma 673 e Upper hamstring tendinopathy 620 Fracture of the patella 673 pl Lower hamstring tendinopathy 621 Patellar dislocation 674Less common causes 621 Less common causes 675 m Nerve entrapments 621 Patellar tendon rupture 675 sa Ischial bursitis 621 Quadriceps tendon rupture 675 Adductor magnus strains 621 Bursal hematoma 677 xix
  21. 21. Conte nts Fat pad impingement 677 Excessive lateral pressure syndrome 723 Fracture of the tibial plateau 677 Biceps femoris tendinopathy 724 Superior tibiofibular joint injury 677 Superior tibiofibular joint injury 724 Ruptured hamstring tendon 677 Referred pain 725 Coronary ligament sprain 677 Medial knee pain 725 Patellofemoral syndrome 72533 Anterior knee pain 684 Medial meniscus abnormality 726 Osteoarthritis of the medial compartmentClinical approach 685 of the knee 726 History 685 Pes anserinus tendinopathy/bursitis 727 Examination 687 Pellegrini-Stieda syndrome 728 Investigations 689 Medial collateral ligament grade 1 sprain 728Patellofemoral pain 689 Posterior knee pain 728 What is patellofemoral pain syndrome? 689 Clinical evaluation 728 Functional anatomy 690 Popliteus tendinopathy 730 Factors that may contribute to pain 690 Gastrocnemius tendinopathy 731 Treatment of patellofemoral pain 693 Baker’s cyst 731Patellofemoral instability 700 Other causes of posterior knee pain 732 Primary patellofemoral instability 700 Secondary patellofemoral instability 700 35 Leg pain 735Patellar tendinopathy 700 Nomenclature 701 Clinical perspective 735 Pathology and pathogenesis of patellar Role of biomechanics 736 tendinopathy 701 History 738 Clinical features 701 Examination 738 Investigations 701 Investigations 743 Treatment 702 Medial tibial stress fracture 745 Partial patellar tendon tear 707 Assessment 746 lyLess common causes 707 Treatment 746 Fat pad irritation/impingement Prevention of recurrence 747 on (insidious onset) 707 Stress fracture of the anterior cortex of the tibia 747 Osgood-Schlatter lesion 708 Treatment 747 Sinding-Larsen–Johansson lesion 708 Medial tibial stress syndrome 748 s Quadriceps tendinopathy 708 Treatment 749 ge Bursitis 709 Chronic exertional compartment syndrome 750 Synovial plica 709 Deep posterior compartment syndrome 752 pa Anterior and lateral exertional34 Lateral, medial, and posterior compartment syndromes 753knee pain 715 Outcomes of surgical treatment of e exertional compartment syndrome 754Lateral knee pain 715 pl Rehabilitation following compartment Clinical approach 716 syndrome surgery 755 m Iliotibial band friction syndrome 718 Less common causes 755 Lateral meniscus abnormality 722 sa Stress fracture of the fibula 755 Osteoarthritis of the lateral compartment Referred pain 755 of the knee 723 Nerve entrapments 756xx