Vasta et al.

Journal of Orthopaedic Surgery and Research (2018) 13:190

https://doi.org/10.1186/s13018-018-0889-8

REVIEW Open Access

Top orthopedic sports medicine procedures

Sebastiano Vasta1, Rocco Papalia1*, Erika Albo1, Nicola Maffulli2,3 and Vincenzo Denaro1

Abstract
Orthopedic sports medicine is a subspecialty of Orthopedics that focuses on managing pathological conditions of
the musculoskeletal system arising from sports practice. When dealing with athletes, timing is the most difficult
issue to face. Typically, athletes aim to return to play as soon as possible and at the pre-injury level. This means that
management should be optimized to combine the need for prompt return to sport and to the biologic healing
time of the musculo-skeletal. This poses a great challenge to sport medicine surgeons, who need to follow with
attention to the latest scientific evidence to offer their patients the best available treatment options. We briefly
review the most commonly performed orthopedic sports medicine procedures, outlining the presently available
scientific evidence on their indications and outcomes.
Keywords: Orthopedic sports injury, Anterior cruciate ligament, Posterior cruciate ligament, Meniscus, Rotator cuff,
Shoulder instability, Ankle instability

Background Lower limb

About 11 athletes out of 100 participating in the Olym- Knee
pic Games will face an injury, based on the data from Meniscal injuries Although meniscal injuries are mainly
the last three editions [1–3]. Although the highest inci- encountered in athletes involved in pivoting maneuvers
dence occurs in contact sports, such as football, American [4], even low-impact sports such as swimming have been
football, hockey, and martial arts, some of the non-contact plagued by meniscal lesions [5]. Meniscal injuries are
sports as athletics are equally affected by high rates of in- one of the most common musculo-skeletal issues and
juries [1]. Looking again at the Olympic Games data, one of the most common orthopedic surgery performed
about half of the injuries involves the lower limb, 20% the worldwide. Vertical peripheral longitudinal tears [6–8]
upper limb, while head, neck, and trunk account all to- as well as root tears [9] should be repaired, leading to
gether for 25% [1]. About a quarter of all the injuries are superior outcomes in terms of symptoms, function, re-
overuse injuries, which are more likely to occur in turn to play, and cartilage preservation compared to
non-contact sports. Regardless of whether an injury is meniscectomy. In more recent years, there is an increas-
acute or overuse, the main issue in dealing with ath- ing body of evidence in favor of repairing horizontal
letes is timing. The deeply engrained strong desire to tears, especially in the young patient [10]. Return to
return to play, within the shortest time, is the main sports after meniscus repair for high-level athletes (bas-
challenge for sport medicine surgeons and drives ketball, American football, baseball) varies between 80
treatment choices. and 90% [11]. However, studies on meniscal repair in
Here, we review the most commonly performed sports athletes have found that up to one third of the patients
medicine procedures, looking at the latest evidences on underwent reoperation for pain [12–16]. Concerning the
the indications and outcomes. surgical technique of a meniscal repair, there is general
agreement to start the procedure performing a debride-
ment and abrasion of the meniscal lesion walls to favor
local bleeding [17], and with regard to the suture tech-
nique, vertical or horizontal sutures are recommended
[18, 19], performed either with all-inside, inside-out or
* Correspondence: [email protected]
1
Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico,
outside-in techniques, since no superiority have been
University of Rome, Via Alvaro del Portillo, 200 Rome, Italy demonstrated of one technique over the others [20, 21].
Full list of author information is available at the end of the article

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Vasta et al. Journal of Orthopaedic Surgery and Research (2018) 13:190 Page 2 of 8

However, it has been demonstrated that vertical suturing definitive superiority has been shown [37]. BPTB grafts
configuration has superior load to failure values com- ensure greater post-operative knee stability but exhibit
pared to a horizontal configuration [22]. Usually, all-in- a higher complication rate [38].On the contrary, ham-
side sutures are used on the far posterior segments, and string autograft, for which revision surgery is most fre-
inside-out for the middle and anterior meniscal seg- quently required, is often associated with post-operative
ments. Alvarez-Diaz et al., in a case-series on 29 com- antero-posterior knee laxity, particularly in females
petitive football players, reported that 26 (89.6%) were [39]. However, despite all the great efforts trying to im-
able to return to play at the same level of competition at prove ACL reconstruction, the rate of patients who return
a mean of 4.3 months after surgery [23]. to sports ranges between 63 and 92% [40, 41]. This trend
confirms the importance of psychological factor and
Anterior cruciate ligament injury Anterior cruciate neuromuscular focused rehabilitation as essential ele-
ligament (ACL) tears, accounting for about 200,000 in- ments in determining the return to play rate [42].
juries per year in the USA, may compromise knee sta-
bility and affect negatively sports activity. Although
Posterior cruciate ligament injury Isolate posterior
most of the ACL tears result from a non-contact injury,
cruciate ligament (PCL) injury has an incidence that
lesions during contrasts in sports such as American
ranges between 3 and 44% after acute trauma to the
football, rugby, or hockey are frequent as well.
knee [43]. A PCL injury is often part of complex knee
Many risk factors have been identified for ACL tear.
injuries, associated respectively in 46, 31, and 62% of
Some depend on bone morphology (narrower intercon-
cases, to ACL tears, medial collateral ligament (MCL)
dylar notch widths, smaller notch width index, and in-
injury, and posterolateral corner injuries [44]. Isolated
creased tibial slopes [24]), some others on hormones
PCL injuries in the knees with reduced joint laxity and
and gender [25]. Recently, biomechanical factors such as
absence of other peripheral lesion are generally managed
limited hip internal rotation have been associated to
conservatively even in athletes, with satisfactory subjective
ACL tear injury [26]. Conservative management of ACL
results, and return to sport at the same level in about 50%
tears can produce acceptable results, but in athletes, sur-
of cases [45]. In patients with PCL injuries managed con-
gical reconstruction is usually preferred [27]. The main
servatively, 41% of the subjects at 14-year follow-up de-
advantage of ACL reconstruction (ACLR) is to restore
velop early osteoarthritis, with progressive reduction of
knee stability what will eventually help to prevent sec-
joint function [46]. Surgical treatment can be performed
ondary injury to menisci and articular cartilage [28]. Dif-
to optimize joint function. After surgery, competitive
ferent techniques are used to perform ACLR. Transtibial
sports are practiced again by 67% of the subjects and high
independent drilling (through the antero-medial portal)
functional demand sports by 26% [47]. Clinical outcomes
and the outside-in techniques are the most commonly
show no differences between single- and double-bundle
used ones. A systematic review showed that independent
reconstruction techniques at approximately 30 months
drilling is more likely to lead to better biomechanical
of follow-up. However, double-bundle PCL reconstruc-
and functional outcomes compared to transtibial tech-
tion mainly improves objective measurement of knee
nique [29], although no clear clinical evidences support
stability [48, 49].
its superiority [30]. Outside-in drilling has the advan-
tages of unconstrained tunnels placement, but it needs
two incisions [31]. Single- or double-bundle graft recon- Hip
structions have been proposed. Biomechanical studies fa- Femoroacetabular impingement Femoroacetabular im-
vored double-bundle graft in terms of rotational stability pingement (FAI) is a common cause of hip and groin
[32]; however, no clinical superiority has been shown [33]. pain in young active people and athletes. FAI initially
Concerning the graft, it is possible to identify three causes chondral lesions and labral tears and, subse-
main categories: autograft, allograft, and synthetic graft. quently, early arthritis [50, 51]. Arthroscopic surgery is
Synthetic graft showed high failure rate, although newer undertaken in subjects refractory to conservative man-
synthetic grafts seem, in the short term, more promising agement, involving targeted physiotherapy and oral
than the older ones [34]. anti-inflammatory drugs. Few studies reported data
Allografts are expensive; there is a risk for infections about surgical procedures, such as femoroplasty, aceta-
transmission, delayed incorporation, and late failure buloplasty, and labral reconstruction, in athletes, and
[35, 36]. Therefore, especially for young athletic indi- they showed that arthroscopic surgery is effective in
viduals, the choice falls on autografts: bone patellar ten- terms of both clinical and functional improvement and
don bone (BPTB), hamstrings, and less commonly return to sport (87% of patients) [52]. Moreover, timing
quadriceps tendon. There is a huge debate on what is for arthroscopic treatment is essential; the length of
better between patellar tendon and hamstring, and no athletic career was significantly affected by symptom
Vasta et al. Journal of Orthopaedic Surgery and Research (2018) 13:190 Page 3 of 8

duration before arthroscopic treatment in professional more of the lateral ligaments of the ankle [69]. Up to 70%
hockey players [53]. of the sprains involve the anterior talo-fibular ligament
(ATFL) alone [67]. More than 50% of the ankle sprains do
Achilles tendon not come to medical attention [70]. Patients with ankle
Achilles tendinopathy is common in athletes, accounting sprain grade I and II, accounting for greatest part, will
for 6–17% of all injuries in running athletes [54–56]. The benefit from the use of RICE (rest, ice [cryotherapy], com-
etiology of tendinopaty is still not well understood, but pression, and elevation) [71]. Grade III has a less standard-
multiple factors play a role in its pathophysiology [57]. ized management. Some authors have proposed surgical
Pharmacological interventions currently lack for scientific repair for the acute grade III lesion [72], but many others
evidences supporting their use [58], while conservative have reported discouraging outcomes following acute re-
management of chronic midportion Achilles tendinopathy pair in favor of functional treatment [73, 74].
by eccentric exercises and extracorporeal shock waves Chronic ankle instability is defined as the condition of
therapy (ESWT) is strongly supported by several level I symptomatic ankle instability following an acute ankle
studies [59]. Patients resistant to those conservative mea- sprain managed with conservative measure [75].
sures can undergo to high-volume image-guided injection, Surgical management of the lateral ligaments of the
effective in relieving patients’ symptoms and restore ten- ankle can be performed with an anatomic reconstruction
don function both in the short and long term [60]. In (the Brostrom-Gould technique) or by several techniques
non-insertional Achilles tendinopathy, minimally invasive in which a tendon graft, either autograft or allograft, rein-
multiple percutaneous longitudinal tenotomies are valid forces the local tissue [75]. A recent comparison of lateral
alternatives to more invasive procedures, at least in pa- anatomic ankle repair (Brostrom-Gould) to allograft re-
tients without evidence of paratendinopathy, unresponsive construction showed that no revision was needed in pa-
to 6 months of conservative management. This method tients from both groups, and no significant differences
leads to satisfactory outcomes in the long term and re- between groups in terms of function and patients’ satisfac-
stores ankle function [61]. Given the renowned complica- tion were found [76].
tions in terms of infections and difficult wound healing, in Allografts showed good to excellent results in up to
most recent years, tendoscopy has been proposed, with 85% of cases, and they should be considered when mul-
satisfactory outcomes, as an alternative method to open tiple ligaments are involved, such as calcaneofibular liga-
surgery, including debridement alone or debridement as- ment (CFL) other than ATFL [77].
sociated to flexor halluces longus tendon transfer [62]. At the time of surgical repair of ankle lateral ligaments, it
Eccentric exercises for insertional Achilles tendinopaty is highly recommended to perform an ankle arthroscopy,
did not show excellent outcomes, while ESWT did bet- since this will allow looking for intrarticular lesions [78].
ter according to a quite recent systematic review [63]. Recently, different minimally invasive techniques have
For those patients not responding to conservative mea- been proposed for chronic ankle instability (arthroscopic
sures, surgery is indicated in order to debride the tendi- repair, non-arthroscopic minimally invasive repair, arthro-
nopathic tissue and/or to excise the calcaneal bony scopic reconstruction, and non-arthroscopic minimally in-
prominence, with or without tendon detachment and vasive reconstruction). However, there is still a lack for
subsequent fixation to calcaneus tuberosity. Surgical high-level evidences to support their use in daily clinical
management of insertional Achilles tendinopathy is indi- practice [79].
cated after failure of 3- to 6-month period of nonsurgical
management. Thorough debridement is necessary, and Ankle osteochondral lesions About 50% of acute ankle
this leads often to a near to complete detachment of the sprain leads to chondral lesions of the talus (OCL), caus-
tendon’s insertion. Therefore, repair with two anchors is ing persisting pain despite conservative or surgical treat-
recommended; indeed, it is associated with good to excel- ment [80]. Most of the OCL are central-lateral (49%)
lent results [64]. Outcomes from surgery can be satisfac- and follow an inversion ankle sprain [81]. Those kinds of
tory, but prolonged rehabilitation is necessary [63, 65, 66]. lesions respond poorly to conservative measures. In the
acute setting, arthroscopic debridement with excision of
Ankle the loose OCL is usually indicated for lesions smaller
Lateral ankle ligaments Ankle sprains are common, es- than 1 cm2 [82]. Fragment fixation using bioabsorbable
pecially in team sports [67]. They account for up to 40% screws is advised for wider lesions [83].
of all athletic injuries, and 29% of American football in- Chronic OCLs are classified in five types according to
juries can be attributed to ankle injuries [68]. The most Loomer et al. [84]. Type I and II lesions can be addressed
common pattern of injury is forefoot adduction, hindfoot by retrograde drilling, a technique that aims to bone
inversion, with the tibia externally rotated and the ankle marrow stimulation [85]. Type III and IV lesions can be
in plantar flexion. This mechanism leads to tears to one or addressed with satisfactory outcomes either by excision
Vasta et al. Journal of Orthopaedic Surgery and Research (2018) 13:190 Page 4 of 8

or curettage [86]. Finally, type V, a cystic lesion, is usu- Superior labrum anterior to posterior (SLAP) lesions
ally bone grafted or filled using osteochondral plugs Snyder reported an incidence of SLAP lesions ranging
(mosaicplasty) [87]. from 4.8 to 6.9% [98, 99]. The injury mechanism is usu-
ally overhead activity that determines a contact between
Spine the articular side of the supraspinatus tendon and the
Disc herniation and disc degeneration disease postero-superior glenoid labrum [98].
Injuries of the cervical spine frequently affect athletes The first line of treatment can be conservative, mainly
who practice contact sports and represent 44.7% of all aiming to scapula stabilization, rotator cuff strengthen-
American football-related spinal injuries [88]. In patients ing, and stretching of the postero-inferior capsule. In-
with diagnosis of cervical disc herniations, surgical indi- deed, an excessive loss of glenohumeral internal rotation
cations are persistent symptoms, evidence of spinal cord (GIRD) is common in overhead athletes [100].
compression on MRI and cervical myelopathy. However, Surgical indication depends on several factors, such as
drug (such as anti-inflammatory medications) and phys- the kind of lesion, the patient’s age, level of activity, and
ical therapy (strengthening exercises) remains the first-line the previous non-operative management. Type II SLAPs
treatment and produces a higher rate of return to sport if are the most common. They present complete detach-
compared with surgical treatment. Furthermore, contact ment of the superior labrum and the biceps anchor from
sports are contraindicated in patients who underwent the superior glenoid tubercle. Repairing the lesion in
multilevel anterior cervical discectomy and fusion (ACDF) older patients (> 40 years old) showed higher rate of un-
or with cervical myelopathy, residual pain, or muscle satisfactory outcomes and surgical revision. In this in-
weakness [89, 90]. stance, the tendon of the long head of the biceps can
Low back pain, reported by 75% of elite athletes, is fre- undergo either a tenodesis or a tenotomy. In young ac-
quent in athletes of all levels [91]. In addition to genetic tive athletes, the lesion should be repaired [101]. How-
and anatomic factors, the incidence of lumbar disc de- ever, this is the most challenging type of lesion: its repair
generation is justified by an abnormal and increased load can result in a stiff shoulder [102], and return to play at
on the lumbar spine arising from sports activity prac- the pre-injury level cannot be guaranteed [103]. When
ticed over the years, which, in the long term, leads to choosing the treatment method, in type II lesion, it is of
early disc degeneration [92]. Similar to the upper spine paramount to take into account the patient’s type and
levels, in lumbar pathology, the first approach is re- level of activity. Recent evidences showed that biceps
habilitation focused on restoring range of motion and suprapectoral [104] or subpectoral [105] tenodesis is
muscular strengthening. Surgery is reserved to symp- preferable over SLAP repair in young patients practicing
tomatic patients non-responsive to non-operative treat- overhead activity. Type I lesions are characterized by frying
ment with imaging evidence of spinal cord compression. of the labrum, and therefore, the proposed surgical treat-
Lumbar disc herniation successfully receives non-operative ment is arthroscopic debridement. Type III lesions show a
treatment in 90% of patients [93]. Professional athletes who bucket handle tear of the labrum, while the biceps tendon
underwent surgery, both total disc replacement or discec- is normal. For these lesions, resection of the unstable
tomy and fusion, experience significant improvement of bucket handle tear is indicated [101]. Type IV is a type III
symptoms in a high percentage of cases and about 95% of lesion with a longitudinal lesion of the biceps tendon,
patients return to sport without significant differences with which may dislocate into the joint. When less than 30% of
previous sports performances [94, 95]. Lumbar discectomy the tendon is torn, the lesion can be abraded together with
offers variable results according to the type of sport prac- the degenerated area of the labrum. If the lesion involves
ticed by professional athletes. Satisfactory outcomes and more than 30% of the biceps tendon, it will be repaired in
high rates of return to sport can be found in American young patients or excised in older ones [106].
football players [96]. On the contrary, baseball players who
underwent surgery had a shorter career compared to col- Bankart lesion Anterior shoulder dislocation is com-
leagues with the same diagnosis but treated conservatively mon especially in contact athletes such as American
[97]. This heterogeneity highlights the importance of load football, ice hockey, and rugby players [107]. The most
forces as causes of lumbar hernia and possible post-surgical common injury mechanism in athletes is abduction and
recurrence. Treatment should be guided by surgeon experi- external rotation of the arm by an externally rotating
ence and set on athlete’s functional requirements. force [108]. This injury mechanism generates a Bankart
lesion where the antero-inferior capsule-labral complex
Upper limb is detached from the glenoid rim either alone or with a
Shoulder bony fragment (bony Bankart). In athletes, even after the
In athletes, shoulder injuries commonly involve rotator first dislocation, non-operative treatment leads to a high
cuff tendons and the labrum. recurrence rate [109].
Vasta et al. Journal of Orthopaedic Surgery and Research (2018) 13:190 Page 5 of 8

Arthroscopic repair of the Bankart lesion has become Abbreviations

more popular than open surgery, with similar reopera- ACDF: Anterior cervical discectomy and fusion; ACL: Anterior cruciate
ligament; ACLR: ACL reconstruction; ATFL: Anterior talo-fibular ligament;
tion and recurrence rate [110]. Return to sport after BPTB: Bone patellar tendon bone; CFL: Calcaneofibular ligament;
arthroscopic Bankart repair is variable, going up to ESWT: Extracorporeal shock waves therapy; FAI: Femoroacetabular
95% [111]. In bony Bankart lesions, following the new impingement; GIRD: Loss of glenohumeral internal rotation; HS: Hill-Sachs;
MCL: Medial collateral ligament; MRI: Magnetic resonance imaging;
concept of glenoid track introduced by Itoi in 2007 OCL: Chondral lesions of the talus; PCL: Posterior cruciate ligament;
[112], there has been much debate on which is the best RICE: Rest, ice [cryotherapy], compression, and elevation; SLAP: Superior
treatment to address both the humeral (Hill-Sachs) labrum anterior to posterior

and the glenoid bony lesions. It is suggested to per- Authors’ contributions

form arthroscopic Bankart repair for patients with SV and EA wrote the manuscript. RP, NM, and ED supervised the manuscript
glenoid bone loss < 25% and on-track Hill-Sachs (HS). writing and checking out the final version. All authors read and approved
the final manuscript.
If the HS is off-track, a remplissage procedure is ne-
cessary to restore shoulder stability [113, 114]. When Ethics approval and consent to participate
facing a glenoid bone loss > 25%, whether it is on-track Not applicable.
or off-track HS, the Latarjet procedure is recom-
Consent for publication
mended [115]. Not applicable.

Competing interests
Rotator cuff tears Throwing athletes are at higher risk NM is the Editor-in-Chief for Journal of Orthopaedic Surgery and Research.
The authors declare that they have no competing interests.
not only for labrum injuries but also for rotator cuff
tears. In addition to the common cuff lesions, the throw-
ing athletes show a higher incidence of partial-thickness Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
articular-sided tears of the postero-superior portion of the published maps and institutional affiliations.
cuff compared to the general population. This is secondary
to the internal impingement syndrome, a phenomenon Author details
1
Department of Orthopaedic and Trauma Surgery, Campus Bio-Medico,
described by Jobe and Walch [116, 117]. University of Rome, Via Alvaro del Portillo, 200 Rome, Italy. 2Department of
That syndrome is due to a conflict between the poster- Musculoskeletal Disorders, University of Salerno School of Medicine, Salerno,
Italy. 3Centre for Sports and Exercise Medicine, Barts and The London School
ior glenoid rim and the postero-superior rotator cuff in-
of Medicine and Dentistry, Mile End Hospital, London, UK.
sertion on the greater tuberosity. Factors associated with
this condition are recurring microtrauma, scapular dis- Received: 10 August 2016 Accepted: 12 July 2018
kynesis, and posterior capsule contracture with conse-
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