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2. Brukner & Khan’s
Clinical
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Medicine
FOURTH E DI TION
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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.
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4. Brukner & Khan’s
Clinical
Sports
Medicine
FOURTH E DITION Brukner
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5. Notice
Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and
drug therapy are required. The editors and the publisher of this work have checked with sources believed to be reliable in their
efforts 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 any
other party who has been involved in the preparation or publication of this work warrants that the information contained herein
is 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 drug
they plan to administer to be certain that the information contained in this book is accurate and that changes have not been
made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance
in connection with new or infrequently used drugs.
First published 1993
Second edition 2001
Revised second edition 2002
Third edition 2006
Revised third edition 2009
Text © 2012 McGraw-Hill Australia Pty Ltd
Additional 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 apologies
should any infringement have occurred.
Reproduction and communication for educational purposes
The Australian Copyright Act 1968 (the Act) allows a maximum of one chapter or 10% of the pages of this work, whichever is the
greater, to be reproduced and/or communicated by any educational institution for its educational purposes provided that the
institution (or the body that administers it) has sent a Statutory Educational notice to Copyright Agency Limited (CAL) and been
granted 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: www.copyright.com.au
Reproduction and communication for other purposes
Apart from any fair dealing for the purposes of study, research, criticism or review, as permitted under the Act, no part of this
publication 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 www.mcgraw-hill.com.au or marked for the attention of the permissions editor at
the address below.
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National Library of Australia Cataloguing-in-Publication Data
Author: Brukner, Peter.
Title: Brukner & Khan’s Clinical Sports Medicine / Peter Brukner,
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Karim Khan.
Edition: 4th ed.
ISBN: 9780070998131 (hbk.)
Notes: Includes index.
Previous ed.: Clinical Sports Medicine, 2007.
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Subjects: Sports medicine.
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Sports injuries.
Other Authors/Contributors:
Khan, Karim.
Dewey Number: 617.1027
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Published in Australia by
McGraw-Hill Australia Pty Ltd
Level 2, 82 Waterloo Road, North Ryde NSW 2113
Publisher: Fiona Richardson
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Senior production editor: Yani Silvana
Production editor: Jess Ní Chuinn
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Publishing and digital manager: Carolyn Crowther
Editorial coordinator: Fiona Collison
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Copy editor: Jill Pope
Illustrator: Vicky Earle (anatomical figures)
Proofreader: Mary-Jo O’Rourke
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Indexer: Russell Brooks
Cover design: Georgette Hall
Internal design: David Rosenmeyer
Typeset in 9/11.5 pt Scala by Midland Typesetters, Australia
Printed in China on 80gsm matt art by iBook Printing Ltd

6. Foreword to the first edition (1993)
Sport in Australia is ingrained in the national consciousness more widely, deeply, and indelibly than almost
anywhere else in the world. When a prominent sportsperson sustains a sporting injury, either traumatically
or 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 same
type of problems occur for recreational athletes, middle-aged people wanting to become fit, or older people
wishing 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 athlete
and place it fairly and squarely where it belongs—as a subspecialty to serve everyone in the community who
wishes to be active.
The book is organized in a manner that is sensible and usable. The chapters are arranged according to
the anatomical region of the symptom rather than diagnostic categories. This results in a very usable text for
the sports physician, general/family practitioner, physiotherapist, masseur, or athletic trainer whose practice
contains many active individuals.
Practical aspects of sports medicine are well covered—care of the sporting team and concerns that a
clinician might have when traveling with a team. In all, this is an eminently usable text which is timely in its
production and will find an important place among clinicians involved in the care of active individuals.
John R Sutton MD, FRACP
Professor of Medicine, Exercise Physiology and Sports Medicine
Faculty of Health Sciences
University of Sydney
Past President, American College of Sports Medicine
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This foreword was written by the late Professor John Sutton before his untimely death in 1996; it is retained in this
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textbook out of profound respect for this champion of the integration of science, physical activity promotion, and multi-
disciplinary patient care.
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7. Foreword to the fourth edition
Humans were not designed to sit at desks all day and in front of televisions all evening, and this physical
inactivity is related to a host of health-related issues. Increasing physical activity is one very powerful way to
mitigate many of the health issues we face today, and programs such as the Healthy People 2020 initiative and
the 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 and
treatment, regional musculoskeletal injuries, and medical problems. The text also addresses those practical
issues of sports medicine that are often missing from other texts, such as dealing with athletic teams, covering
endurance events, and working with the elite athlete.
The organization of the text makes it remarkably easy to use, including such features as color-coded book
sections, flow diagrams to reinforce concepts, and tables that clearly organize information. Vicky Earle’s
anatomical drawings are truly among the best in the business. All these features put an astounding wealth
of 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-date
references 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 what
I 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-
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classes that allow you, through videos and podcasts on the Clinical Sports Medicine website, to learn directly
from the experts. These masterclasses will be continually updated and they provide a remarkably dynamic
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component to the text.
It is exciting to watch Clinical Sports Medicine evolve substantially with each edition. The editors’ focus of
this text is to “help clinicians help patients” and they have clearly hit their mark. This book is an absolute must-
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have for any sports medicine professional.
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Professor Irene Davis, PT, PhD, FACSM, FAPTA, FASB
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Director, Spaulding National Running Center
Department of Physical Medicine and Rehabilitation
Harvard Medical School
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Spaulding-Cambridge Outpatient Center
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Cambridge, MA, USA
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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 113
10 Recovery 138
11 Principles of diagnosis: clinical assessment 145
12 Principles of diagnosis: investigations including imaging 157
13 Treatments used for musculoskeletal conditions: more choices and more evidence 164
14 Core stability 210
15 Principles of rehabilitation 227
16 Principles of physical activity promotion for clinicians 254
Part B Regional problems
17 Sports concussion 272
18 Headache 290
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19 Facial injuries 300
20 Neck pain 313
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21 Shoulder pain 342
22 Elbow and arm pain 390
23 Wrist pain 413
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24 Hand and finger injuries 435
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25 Thoracic and chest pain 449
26 Low back pain 463
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27 Buttock pain 492
28 Hip-related pain 510
29 Groin pain 545
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30 Anterior thigh pain 579
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31 Posterior thigh pain 594
32 Acute knee injuries 626
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33 Anterior knee pain 684
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34 Lateral, medial, and posterior knee pain 715
35 Leg pain 735
36 Calf pain 761
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9. Br ie f contents
37 Pain in the Achilles region 776
38 Acute ankle injuries 806
39 Ankle pain 828
40 Foot pain 844
41 The patient with longstanding symptoms: clinical pearls 878
Part C Special groups of participants
42 The younger athlete 888
43 Women and activity-related issues across the lifespan 910
44 The older person who exercises 936
45 Military personnel 943
46 The athlete with a disability 960
Part D Management of medical problems
47 Medical emergencies in the sporting context 972
48 Sudden cardiac death in sport 996
49 Managing cardiovascular symptoms in sportspeople 1024
50 Respiratory symptoms during exercise 1038
51 Gastrointestinal symptoms during exercise 1056
52 Renal symptoms during exercise 1063
53 Diabetes mellitus 1070
54 Exercise to treat neurological diseases and improve mental health 1082
55 Joint-related symptoms without acute injury 1093
56 Common sports-related infections 1102
57 The tired athlete 1118
58 Exercise in the heat 1132
59 Exercise at the extremes of cold and altitude 1146
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60 Quick exercise prescriptions for specific medical conditions 1158
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Part E Practical sports medicine
61 The preparticipation physical evaluation 1176
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62 Screening the elite sportsperson 1185
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63 Providing team care 1203
64 Traveling with a team 1208
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65 Medical coverage of endurance events 1221
66 Drugs and the athlete 1228
67 Ethics and sports medicine 1261
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10. Contents
Foreword to the first edition v Co-authors xxxvi
Foreword to the fourth edition vi Other contributors xlii
Preface xxxi Acknowledgments xliv
About the authors xxxiii Guided tour of your book xlv
Editors xxxv
PART Fundamental principles 4 Sports injuries: acute 15
A
Bone 16
1 Sports and exercise medicine: Fracture 16
addressing the world’s greatest public Periosteal injury 17
health problem 2 Articular cartilage 17
Joint 18
The burden of physical inactivity and sedentary
Dislocation/subluxation 18
behavior 2
Ligament 18
The one trillion dollar argument (US alone!) 2
Muscle 20
Physical fitness—more health benefits than
Strain/tear 20
smoking cessation or weight loss 2
Contusion 21
The molecular mechanisms that explain the
Myositis ossificans 21
health benefits of physical activity 2
Cramp 22
Putting 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
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Skin 23
2 Sports and exercise medicine: the
team approach
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6 5 Sports injuries: overuse 25
The sports and exercise medicine team 6 Bone stress 25
Multiskilling 6 Mechanism 26
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The sports and exercise medicine model 7 Risk factors 26
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The challenges of management 7 Skeletal sites 28
Diagnosis 8 Clinical diagnosis 28
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Treatment 9 Imaging diagnosis 28
Meeting individual needs 9 Low-risk and high-risk stress fracture 29
The coach, the athlete, and the clinician 9 General principles of stress fracture treatment 30
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“Love thy sport” (and physical activity!) 9 Osteitis and periostitis 31
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Apophysitis 31
3 Integrating evidence into clinical Articular cartilage 31
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Joint 31
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Life before evidence-based practice 12 Ligament 31
Sackett and the McMaster contribution 12 Muscle 31
This seems obvious—so what is the problem? 13 Focal tissue thickening/fibrosis 32
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11. Conte nts
Chronic compartment syndrome 32 Bone and soft tissue tumors 54
Muscle soreness 32 Rheumatological conditions 56
Tendon 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 59
Bursa 37 Pain syndromes 59
Nerve 37
Skin 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 64
But 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 69
6 Pain: why and how does it hurt? 41
Terminal swing 69
What is pain? 41 Angle and base of gait 69
What 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
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The brain decides 45 Structural (“static”) biomechanical
The brain corrects the spinal cord 45 assessment 73
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When pain persists, the brain changes 47 Functional lower limb tests—single-leg
Treating someone in pain—a complex system stance, heel raise, squat, and landing from
requires a comprehensive approach 47 a jump 77
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Clinical approach to referred pain—often Dynamic movement assessment
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neglected in clinical teaching 48 (e.g. running biomechanics) 82
Radicular pain 49 Sport-specific assessment 83
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Somatic pain 49 Summary of the lower limb biomechanical
Clinical assessment of referred pain 51 assessment 83
Clinical summary 52 Clinical assessment of footwear—the Footwear
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Assessment Tool 83
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7 Beware: conditions masquerading Fit 83
as sports injuries 54 General structure 83
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Motion control properties 83
How to recognize a condition masquerading
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Cushioning 85
as a sports injury 54
Wear patterns 85
Conditions masquerading as sports injuries 54
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12. Contents
Conditions related to suboptimal lower limb Appropriate training 128
biomechanics 85 Principles of training 128
Management of lower limb biomechanical Training methods 130
abnormalities 86 Adequate recovery 134
Foot orthoses 86
Taping 91 10 Recovery 138
Biomechanics 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 140
Upper 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
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Biomechanics of other overhead sports 107 History 146
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Allow enough time 146
9 Principles of injury prevention 113 Be a good listener 146
Know the sport 146
Systematic injury prevention 113
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Circumstances of the injury 146
Warm-up 116
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Obtain an accurate description of
Taping and bracing 121
symptoms 146
Taping 121
History of a previous similar injury 147
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Bracing 122
Other injuries 147
Protective equipment 122
General health 147
Suitable equipment 123
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Work and leisure activities 147
Running shoes 123
Consider why the problem has occurred 147
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Running spikes 124
Training history 147
Football boots 125
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Equipment 148
Ski boots 125
Technique 148
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Tennis racquets 126
Overtraining 148
Appropriate surfaces 127
Psychological factors 148
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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 162
Examination 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 167
12 Principles of diagnosis: Continuous passive motion 167
investigations including imaging 157 Therapeutic drugs 167
Analgesics 167
Investigations 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
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the requisition 157
Prolotherapy 177
5. Do not accept a poor quality test 157
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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
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Ostenil, Orthovisc) 178
Radiological investigation 158
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Antidepressants 179
Plain X-ray 158
Local anesthetic injections 179
Computed tomographic (CT) scanning 158
Traumeel 180
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Magnetic resonance imaging (MRI) 158
Bisphosphonates 180
Ultrasound scan (for diagnosis) 159
Blood and blood products 180
Radioisotopic bone scan 160
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Autologous blood injections 180
Neurological investigations 161
Platelet-rich plasma 180
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Electromyography 161
Heat and cold 181
Nerve conduction studies 161
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Cryotherapy 181
Neuropsychological testing 161
Superficial heat 183
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Muscle assessment 161
Contrast therapy 184
Compartment pressure testing 161
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14. Contents
Electrotherapy 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 228
Extracorporeal shock wave therapy 190
Begin as soon as possible 228
Manual 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 240
Acupuncture 198
Sport skills 240
Dry needling 198
Hydrotherapy 242
Hyperbaric oxygen therapy 200
Deep-water running 242
Surgery 200
Correction of biomechanical abnormalities 243
Arthroscopic surgery 200
Stages of rehabilitation 243
Open surgery 201
Initial stage 243
Intermediate preparticipation stage 243
14 Core stability 210
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Advanced stage 244
Anatomy 212 Return to sport 245
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Osseous and ligamentous structures 212 Secondary prevention 246
The thoracolumbar fascia 212 Progression of rehabilitation 246
Paraspinals 212 Type of activity 246
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Quadratus lumborum 213 Duration of activity 246
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Abdominals 213 Frequency 246
Hip girdle musculature 213 Intensity 246
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Diaphragm and pelvic floor 213 Complexity of activity 246
Assessment of core stability 213 Monitoring rehabilitation programs 246
Exercise of the core musculature 215 Psychology 247
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Decreasing spinal and pelvic viscosity 215 Emotional responses to injury 247
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Use of biofeedback and real-time Psychological strategies to facilitate
ultrasound in retraining core control 216 recovery 247
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Stabilization exercises 216 Conclusion 250
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Functional progression 219
Core strengthening for sports 223
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15. Conte nts
16 Principles of physical activity Migraine 293
promotion for clinicians 254 Cluster headache 295
Cervical headache 295
Who should receive exercise counseling? 255
Mechanism 295
Are there medical contraindications to being
Clinical features 296
active? 255
Exercise-related causes of headache 297
Executing the prescription 256
Primary exertional headache 297
Practical steps with the consultation 256
Exertional migraine 297
Exercise 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 300
An overlooked element of motivation 267
Summary 268 Functional anatomy 300
Clinical assessment 300
Soft tissue injuries 301
PART Regional problems Nose 303
B Epistaxis (nosebleed) 303
Nasal fractures 303
17 Sports concussion 272 Septal hematoma 303
Definition of concussion 273 Ear 304
Prevention of concussion 273 Auricular hematoma 304
The initial impact: applied pathophysiology 274 Lacerations 304
Management of the concussed athlete 274 Perforated eardrum 304
On-field management 274 Otitis externa 304
Determining when the player can return Eye 305
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safely to competition 277 Assessment of the injured eye 305
The risk of premature return to play and Corneal injuries: abrasions and foreign
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concussion sequelae 281 body 306
Risk of further injury 281 Subconjunctival hemorrhage 307
Eyelid injuries 307
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Second impact syndrome 281
Concussive convulsions 281 Hyphema 307
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Prolongation of symptoms 281 Lens dislocation 307
Chronic traumatic encephalopathy 281 Vitreous hemorrhage 307
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Mental health issues 282 Retinal hemorrhage 307
Children and concussion in sport 282 Retinal detachment 308
Orbital injuries 308
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18 Headache 290 Prevention of eye injuries 308
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Teeth 309
Headache in sport 290
Prevention of dental injuries 309
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Clinical approach to the patient with headache 291
Fractures of facial bones 309
History 292
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Fractures of the zygomaticomaxillary
Examination 293
complex 310
Vascular headaches 293
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16. Contents
Maxillary fractures 310 Glenoid labrum injuries 360
Mandibular fractures 311 Clinically relevant anatomy 360
Temporomandibular injuries 311 Making the diagnosis 360
Prevention of facial injuries 312 Treatment 361
Dislocation of the glenohumeral joint 362
20 Neck pain 313 Anterior dislocation 362
Posterior dislocation of the glenohumeral
Clinical perspective 313
joint 363
Assessing patients with neck pain 315
Shoulder instability 364
History 315
Anterior instability 364
Physical examination 317
Posterior instability 367
Treatment 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 371
Neck 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 373
Conclusion 336
Nerve entrapments 373
Thoracic outlet syndrome 375
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21 Shoulder pain 342
Axillary vein thrombosis (“effort”
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Functional anatomy—static and dynamic 342 thrombosis) 376
Static stabilizers 342 Fractures around the shoulder joint 376
Dynamic stabilizers 343 Principles for shoulder rehabilitation 377
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Scapulohumeral rhythm 343 Make a complete and accurate diagnosis 377
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Clinical perspective 344 Early pain reduction 377
A practical approach to shoulder pain 344 Integration of the kinetic chain into
History 345
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rehabilitation 377
Examination 345 Scapular stabilization 378
Shoulder investigations 352 Early achievement of 90° of abduction
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Impingement 353 and improved glenohumeral rotation 378
Primary external impingement 354
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Closed chain rehabilitation 381
Secondary external impingement 354 Plyometric exercises 382
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Internal impingement 355 Rotator cuff exercises 383
Rotator cuff injuries 357 Putting it all together—specific rehabilitation
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Rotator cuff tendinopathy 357 protocols 384
Rotator cuff tears 359 Acute phase 384
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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 427
22 Elbow and arm pain 390 Injuries to the distal radial epiphysis 430
Articular causes of subacute and chronic
Lateral 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 435
Medial elbow pain 401
Flexor/pronator tendinopathy 401 Clinical evaluation 435
Medial collateral ligament sprain 401 History 435
Ulnar neuritis 402 Examination 436
Posterior 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 439
Acute 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 442
Forearm 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
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Entrapment of the posterior interosseous Dislocations of the PIP joint 443
nerve (radial tunnel syndrome) 408 Dislocations of the DIP joint 443
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Forearm compartment pressure syndrome 409 Ligament and tendon injuries 443
Upper arm pain 409 Sprain of the ulnar collateral ligament of
Myofascial pain 409 the first MCP joint 443
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Stress reaction of the humerus 409 Injuries to the radial collateral ligament
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of the first MCP joint 444
23 Wrist pain 413 Capsular sprain of the first MCP joint 444
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PIP joint sprains 444
Acute wrist injuries 413
Mallet finger 445
History 413
Boutonnière deformity 446
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Examination 415
Avulsion of the flexor digitorum
Investigations 418
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profundus tendon 447
Fracture of the distal radius and ulna 420
Lacerations and infections of the hand 447
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Fracture of the scaphoid 420
Overuse conditions of the hand and fingers 447
Fracture of the hook of hamate 423
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Dislocation of the carpal bones 424
Scapholunate dissociation 425
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18. Contents
25 Thoracic and chest pain 449 Treatment 480
Stress fracture of the pars interarticularis 480
Thoracic 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 484
Chest 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 461
Conclusion 461 Clinical approach 492
History 492
26 Low back pain 463 Examination 494
Investigations 496
Epidemiology 463
Referred pain from the lumbar spine 497
Clinical 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
ge
Severe 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
e
Mild-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
sa
Acute nerve root compression 478
Clinical features 480
xvii

19. Conte nts
28 Hip-related pain 510 Factors that increase local bone stress 550
Clinical approach 552
Functional 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 559
Clinical perspective: making sense of a complex
Early warning signs 560
problem 516
Treatment 560
Femoroacetabular impingement (FAI) 516
Iliopsoas-related groin pain 565
Factors that may contribute to the
Epidemiology 566
development of hip-related pain 518
Clinical concepts 566
Extrinsic factors 518
Treatment 567
Intrinsic factors 519
Abdominal wall–related groin pain 567
Clinical 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 568
Labral tears 526
Tear of the external oblique aponeurosis
Ligamentum teres tears 527
(hockey groin) 568
Synovitis 528
Inguinal hernia 569
Chondropathy 529
Rectus abdominis injuries 569
Rehabilitation 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 573
Surgical management of the injured hip 534
Referred pain to the groin 574
Rehabilitation following hip arthroscopy 535
Os acetabulare 536
s
30 Anterior thigh pain 579
Lateral hip pain 538
ge
Greater trochanter pain syndrome (GTPS) 538 Clinical approach 579
Gluteus medius tendon tears 540 History 579
pa
Examination 580
29 Groin pain 545 Investigations 581
Quadriceps contusion 582
e
Anatomy 545
Treatment 583
pl
Prevalence 547
Acute compartment syndrome of the thigh 586
Risk factors 547
Myositis ossificans 587
m
Clinical 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? 549
xviii

20. Contents
Differentiating between a mild quadriceps Compartment syndrome of the posterior
strain and a quadriceps contusion 590 thigh 621
Less 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? 627
31 Posterior thigh pain 594
History 627
Functional anatomy 594 Examination 629
Clinical 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 638
Acute 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 the
Risk factors for acute hamstring strain 615 torn ACL? 647
Intrinsic risk factors 615 Surgical treatment 650
Extrinsic risk factors 616 Combined injuries 652
Prevention 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 659
Referred 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 669
Other 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 674
Less 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. 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 725
33 Anterior knee pain 684 Medial meniscus abnormality 726
Osteoarthritis of the medial compartment
Clinical 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 728
Patellofemoral 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 731
Patellofemoral instability 700
Other causes of posterior knee pain 732
Primary patellofemoral instability 700
Secondary patellofemoral instability 700
35 Leg pain 735
Patellar 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
ly
Less 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 exertional
34 Lateral, medial, and posterior compartment syndromes 753
knee pain 715 Outcomes of surgical treatment of
e
exertional compartment syndrome 754
Lateral 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 756
xx