Sports Medicine: Just the Facts

CHAPTER 80 • CROSS-COUNTRY SKI INJURIES 479

can develop through repetitive overload that leads to

tendinitis. With an acute injury, the peroneus tendon

can be torn or may be subluxed from the fibular

groove with disruption of the overlying retinaculum.

Acute injuries occur with both classic and skating

techniques, whereas chronic tendinitis is usually seen

in the skating technique.

• Clinical features:Acute injuries will present with
  pain, swelling, and bruising along the posterior and
  inferior fibula. The athlete will often report a pop in
  association with an appropriate mechanism.
  •Following the acute phase, a chronic clicking sensa-
  tion may be present representing subluxation of the
  peroneal tendon.


• Peroneal tendinitis will usually present with pain and
  swelling along the posterior and inferior fibula. Pain
  will be worse after skiing and will interfere with other
  activities, such as running and walking.
  •Physical examination may demonstrate subluxation of
  the effected peroneus tendon when compared to the
  contralateral ankle. Resisted eversion of the foot will
  reproduce pain.


• Diagnostic testing:In most acute injuries, an ankle
  X-ray is useful to rule out associated fracture.


• In an acute peroneal tear or subluxation, magnetic res-
  onance imaging(MRI) evaluation may be helpful to
  evaluate the extent of injury.


• Treatment:Acute strain injuries without a complete
  tear can be treated with immobilization (either casting
  or computer-aided manufacturing(CAM) walker boot
  depending on extent of injury). This is typically con-
  tinued for 4 to 6 weeks.


• Complete tear of the tendon or avulsion of the reti-
  naculum is best managed surgically.
  •Tendinitis is managed with temporary immobilization
  in a CAM walker followed by active rehabilitation
  incorporating passive stretching and eccentric over-
  load exercise.


• Anti-inflammatory medications may be helpful for
  pain management. Corticosteroid injection may also
  address the athlete’s discomfort. This is accomplished
  by injecting a solution of 60 mg of triamcinolone in 2
  to 3 cc of 1% lidocaine into the peroneus sheath. An
  ankle brace or taping may allow the athlete to con-
  tinue active training during the rehabilitationprocess.

SKIER’STOE

• Pathophysiology: Skier’s toe is a term frequently
  used to describe pain in the 1st MTP joint.


• This may represent either an acute injury (turf toe or
  acute sesamoid injury) or chronic problem (hallux
  rigidus, MTP synovitis, or sesamoiditis).


• In skiers, the chronic form stemming from degenerate
  joint disease and synovitis is most common and is

associated almost exclusively with the classical tech-

nique. The mechanism of injury is repetitive extreme

extension of the MTP joint.

• Clinical features: Athlete complains of pain,
  swelling, and limited motion at the great MTP joint.


• Symptoms are exacerbated with classical skiing, run-
  ning, and other activities involving repetitive forced
  extension of the toe.
  •Physical examination may reveal obvious degenera-
  tive changes on inspection of the joint. Tenderness
  and erythema are common. Pain is exacerbated with
  passive extension/flexion.


• Diagnostic testing:Radiographs will typically demon-
  strate 1st MTP degenerative disease.


• If a stress fracture or sesamoiditis is suspected a three
  phase bone scan or limited MRI study may be useful.


• Analysis of joint aspirate may demonstrate uric acid
  crystals if degeneration is caused by gouty arthritis.


• Treatment:Temporary exclusion of the classic tech-
  nique will help to alleviate symptoms.


• Modifying nonskiing footwear to eliminate flexion with
  a spring steel insert or rigid orthotic is also beneficial.
  •Severe cases may require temporary use of a rocker
  bottom boot. Nonsteroidal anti-inflammatory drugs
  (NSAIDs) are often helpful.


• In cases with substantial degeneration the athlete may
  benefit from surgical intervention.

UPPER EXTREMITY

DEQUERVAIN’STENOSYNOVITIS

• Pathophysiology: The repetitive gripping and
  ulnar/radial deviation motion associated with double
  poling can lead to tendinitis of the extensor pollicis
  brevis or abductor pollicis longus. Both tendons
  occupy the 1st dorsal wrist compartment and are gen-
  erally both involved.


• Symptoms can be insidious in onset or may arise
  acutely with a traumatic event. Chronic pain is
  common if untreated.


• Clinical features: Typical symptoms include pain
  and swelling along the radial aspect of the wrist.
  •Pain is precipitated by gripping and rotational motions
  (removing the lid from a jar or opening a door).


• Examination reveals tenderness along the extensor
  surface of the thumb, radial wrist, and forearm. Pain
  is precipitated with resisted thumb abduction or exten-
  sion. The patient may demonstrate a positive
  Finklestein’s test (see chapter 52).


• Treatment: Pain modification via the principles of
  PRICEMM (protection, rest, ice, elevation, medication,
  modalities).


• Corticosteroid injection may also be beneficial.
  Triamcinolone (60 to 80 mg) with 3 cc lidocaine is