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Essential Orthopaedics
Second Edition
Mark D. Miller, MD
S. Ward Casscells Professor of Orthopaedic Surgery
Department of Orthopaedics
University of Virginia
Charlottesville, Virginia
Jennifer A. Hart, MPAS, PA-C

Physician Assistant
Department of Orthopaedic Surgery
John M. MacKnight, MD, FACSM

Professor of Internal Medicine
Medical Director and Primary Care Team Physician
Department of Athletics
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ESSENTIAL ORTHOPAEDICS, SECOND EDITION ISBN: 978-0-323-56894-4
Copyright © 2020 by Elsevier, Inc. All rights reserved.
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Ste 1600
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To Ann Etchison, a smart lady and a great wife.
MDM
To my past teachers, from whom I learned what it takes to be a PA; to my current

mentors, Drs. Diduch and Miller, from whom I gained my knowledge of orthopaedics;
to all of the students I have encountered over the years from whom I learned that
knowledge is ongoing; and to my husband, Joe, and my children, Jordyn, Julia, and
Andrew, from whom I have learned everything else.
JAH
To my wife, Melissa, for her love, patience, and support. To my children, Abby, Hannah,
Eliza, and JD, for their sacrifice and understanding. And to the memory of my parents for
the inspiration to live a life of service.
JMM
Contributors
Sonya Ahmed, MD Laurie Archbald-Pannone, David J. Berkoff, MD
Co-Director MD, MPH, AGSF, FACP Clinical Professor of Orthopedics and
Private Practice Associate Professor of Internal Medicine Emergency Medicine
Nilssen Orthopedics University of Virginia University of North Carolina Chapel Hill
Pensacola, Florida Charlottesville, Virginia Chapel Hill, North Carolina
James Alex, MD Anthony J. Archual, MD Anthony Beutler, MD
Algone Sports and Regenerative Medicine Resident Physician NCC Sports Medicine Fellowship
Wasilla, Alaska Department of Plastic Surgery Director
University of Virginia Injury Prevention Research Laboratory
R. Todd Allen, MD, PhD Charlottesville, Virginia CHAMP Consortium Professor
Associate Professor of Orthopaedic
Department of Family Medicine
Surgery Michael Argyle, DO Uniformed Services University
Director, UCSD Spine Surgery Fellowship Sports Medicine Physician
Bethesda, Maryland
University of California San Diego 18th Medical Group
Health System U.S. Air Force Matthew H. Blake, MD
San Diego, California Kadena Air Base, Japan Director of Sports Medicine
Department of Orthopedics and Sports
Annunziato Amendola, MD Joseph Armen, DO Medicine
Professor of Orthopaedic Surgery Team Physician, Student Health Services
Avera McKennan Hospital & University
Chief, Division of Sports Medicine Sports Medicine Fellowship Program
Health Center
Duke University Director
Sioux Falls, South Dakota
Durham, North Carolina Department of Family Medicine
East Carolina University Jeffrey D. Boatright, MD, MS
Nicholas Anastasio, MD Greenville, North Carolina Division of Hand and Upper Extremity
Department of Physical Medicine &
Surgery
Rehabilitation Keith Bachmann, MD Department of Orthopaedic Surgery
University of Virginia Assistant Professor of Orthopaedic
Charlottesville, Virginia Surgery
Bradley M. Anderson Charlottesville, Virginia Benjamin Boswell, DO
Research Assistant
ED Physician, Sports Medicine Fellow
Rothman Institute Spine Section Geoffrey S. Baer, MD, PhD Primary Care Sports Medicine Fellowship
Philadelphia, Pennsylvania Associate Professor of Orthopedics
Duke University
and Rehabilitation
D. Greg Anderson, MD Durham, North Carolina
University of Wisconsin
Professor of Orthopaedic Surgery
Madison, Wisconsin Seth Bowman, MD
Thomas Jefferson University
Hand Fellow
Philadelphia, Pennsylvania Kaku Barkoh, MD Department of Plastic Surgery
Spine Surgery Fellow
Kelley Anderson, DO, CAQSM University of Virginia
Assistant Professor of Orthopedics Charlottesville, Virginia
University of Southern California
University of Pittsburgh;
Los Angeles, California Robert Boykin, MD
Primary Care Sports Medicine Physician
Staff Physician
University of Pittsburgh Medical Center Michael A. Beasley, MD Blue Ridge Division
Pittsburgh, Pennsylvania Instructor of Orthopedics
EmergeOrtho
Harvard Medical School;
Mark W. Anderson, MD Asheville, North Carolina
Division of Sports Medicine
Professor of Radiology and Orthopaedic
Boston Children’s Hospital Rebecca Breslow, MD
Surgery
Boston, Massachusetts Associate Physician, Primary Care
Department of Radiology
Sports Medicine
University of Virginia Anthony J. Bell, MD Department of Orthopaedics
Charlottesville, Virginia Assistant Professor of Orthopaedic
Brigham and Women’s Hospital
Surgery and Rehabilitation
Boston, Massachusetts
University of Florida College of Medicine
Jacksonville, Florida
iv
Contributors
Thomas E. Brickner, MD Dennis Q. Chen, MD D. Nicole Deal, MD

Team Physician Resident Physician Associate Professor of Orthopaedic
Department of Sports Medicine Department of Orthopaedic Surgery Surgery
University of North Carolina University of Virginia University of Virginia
Chapel Hill, North Carolina Charlottesville, Virginia Charlottesville, Virginia
Stephen Brockmeier, MD Mario Ciocca, MD Monika Debkowska, MD
Associate Professor of Orthopaedic Director of Sports Medicine Department of Orthopedic Surgery
Surgery Assistant Professor of Internal Virginia Commonwealth University
University of Virginia Medicine and Orthopaedics Richmond, Virginia
Charlottesville, Virginia University of North Carolina
Christopher DeFalco, MD
Chapel Hill, North Carolina
Per Gunnar Brolinson, Community Physician Network
DO, FAOASM, FAAFP Adam R. Cochran, MD Orthopedic Specialty Care
Vice Provost for Research Hand Surgery Fellow Indianapolis, Indiana
Professor of Family and Sports Medicine Department of Orthopedic Surgery
Ian J. Dempsey, MD, MBA
Discipline Chair for Sports Medicine Virginia Commonwealth University
Resident Physician
Edward Via College of Osteopathic Richmond, Virginia
Medicine
Alexander D. Conti, MD University of Virginia
Virginia Tech and Virginia College of
Resident Physician Charlottesville, Virginia
Osteopathic Medicine
Blacksburg, Virginia Christopher J. DeWald, MD
West Virginia University
Assistant Professor of Orthopaedic
James A. Browne, MD Morgantown, West Virginia
Surgery
Minton Truitt Cooper, MD Director, Section of Spinal Deformity
Surgery
Assistant Professor of Orthopaedic Rush University Medical Center
Head, Division of Adult Reconstruction
Surgery Chicago, Illinois
University of Virginia School of
University of Virginia School of Medicine
Medicine Kevin deWeber, MD, FAAFP,
Charlottesville, Virginia FACSM
Gianmichel Corrado, MD Program Director, Sports Medicine
Chester Buckenmaier III, MD
Sports Medicine Physician Fellowship
Director, Defense & Veterans Center
Associate Program Director for Primary Family Medicine of SW Washington
for Integrative Pain Management
Care Sports Medicine Fellowship Vancouver, Washington;
Department of Military and Emergency
Lecturer in Orthopedic Surgery Affiliate Associate Professor of Family
Medicine
Harvard Medical School; Medicine
Uniformed Services University
Head Team Physician Oregon Health and Science University
Bethesda, Maryland
Northeastern University Portland, Oregon;
Jeffrey R. Bytomski, DO Boston, Massachusetts Clinical Instructor of Family Medicine
Associate Professor of Community University of Washington School of
Quanjun (Trey) Cui, MD
and Family Medicine Medicine
G.J. Wang Professor of Orthopaedic
Duke University Seattle, Washington
Surgery
Durham, North Carolina
University of Virginia School of William Dexter, MD, FACSM
Adam Carlson, MD Medicine Division of Orthopedics and Sports
Assistant Professor of Rheumatology Charlottesville, Virginia Medicine
University of Virginia School of Maine Medical Partners
Rashard Dacus, MD
Medicine Portland, Maine;
Charlottesville, Virginia Professor of Family Medicine
Surgery
Tufts University School of Medicine
Wesley W. Carr, MD University of Virgnia
Boston, Massachusetts
Sports Medicin Physician Charlottesville, Virginia
Uniformed Services University Caleb Dickison, DO, CAQSM
Jeffrey Dart, MD
Bethesda, Maryland Sports Medicine Physician
Physician
National Capital Consortium
S. Evan Carstensen, MD Departments of Sports Medicine,
Uniformed Services University of the
Staff Physician Family Medicine
Health Sciences
Department of Orthopaedics PeaceHealth
Bethesda, Maryland
University of Virginia Vancouver, Washington
Contributors
David Diduch, MD Gregory C. Fanelli, MD Eric J. Gardner, MD

Professor of Orthopaedic Surgery Geisinger Sports Medicine and Mountain Vista Orthopedics
Head Orthopaedic Team Physician Orthopedic Surgery Greeley, Colorado
Division Head, Sports Medicine Danville, Pennsylvania
Trent Gause II, MD
Matthew G. Fanelli, MD Orthopaedic Surgeon
Geisinger Orthopedic Surgery Department of Orthopaedic Surgery
Robert J. Dimeff, MD Danville, Pennsylvania University of Virginia
Professor of Orthopedic Surgery, Charlottesville, Virginia
Patricia Feeney, DO, FAWM
Pediatrics, Family & Community
Sports Medicine Fellow Nicholas E. Gerken, MD
Medicine
Department of Family Medicine Adult Reconstruction Fellow
University of Texas Southwestern
Mountain Area Health Education Center Department of Adult Reconstruction/
Medical Center
Asheville, North Carolina Orthopaedic Surgery
Dallas, Texas
Christopher Felton, DO, CAQSM,
Julie Dodds, MD Charlottesville, Virginia
ATC
Clinical Associate Professor
Novant Health Primary Care Sports Sanjitpal S. Gill, MD
Michigan State University
Medicine Adjunct Assistant Professor
East Lansing, Michigan
Charlotte, North Caroline Department of Bioengineering
Gregory F. Domson, MD, MA Clemson University
Adam C. Fletcher, MD
Residency Director Clemson, South Carolina;
Sports Medicine/Family Medicine
Department of Orthopaedics Orthopaedic Surgery
Winona Health
Virginia Commonwealth University Medical Group of the Carolinas
Winona, Minnesota
Medical Center Greer, South Carolina
Richmond, Virginia Jason A. Fogleman, MD Heather Gillespie, MD, MPH
Foot and Ankle Fellow
Andrew S. Donnan III, MMSc Maine Medical Partners
Reno Orthopedic Clinic
Physician Assistant, Distinguished Fellow Orthopedics and Sports Medicine
University of California Davis
Spartanburg Regional Health Care Portland, Maine;
Reno, Nevada
System Clinical Associate Professor
Spartanburg, South Carolina Travis Frantz, MD Tufts University School of Medicine
Resident Physician Boston, Massachusetts
Jeanne Doperak, DO
Assistant Professor Andrea Gist, MD
The Ohio State University Wexner
Program Director, Primary Care Sports Resident Physician
Medical Center
Medicine Fellowship Wake Forest Family Medicine
Columbus, Ohio
Associate Program Director, PM&R Winston-Salem, North Carolina
Sports Medicine Fellowship Tyler W. Fraser, MD Victor Anciano Granadillo, MD
Department of Orthpaedic Surgery Resident Physician
University of Pittsburgh Department of Orthopedics
University of Virginia Healthsystem
Pittsburgh, Pennsylvania University of Tennessee
Chattanooga, Tennessee
Jesse F. Doty, MD
Anna Greenwood, MD
Assistant Professor of Orthopaedic Brett A. Freedman, MD Resident Physician
Surgery Associate Professor of Orthopedics
University of Tennessee College of Mayo Clinic
Virginia Commonwealth University
Medicine; Rochester, Minnesota
Richmond, Virginia
Director of Foot and Ankle Surgery
Ryan L. Freedman, MD, MS
Erlanger Health System Kelly E. Grob, MD
Chattanooga, Tennessee Primary Care Sports Medicine
Resident Physician
Thomas Ergen, MD Clinical Associate
Resident Physician Department of Emergency Medicine
Department of Orthopaedics Duke University
University of South Carolina Durham, North Carolina F. Winston Gwathmey, Jr., MD
Columbia, South Carolina Associate Professor of Orthopaedic
Aaron M. Freilich, MD Surgery
David G. Fanelli, MD Associate Professor of Orthopaedic
Pennsylvania State University College Surgery
of Medicine University of Virginia
Hershey Medical Center Charlottesville, Virginia
Hershey, Pennsylvania
vi
Contributors
Michael Hadeed, MD Joel Himes, DO Chad D. Hulsopple, DO

Resident Physician Fellow, Primary Care Sports Medicine Assistant Professor of Family Medicine
Department of Orthopaedic Surgery University of Pittsburgh Medical Center Uniformed Services University of the
University of Virginia Pittsburgh, Pennsylvania Health Sciences
Charlottesville, Virginia Bethesda, Maryland
Sarah Hoffman, DO, FAAP, CAQSM
Corey A. Hamilton, MD Pediatric Sports Medicine Physician Michael Hunter, MD
Resident Physician Department of Orthopedics and Sports Department of Orthopaedic Surgery
Department of Orthpaedics Medicine Greenville Health System
University of South Carolina Maine Medical Partners Greenville, South Carolina
Columbia, South Carolina South Portland, Maine;
Mary C. Iaculli, DO
Pediatric Hospitalist
Kyle Hammond, MD Martins Point Health Care
Department of Pediatrics
Assistant Professor Portland, Maine
Barbara Bush Children’s Hospital
Departments of Orthopaedic Surgery,
Portland, Maine; Jonathan E. Isaacs, MD
Sports Medicine
Clinical Assistant Professor of Pediatrics Herman M. & Vera H. Nachman
Emory University
Tufts University School of Medicine Distinguished Research Professor
Atlanta, Georgia
Boston, Massachusetts Chief, Division of Hand Surgery
Jennifer A. Hart, MPAS, PA-C Vice Chairman of Research and Education
Jarred Holt, DO
Physician Assistant Department of Orthopaedic Surgery
Sparrow Health System Sports Medicine
Department of Orthopaedic Surgery Virginia Commonwealth University
East Lansing, Michigan
University of Virginia Health System
Charlottesville, Virginia Jason A. Horowitz, MD Richmond, Virginia
Research Fellow
Hamid Hassanzadeh, MD Marissa Jamieson, MD
Department of Orthopaedics Resident Physician
University of Virginia Department of Orthopaedic Surgery
Charlottesville, Virginia Ohio State Medical Center
Thomas M. Howard, MD Columbus, Ohio
Emanuel C. Haug, MD Physician
Resident Physician Jeffrey G. Jenkins, MD
Flexogenix
Department of Orthopaedic Surgery Associate Professor
Cary, North Carolina
University of Virginia Department of Physical Medicine and
Charlottesville, Virginia David Hryvniak, DO Rehabilitation
Assistant Professor of Physical University of Virginia
C. Thomas Haytmanek, Jr., MD Medicine and Rehabilitation Charlottesville, Virginia
Attending Surgeon
Team Physician, University of Virginia
Department of Orthopaedic Surgery Patrick Jenkins III, MD
Athletics
The Steadman Clinic Prompt Care
Vail, Colorado Division of Ambulatory Medicine
Charlottesville, Virginia;
University Hospital
Jonathan R. Helms, MD Team Physician, James Madison
Augusta, Georgia
Assistant Professor of Orthopaedic University Athletics
Surgery James Madison University Darren L. Johnson, MD
University of Florida Health Harrisonburg, Virgin Professor
Jacksonville Department of Orthopaedic Surgery
Elizabeth W. Hubbard, MD
Jacksonville, Florida University of Kentucky
Lexington, Kentucky
Shane Hennessy, DO Duke University Medical Center
Primary Care Sports Medicine Durham, North Carolina Christopher E. Jonas, DO, FAAFP,
University of Pittsburgh Medical Center CAQSM
Logan W. Huff, MD
Pittsburgh, Pennsylvania Assistant Professor of Family Medicine
Resident Physician
Uniformed Services University of the
Donella Herman, MD, MEd Department of Orthopaedics
Health Sciences
Primary Care Sports Medicine Physician University of South Carolina
Bethesda, Maryland
Sanford Orthopedics and Sports Columbia, South Carolina
Medicine Carroll P. Jones, MD
Brandon S. Huggins, MD
Sanford Health Fellowship Director
Orthopedic Surgery Resident
Sioux Falls, South Dakota Foot and Ankle Institute
Department of Orthopedic Surgery
OrthoCarolina
Greenville Health System
Charlotte, North Carolina
Greenville, South Carolina
vii
Contributors
Anish R. Kadakia, MD Amy Kite, MD Larry Lee, MD

Associate Professor of Orthopedic Department of Plastic and Spine Surgery Fellow
Surgery Reconstructive Surgery Department of Orthopaedics, Spine
Fellowship Director, Foot and Ankle Virginia Commonwealth University Center
Orthopedic Surgery Richmond, Virginia University of Southern California
Northwestern University Feinberg Los Angeles, California
Alexander Knobloch, MD, CAQSM
School of Medicine
Faculty Physician, Family Medicine Jeffrey Leggit, MD, CAQSM
Northwestern Memorial Hospital
and Sports Medicine Associate Professor of Family Medicine
Chicago, Illinois
David Grant Medical Center Family Uniformed Services University of the
Samantha L. Kallenback, BS Medicine Residency Health Sciences
Steadman Philippon Research Institute Travis Air Force Base, California Bethesda, Maryland
The Steadman Clinic
Mininder S. Kocher, MD, MPH David Leslie, DO
Vail, Colorado
Professor of Orthopaedic Surgery Ochsner Sports Medicine Institute
Jerrod Keith, MD Harvard Medical School; Ochsner Health System
Associate Professor Associate Director, Division of Sports New Orleans, Louisiana
Divison of Plastic Surgery Medicine
Xudong Li, MD, PhD
University of Iowa Hospitals and Clinics Boston Children’s Hospital
Iowa City, Iowa Boston, Massachusetts
Surgery
Blane Kelly, MD Andrew Kubinski, DO, MS University of Virginia
Surgeon Nonsurgical Orthopaedics and Sports Charlottesville, Virginia
Department of Orthopaedics Medicine
Scott Linger, MD
Virgina Commonwealth/Medical Department of Private Diagnostic
Bloomington Bone & Joint Clinic
College of Virginia Clinics, PLLC
Bloomington, Indiana
Richmond, Virginia Duke University
Durham, North Carolina Catherine A. Logan, MD, MBA,
Brian R. Kelly, MD
MSPT
UT Southwestern Medical Center Justin Kunes, MD
Orthopaedic Surgeon
Dallas, Texas Orthopedic Surgeon
Jeremy Kent, MD The Steadman Clinic
Piedmont Medical Care Corporation
Assistant Professor of Family Medicine Vail, Colorado
Covington, Georgia
Brian Lowell, MD
Charlottesville, Virginia Helen C. Lam, MD
Resident Physician
Michelle E. Kew, MD Southwest Peacehealth
Resident of Orthopaedic Surgery Vancouver, Washington
Kaiser Napa-Solano
University of Viriginia
Vallejo, California Myro A. Lu, DO
Stephanie N. Lamb, MEd, ATC
A. Jay Khanna, MD, MBA Tripler Army Medical Center
VIPER Sports Medicine
Professor and Vice Chair of Honolulu, Hawaii
559th Medical Group
Orthopaedic Surgery
JBSA-Lackland, Texas Evan Lutz, MD, CAQSM
Sports Medicine Division Director
Johns Hopkins University Matthew D. LaPrade, BS
Bethesda, Maryland Steadman Philippon Research Institute
East Carolina University Sports Medicine
The Steadman Clinic
Patrick King, MD Greenville, North Carolina
Vail, Colorado
Sports Medicine Fellow
Robert H. Lutz, MD
Department of Family Medicine Robert F. LaPrade, MD, PhD
Team Physician
Mountain Area Health Education Center Chief Medical Research Officer
Davidson College Sports Medicine
Asheville, North Carolina Steadman Philippon Research Institute
Davidson, North Carolina
The Steadman Clinic
Jason Kirkbride, MD, MS Vail, Colorado Matthew L. Lyons, MD
Department of Physical Medicine and
Orthopedic Surgeon
Rehabilitation Leigh-Ann Lather, MD
University of Virginia Associate Professor of Orthopaedics
Kaiser Permanente Washington
Charlottesville, Virginia University of Virginia
Bellevue, Washington
viii
Contributors
John M. MacKnight, MD, FACSM Todd Milbrandt, MD, MS Nathaniel S. Nye, MD

Professor of Internal Medicine Associate Professor of Orthopedics VIPER Sports Medicine Element Chief
Medical Director and Primary Care Consultant, Department of Orthopedic 559th Medical Group
Team Physician Surgery JBSA-Lackland, Texas
Department of Athletics Mayo Clinic
Michael O’Brien, MD
University of Virginia Rochester, Minnesota
Assistant Professor of Orthopedics
Christopher Miles, MD Boston Children’s Hospital
Steven J. Magister, MD Associate Program Director of Primary Boston, Massachusetts;
Resident Physician Care Sports Medicine Fellowship Staff Physician
Case Western Reserve University Assistant Professor of Family and The Micheli Center for Sports Injury
Cleveland, Ohio Community Medicine Prevention
Wake Forest University School of Waltham, Massachusetts
Eric Magrum, DPT, OCS, Medicine
FAAOMPT Francis O’Connor, MD, PhD
Winston-Salem, North Carolina
Director, VOMPTI Orthopaedic Uniformed Services University
Physical Therapy Residency Mark D. Miller, MD Consortium for Health and Military
Program S. Ward Casscells Professor of Performance
University of Virginia/Encompass Orthopaedic Surgery Bethesda, Maryland
Sports Medicine and Rehabilitation Department of Orthopaedics
Matthew J. Pacana, MD
Charlottesville, Viriginia University of Virginia
Resident Physician
Harrison Mahon, MD Department of Orthopaedics
Resident Physician Ryan D. Muchow, MD University of South Carolina
University of Virginia Staff Pediatric Orthopaedic Surgeon Columbia, South Carolina
Charlottesville, Virginia Department of Orthopaedic Surgery
Hugo Paquin, MD
Shriners Hospital for Children, Lexington;
Aaron V. Mares, MD Assistant Professor of Pediatrics
Assistant Professor of Orthopaedic University of Montreal;
Surgery
Surgery Attending Physician
University of Kentucky
Department of Orthopaedics Division of Pediatric Emergency
Lexington, Kentucky
University of Pittsburgh Medical Center Medicine
Pittsburgh, Pennsylvania John V. Murphy, DO Centre Hospitalier Universitaire
Primary Care Sports Medicine Fellow Sainte-Justine
Robert G. Marx, MD, MSc, FRCSC Department of Orthopedics Montreal, Quebec, Canada
Attending Orthopedic Surgeon
University of Pittsburgh Medical Center
Hospital for Special Surgery; Joseph S. Park, MD
Pittsburgh, Pennsylvania
Professor of Orthopedic Surgery Associate Professor
Weill Cornell Medical College Tenley Murphy, MD Foot and Ankle Division Head
New York, New York Associate Team Physician Department of Orthopedic Surgery
Clemson University University of Virginia Health System
Scott McAleer, MD Clemson, South Carolina Charlottesville, Virginia
University of Virginia School of Medicine
Charlottesville, Virginia Lauren Nadkarni, MD Milap S. Patel, DO
Primary Care Sports Medicine Fellow Attending Physician
Melissa McLane, DO Department of Family Medicine/Sports Northwestern Memorial Hospital
Medicine Chicago, Illinois
Surgery
Maine Medical Center
University of Pittsburgh William Patterson, DO
Portland, Maine
Pittsburgh, Pennsylvania Primary Care Sports Medicine Fellow
Michael T. Nolte, MD Department of Sports Medicine
Michael McMurray, PT, DPT, OCS, Resident Physician Maine Medical Center
FAAOMPT
Department of Orthopaedic Surgery Portland, Maine
Physical Therapist
Rush University Medical Center
University of Virginia/Encompass Sergio Patton, MD
Chicago, Illinois
Sports Medicine and Rehabilitation University of Virginia
Center Ali Nourbakhsh, MD Charlottesville, Virginia
Charlottesville, Virginia Spine Surgeon
Venkat Perumal, MD
Department of Orthopedics
James Medure, MD Assistant Professor of Orthopaedics
WellStar Atlanta Medical Center
University of Pittsburgh University of Virginia
Atlanta, Georgia
Pittsburgh, Pennsylvania Charlottesville, Virginia
ix
Contributors
Christopher J. Pexton, DO Tracy R. Ray, MD Andrew Schwartz, MD

Family Medicine Physician Director, Sports Medicine Primary Care Resident Physician
Peacehealth Department of Orthopedic Surgery Department of Orthopaedics, Sports
Vancouver, Washington Associate Professor Medicine, and Spine
Departments of Orthopaedic Surgery Emory University
Frank M. Phillips, MD and Community and Family Atlanta, Georgia
Professor and Spine Fellowship
Medicine
Co-Director Nicholas Sgrignoli, MD
Duke University
Department of Orthopaedic Surgery Resident Physician
Durham, North Carolina
Rush University Medical Center Family and Community Medicine
Chicago, Illinois Scott Riley, MD Wake Forest University
Department of Orthopaedic Surgery Winston-Salem, North Carolina
Jennifer Pierce, MD Shriners Hospital for Children
Department of Radiology Stephen Shaheen, MD, CAQSM
Lexington, Kentucky
University of Virginia Assistant Professor, Orthopedic
Charlottesville, Virginia Mark Rogers, DO, CAQSM, FAAFP, Surgery and Emergency Medicine
FAOASM Primary Care Sports Medicine
Tinnakorn Pluemvitayaporn, MD Associate Professor of Family Duke University Medical Center
Spine Unit
Medicine Durham, North Carolina
Discipline Sports Medicine
Institute of Orthopaedics Alan Shahtaji, DO, CAQ-SM
Edward Via College of Osteopathic
Lerdsin Hospital Associate Clinical Professor of Family
Medicine, Virginia Campus;
Bangkok, Thailand Medicine and Public Health
Team Physician
University of California San Diego
Brian D. Powell, MD Department of Performance & Sports
San Diego, California
Foot and Ankle Surgeon Medicine
Department of Orthopaedics Virginia Tech Lisa A. Sienkiewicz, MD
Ogden Clinic Blacksburg, Virginia Department of Orthopedics and
Ogden, Utah Rehabilitation
Mark J. Romness, MD
University of Wisconsin School of
Bridget Quinn, MD Associate Professor of Orthopaedic
Medicine and Public Health
Department of Orthopedic Surgery Surgery
Madison, Wisconsin
Boston Children’s Hospital University of Virginia
Boston, Massachusetts Charlottesville, Virginia Anuj Singla, MD
Instructor
Kate Quinn, DO Michael Rosen, DO
Division of Sports Medicine Adjunct Clinical Faculty
Maine Medical Partners Orthopedics Osteopathic Surgical Specialties
and Sports Medicine Michigan State University
South Portland, Maine East Lansing, Michigan Bryan Sirmon, MD
Attending Surgeon
Rabia Qureshi, MD Jeffrey Ruland, BA
Georgia Hand, Shoulder & Elbow
Researcher Medical Student
Atlanta, Georgia
Department of Orthopedics University of Virginia School of Medicine
University of Virginia Charlottesville, Virginia Jonathan P. Smerek, MS, MD
Charlottesville, Virginia Associate Professor of Orthopaedics
Robert D. Santrock, MD
Indiana University School of Medicine
Sara N. Raiser, MD Assistant Professor of Orthopaedics
Indianapolis, Indiana
Resident Physician West Virginia University
Department of Physical Medicine & Morgantown, West Virginia W. Bret Smith, DO, MS
Rehabilitation Director, Foot and Ankle Division
Thomas Schaller, MD
University of Virginia Department of Orthopedic Surgery
Program Director
Charlottesville, Virginia PH-USC Orthopedic Center;
Associate Professor
Assistant Professor of Orthopedics
Justin J. Ray, MD Department of Orthopedics
University of South Carolina
Resident Physician Greenville Health System
Columbia, South Carolina
Department of Orthopaedics Greenville, South Carolina
West Virginia University Avinash Sridhar, MD
David Schnur, MD
Morgantown, West Virginia Family Medicine Resident
Private Practice
Plastic Surgery Clinic
Mountain Area Health Education Center
Denver, Colorado
Asheville, North Carolina
Contributors
Michael S. Sridhar, MD Marc Tompkins, MD Janet L. Walker, MD

Assistant Professor of Orthopaedic Associate Professor of Orthopaedic Professor of Orthopaedic Surgery
Surgery Surgery University of Kentucky College of
Greenville Health System University of Minnesota Medicine;
Greenville, South Carolina Minneapolis, Minnesota; Attending Physician
TRIA Orthopaedic Center Shriners Hospital for Children
Uma Srikumaran, MD, MBA, MPH Bloomington, Minnesota Lexington, Kentucky
Surgery Benjamin A. Tran Nathan Wanderman, MD
Johns Hopkins School of Medicine University of Virginia School of Resident, Orthopedic Surgery Department
Baltimore, Maryland Medicine Mayo Clinic
Charlottesville, Virginia Rochester, Minnesota
Siobhan M. Statuta, MD, CAQSM
Assistant Professor Obinna Ugwu-Oju, MD Jeffrey Wang, MD
Departments of Family Medicine and Resident Physician Co-Director, University of Southern
Physical Medicine & Rehabilitation Department of Orthopaedic Surgery California Spine Institute
Director, Primary Care Sports Medicine Virginia Commonwealth University Professor of Orthopaedic Surgery
Fellowship Richmond, Virginia Clinical Scholar
Department of Family Medicine Department of Orthopaedics, Spine
Jon Umlauf, DPT
University of Virginia Center
Department of Physical Therapy
Charlottesville, Virginia University of Southern California
Brooke Army Medical Center
Los Angeles, California
Andrea Stracciolini, MD Fort Sam Houston, Texas
Department of Sports Medicine Robert P. Waugh, MD
Christopher E. Urband, MD
Boston Children’s Hospital Orthopaedic Surgeon
Orthopaedic Surgeon
Boston, Massachusetts Coastal Orthopedic Associates
Beverly, Massachusetts
Nicholas Strasser, DO Torrey Pines Orthopaedics and Sports
Clinical Faculty Medicine Justin L. Weppner, DO
Department of Family Medicine–Sports La Jolla, California Department of Physical Medicine and
Medicine Rehabilitation
Ryan Urchek, MD
Edward Via College of Osteopathic University of Virginia
Fellow, Orthopaedic Sports Medicine
Medicine Charlottesville, Virginia
Emory University
Blacksburg, Viriginia
Atlanta, Georgia Brian C. Werner, MD
Jillian Sylvester, MD, CAQ Assistant Professor of Orthopaedic
Kevin Valvano, DO
Saint Louis University Family Medicine Surgery
Primary Care Sports Medicine
Residency University of Virginia
O’Fallon, Illinois Charlottesville, Virginia
Medicine, Virginia Campus;
Vishwas R. Talwalkar, MD Assistant Team Physician Andrea M. White, PA, MEd
Professor of Orthopaedic Surgery and Department of Performance and Physician Assistant
Pedatrics Sports Medicine Department of Orthopaedics
University of Kentucky College of Virginia Tech University of Virginia
Medicine; Blacksburg, Virginia Charlottesville, Virginia
Scott Van Aman, MD Robert P. Wilder, MD, FACSM
Shriners Hospital for Children
Orthopedic Surgeon, Foot and Ankle Professor and Chair of Physical
Lexington, Kentucky
Orthopedic One Medicine and Rehabilitation
Cole Taylor, MD, CAQSM, FAAFP Columbus, Ohio University of Virginia
Clinic Chief, Sports Medicine Charlottesville, Virginia
Corey Van Hoff, MD
Fort Belvoir Community Hospital
Orthopaedic Trauma Surgeon George Lee Wilkinson III, BA
Fort Belvoir, Virginia
Orthopaedic One Scribe, Foot and Ankle
John B. Thaller, MD Columbus, Ohio Department of Orthopedic Surgery
Director of Orthopaedics University of Virginia
Aaron Vaughan, MD
Department of Orthopaedic Surgery Charlottesville, Virginia
Sports Medicine Director
Maine General Medical Center
Department of Family Medicine Christina M. Wong, DO
Augusta, Maine
Mountain Area Health Education Center Primary Care Sports Medicine Fellow
Asheville, North Carolina Department of Sports Medicine
Medicine
Blacksburg, Virginia
xi
Contributors
Colton Wood, MD Seth R. Yarboro, MD Dan A. Zlotolow, MD

Resident Physician Assistant Professor of Orthopaedic Associate Professor of Orthopaedics
Family Medicine Residency Program Surgery Thomas Jefferson University School of
University of Virginia University of Virginia Medicine;
Charlottesville, Virginia Charlottesville, Virginia Attending Physician
Shriners Hospital for Children
Katherine Victoria Yao, MD S. Tim Yoon, MD, PhD Philadelphia, Pennsylvania
Assistant Professor of Clinical Associate Professor of Orthopedic
Rehabilitation Medicine Surgery
Weill Cornell Medical College Emory University
Cornell University; Atlanta, Georgia
Adjunct Assistant Professor of Clinical
Rehabilitation and Regenerative
Medicine
Columbia University College of
Physicians and Surgeons;
Assistant Attending Physiatrist
Department of Rehabilitation Medicine
New York-Presbyterian Hospital
New York, New York
xii
Video Contents
Chapter 104 Trigger Finger Injection
Section 2 Video 104.1 Trigger Finger Injection
The Shoulder Chapter 105 Digital Blocks
Chapter 25 Overview of the Shoulder Video 105.1 Digital Block (Finger)
Video 25.1 Shoulder Joint Examination
Chapter 28 Multidirectional Shoulder Instability Section 5
Video 28.1 Shoulder Apprehension and Relocation Tests The Spine
Chapter 30 Superior Labral Injuries Chapter 106 Overview of the Spine
Video 30.1 The O’Brien Test Video 106.1 Spine Examination
Video 30.2 Load and Shift Test of the Shoulder
Chapter 33 Shoulder Impingement Syndrome Section 6
Video 33.1 Impingement Tests
The Pelvis/Hip
Chapter 34 Rotator Cuff Tear
Video 34.1 Shoulder Strength Testing Chapter 118 Physical Examination of the Hip and Pelvis
Chapter 48 Glenohumeral Joint Injection Video 118.1 Hip Joint Examination
Video 48.1 Glenohumeral Joint Injection Video 118.2 Ober Test
Chapter 49 Subacromial Injection
Video 49.1 Subacromial Injection Section 7
Chapter 50 Acromioclavicular Injection
The Knee and Lower Leg
Video 50.1 Acromioclavicular (AC) Joint Injection Chapter 141 Overview of the Knee and Lower Leg
Video 141.1 Knee Joint Examination
Section 3 Chapter 142 Anterior Cruciate Ligament Injury
The Elbow Video 142.1 Lachman Test
Video 142.1 Pivot Shift Test
Chapter 52 Overview of the Elbow
Video 52.1 Elbow Joint Examination Chapter 143 Posterior Cruciate Ligament Injury
Video 143.1 Posterior Drawer Test
Chapter 67 Injection or Aspiration of the Elbow Joint
Video 67.1 Elbow Joint Aspiration/Injection Chapter 144 Medial Collateral Ligament Injury
Video 144.1 Varus and Valgus Stress Tests
Chapter 68 Lateral Epicondylitis (Tennis Elbow) Injection
Video 68.1 Lateral Elbow Injection Chapter 148 Meniscus Tears
Video 148.1 McMurray’s Test
Chapter 69 M edial Epicondylitis (Golfer’s Elbow)
Injection Chapter 166 Knee Aspiration and/or Injection Technique
Video 69.1 Medial Elbow Joint Injection Video 166.1 Knee Joint Injection
Chapter 70 Olecranon Bursa Aspiration/Injection Chapter 167 P repatellar Bursa Aspiration and/or
Video 70.1 Olecranon Bursa Aspiration/Injection Injection Technique
Video 167.1 P
repatellar Bursa Aspiration/Injection
Section 4 Chapter 168 Pes Anserine Bursa Injection Technique
Video 168.1 Pes Anserine Bursa Aspiration/Injection
The Wrist and Hand
Chapter 71 Overview of the Wrist and Hand Section 8
Video 71.1 Wrist and Hand Evaluation The Ankle and Foot
Video 71.2 The Allen Test
Chapter 76 de Quervain Tenosynovitis Chapter 171 Overview of the Ankle and Foot
Video 76.1 Finkelstein Test Video 171.1 Ankle Joint Examination
Chapter 79 Carpal Tunnel Syndrome Chapter 201 Ankle Aspiration and/or Injection Technique
Video 79.1 Special Tests for Carpal Tunnel Syndrome Video 201.1 Ankle Injection
Chapter 100 d e Quervain/First Dorsal Compartment Chapter 202 Plantar Fascia Injection
Injection Video 202.1 Plantar Fascia Injection
Video 100.1 de Quervain Injection Chapter 203 Morton Neuroma Injection
Chapter 102 Carpal Tunnel Injection Video 203.1 Morton Neuroma Injection
Video 102.1 Carpal Tunnel Injection
Chapter 103 Carpometacarpal Injection
Video 103.1 Carpometacarpal (CMC) Injection xix
1 Section 1 General Principles
Chapter 1 How to Use This Book

Mark D. Miller, John M. MacKnight, Jennifer A. Hart
Welcome to what we hope will be the most comprehensive graphic that will direct you to likely diagnoses based on the
and useful textbook of orthopaedics you will ever own. location of the patient’s symptoms or findings. The following
Appreciating that the vast majority of orthopaedic care takes pages include a review of regional anatomy, pertinent history
place not in the orthopaedic surgeon’s office or operating that is characteristic for each anatomic area, a review of
room, but rather in a myriad of primary care settings, this specific physical examination techniques, and practical
work is designed to be a user-friendly reference to assist management of imaging strategies.
primary care physicians, physician’s assistants, nurse prac- Within each specific topic chapter you will find a consistent
titioners, physical therapists, and athletic trainers. Having a format designed to aid efficiency in finding the information
reliable, thorough resource of clinical information is essential that you need as quickly as possible. After alternative condition
to ensure timely and appropriate management of all orthopaedic names and ICD-10-CM codes are provided, topic headings
concerns. As such, we have produced Essential Orthopaedics include Key Concepts, History, Physical Examination, Imaging,
to be your go-to resource in the clinic or the training room. Additional Tests (if applicable), Differential Diagnosis, Treatment,
The new edition also brings some exciting updates such as Troubleshooting, Patient Instructions, Considerations in Special
ICD-10-CM codes for the most common orthopaedic condi- Populations, and Suggested Reading. We have placed great
tions, current concept updates, new composite figures, and emphasis on including multiple drawings, photographs, and
even some new chapters to highlight the changes in the field. radiologic images to enhance the quality of each topic. In
As you peruse the text, you will find that the initial sections addition, we have added an accompanying DVD that covers
are devoted to a number of general topics important to in great detail the key orthopaedic physical examination
orthopaedic care. A review of orthopaedic anatomy and techniques and procedures that any provider should know.
terminology is followed by information on the nuances of We want you to feel comfortable that you have seen what
radiologic evaluation of orthopaedic conditions. Subsequent you need to provide great care.
chapters are dedicated to such vital topics as pharmacology, It is our sincere hope that you will find the latest edition
impairment and disability, and principles of rehabilitation. of Essential Orthopaedics to be the finest orthopaedic reference
Additional chapters are dedicated to special populations and for primary care providers of all types. Having a comprehensive
conditions such as the obese, elderly, pediatric, and female reference designed for rapid access of information is crucial
and pregnant patients, and those with multiple comorbid for busy practitioners. This text will help you find the right
conditions, arthritides, and trauma. answer quickly and will help enhance your comfort with
The remainder of the text is divided into major anatomic orthopaedic diagnosis, management, and appropriate referral.
groups: shoulder, elbow, wrist/hand, spine, pelvis/hip, knee Musculoskeletal care accounts for a sizable percentage of
and lower leg, and ankle and foot, with a special section medical encounters; let Essential Orthopaedics help enhance
dedicated to pediatrics. Each section begins with an anatomic the care of every orthopaedic patient whom you see.
Chapter 2 Orthopaedic Terminology 1
Chapter 2 Orthopaedic Terminology
Siobhan M. Statuta
Introduction • Medial collateral ligament: The primary knee stabilizer to

Orthopaedic complaints account for some of the most common valgus stress.
presentations to physicians. A thorough working knowledge • Meniscus: C-shaped fibrocartilage cushion in the knee;
of basic anatomy, function, and movement is essential for distributes load forces between the femur and tibia.
prompt diagnosis and appropriate management of these • Metaphysis: The portion of a long bone between the
conditions. The following terms are commonly used in ortho- epiphysis and the diaphysis.
paedic practice. Mastery of these basic terms will allow the • Posterior cruciate ligament: The primary stabilizer that
reader to better understand the material presented in the prevents posterior translation of the tibia to the femur and
following chapters. also contributes to rotary stability.
• Tendon: Fibrous connective tissue that attaches muscle
to bone.
Anatomy • Triangular fibrocartilage complex: A collection of ligaments
• Allograft: Tissue or specimen that comes from the same and fibrocartilage located on the ulnar side of the wrist,
species but a different individual (e.g., cadaver grafts in which stabilizes the distal radius, ulna, and carpal bones.
reconstruction of the anterior cruciate ligament). • Tuberosity: A bony prominence that serves as the site of
• Anterior cruciate ligament: The primary stabilizer that pre- attachment for tendons and/or ligaments.
vents anterior translation of the tibia on the femur, as well
as for rotational movement. It is one of the most commonly
injured knee ligaments. It heals poorly due to its limited Injury
blood supply and often requires surgical reconstruction. • Apophysitis: An overuse injury, caused by inflammation
• Articular cartilage: Hyaline cartilage that lines the end of or repeated stress, at the attachment site of a tendon to
long bones, forming the surface of a joint. bone. Commonly affected sites: tibial tubercle of the knee
• Autograft: Tissue specimen that comes from the same indi- (Osgood-Schlatter disease), medial epicondyle in the elbow.
vidual but from a different anatomic site (e.g., bone–patellar • Bursitis: Inflammation of the synovial sac (bursa) that protects
tendon–bone or hamstring grafts in the reconstruction of the soft-tissue structures (muscles, tendons) from underlying
the anterior cruciate ligament in the same individual). bony prominences. Common areas of involvement include
• Bipartite: Meaning two parts, it refers to the anatomic variant the shoulder (subacromial bursa), knee (prepatellar bursa),
in which the ossification centers of a sesamoid bone fail elbow (olecranon bursa), and hip (trochanteric bursa).
to properly fuse. Most commonly seen in the patella and • Dislocation: Complete disassociation of the articular
sesamoids of the foot. surfaces of a joint. Commonly affected sites: the patella,
• Diaphysis: The shaft of a long bone composed of bone the glenohumeral joint.
marrow and adipose tissue. • Impingement: The process by which soft tissues (i.e.,
• Discoid meniscus: Anatomic variant in which the typical tendons, bursae) are compressed by bony structures,
C-shaped fibrocartilage meniscus assumes a thickened, often dynamic in nature. Frequently encountered in the
flat contour. shoulder and ankle.
• Epiphyseal plate (physis): The “growth plate.” This hyaline • Myositis ossificans: Heterotopic bone formation at the site
cartilage structure is the site of elongation of long bones. of previous trauma and hematoma formation. The most
Physes are inherently weak compared with the surrounding common site of involvement is the thigh following a contusion.
bone and thus are often sites of injury in developing children • Osteoarthritis: Degenerative condition that causes break-
and adolescents. down of articular cartilage and underlying bone. Results
• Epiphysis: The end of a long bone that ultimately forms in joint pain, stiffness, and decreased range of motion.
the articular cartilage–lined edges of a long bone. • Osteochondritis dissecans: Injury (often traumatic) to a joint
• Labrum: A fibrocartilage ring that surrounds the articular surface of bone that results in the detachment of subchon-
surface of a joint helping deepen and stabilize the joint dral bone from its overlying articular cartilage. Commonly
(e.g., glenoid labrum of the shoulder and the acetabular affected sites include the knee, elbow, and ankle.
labrum of the hip). • Salter-Harris: Classification system used to categorize
• Lateral collateral ligament: Primary knee stabilizer to varus injuries to the growth plate (physis) in the skeletally immature:
stress. • Type I: Transverse fracture through the physis without
• Ligament: Fibrous connective tissue attaching one bone other injury. Widening of the physis can be seen or
to another. Provides structural support to the joint. radiographs may remain normal. 3
• Type II: Physeal fracture that extends into the metaphysis. • Eversion: Rotation of the foot or ankle outward away from
• Type III: Physeal fracture that extends into the epiphysis. midline.
• Type IV: Fracture that involves the metaphysis, physis • Inversion: Rotation of the foot or ankle inward toward
and epiphysis. midline.
• Type V: Crush-type fracture that involves compression • Pronation: Rotary movement described at the wrist, where
of the epiphyseal plate. the palm of the hand rotates from a superior facing position
• Spondylolisthesis: The abnormal anterior or posterior to one facing inferiorly. Similarly, at the ankle, the plantar
translation of one vertebral body with respect to another. aspect of the foot rotates outward or laterally.
• Spondylolysis: A fracture of the pars interarticularis of the • Supination: Rotary movement described at the wrist, where
vertebra usually due to repetitive stress. The lower lumbar the palm of the hand rotates from an inferior facing position
vertebrae are most frequently affected. to one facing superiorly. Similarly, at the ankle, the plantar
• Sprain: An injury to the ligaments that support a joint. aspect of the foot rotates inward or medially.
Mild injuries involve microscopic tearing; moderate injuries • Valgus: Anatomic alignment of a joint where the distal
involve partial tearing of the ligament; severe insults involve portion is angulated away from the midline (i.e., knock
complete disruption of the ligament. knees).
• Strain: An injury to muscle or tendon around or attached to • Varus: Anatomic alignment of a joint where the distal portion
a joint. Grading scale is similar to sprains with mild injuries is angulated toward the midline (i.e., bowlegs).
involving microscopic tearing, moderate injuries involving
partial tearing of the muscle or tendon, and severe injuries
resulting in complete disruption of muscle or tendon fibers. Treatment
• Stress fracture: Microscopic fractures in bone caused by • Arthrocentesis: Aspiration of synovial fluid from a joint.
isolated repetitive forces to a focal area. Bony breakdown • Arthroscopy: A surgical technique that uses a small camera
occurs more rapidly than repair due to overuse or lack of (arthroscope) in a joint space for the diagnosis and treatment
recovery time. of joint-related conditions.
• Subluxation: Partial dislocation of the articular surfaces of • Dry needling: Technique in which needles are inserted into
a joint. myofascial trigger points with the goal of improving muscle
• Syndesmotic ankle (“high ankle”) sprain: Ankle sprain result- tension and pain.
ing in injury to the syndesmotic ligament that connects the • Iontophoresis: Process by which an electrical current is used
tibia and fibula superior to the ankle joint proper. These to deliver a drug (often a corticosteroid) to the surrounding
injuries are generally more severe than routine ankle sprains. soft tissues or joint transdermally.
• Tendinitis: Acute inflammation of a tendon. Symptoms are • Physical therapy: The branch of medicine that specializes
typically present for several weeks. Commonly affected in treatment, prevention, and functional optimization of
sites include the shoulder, knee, elbow, and heel. disorders of the musculoskeletal system. It encompasses
• Tendinosis/tendinopathy: Degenerative breakdown of numerous treatment modalities including mobilization,
the tendon and abnormal vascularization due to chronic, strengthening, flexibility, massage, heat, and dry needling.
repetitive stress. Symptoms are often present for several • Rehabilitation: The process of restoring one’s health
weeks to months. functionality.
• Tenosynovitis: Inflammation of a tendon sheath. This
can occur concomitantly with tendon involvement or Suggested Readings
independently. Armstrong AD, Hubbard MC, eds. Essentials of Musculoskeletal Care. 5th
ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2016.
Miller MD, Thompson SR, eds. DeLee & Drez’s Orthopaedic Sports
Movement Medicine: Principles and Practice. 4th ed. Philadelphia: Elsevier; 2015.
• Abduction: Movement away from the body’s midline. Thompson JC. Netter’s Concise Orthopaedic Anatomy. 2nd ed (Updated
• Adduction: Movement toward the body’s midline. Edition). Philadelphia: Elsevier; 2015.
Chapter 3 Imaging of the Musculoskeletal System 1
Chapter 3 Imaging of the
Musculoskeletal System
Mark W. Anderson
based on the differential attenuation of the beam by various

Key Concepts tissues.
• Imaging studies should be used as an adjunct to the history • The primary modality for investigating the musculoskeletal
and physical examination. system; it should be the first imaging study ordered for
• Obtain the least number of imaging studies needed to most indications.
arrive at a diagnosis (or reasonable differential diagnosis). • Four basic tissues are recognizable on a radiograph: metals,
• Each imaging modality has specific strengths and weak- which are the densest structures on a film (this category
nesses that must be taken into account when considering includes bone because of its calcium content); air, which
which test to perform. is the most lucent (black); fat, which is dark gray; and soft
tissue, which appears as intermediate gray (this category
includes fluid that cannot be differentiated from muscle,
Imaging etc.) (Fig. 3.1).
Radiography • At least two views are usually obtained, most often in the
• Technique: A beam of x-rays is projected through the body frontal and lateral projections (Fig. 3.2).
to a detector that constructs a two-dimensional image
Strengths
• Relatively inexpensive
• Widely available
A B
Fig 3.1 Radiography: Soft-tissue contrast. Lateral radiograph
of the knee demonstrates dark, lucent air (A); dark gray fat in Fig 3.2 Radiography: Importance of obtaining more than one
Hoffa fat pad (arrow); intermediate gray fluid in the suprapatellar view. (A) Posteroanterior radiograph of the finger demonstrates
bursa (F) related to a large joint effusion (note the similarity in a transverse fracture of the distal phalanx that does not appear
density between the fluid and the hamstring muscles [M] pos- to involve its articular surface (arrow). (B) Corresponding lateral
teriorly); and the relatively dense bones (related to their calcium view reveals intra-articular extension and mild distraction along
content). the fracture line. 5
A B
Fig 3.3 Radiography: Tumor and arthritis. (A) Frontal view of the shoulder reveals a coarse, sclerotic intramedullary lesion within the
proximal humerus, compatible with a chondroid neoplasm, most likely an enchondroma. (B) Posteroanterior radiograph of the foot
demonstrates classic findings of gout involving the first metatarsophalangeal joint including large marginal and para-articular erosions,
calcific densities in the adjacent soft-tissue tophus, and relative sparing of the joint space.
• Evaluation of bone pathology (fracture, tumor, arthritis,

osteomyelitis, metabolic bone disease) (Fig. 3.3)
• Assessment of orthopaedic hardware and fracture healing
(Fig. 3.4)
Weaknesses
• Pathology of the medullary cavity (bone contusion, occult
fracture, medullary tumor) (Fig. 3.5)
• Soft-tissue pathology
• Uses ionizing radiation
Computed Tomography
• Technique: An x-ray source is rotated around the patient,
who is lying on a moving gantry, resulting in image “slices”
in the transaxial plane.
• The data from these slices can then be viewed as axial
images or used to create reformatted images in any plane
(typically sagittal and coronal planes).
• Can be combined with intravenous (IV) contrast, which
results in increased density (enhancement) in vessels and
hypervascular tissues owing to its iodine content
Strengths
Fig 3.4 Radiography: Joint prosthesis. Frontal radiograph of the
• Tomographic depiction of anatomy allowing for two- and left hip shows prosthetic discontinuity of the femoral component
three-dimensional reformatted images (Fig. 3.6) at the junction of its head and neck with resulting superolateral
• Depiction of complex fractures, especially those involving migration of the proximal femur.
the spine and flat bones (pelvis and scapula) (Fig. 3.7)
• Evaluation of fracture healing
• Postoperative evaluation of the degree of fusion or hardware
complications (Fig. 3.8)
• Can be combined with intrathecal or intra-articular con-
trast (computed tomography [CT] myelography and CT
6 arthrography, respectively) (Fig. 3.9)
A B
Fig 3.5 Radiography: occult fracture. (A) No discrete fracture is evident on this posteroanterior view of the wrist obtained after injury.
(B) Coronal T1-weighted magnetic resonance image reveals numerous nondisplaced, low-signal-intensity fracture lines within the
distal radius.
A B
Fig 3.6 Computed tomography: Reformatted images. (A) Thin-slice computed tomography images obtained in the axial plane were
combined to create this two-dimensional sagittal reconstructed image of the cervical spine. (B) A three-dimensional reformatted
image of the pelvis depicts prominent diastasis of the symphysis pubis and less prominent widening of the right sacroiliac joint.
• Accurate demonstration of urate acid crystals using

dual-energy CT allowing for a specific diagnosis of gout Radionuclide Scanning
(Fig. 3.10) • Technique: A bone-seeking radioactive material is injected
intravenously (typically technetium-99m diphosphonate, a
Weaknesses phosphorous analog that is taken up in areas of increased
• Fracture detection in the setting of significant osteopenia bone turnover such as tumor, infection, and fracture), and
(Fig. 3.11) the patient is scanned 4 to 6 hours later, at which time
• Although CT produces much better soft-tissue contrast whole-body images may be obtained.
than radiographs, it is not as good as that obtained with • More localized, “spot” images may also be acquired in areas
magnetic resonance imaging (MRI). of specific clinical concern, and the use of single-photon
• Uses ionizing radiation (unlike ultrasonography and MRI) emission tomography technology can produce tomographic
images in the axial, sagittal, and coronal planes.
• Positron emission tomography scanning uses a metabolically
active tracer, typically 18F-fluorodeoxyglucose, a glucose
analog that is taken up in tissues proportional to glucose
use.
Fig 3.7 Computed tomography: Complex fractures. Coronal, Fig 3.9 Computed tomography arthrogram. Coronal reformat-
two-dimensional reformatted image from a computed tomography ted image from a computed tomography arthrogram of the left
scan of the pelvis demonstrates an essentially nondisplaced, hip reveals a small cartilage flap along the medial femoral head
comminuted right acetabular fracture (arrows). (arrow).
A B
Fig 3.8 Computed tomography: Postoperative assessment. (A) and (B) Adjacent coronal reformatted images of the wrist reveal a
8 nondisplaced scaphoid fracture transfixed with a surgical screw. Note the lack of metal-related artifact.
• Pathologic processes typically show increased metabolic
activity and increased 18F-fluorodeoxyglucose uptake.
• This modality also has theoretical value for the evaluation of a
variety of neoplastic, infectious, and inflammatory conditions
of the musculoskeletal system. Although promising results
have been reported for some indications, the number of
studies has been limited to date, and further investigation
is needed.
Strengths
• Whole-body imaging allows rapid assessment of the entire
skeleton; this is the study of choice to evaluate possible
skeletal metastases.
• Provides physiologic information regarding the activity of
a bone lesion (Fig. 3.12)
• High sensitivity
Weaknesses
Fig 3.10 Dual energy computed tomography (CT): Gout. Color- • Relatively low specificity.
coded coronal reformatted image from a dual energy CT examina- • Any process resulting in increased bone turnover (infection,
tion demonstrates extensive monosodium urate deposition (green tumor, fracture) may result in a focus of increased activity.
foci) throughout the wrist. • False-negative examinations may occur in the initial 24 to
48 hours, especially in elderly patients.
• Insensitive for detecting multiple myeloma (plain radiographs
are actually better for this purpose).
• Poor soft-tissue evaluation.
• Produces ionizing radiation.
A B
Fig 3.11 Computed tomography versus magnetic resonance imaging for a tibial plateau fracture. (A) Coronal reformatted computed
tomography image of the knee reveals a very small cortical lucency (arrowhead) in the tibial plateau at the site of a nondisplaced
fracture that is much better demonstrated using MRI as indicated by the arrow in (B), a coronal T1-weighted image. 9
A B
Fig 3.12 Bone scan. (A) Anterior and posterior whole-body bone scan images reveal focal uptake at the thoracolumbar junction
(arrow) at the site of a pathologic fracture related to a vertebral metastasis. (B) Spot images of the lower legs from a bone scan in
a different patient show abnormal uptake in the right mid-tibia at the site of a stress fracture (arrow).
Ultrasonography • Foreign body detection (Fig. 3.15).

• Technique: Sound waves are passed into tissue via a • No ionizing radiation.
handheld transducer, and the image is produced based
on the pattern of returning waves. Weaknesses
• Tissues can be assessed in a dynamic, real-time fashion • Limited assessment of deeper tissues and bone
or on static images. • Relatively time consuming and very operator dependent
• Best if used for a specific clinical question (e.g., tendon • Limited field of view
laceration, evaluation of a soft-tissue mass, foreign body
detection). Magnetic Resonance Imaging
• Vascularity and flow dynamics can be assessed with Doppler • Technique: MRI is based on the fact that hydrogen protons
ultrasound imaging. within the body (most abundant in water and fat) will act
like small bar magnets. The patient is placed in a strong
Strengths magnetic field, and a small percentage of protons will align
• Allows anatomic and dynamic functional evaluation of with the field.
musculoskeletal tissues (e.g., tendon function, develop- • Energy, in the form of radio waves, is added to the tissue
mental dysplasia of the hip) (Fig. 3.13). causing some of the protons to shift to a higher-energy state.
• Determining whether a soft-tissue mass is of a cystic or When the radiofrequency source is turned off, the protons
solid nature. will relax back to their resting state and in the process release
• Cystic masses appear as anechoic (black) structures with energy, again in the form of radio waves, which are detected
a sharp posterior wall and enhanced through transmission and used to create the magnetic resonance image.
(owing to the lack of sound reflectors within the homoge- • The protons resonate differently in different tissues, based
neous fluid) (Fig. 3.14). primarily on two tissue-specific factors called T1 and T2,
• Assessing the vascularity of a lesion. and scanning parameters can be set to emphasize either
• Real-time guidance for percutaneous interventional factor, thereby producing T1-weighted and T2-weighted
10 procedures. images, respectively.
A B
Fig 3.13 Ultrasonography: Tendons. (A) Longitudinal sonogram of a normal Achilles tendon (arrows). (B) Longitudinal scan of the
Achilles tendon in a different patient demonstrates diffuse thickening of the tendon (arrows) and an area of high-grade partial tearing
(arrowheads).
Fig 3.15 Ultrasonography: Foreign body. A small, echogenic

foreign body (arrow) and surrounding hypoechoic (dark) reactive
Fig 3.14 Ultrasonography: Ganglion cyst. Ultrasound scan of tissue is identified on this longitudinal sonogram of the finger.
the finger reveals a small, bilobed ganglion cyst. Note the lack
of internal echoes, sharp posterior wall (arrows), and enhanced
through transmission (arrowheads), all of which are typical
sonographic characteristics of a cyst.
TABLE 3.1 Tissue Characterization on Magnetic
Resonance Images
Tissue T1 T2
• Each tissue displays a specific signal intensity on T1-weighted
and T2-weighted images, allowing some degree of tissue Fluid Dark Bright
characterization (Table 3.1 and Fig. 3.16). Fat Bright Intermediate
• Using special techniques, the high signal from fat can Tendon/ligament Dark Dark
be suppressed during scanning, thereby producing a fat-
saturated image. This is especially useful for demonstrating Air Black Black
marrow pathology on “fat-saturated” T2-weighted images,
and areas of tissue enhancement after intravenous con-
trast administration on fat-saturated T1-weighted images
(because gadolinium contrast results in increased T1 signal)
(examples are shown in Figs. 3.17 and 3.18). 11
A B
Fig 3.16 Magnetic resonance imaging: T1- and T2-weighted images. Sagittal T1-weighted (A) and T2-weighted (B) images of the
lumbar spine illustrate the characteristic signal characteristics of fluid. Note the low signal intensity of the cerebrospinal fluid on the
T1-weighted image and bright signal on the T2-weighted scan.
A B
Fig 3.17 Magnetic resonance imaging: Osteomyelitis. Sagittal T1-weighted (A) and T2-weighted (B) images of the foot reveal
abnormal, fluidlike signal throughout the marrow of the proximal and distal phalanges of the great toe compatible with osteomyelitis
in this diabetic patient who had an adjacent cutaneous ulcer.
12
A B
Fig 3.18 Magnetic resonance imaging: Use of intravenous contrast. (A) Coronal T1-weighted image before intravenous contrast
administration shows no abnormality. (B) Coronal T1-weighted fat-saturated postcontrast image demonstrates prominent synovial
enhancement throughout the joints of the hand and wrist, compatible with an inflammatory (rheumatoid) arthritis.
• Because of the strong magnetic field involved, contraindica- • The test of choice for evaluating neurologic deficits related
tions to MRI include the presence of a cardiac pacemaker, a to spinal trauma or neoplasm.
metallic foreign body in the orbit, certain vascular aneurysm • Can be combined with gadolinium-based contrast agents
clips and cochlear implants, and a metallic fragment (e.g., injected either intravenously (to highlight tissues with
bullet) of unknown composition near a vital structure (e.g., increased vascularity) or directly into a joint (magnetic
spinal cord, heart), among other items. As a result, each resonance arthrography) (Fig. 3.22, see also Fig. 3.18).
patient should undergo a thorough screening process prior • No ionizing radiation.
to scanning.
Weaknesses
Strengths • Fractures of the posterior elements of the spine are difficult
• Images can be obtained in any plane and provide superb to detect with MRI.
soft-tissue contrast, anatomic detail, and simultaneous dem- • Assessment of fracture healing.
onstration of bones and soft tissues. As a result, it is the best • Hardware (depending on type, may produce severe artifact,
single modality for evaluating most types of musculoskeletal obscuring adjacent tissues) (Fig. 3.23).
pathology (Fig. 3.19, see also Figs. 3.17 to 3.18).
• The most sensitive modality for detecting marrow pathol-
ogy (neoplastic marrow infiltration, bone contusion, occult Imaging Algorithms
fracture, tumor) (Figs. 3.20 and 3.21). • Please see Figs. 3.24 to 3.28.
13
A B
C
Fig 3.19 Magnetic resonance imaging: Ligament injuries. (A) Sagittal T2-weighted image with fat saturation demonstrates a complete
rupture of the anterior cruciate ligament. Note the high signal edema and hemorrhage in the central intercondylar notch, as well as
the absence of discernible ligament fibers. (B) A normal anterior cruciate ligament with taut, parallel fibers (arrow) is shown for
comparison. (C) Coronal T2-weighted image with fat saturation shows a partial tear of the proximal medial collateral ligament (arrow).
Note the intact ligament fibers distally (arrowhead).
14
A B
Fig 3.20 Magnetic resonance imaging: radiographically occult fracture. Sagittal (A) and coronal (B) T1-weighted images of the knee
reveal a nondisplaced fracture in the lower pole of the patella (arrows). The fracture was not visible on radiographs. (This is the same
patient as in Fig. 3.1.)
A B
C
Fig 3.21 Magnetic resonance imaging: bone tumor. (A) Anteroposterior radiograph of the pelvis reveals subtle lucency in the right
acetabulum (arrow) that could be potentially missed owing to the degree of diffuse osteopenia. Coronal T1-weighted (B) and fat- 15
saturated T2-weighted (C) images demonstrate the lesion to much better advantage (arrows).
A B
Fig 3.22 Magnetic resonance arthrography. (A) Axial T1-weighted image of the shoulder after an intra-articular injection of a dilute
gadolinium solution reveals a posterior labral tear (large arrow). Note also the normal labrum (small arrow) and middle glenohumeral
ligament (arrowhead) anteriorly. (B) Oblique sagittal T1-weighted image with fat saturation confirms the posterior labral tear (arrow).
Skeletal
trauma
Radiographs
If normal but high degree of clinical suspicion
If no contraindication for MRI If MRI is contraindicated
MRI Bone scan
Fig 3.24 Skeletal trauma algorithm.
Fig 3.23 Magnetic resonance imaging: Metal artifact. Sagittal Focal lesion:
T2-weighted image of the knee after anterior cruciate ligament bone
reconstruction demonstrates the normal anterior cruciate ligament Radiographs
graft (arrowheads), as well as prominent low-signal artifacts related
to associated metal hardware (arrows). Note how these partially Normal, but high
degree of clinical Abnormal
obscure and distort adjacent tissues.
suspicion
Abnormal
MRI MRI
Detection and Bone Local staging
local staging scan
Distant
staging
Normal Stop
16 Fig 3.25 Focal lesion: Bone algorithm.
Focal lesion: Suggested Readings
soft tissue Ahn JM, El-Khoury GY. Role of magnetic resonance imaging in
Radiographs musculoskeletal trauma. Top Magn Reson Imaging. 2007;18:155–168.
Look for calcifications, Collin D, Geijer M, Gothlin JH. Computed tomography compared to
relationship to bone magnetic resonance imaging in occult or suspect hip fractures. A
retrospective study in 44 patients. Eur Radiol. 2016;26:3932–3938.
Duet M, Pouchot J, Liote F, Faraggi M. Role for positron emission
Possible cyst? Probable solid mass tomography in skeletal diseases. Joint Bone Spine. 2007;74:14–23.
Geijer M, El-Khoury GY. MDCT in the evaluation of skeletal trauma: prin-
ciples, protocols, and clinical applications. Emerg Radiol. 2006;13:7–18.
Imhof H, Mang T. Advances in musculoskeletal radiology: multidetector
Ultrasound Solid computed tomography. Orthop Clin North Am. 2006;37:287–298.
MRI
Characterization Khoury V, Cardinal E, Bureau NJ. Musculoskeletal sonography: a
Stop or local staging dynamic tool for usual and unusual disorders. AJR Am J Roentgenol.
Cyst
aspirate 2007;188:W63–W73.
Kransdorf MJ, Bridges MD. Current developments and recent advances
in musculoskeletal tumor imaging. Semin Musculoskelet Radiol.
Fig 3.26 Focal lesion: Soft-tissue algorithm. 2013;17:145–155.
Lalam RK, Cassar-Pullicino VN, Tins BJ. Magnetic resonance imaging
of appendicular musculoskeletal infection. Top Magn Reson Imaging.
2007;18:177–191.
Possible skeletal Love C, Din AS, Tomas MB, et al. Radionuclide bone imaging: an illustrative
metastases review. Radiographics. 2003;23:341–358.
Bone scan Mhuircheartaigh NN, Kerr JM, Murray JG. MR imaging of traumatic spinal
injuries. Semin Musculoskelet Radiol. 2006;10:293–307.
Nacey NC, Geeslin MG, Miller GW, Pierce JL. Magnetic resonance imaging
of the knee: an overview and update of conventional and state of the
art imaging. J Magn Reson Imaging. 2017;45:1257–1275.
Nicholau S, Yong-Hing CJ, Galea-Soler S, et al. Dual–energy CT as a
potential new diagnostic tool in the management of gout in the acute
MRI setting. AJR Am J Roentgenol. 2010;194:1072–1078.
Spine and pelvis Radiography Papp DR, Khanna AJ, McCarthy EF, et al. Magnetic resonance imaging
of positive area(s) for of soft-tissue tumors: determinate and indeterminate lesions. J Bone
further characterization Joint Surg Am. 2007;89A(suppl 3):103–115.
Schoenfeld AJ, Bono CM, McGuire KJ, et al. Computed tomography alone
Image-
versus computed tomography and magnetic resonance imaging in the
guided
biopsy identification of occult injuries to the cervical spine: a meta-analysis.
J Trauma. 2010;68:109–114.
Fig 3.27 Possible skeletal metastases algorithm. Tuite MJ, Small KM. Imaging evaluation of nonacute shoulder pain. AJR
Am J Roentgenol. 2017;209:525–533.
Turecki MB, Taljanovic MS, Stubbs AY, et al. Imaging of musculoskeletal
soft tissue infections. Skeletal Radiol. 2010;39:957–971.
Vande Berg B, Malghem J, Maldague B, Lecouvet F. Multi-detector CT
Low back pain Clinical “red flags?” imaging in the postoperative orthopedic patient with metal hardware.
Neurologic findings, signs of infection, Eur J Radiol. 2006;60:470–479.
history of trauma, known primary neoplasm
Yes No
Radiography Still Conservative therapy

symptomatic 6 weeks–no imaging
Fracture Normal Focal

lesion(s)
CT MRI Bone scan
Fig 3.28 Low back pain algorithm.
17
Chapter 4 Rehabilitation
Jeffrey G. Jenkins, Sara N. Raiser, Justin L. Weppner
Key Concepts • High-resistance techniques are generally considered more

• Within a medical context, rehabilitation can be defined as effective and efficient in building strength.
a process by which the patient strives to achieve his or • Low-resistance techniques are useful during injury or as
her full physical, social, and vocational potential. training for highly repetitive tasks.
• A formal medical rehabilitation program is most commonly • The most important factor in increasing strength in either
used after an individual has experienced a loss of function case is to exercise the muscle to the point of fatigue.
due to an injury or disease process or as a side effect of • Observed effects of strength training occur primarily due
necessary medical treatment (e.g., surgery). to neuromuscular adaptations, specifically improvement in
• For rehabilitation to be successful, it is crucial that the the efficiency of neural recruitment of large motor units.
patient, physician, and therapist(s) involved in the case • Additional increases in muscle strength result from muscle
share the same clearly defined functional goals; treatment hypertrophy, via the enlargement of total muscle mass and
will be directed toward the achievement of these goals. cross-sectional area.
• Although medical professionals provide direction and
guidance during rehabilitation, the patient plays the most Flexibility Training
important active role in the program. • Flexibility generally describes the range of motion present in
• The patient should give frequent feedback regarding a joint or group of joints that allows normal and unimpaired
effectiveness of interventions and any detrimental effects of function.
treatment so that the rehabilitation plan and functional goals • Flexibility can be defined as the total achievable excursion
can be modified as needed throughout the rehabilitation (within the limits of pain) of a body part through its range
process. of motion.
• Therapeutic exercise, physical modalities, and orthotic • Flexibility training is an important aspect of most therapeutic
devices are the main components of a medical rehabilitation exercise regimens.
program for patients with musculoskeletal dysfunction. • Flexibility training seeks to achieve a maximal functional
• Physical therapists are trained to identify, assess, and range of motion and is most typically accomplished by
work with the patient to alleviate acute or prolonged stretching.
movement dysfunction. Most physical therapists use a • Three categories of stretching exercises have been used.
combination of therapeutic exercise, physical modalities, • Passive stretching:
manual manipulation, and massage to achieve the treatment • Uses a therapist or other partner who applies a stretch
goals. to a relaxed joint or limb
• Occupational therapists are trained to identify, assess, and • Requires excellent communication and slow, sensitive
work with the patient to alleviate functional deficits in the application of force
areas of self-care, vocational, and avocational activities. • Very efficient means of flexibility training
• Should be performed in the training room or in a physical
or occupational therapy context
Therapeutic Exercise (Fig. 4.1) • Potentially increases risk of injury when performed without
• In most cases, therapeutic exercise should be taught and due caution
supervised, particularly during early stages, by a physical • Static stretching
therapist. • A steady force for a period of 15 to 60 seconds is
• Occupational therapists are specifically trained to supervise applied.
exercises directly related to self-care, vocational, and • Easiest and safest type of stretching
avocational activities and are appropriate to refer to in • Associated with decreased muscle soreness after
these cases. exercise
• Major categories of exercise include muscle strengthen- • Ballistic stretching
ing (strength training), range of motion (flexibility), and • Uses the repetitive, rapid application of force in a bounc-
neuromuscular facilitation. ing or jerking maneuver
• Momentum carries the body part through the range of
Strength Training motion until muscles are stretched to their limits.
• Both high-resistance/low-repetition and low-resistance/ • Less efficient than other techniques because muscles con-
18 high-repetition techniques exist and can be effective. tract during these conditions to protect from overstretching
Chapter 4 Rehabilitation 1
Fig 4.1 Therapeutic exercise and modalities.
• A rapid increase in force can cause injury. • Proprioceptive exercises seek to improve joint position
• This type of stretching has been largely abandoned as sense and thereby prevent injury.
a training technique. • For example, a tilt or wobble board is commonly used
after ankle ligamentous injury to reduce the incidence
Neuromuscular Facilitation of recurrence.
• Seeks to improve function through improved efficiency of
the interplay between the nervous and musculoskeletal Exercise Prescription
systems • A prescription for therapeutic exercise with a therapist
• Neuromuscular facilitation techniques in flexibility training: should always include the following components:
• Isometric or concentric contraction of the musculoten- • Diagnosis
dinous unit followed by a passive or static stretch • Frequency of treatment (i.e., number of sessions per
• Prestretch contraction of muscle facilitates relaxation week)
and flexibility. • Specific exercises required
• Examples include hold-relax and contract-relax • Precautions (includes restrictions on weight bearing and
techniques limb movement, as well as identification of significant
tissue damage or other factors that may interfere with
Plyometrics performance of specific exercises)
• Performance of brief explosive maneuvers consisting of • Contraindicated exercises or modalities (should include
an eccentric muscle contraction followed immediately by any specific motions, positions, or modalities that should
a concentric contraction be avoided to ensure appropriate tissue healing and
• This technique is primarily employed in the training of patient safety without incurring further injury)
athletes. • Ideally, individual exercises are further defined by:
• Should be approached with caution under the supervi- • Mode: specific type of exercise (e.g., closed chain
sion of a trained therapist and begun at an elementary quadriceps strengthening)
level • Intensity: relative physiologic difficulty of the exercise
• Some studies demonstrate a decreased risk of serious (this is often best described in terms of the patient’s
injury during sports activity among athletes who receive rating of perceived exertion, ranging from very light to
plyometric training (e.g., reduction in the incidence of knee very hard)
injuries in female athletes participating in a jump training • Duration: length of an exercise session
program). • Frequency: number of sessions per day/week
• Progression: increase in activity expected over the course
Proprioceptive Training of training
• Background:
• Proprioceptive deficits have been shown to result from
Modalities: Heat, Cold, Pressure,
and predispose to injury.
• Impairment of joint proprioception is believed to influ- Electrotherapy
ence progressive joint deterioration associated with both • Physical agents: use of physical forces to produce beneficial
rheumatoid arthritis and osteoarthritis. therapeutic effects (see Fig. 4.1) 19
• Therapeutic US is typically avoided in the acute stages of

Heat an injury due to concerns that it may aggravate bleeding,
Superficial Heat Application tissue damage, and swelling.
• Hot packs (hydrocollator) • Therapeutic US contraindications:
• Transfer of heat energy by conduction • Fluid-filled areas (i.e., eye and the pregnant uterus),
• Application: silicate gel in a canvas cover growth plates, inflamed joints, acute hemorrhages,
• When not in use, packs are kept in thermostatically ischemic tissue, tumor, laminectomy site, infection, and
controlled water baths at 70 to 80°C. implanted devices such as pacemakers and pumps
• Used in terry cloth insulating covers or with towels placed • US is relatively contraindicated near metal plates
between the pack and the patient for periods of 15 to or cemented artificial joints because the effects of
20 minutes localized heating or mechanical forces on prosthesis-
• Advantages: low cost, easy use, long life, and patient cement interfaces are not well known.
acceptance • Phonophoresis
• Disadvantages: difficult to apply to curved surfaces • US may be used to deliver medication into tissues.
• Safety: One should never lie on top on the pack because The medication is mixed into a coupling medium,
it is more likely to cause burns. and US is used to drive (phonophorese) the material
• Towels should be applied between the skin and the through the skin.
hydrocollator pack. • Corticosteroids and local anesthetics are most frequently
• Paraffin baths used in the treatment of musculoskeletal conditions.
• Heat primarily by conduction: liquid mixture of paraffin
wax and mineral oil Therapeutic Cold or Cryotherapy
• Helpful in the treatment of scars and hand contractures • Superficial only
• Temperatures (52 to 54°C) are higher than hydrotherapy • Used for analgesic effects, reduction of muscle spasm,
(40 to 45°C) but are tolerated well due to the low heat decreasing inflammation, decreasing muscle spasticity/
capacity of the paraffin/mineral oil mixture and lack of hyperactivity, vasoconstriction (reduction in local blood
convection. flow and associated edema)
• Treatments may include dipping, immersion, or, occasion- • Ice massage used for treatment of localized, intense
ally, brushing onto the area of treatment for periods of musculoskeletal pain (e.g., lateral epicondylitis)
20 to 30 minutes. • General indications:
• Safety: Burns are the main safety concern with paraffin • Acute musculoskeletal trauma
treatment. • Pain
• Visual inspection is important: The paraffin bath should • Muscle spasm
have a thin film of white paraffin on its surface or an • Spasticity
edging around the reservoir. • Reduction of metabolic activity
• General contraindications and precautions:
• Impaired circulation (i.e., ischemia, Raynaud phenom-
Diathermy (Deep Heating) enon, peripheral vascular disease), hypersensitivity to
• Deep heating agents (diathermies) raise tissue to therapeutic cold, skin anesthesia, local infection
temperatures at a depth of 3.5 to 7 cm. • Methods of application:
• Used for analgesic effects, decreasing muscle spasms, • Ice packs and compression wraps are most common.
enhancing local blood flow, and increasing collagen • Sessions typically last 20 minutes.
extensibility • Ice massage is a vigorous approach suitable for limited
• Deep heating modality: therapeutic ultrasound (US) portions of the body. A piece of ice is rubbed over the
• US is defined as sound waves at a frequency greater than painful area for 15 to 20 minutes.
the threshold of human hearing (frequencies >20 kHz). • Iced whirlpools cool large areas vigorously.
Therapeutic US uses sound waves to heat tissues. A • Vapocoolant and liquid nitrogen sprays produce large
wide range of frequencies are potentially useful, but in (as much as 20°C), rapid decreases in skin temperature
the United States, most machines operate between 0.8 and are used at times to produce superficial analgesia
and 1 MHz. as well as in spray and stretch treatments.
• US penetrates soft tissue well and bone poorly; the • Trauma application:
most intense heating occurs at the bone–soft tissue • Cooling applied soon after trauma may decrease edema,
interface. metabolic activity, blood flow, compartmental pressures,
• Treatments are relatively brief (5 to 10 minutes) and and tissue damage, and accelerate healing.
require constant operator attention. • Rest, ice, compression, and elevation are the mainstays
• Indications for therapeutic US: of treatment.
• Tendonitis, bursitis, muscle pain and overuse, con- • Cyclic ice application is often recommended (e.g., 20
tractures, inflammation, trauma, scars, and keloids minutes on, 10 minutes off) for 6 to 24 hours.
• Fractures: low-intensity US (e.g., 30 mW/cm2) acceler- • Contrast baths
ates bone healing and is approved by the U.S. Food • Two water-filled reservoirs, warm (43°C) and cool (16°C);
and Drug Administration for the treatment of some alternate soaks; duration varies according to treatment
20 fractures. protocol
• Used for desensitization and vasogenic reflex effects • Effective as an adjunct to passive stretching in the
• Mostly used on hands or feet; typical indications include treatment and prevention of contractures
rheumatoid arthritis and sympathetically mediated pain • Myofascial release
(reflex sympathetic dystrophy) • Applies prolonged light pressure specifically oriented
with regard to fascial planes
Traction • Typically combined with passive range of motion
• Technique used to stretch soft tissues and to separate joint techniques to stretch focal areas of muscle or fascial
surfaces or bone fragments by the use of a pulling force. tightness
• Based on available medical evidence, therapeutic use of • Contraindications:
spinal traction is generally limited to the cervical spine. • Should not be performed in patients with known malig-
• The efficacy of lumbar traction is controversial. nancies, open wounds, thrombophlebitis, or infected
• Traction has been shown to lengthen the intervertebral tissues
space up to 1 to 2 mm, but the lengthening is transient.
• Decreases muscle spasm, possibly by inducing fatigue in Electrotherapy
the paravertebral musculature • Transcutaneous electrical nerve stimulation (TENS)
• May decrease neuroforaminal narrowing and associated • Most common direct therapeutic application of electrical
radicular pain current
• The patient should be positioned in 20 to 30 degrees of • Used for its analgesic properties
cervical flexion during traction to optimize the effect on • The unit uses superficial skin electrodes to apply small
the neural foramina. electrical currents to the body.
• Therapeutic benefit is usually obtained with 25 pounds of • Theorized to provide analgesia via the gate control theory
traction (this includes the 10 pounds required to counterbal- of pain, in which stimulation of large myelinated afferent
ance the weight of the head). nerve fibers block the transmission of pain signals by
• The duration of a treatment session is typically 20 minutes. small, unmyelinated fibers (C, A delta) at the spinal cord
• The best results are obtained when a trained therapist level
administers manual traction in a controlled setting. • Signal amplitudes generally do not exceed 100 mA.
• Home cervical traction devices can be used (these typically • With initiation of treatment, TENS use is typically taught
use a pulley system over a door, and a bag filled with 20 and monitored by a physical therapist. Once the patient
pounds of sand or water). is competent and confident in using the device (electrode
• Home cervical traction devices should not be used without placement, stimulator settings, duration of treatments),
previous training and observation by a trained therapist or the unit can be used independently, outside the medical
physician. or therapy setting.
• Heat (hot packs) is helpful in decreasing muscle contraction • Common indications include posttraumatic/postsurgical
and maximizing the benefit of treatment. pain, diabetic neuropathic pain, chronic musculoskeletal
• Contraindications: pain, peripheral nerve injury, sympathetically mediated
• Cervical ligamentous instability resulting from conditions pain/reflex sympathetic dystrophy, and phantom limb
such as rheumatoid arthritis, achondroplastic dwarfism, pain.
Marfan syndrome, or previous trauma • Iontophoresis
• Documented or suspected tumor in the vicinity of the • Uses electrical fields to drive therapeutic agents through
spine the skin into underlying soft tissue
• Infectious process in the spine • Treatments in the musculoskeletal patient population
• Spinal osteopenia typically use antiinflammatory agents and/or local
• Pregnancy anesthetics.
• Cervical spinal traction should not be administered with • Conditions commonly treated include plantar fasciitis,
the neck in extension, particularly in patients with a history tendinitis, and bursitis.
of vertebrobasilar insufficiency. • Most physical therapists are trained in this technique,
although not all have access to the necessary equipment.
Therapeutic Massage • It is worth noting that, in most cases, injection enables
• Causes therapeutic soft-tissue changes as a direct result a more efficient delivery of a greater concentration of
of the manual forces exerted on the patient by a trained the therapeutic agent in question.
therapist • Electrical stimulation (E-stim)
• Specific techniques can be helpful for musculoskeletal • At higher intensities than those used in TENS, E-stim
patients: can be used to maintain muscle bulk and strength.
• Deep friction massage • Useful for immobilized limbs and for paretic muscles
• Used to prevent and break up adhesions after muscle after nerve injury.
injury • Evidence does not suggest that E-stim can strengthen
• Friction is applied transversely across muscle fibers otherwise healthy muscle.
or tendons. • Relative contraindications to E-stim include implanted or
• Soft-tissue mobilization temporary stimulators (pacemakers, intrathecal pumps,
• Forceful massage performed with the fascia and spinal cord stimulators, etc.), congestive heart failure,
muscle in a lengthened position pregnancy, skin sensitivity to electrodes, and actively 21
healing wounds near the stimulation site. Stimulation • There is some evidence that use of a semirigid ankle
over the carotid sinus is also highly discouraged due orthosis can decrease the risk of ligamentous injury in
to the propensity for vagal response. athletes, particularly those with a history of sprain.
Orthoses
• An orthosis is an external device that is worn to restrict or When to Refer
assist movement. Examples include braces and splints. • To a significant extent, the primary physician’s own per-
• Orthoses are typically prescribed and used for one or more sonal comfort level in managing a rehabilitation program
of the following reasons: determines the need for referral. However, some indications
• To rest or immobilize the body part: reduce inflammation, for referral include:
prevent further injury • Patient’s inability to progress functionally with the current
• To prevent contracture: minimize loss of range of motion therapy regimen
in a joint or limb • Suboptimally controlled acute or chronic pain
• To correct deformity: typically in conjunction with therapy • Painful or functionally disabling spasticity
or surgery • Neuromuscular or musculoskeletal comorbidities (e.g.,
• To promote exercise: encourage strengthening of certain stroke, spinal cord injury, cerebral palsy, multiple scle-
muscles and/or correct muscle imbalances rosis, rheumatoid arthritis, fibromyalgia, and chronic
• To improve function pain syndromes) that can compound functional deficits
• Orthoses can be subdivided into static and dynamic devices. and/or complicate the process of progressing toward
• Static orthoses keep underlying body parts from moving, functional goals
thereby encouraging rest and healing via immobilization
while preventing or minimizing deformity.
• Dynamic orthoses have internal or external power Patient Instructions
sources that encourage restoration and/or control of • Your active participation in the rehabilitation process is the
joint movements. most important factor in determining the success of the
• Orthoses are often named for the body parts that they program.
incorporate (e.g., ankle-foot orthosis and wrist-hand • Be involved in the development of functional goals for your
orthosis). rehabilitation program.
• Prescriptions for orthotics should include the type (defined • Follow physician and physical therapist instructions as
by incorporated limb segments/body parts) and a static/ closely as possible.
dynamic classification. If a dynamic orthosis is to be used, • Give feedback to care providers as to the effectiveness of
the prescription should specifically identify the motion(s) interventions as well as any side effects of treatment.
to be assisted or inhibited. • Do not continue to do exercises or use modalities that
• Prefabricated, off-the-shelf orthotics can be effectively used worsen your symptoms or condition without checking with
in the treatment of most orthopedic injuries. Frequently your physician.
encountered examples include knee and ankle braces
prescribed for ligamentous injury or wrist splints for carpal
tunnel syndrome. Considerations in Special Populations
• In special populations (e.g., hand trauma, nerve injury, • Hand injuries
partial limb loss, severe deformity), orthoses should be • Whenever possible, a rehabilitation program for hand or
custom fitted by an orthotist or an appropriately trained wrist dysfunction should involve evaluation and treatment
occupational therapist. of the patient by a certified hand therapist.
• Orthotic use should generally be restricted to injured • Swelling will occur after any surgery or injury to the
or dysfunctional limbs. Prophylactic bracing of joints is hand. Orthoses can potentially aggravate edema, and
controversial. their use must be carefully monitored during this stage
• Indications for orthoses include: of rehabilitation to prevent loss of function.
• Trauma (e.g., fracture, joint sprain) • Sensory deficits
• Surgery (e.g., tendon repair, joint reconstruction) • For obvious reasons, physical modalities and orthotic
• Central or peripheral nervous system pathology (e.g., devices should be used with great caution in patients
weakness, spasticity) with sensory deficits (e.g., peripheral neuropathies,
• Painful disorders (e.g., rheumatoid arthritis, carpal tunnel central nervous system disorders). Orthotic pressure
syndrome) over insensate areas must be minimized, and cryotherapy
• Orthoses and sports of these areas is contraindicated.
• There is no compelling evidence in the literature to • Pregnancy
support the use of prophylactic knee bracing in football • The safety of some physical modalities, including TENS
players. In fact, both the American Academy of Pediatrics and E-stim, has not been established in patients who are
and the American Academy of Orthopaedic Surgeons pregnant. Therapeutic US is absolutely contraindicated
have advised against the routine use of prophylactic over the low back and abdomen of a pregnant woman.
knee bracing in football, in part due to data that actually • Diabetes
showed an increase in anterior cruciate ligament injuries • Many patients with diabetes will experience a decrease in
22 in brace wearers. blood glucose levels when beginning a new therapeutic
exercise regimen. Levels should be monitored closely American Society of Hand Therapists (ASHT). Splint Nomenclature Task
and medications adjusted as necessary to avoid Force: Splint Classification System. Garner, NC: ASHT; 1991.
hypoglycemia. Hennessey WJ, Uustal H. Lower limb orthoses. In: Cifu DX, eds. Braddom’s
Physical Medicine and Rehabilitation. 5th ed. Philadelphia: Elsevier;
• Elderly
2016:249–274.
• Where possible, therapeutic exercise modalities pre-
Kelly BM, Patel AT, Dodge CV. Upper limb orthotic devices. In: Cifu
scribed for patients who are elderly should be chosen DX, eds. Braddom’s Physical Medicine and Rehabilitation. 5th ed.
to minimize stress on the bones and joints. Philadelphia: Elsevier; 2016:225–248.
• Pain Wilder RP, Jenkins JG, Panchang P, Statuta S. Therapeutic exercise. In:
• Pain is not a contraindication to therapeutic exercise, Cifu DX, eds. Braddom’s Physical Medicine and Rehabilitation. 5th
physical modalities, or the use of orthotic devices. ed. Philadelphia: Elsevier; 2016:321–346.
However, significant worsening of pain or onset of Wolf CJ, Brault JS. Manipulation, traction, and massage. In: Cifu DX, eds.
new pain after initiation of treatment demands further Braddom’s Physical Medicine and Rehabilitation. 5th ed. Philadelphia:
investigation and/or referral. Elsevier; 2016:347–367.
Suggested Readings
Alfano AP. Physical modalities in sports medicine. In: O’Connor FG, Sallis
RE, Wilder RP, St. Pierre P, eds. Sports Medicine: Just the Facts.
New York: McGraw-Hill; 2005:405–411.
23
Chapter 5 Special Populations:

Geriatrics
Laurie Archbald-Pannone
• Elderly adults have a decrease in bone mineral density,

ICD-10-CM CODES
with losses as high as 3% per year in postmenopausal
M15.0 Osteoarthritis (OA)
women and 0.5% per year in men older than 40 years.
M67.90 Tendonoses
• Elderly adults can develop sarcopenia, with an average 30%
S46.019A Rotator cuff strains
reduction in strength from age 50 to age 70 secondary to
M77.0 Medial epicondylitis
atrophy of type II muscle fibers, with associated decrease
M76.60 Achilles tendinitis
in tensile strength and increased stiffness of tendons and
M23.309 Degenerative meniscus tears
ligaments.
T14.8XXA Muscle strains
• Elderly adults also have weakening of articular cartilage
M84.40XA Spontaneous fracture
and a decrease in elastic properties of intervertebral disks.
M84.50XA Non-traumatic fracture
• Geriatric patients do not have increases of antidiuretic
M85.80 Osteopenia
hormone (ADH) with activity to signal thirst and need for
M81.0 Osteoporosis
hydration.
• Body composition changes with age, leading to increased
total body fat distribution that leads to increased retention of
fat-soluble medication, such as those that cross the blood-
Key Concepts brain barrier, as well as increased risk for dose stacking.
• By 2030, approximately 20% of the U.S. population will • With normal aging, there is a decrease in renal function
be older than 65 years of age. (both number of functioning nephrons and incoming blood
• Geriatric medicine is medicine focused on patients older flow) in the geriatric population. Hepatic metabolism is not
than 65 years. affected by normal aging. This change in renal function
• Research has proven that regular exercise in the geriatric affects the types and doses of safe medications.
population provides many health benefits. • Functional changes with aging can lead to impairment
• Appropriate exercise is safe in the geriatric population and that can be assessed by determining a patient’s ability to
provides numerous health benefits. perform their activities of daily living (ADLs) (Box 5.1).
• It is recommended that geriatric patients have 30 minutes • As a person is less able to independently do their ADLs,
of exercise at least 5 days each week. their all-cause mortality risk increases with this functional
• Although physiologic changes occur with aging, the capacity decline.
for the geriatric patient to exercise and improve strength,
endurance, flexibility, and performance is maintained.
Common Orthopaedic Conditions in the
• Age-related changes in physiology affect metabolism of
many medications, especially medications used to treat pain Geriatric Patient
related to acute, chronic, or postoperative musculoskeletal • Older athletes experience fewer acute traumatic injuries
conditions. than younger athletes during competition.
• With the increasing geriatric population, every health care • The geriatric population has a high rate of falls—1 in 3
provider must be familiar with the physiologic changes with people over 65 years old is affected by falls. Falls result
aging, as well as common musculoskeletal conditions and in moderate to severe injuries in approximately 25% of
the impact of comorbidities on these conditions. cases.
• Physicians can support healthy lifestyles in the geriatric • The biggest risk factor for falls is a history of falls. A fall
without injury is a critical opportunity to explore the cause
patient with an exercise prescription. of the fall so as to help prevent future falls that may result
in injury.
• Osteoarthritis (OA) is the most common musculoskeletal
Physiologic Changes Associated condition in the geriatric population. OA can affect multiple
With Aging joints and significantly impact a person’s ADLs and general
• Elderly adults have a decline in coordination, balance, function.
and reaction time, as well as impaired vision, hearing, and • Secondary to the decrease in tensile strength and increase
24 short-term memory. in stiffness of ligaments and tendons with aging, the geriatric
Chapter 5 Special Populations: Geriatrics 1
• Often geriatric patients are on multiple medications, and
BOX 5.1 Activities of Daily Living
polypharmacy (>3 medications) is frequent in this popula-
• Dressing tion. The addition of any new medication, as well as the
• Eating dose, frequency, and duration of the medication, must
• Ambulating account for the geriatric patient’s comorbidities and other
• Toileting medications.
• Hygiene • A geriatrician can assist in the management of medica-
tions and comorbidities associated with elderly patients.
Studies have shown that the rate of delirium is decreased
in postoperative units that comanage elderly patients with
patient is more likely to present with tendinoses such as geriatric physicians and an interdisciplinary team.
rotator cuff strains, medial epicondylitis, and Achilles
tendinitis.
Benefits of Exercise in the
• Geriatric patients are also more likely to have degenerative
meniscus tears because of age-related collagen changes. Geriatric Patient
• Muscle strains are also common in the geriatric population • Exercise can impact the rate and extent of functional decline.
secondary to a decrease in flexibility. • It is recommended that geriatric patients have approximately
• Due to decrease in bone density, geriatric patients are at 30 minutes of exercise at least 5 days each week.
risk from spontaneous, nontraumatic, or minimally traumatic • Exercise programs that include balance, flexibility, and
fractures. strength exercises have been shown to significantly reduce
the number of falls in the geriatric population.
• Light to moderate exercise training has been shown to
Treating Chronic Osteoarthritis Pain in the decrease systolic blood pressure.
Geriatric Patient • Endurance training is associated with improved insulin
• Due to physiologic changes with normal aging, medication sensitivity, and regular exercise has been shown to decrease
administration must be adjusted in the geriatric patient, as depressive symptoms.
compared with a younger patient. • Weight-bearing exercise has been shown to attenuate bone
• In 2015 the American Geriatrics Society updated the Beers density loss in several studies.
Criteria for medications to use with extreme caution in • A regular exercise program has been shown to improve
older adults. OA pain and improve function in this population.
• Due to age-related renal changes, nonsteroidal antiinflam-
matory drugs (NSAIDs) are not recommended for long-term
Promoting Safe Exercise for the
use in the geriatric population. NSAIDs can be helpful
for short-course treatment of acute pain or inflammation. Geriatric Patient
Adverse effects commonly associated with NSAID use in • To promote safe exercise, a preparticipation screening
the geriatric population include acute kidney injury, gastric evaluation can assess for cardiovascular risk factors prior
bleeding, and peripheral edema. to initiating or escalating an exercise program.
• Acetaminophen can be used safely in the treatment of • Established cardiovascular screening guidelines for masters’
chronic arthritis pain in the geriatric patient. Regular dosing level athletes should be followed with particular attention
of scheduled acetaminophen can decrease pain level and to key clinical risks such as family history of sudden
act as a “narcotic-sparing medication” in chronic and death, exertional syncope, exertional dyspnea, chest pain,
postoperative pain control. Maximum dosing of acetamino- or hypertension. The cardiovascular exam should focus
phen in the geriatric patient is 3000 mg a day in divided on identification and characterization of heart murmurs,
doses of 1000 mg TID. All formulations of acetaminophen peripheral pulse quality, and stigmata of Marfan’s syndrome.
must be accounted for and be less than 3000 mg in any • Geriatric patients can work under direct monitoring of a
1 day. physical therapist or personal trainer to first establish an exer-
• Geriatric patients who are acutely ill are at risk for delirium cise regimen before transitioning to working independently.
from a variety of factors, including hospitalization, dehy- • After medical clearance for exercise, prescribe an exercise
dration, medications, and postoperative state. Although regimen that is consistent with that individual’s cognitive
pain medication, especially narcotic medication, can be and functional abilities.
associated with delirium, untreated pain is also associated • Proper hydration and nutrition must be maintained
with delirium. for optimal function. Hydration is especially important due
• Short-course narcotic pain medication at appropriate dosing to a decrease in thirst perception that is part of normal
can be used in the geriatric population with close monitoring aging.
for side effects. Narcotic-induced constipation is a common
side effect in this population and can be treated with a
Exercise Prescriptions for the
promotility stimulant laxative such as senna.
• A key principle in dosing medication in elderly population is Geriatric Patient
“start low, go slow.” Start a medication at a low therapeutic • After cardiac clearance, an exercise prescription is an
dose and slowly titrate up while reevaluating for effect and excellent way to promote a healthy lifestyle in an elderly
adverse effects in the geriatric patient. patient. 25
• A screening evaluation should be done before initiating an

BOX 5.2 Exercise Prescription
exercise program to ensure a safe plan and determine a
An exercise prescription should specify the following: need for monitored exercises or any limitations.
• Exercise frequency
• Intensity of exercise
• Type(s) of exercise
Suggested Readings
• Duration of exercise session Anderson LA, Deokar A, Edwards VJ, et al. Demographic and health
• Progression of exercise program status differences among people aged 45 or older with and without
functional difficulties related to increased confusion or memory loss,
Exercise prescription goals 2011 Behavioral Risk Factor Surveillance System. Prev Chronic Dis.
2015;12:140429.
• At least 5 times each week Barbour KE, Stevens JA, Helmick CG, et al. Falls and fall injuries among
• At least 30 min sessions adults with arthritis—United States, 2012. MMWR Morb Mortal Wkly
• Increase daily exercise time by 10 min every week Rep. 2014;63(17):379–383.
until at a maximum of 60 min per day Concannon LG, Grierson MJ, Harrast MA. Exercise in the older adult:
• Moderate activity can be defined at a participant’s from the sedentary elderly to the masters athlete. PMR. 2012;4(11):
ability to carry on a conversation while engaged in 833–839.
exercise (approximately 50% maximum heart rate) Faul M, Stevens JA, Sasser SM, et al. Older adult falls seen by emergency
medical service providers: a prevention opportunity. Am J Prev Med.
2016;50(6):719–726.
Fick DM, Semla TP, Beizer J, et al. American Geriatrics Society 2015
• An exercise prescription should include the recommended updated Beers criteria for potentially inappropriate medication use in
frequency, intensity, type, duration, and progression of older adults. J Am Geriatr Soc. 2015;63(11):2227–2246.
exercise (Box 5.2). Maron B, Araujo C, Thompson P, et al. Recommendations for preparticipa-
• Exercise prescriptions should also take acute and chronic tion screening and the assessment of cardiovascular disease in master
athletes. Circulation. 2001;103:327–334.
medical conditions into account, such as avoiding high-
Roddy E, Zhang W, Doherty M, et al. Evidence-based recommendations
impact activities in patients with severe OA.
for the role of exercise in the management of osteoarthritis in the
• Exercise prescriptions should account for a patient’s level hip or knee—the MOVE consensus. Rheumatology. 2005;44:67–73.
of function, cognition, and goals of care. Improvement in Snowden M, Steinman L, Carlson WL, et al. Effect of physical activity, social
ADLs can lead to decrease risk of frailty. support and skills training on late-life emotional health: a systematic
literature review and implications for public health research. Front
Public Health. 2015;2:213.
Geriatric Patient Instructions
• A regular exercise program with balance, flexibility, and
strength components provides numerous health benefits.
26
Chapter 6 Special Populations: Disabled 1
Disabled
David Hryvniak, Jason Kirkbride
• The International Paralympic Committee was established in

ICD-10-CM CODES
1989 to act as the representative body of adaptive sports.
Z73.6 Limitation of activities due to disability
• The Rehabilitation Act of 1973 aided in bringing physical
Z74.09 Other reduced mobility
activity programs to most disabled people regardless of
F79 Unspecified intellectual disabilities
participation in competitive sports.
• Currently, there are a myriad of programs promoting physical
activity for the disabled, including the Special Olympics, the
United States Association of Blind Athletes, the National
Key Concepts Wheelchair Athlete Association, the National Association
• A disability, as defined by the World Health Organization of Sports for Cerebral Palsy, and Adaptive Sports USA.
(WHO), is a condition (either mental or physical) that limits • In addition, the Centers for Disease Control and Prevention
the ability of a person to perform an activity in the range sponsor several programs, such as Healthy People, aimed
considered normal for a human being. at improving physical fitness and promoting healthy lifestyles
• An impairment, as defined by the WHO, is “any loss or for disabled persons.
abnormality of psychological, physiological or anatomical
structure or function” and is used by the International
Paralympic Committee to create their competition clas- Musculoskeletal Disabilities
sification system. • Several different types of disabilities exist (Box 6.1).
• Nearly 60 million Americans have some type of disability • Musculoskeletal disabilities are among the most common
according to 2010 U.S. Census Bureau data—an increase types and affect social functioning and mental health, further
of 2.2 million since 2005. worsening a patient’s quality of life.
• Musculoskeletal diseases are some of the major causes • The burden to the health care system from musculoskeletal
of disability in the United States and the world. disabilities worldwide is significant and is growing.
• The benefits of a regular exercise program can be obtained • The Bone and Joint Decade was established worldwide
by those with disabilities, but 54% of people with disabilities to help prevent musculoskeletal disability and improve the
engage in no leisure-time physical activity compared with quality of life for those with musculoskeletal disease.
just 32% of their peers without disabilities and are 4 times
more likely to suffer from cardiovascular disease among
adults ages 18 to 44 years. Common Injuries in the Disabled
• Physicians who have disabled patients must encourage • According to data from the Special Olympics, the injuries
physical activity while being mindful of both the limitations sustained in disabled athletes are similar to those sustained
of the disability and common injury patterns either unique in their nondisabled peers, with musculoskeletal injuries
to the disability or the result of the activity type. accounting for the majority of medical tent visits during
• Physicians must also be aware of societal and environmental competition.
factors that hinder the activities of disabled persons and • When a physician performs a preparticipation physical
provide tools to eliminate obstacles as necessary. examination on a disabled athlete, it is important to identify
abnormalities that predispose to injury.
• The relationship of Down syndrome to atlantoaxial instability
Background requires that all Down syndrome athletes obtain lateral
• A disabled sports program was started for wheelchair cervical spine x-rays in flexion, extension, and neutral:
athletes in the 1950s, borne from a need to rehabilitate the atlantodens interval must be less than 5 mm. If the
war veterans radiographs are abnormal, then participation in contact
• The first Paralympic Games were held in Rome in 1960. sports is precluded.
The Paralympics were games established for athletes with • All traumatic paraplegic or quadriplegic athletes should
either a physical disability or visual impairment. undergo a stress test before participation in high-demand
• The Special Olympics began in 1960 and has since grown sports (i.e., basketball, track).
to involve more than 5.7 million athletes in 172 different • The athlete should be examined for any skin abnormalities
countries. The games are for those athletes with mental including pressure sores. If pressure sores are present, the
retardation regardless of physical ability. athlete cannot compete. 27
BOX 6.1 Types of Disabilitiesa

Visual impairment
Hearing impairment Benefits of athletic activity
Mental retardation Quality of life
Autism
Mental health
Spinal cord injuries
Cerebral palsy Social function
Muscular dystrophy Incidence of diabetes
Multiple sclerosis Incidence of heart disease
Chronic pain
Osteoarthritis
Traumatic brain injury
Limb loss Resources for patients:
Depression • National Organization on Disability www.nod.org
Dementia • National Center on Physical Activity and Disability www.ncpad.org
• International Paralympic Committee www.ipc.org
Stroke • Adaptive Sports USA www.adaptivesportsusa.org
Addiction
Diabetes mellitus Fig 6.1 The benefits of sports participation for the disabled
Obesity population and patient resources.
a
This is a partial list. The definition of disability encompasses any
condition that prohibits an individual from performing an activity in the
range considered normal for a human being.
• There are online resources and community programs that
can help to provide access to services offered to help
people with a disability summarized in Fig. 6.1.
• Other medical conditions should be carefully documented.
These include seizure disorders, congenital and acquired
cardiovascular disease, visual problems, and allergies. Suggested Readings
Batts KB, Glorioso JE, Williams MS. The medical demands of the special
athlete. Clin J Sport Med. 1998;8:22–25.
Treatment Billinger S, Arena R, Bernhardt J, et al. Physical activity and exercise
• Following a preparticipation physical, physical activity should recommendations for stroke survivors: a statement for healthcare
be encouraged for all individuals with disabilities because Professionals from the American Heart Association/American Stroke
Association. Stroke. 2014;45:2532–2553.
it has been demonstrated to improve overall health.
Birrer R. The Special Olympics athlete: evaluation and clearance for
• Education should be provided to prevent injuries specific
participation. Clin Pediatr (Phila). 2004;43:777–782.
to the disabled athlete. Brooks P. The burden of musculoskeletal disease—a global perspective.
• Prevention of skin breakdown should be attempted Clin Rheumatol. 2006;25:778–781.
through the use of protective clothing, avoidance of Carmona R. Disability and Health 2005: Promoting the Health and
moist clothing, and frequent skin checks. Well-Being of People with Disabilities. Rockville, MD: Department
• Prevention of overuse injuries is increasingly important in of Health and Human Services, Centers for Disease Control and
wheelchair-bound athletes because they are increasingly Prevention; 2005.
dependent on upper extremities for mobility and activities Global Alliance for Musculoskeletal Health of the Bone and Joint Decade
of daily living (ADLs). (website). Available at www.bjdonline.org. Accessed April 5, 2018.
Klenck C, Gebke K. Practical management: common medical problems
• Spinal cord–injured athletes are more susceptible to
in disabled athletes. Clin J Sport Med. 2007;17(1):55–60.
heat illness due to impaired thermoregulation and should
Kosma M, Ellis R, Cardinal B, et al. The mediating role of intention and
additionally be educated about risks of autonomic stage of change in physical activity among adults with physical disabili-
dysreflexia and boosting. ties: an integrative framework. J Sport Exerc Psychol. 2007;29:21–38.
• A disabled patient’s attitude toward physical activity has Hawkeswood JP, O’Connor R, Anton H, Finlayson H. The preparticipa-
been shown to be the strongest predictor of future physical tion evaluation for athletes with disability. Int J Sports Phys Ther.
activity. 2014;9(1):103–115.
• A strong support system has been shown to limit an Lerman J, Sullivan E, Barnes D, Haynes R. The Pediatric Outcomes
individual’s disability. Data Collection Instrument (PODCI) and functional assessment of
• A multidisciplinary approach involving physical therapists, patients with unilateral upper extremity deficiencies. J Pediatr Orthop.
2005;25:405–407.
physicians, social workers, occupational therapists, and
Pelliccia A, Quattrini FM, Squeo MR, et al. Cardiovascular diseases in
others provides the disabled athlete the most benefit.
Paralympic athletes. Br J Sports Med. 2016;50(17):1075–1080.
Platt L. Medical and orthopaedic conditions in Special Olympics athletes.
J Athl Train. 2001;36:74–80.
Patient Instructions Price MJ, Campbell IG. Effects of spinal cord lesion level upon ther-
• A disability should not preclude an individual from obtaining moregulation during exercise in the heat. Med Sci Sports Exerc.
28 the benefits of living a healthy lifestyle. 2003;35:1100–1107.
Chapter 6 Special Populations: Disabled 1
Pueschel SM, Scola FH, Perry CD, Pezzullo JC. Atlanto-axial instability Vallaint PM, Bezzubyk I, Daley ME. Psychological impact of sport on
in children with Down syndrome. Pediatr Radiol. 1981;10:129– disabled athletes. Psychol Rep. 1985;56:923.
132. Warms C, Belza B, Whitney J. Correlates of physical activity in adults with
Storheim K, Zwart J. Musculoskeletal disorders and the Global Burden mobility limitations. Fam Community Health. 2007;30(2 suppl):S5–S16.
of Disease study. Ann Rheum Dis. 2014;73:949–950. World Health Organization. The Burden of Musculoskeletal Conditions
U.S. Department of Health and Human Services. The Surgeon General’s at the Start of the New Millennium. Technical Report Series 919.
Call to Action to Improve Health and Wellness of Persons with Dis- Geneva: World Health Organization; 2003.
abilities. Rockville, MD: U.S. Department of Health and Human Services, World Health Organization. International Classification of Functioning,
Office of the Surgeon General; 2005. Disability and Health: ICF. Geneva: World Health Organization; 2001.
29

Pediatrics
Mark Rogers, Kevin Valvano
• The increase in female participation is associated with

ICD-10-CM CODES
Title IX, a 1972 federal law that mandated equal athletic
X50.3 Overexertion from repetitive movements
facilities and programs for females and males.
R62.50 Development arrested or delayed (child)
• This has led to a greater acceptance of girls and women
N91.2 Amenorrhea
in competitive sports and the ascension of female sports
Z71.3 Dietary counseling and surveillance
figures as role models.
E58 Dietary calcium deficiency
• The athletic focus has shifted away from the recreational
Z71.83 Exercise counseling
component of sports to that of increased competition
resulting in participation earlier in life, single-sport spe-
cialization, and an increase in frequency and intensity
of training at younger ages.
Key Concepts • Traditionally, coaches and (less so) parents are the
• More than 60 million American young people of all ages driving forces behind single-sport specialization.
participate in organized sports today. • Specialization can limit development of various
• Youth sports are now more competitive than previously. physical and mental athletic skill sets.
Many children play at competitive levels at younger ages, • The most frequently cited reasons for younger children’s
often specializing in a single sport at a younger age. These participation in organized sports are to have fun, learn
athletes may even follow a year-round cycle of practice, new skills, test abilities, and experience excitement.
private training, and events for that sport. • Receiving individual awards, winning games, and
• Sports-related injuries have been increasing among young pleasing others are ranked lower.
people, becoming the leading cause of all injuries in ado-
lescents, as well as the leading reason for adolescents to
visit health care providers. Many of these injuries present Sports Injuries
because of overtraining and overuse. • Sports injuries are the most common type of injury in
• Skeletal growth, physiologic development, and the psy- adolescents, and sports-related injury is the leading reason
chological changes of puberty can influence which sports for adolescent visits to primary care providers.
activities adolescent athletes choose and how well they • The highest incidence of sports-related pediatric injuries
perform. occurs in the 5- to 14-year-old age range.
• There is growing interest in training and conditioning pro- • These children are less coordinated, have slower reaction
grams for young athletes. Well-designed and supervised times, and are less proficient than older children and
training programs have shown significant value and are adults in assessing and avoiding the risks of sports.
safe for all youth athletes, including prepubertal children. • Most sports-related overuse injuries in young athletes
• Primary care providers should encourage age- and are related to musculoskeletal and physiologic immaturity
developmentally appropriate physical activities for their due to underdeveloped muscles, ligaments, and bones.
young patients and should provide anticipatory guidance • In other words, immature epiphyses are weaker than
to parents, with the goal of choosing activities that are fun, the surrounding soft tissue (muscles and ligaments),
safe, and rewarding. allowing significant stress to cause a traumatic
• Providers should be able to assess young people’s “sports epiphyseal fracture.
readiness,” via their cognitive, social, and motor develop- • Injury risk is greatest during times of poor physical condition,
ment, to determine if they can meet the demands of the usually at the beginning of sports seasons. Other factors
specific sport and level of competition that they desire. increasing the risk of injury include rapid increases in activity
over short periods of time, athletes playing above their
skill/age level, improper rest, and poor adaptation to the
Trends in American Youth Sports increased demands of their sport.
• Over the past several decades, the numbers of children • Most, if not all, of these risk factors can be observed in the
and adolescents involved in formal youth sports have nearly increased specialization, intensity, and year-round athletic
tripled (Table 7.1). The increase in female participants has activity of the pediatric athletic population.
been greater than that of male participants, although males • Recent analyses revealed (1) elite athletes specialized in
30 still outnumber females in absolute numbers. their respective sports at a later age than the nonelite
Chapter 7 Special Populations: Pediatrics 1
TABLE 7.1 Numbers of High School–Age American skill sports such as football, basketball, soccer, and field
Boys and Girls Involved in Organized hockey.
Sports • Can accept increasing emphasis on game tactics and
strategy
Group 1971 1996 2006 2016 Many changes occurring during puberty can affect children’s
Boys 3,670,000 3,700,000 4,321,000 4,560,000 athletic performance. The exact timing of these changes can
Girls 294,000 2,500,000 3,022,000 3,400,000 be affected by genetics, endocrine function, nutritional status,
and amounts and types of exercise.
Total 3,960,000 6,200,000 7,342,000 7,960,000
Athletic and Sports Issues of Puberty
population and (2) professional baseball players surveyed Co-Ed Youth Teams
did not feel sport specialization was required prior to high • Muscle strength, speed, and skills are usually nearly equal
school to master their skills (as indicated in an early sport in boys and girls until age 10 to 11 years, and sports
specialization article [Wilhelm et al., 2017]). activities can still be coeducational due to these similarities.
• Girls generally begin their pubertal changes at approximately
10 years of age, approximately 2 years before boys.
Growth and Maturation • By age 12 to 13 years, pubertal differences start to affect
• Preparedness for particular sports, capabilities for training, the skill and strength involved in sports, and depending
and skills development are all directly related to age-specific on the sport, these differences may affect whether girls
maturation in children’s neuromuscular, cardiovascular, and and boys should continue to play and compete together.
cognitive systems.
• By age 6 years, most children have acquired sufficient Physiologic Changes of Puberty
physical skills to participate in some organized sports. • Capacities for both aerobic and anaerobic exercise are
• Gaining experience in a variety of sports is important for beginning to increase, which allow longer and more intense
the young athlete to enable them to acquire a mix of skill periods of exercise to be tolerated.
sets and to keep physical activity interesting and fun. • Aerobic capacity: Greater maximum oxygen uptake
(VO2max)
Developmental Levels and Readiness for Sports • Due to increases in pulmonary ventilation and cardiac
at Various Prepubertal Ages output and to more efficient extraction and use of
• Selection of appropriate athletic activities for children should oxygen by muscle
be guided by knowledge of the developmental skills and • Anaerobic capacity: allows for short, intense bursts of
limitations of specific age groups. activity
• Note: The downside of these physiologic changes is that
Ages 3 to 5 Years although pubertal children are less limited by body fatigue
• Focus on learning basic skills such as running, swimming, and can thus exercise longer, they are also more capable
tumbling, throwing, and catching. of overexercising, which can lead to overuse injuries.
• It is recommended that direct competition should be
avoided; fun play should be emphasized. Musculoskeletal Changes of Puberty
• Changing body contours during early puberty can lead
Ages 6 to 9 Years to physical awkwardness, which may be associated with
• Focus on developing fundamental sports skills with limited increased chances of injury, especially in early adolescence
emphasis on direct competition. when new skills have not caught up with new capacities
• To learn additional fundamental skills and work toward and new growth.
a transition to direct competition, sports like swimming, • Flexibility and joint hypermobility are increased, which
running, and gymnastics can be tried. increases the risk of glenohumeral and patellar subluxation
• Note: Children have a short attention span, limited and dislocation.
memory development, and do not easily make rapid
decisions; they need simple, flexible rules and short Bone Density and Calcium Needs
instruction times. • During early puberty, bone mineral density begins to increase
in both boys and girls.
Ages 10 to 12 Years (Prepubertal Years) • The calcium needs of all adolescents are great during puberty,
• With the mastery of basic skills, children can now compete due to the deposition of calcium into rapidly growing bone.
in activities and are able to learn more complex motor skill • Adolescents accrue 40% of their eventual adult bone
patterns. mass during puberty.
• Children begin to develop their sense of confidence, • Recommended calcium intake for adolescents is 1300 mg/
esteem, and self-awareness. At these ages, body day (amenorrheic females may need up to 1500 mg/day).
image and popularity are distinguished, and successful
mastery of new skills become closely linked to child’s Linear Growth
self-esteem. • Linear growth begins first in the long bones of the extremities
• They have the cognitive, social, and emotional maturity and can contribute to a temporary clumsiness that can
to handle modest competitive pressure and complex have an impact on the athletic performance of younger 31
TABLE 7.2 Average Timing of Pubertal Changes in • There has been a recent increase of training facilities
Linear Growth (Height) focusing on proper lifting and sports-related techniques,
rather than growth and power, at younger ages.
Specific Pubertal • Young athletes, regardless of gender, should avoid power
Change Girls Boys
lifting until the growth plates are closed, due to an associ-
Increasing height 9 years 11 years ated with avulsion fractures at the growth plates.
velocity begins
Peak height 9 cm/year, at 10 cm/year, at Weight Increases During Puberty
velocity and Tanner Tanner • Puberty-related weight increases account for approximately
timing stage 2–3 stage 3–4 50% of adult total body weight.
Duration of 24–36 months 24–36 months Weight Changes in Girls
growth spurt
• Lean body mass decreases during puberty to 75% of the
Average age at 14 years 16 years total body weight, due to increases in body fat.
complete • Maximum weight velocity occurs approximately 6 months
skeletal maturity before their linear growth (height) spurt.
• Hip enlargement decreases waist-to-hip ratio.
Body Image
adolescents (Table 7.2). The child who previously exhibited • Body image concerns in young female athletes may arise
strong skills may suddenly appear to be less coordinated. because of higher levels of fat in this population.
Puberty-related increases in height velocity usually begin • Sports where low body fat is valued include dancing,
in girls at approximately 9 years of age and in boys at gymnastics, cheerleading, figure skating.
approximately 11 years of age. • Loss of self-esteem and eating disorders are a particular
• The preadolescent and adolescent growth spurt, which risk in this age group.
can last for 24 to 36 months, accounts for approximately
20% of final adult height. Weight Changes in Boys
• Lead body mass increases to approximately 90% of total
Epiphyseal Growth Plates and Other Vulnerable body weight due to higher androgen levels.
Anatomic Sites • On average, boys end up with 1.5 times the lean body
• In early puberty, areas of rapid cell production include mass and one-half the body fat of girls.
(1) articular surfaces, (2) physes (growth plates), and (3) • Muscle mass accounts for 54% of boys’ body weight,
apophyses. The relative weakness of these areas compared making the average male athletes stronger and faster than
to adjacent ligaments, tendons, and bone make these sites the average female athletes.
more susceptible to injury, including fracture.
• Articular Surfaces
• Examples include osteochondritis dissecans and patel- Training and Conditioning
lofemoral syndrome. • The purpose of all athletic training programs for young
• Physes and Apophyses athletes should include improvement of skills, speed, flex-
• Physes are responsible for the linear growth of bones, ibility, strength, conditioning, maintenance of good nutrition,
while apophyses are responsible for growth at tendinous and attention to hydration.
insertion sites. • Benefits of training and conditioning include greater
• Physeal fractures represent 15-30% of all childhood muscle strength, power, and coordination and a lower
fractures. risk of athletic injuries (especially knee injuries).
• Apophysites include Sever disease (calcaneus), Osgood- • Training is a noncompetitive (or less competitive)
Schlatter and Sinding-Larsen-Johansson diseases means of improving conditioning, strength, and
(Chapter 221), and Iselins disease (fifth metatarsal). coordination.
• Physeal and epiphyseal injuries include little league • Training can improve athletic performance, increase
shoulder (Chapter 218), little league elbow (Chapter 219), bone density, promote weight loss, and enhance
and spondylolysis and spondylolisthesis (Chapter 223). children’s self-esteem.
• These are self-limited and usually resolve with a • Training can promote a healthy lifestyle that can last
temporary reduction in activity. into adulthood.
• Additional injuries can result from overuse, lack of skills,
lack of appropriate protective equipment, improperly learned Training Guidelines
(or taught) techniques, and/or excessive performance • Successful training programs should include qualified adult
expectations. supervision, no/low weight to focus on technique, and
enjoyment.
Injury Prevention • Age: No minimum age for participation in a youth
• Regular conditioning, stretching regimens, and light strength resistance training program
training can be particularly beneficial in prevention of injuries • Need emotional maturity to accept and follow direc-
32 (especially lower extremity injuries). tions (~7 to 8 years old)
Chapter 7 Special Populations: Pediatrics 1
• Instruction: Training should include sufficient instruction Benjamin HJ, Glow KM. Strength training for children and adolescents: what
and supervision in proper techniques and equipment can physicians recommend? Physician Sports Med. 2003;31:19–25.
use. Coon ER, Young PC, Quinonez RA, et al. Update on pediatric overuse.
Pediatrics. 2017;139(2).
• Adult supervisors should stress positive attitude,
Feeley BT, Agel J, Laprade RF. When is it too early for single sport
character building, teamwork, and safety.
specialization? Am J Sports Med. 2015;44(1):234–241.
• Results: Improvement of baseline strength and muscle Greydanus DE, Patel DR, Pratt HD. Essential Adolescent Medicine. New
tone by 40-50% over a 6-week period. York: McGraw Hill Professional; 2011.
• Prepubertal athletes: training increases strength and Kraemer WJ. Strength Training for Young Athletes. Champaign, IL: Human
neuromuscular adaption but will not result in muscle Kinetics; 2005.
hypertrophy. Marques A, Santos R, Ekelund U, Sardinha LB. Association between
• Pubescent athletes: training will result in larger muscle physical activity, sedentary time, and healthy fitness in youth. Med
mass, due to increasing testosterone, especially with Sci Sports Exerc. 2015;47(3):575–580.
increasing weights and resistances. Metzl JD. Sports Medicine in the Pediatric Office. Elk Grove Village, IL:
American Academy of Pediatrics; 2017.
• Conditioning: should start at least 6 weeks before
Metzl JD, Shookhoff C. The Young Athlete: A Sports Doctor’s Complete
beginning a sports season.
Guide for Parents. New York: Time Warner; 2002.
• Two to three times per week on nonconsecutive Patel DR, Soares N, Wells K. Neurodevelopmental readiness of children
days (to allow a day of rest between sessions) for participation in sports. Transl Pediatr. 2017;6(3):167–173.
• Warm-ups and cool-downs, including stretching, Rosenbloom C. Youth athletes: nourishing young bodies and minds.
should be part of each session. Nutr Today. 2016;51(5):221–227.
• One to 3 sets of 6 to 15 repetitions with light weights Stracciolini A, Casciano R, Friedman HL, et al. A closer look at overuse
on a variety of exercises, starting with a small number injuries in the pediatric athlete. Clin J Sport Med. 2015;25(1):30–35.
of exercises Strasburger VC, Brown RT, Braverman PK. Adolescent Medicine: A
• Gradual increase in weights, number of repetitions, Handbook for Primary Care. Philadelphia: Wolters Kluwer; 2015.
Wilhelm A, Choi C, Deitch J. Early sport specialization: effectiveness and
and number of exercises
risk of injury in professional baseball players. Orthop J Sports Med.
• Core exercise should be supplemented by some
2017;5(9):232596711772892.
form of cardiovascular activity for 30 to 40 minutes
three to four times weekly.
Suggested Readings
Anderson SJ, Harris SS. Care of the young athlete. Elk Grove Village,
IL: American Academy of Pediatrics; 2010.
33
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no related content on Scribd:
Armilla, la première bourgade que nous rencontrons, est
annuellement ravagée par des fièvres putrides dont les villages
voisins ne sont pas exempts.
Après Armilla s’étend une grande plaine sablonneuse. La
campagne se dépouille de sa puissante verdure pour se couvrir de
chardons comme la Manche.
A propos des chardons qui atteignent ici des dimensions
colossales, il s’en épanouit quarante-deux espèces en Espagne, et il
n’y a pas que les ânes qui en mangent, car l’une de ces espèces,
l’alcarille, est appréciée des gourmets à l’égal de l’artichaut.
Un Christ de pierre, vêtu d’une jupe de velours bordée de
paillettes d’or, se dresse au milieu de cette solitude. Des bouquets
fanés et des ex-voto sont posés au pied de la croix. Une bonne
femme nous dit que ce Seigneur Christ est très estimé dans le pays
et fait de temps en temps des miracles. Il devrait bien faire pousser
des pastèques dans cette plaine, car il y souffle une soif saharienne
et l’on n’y rencontre pas une seule fonda.
Enfin, après deux heures de marche, nous atteignons Algendin,
misérable bourgade bâtie sur un rocher. Une jolie paysanne
renouvelle le vin surchauffé de nos gourdes et nous invite à prendre
notre part d’une soupe au piment et à l’ail. Nous allions accepter
quand un abominable marmot, frère ou neveu de l’aimable fille, tyran
pouilleux et mal mouché, éternue dans le plat commun. Il ne faut pas
être dégoûté en voyage, mais il est de ces détails qui enlèvent
brusquement l’appétit le plus robuste ; aussi prenons-nous congé de
notre jeune hôtesse en la remerciant de sa bonne intention.
D’Algendin l’on aperçoit pour la dernière fois Grenade. C’est de
là, d’une place appelée El ultimo suspiro del Moro, le dernier soupir
du Maure, que Boabdil vaincu et fugitif jeta un suprême adieu à sa
belle capitale, à jamais perdue. Il pouvait distinguer comme une
tache sombre dominant l’éclatante silhouette de la ville, les jardins
de l’Alhambra et le Generalife où, sous de gigantesques cyprès que
l’on voit encore, la belle sultane Zoréide donna tant de coups de
canif dans le cœur de l’époux.
« Pleure ton royaume comme une femme, lui dit sa mère qui
surprit des larmes couler lentement sur les joues du dépossédé,
puisque tu n’as pas su le défendre comme un homme. »
Loin de la bourgade, en bas de la côte, dans une plaine entourée
de rochers et au fond d’un ravin qui nous donne un peu d’ombre,
nous mettons sac à terre. C’est le dernier déjeuner que nous ferons
en plein air ; il est composé de ces excellents saucissons appelés
chorizos, qui émoustillent les palais les plus blasés, et d’une poignée
de figues fraîchement cueillies. Une sorte de paysan, à mine
sauvage, en gilet et pantalon de velours, fusil sur l’épaule, débouche
tout à coup d’une crevasse de rocher et nous regarde curieusement.
« Bonjour, hommes !
— Bonjour, homme ! »
Il s’avance. Nous lui tendons nos gourdes. Il boit une bonne
gorgée à la régalade et, pour nous rendre la politesse, nous offre
des cigarettes.
« Vous venez de Grenade ? Avez-vous rencontré des gardes
civiques ? »
Il n’avait pas achevé que deux bicornes, enveloppés de coiffes
blanches, surgissent à deux cents pas sur la route.
« Si fort intrépide que l’on soit en présence de toutes choses,
disait plaisamment Dumas, on éprouve toujours en celle des
gendarmes une vive satisfaction lorsqu’on est assuré qu’on n’aura
rien à démêler avec eux. » C’était notre cas, bien qu’à l’étranger on
ne soit jamais certain de ce qui peut survenir ; mais ce n’était pas
celui de notre homme, car il battit prestement en retraite, en nous
disant vivement :
« Silence, camarades. »
Et, le corps courbé, le fusil bas, suivant les sinuosités du ravin, il
disparut dans les rochers.
Les gendarmes arrivaient paisiblement sur nous, la carabine à
l’épaule. Ils nous hélèrent.
Nous pensions qu’ils allaient nous demander nos passeports.
« Avez-vous des cigarettes ? »
Nous n’avions pas encore allumé celles que le bandit venait de
nous offrir ; nous les leur présentâmes.
L’un d’eux sauta dans le ravin.
« Ah ! vous déjeunez !
— A votre service ; il nous reste encore quelques chorizos.
— Merci, nous n’avons pas faim. Qu’est-ce qu’il y a dans vos
gourdes, de l’eau ?
— Non, du vin. »
Ils firent un geste de dégoût.
« Vous êtes étrangers, seigneurs cavaliers ?
— Oui, seigneurs gendarmes.
— Vous êtes armés ?
— Oui, seigneurs gendarmes, avec d’excellents revolvers.
— Bonne précaution ! » remarqua sentencieusement le plus
ancien.
Ils allumèrent leurs cigarettes, remirent l’arme sur l’épaule droite
et partirent du pied gauche, militairement.
« Merci, seigneurs cavaliers, allez avec Dieu !
— C’est la grâce que nous vous souhaitons, seigneurs
gendarmes. »
Après trois ou quatre pas, l’ancien, ayant réfléchi, s’arrêta pour
nous crier :
« Avez-vous rencontré un particulier de mauvaise mine avec un
gilet et un pantalon de velours ?
— Aucun Espagnol n’a mauvaise mine, répondis-je ; je n’en ai
pas encore rencontré. »
Je pensais qu’ils allaient rire ; mais ils me regardèrent fièrement,
en gens convaincus de la vérité de ma réponse, frisèrent leur
moustache, redressèrent leur taille et continuèrent gravement leur
chemin.
XXXVI
LA POSADA DU PARADIS
Après une longue sieste à l’abri d’un coin de rocher, nous nous
réveillons, lorsque le soleil commençait à allonger les ombres. Il est
trop tard pour atteindre Motril ; aussi continuons-nous, couchés sur
le dos, à goûter ce farniente méridional qui engourdit si
délicieusement le cerveau et les membres, tout en suivant
machinalement de petits nuages blancs qui flottaient dans l’azur
profond.
Et perdu dans le grand silence, au milieu de cette belle et chaude
nature, je me murmurais à moi-même ces vers d’un poète espagnol :
« Si je me perds, que l’on me cherche du côté du Midi, là où
éclosent les brunes jeunes filles, où les grenades éclatent au
soleil. »
Ce ne fut pas le bruit des grenades mûres qui éclatent, mais celui
de grelots, qui nous tira de notre torpeur. Un coche attelé de mules
débouchait du coin de la vallée. Nous nous étions levés pour le voir
passer, et l’idée nous vint de le prendre pour achever notre voyage.
« Hé ! cocher ! » Mais, bien qu’il parût nous voir et nous entendre, il
se mit à exciter ses mules, qui du trot passèrent à un galop effréné.
« Arrête ! arrête ! cocher ! » Il n’en court que plus vite. Sans doute
le bruit des grelots et surtout la kyrielle de malédictions qu’il fait
pleuvoir à grands renforts de coups de manche de fouet sur son
attelage, couvrent nos voix ; aussi, pour mieux nous faire entendre,
nous déchargeons nos revolvers.
Si nous voulions attirer l’attention, le succès dépassa nos
espérances. Les échos des rochers répercutèrent sur tous les tons
les trois ou quatre coups tirés ; on eût cru à une fusillade entre
bandits et carabiniers royaux ; des têtes d’hommes et de femmes
effarées parurent aux portières, conducteur et cocher hurlèrent aux
mules tout leur répertoire d’injures, et le coche disparut bientôt dans
un tourbillon de poussière [13] .
[13] Nous eûmes, le surlendemain, à Malaga,
l’explication de cette fugue. L’avant-veille, la même
diligence avait été, presque au même endroit, attaquée et
pillée. Quelques semaines plus tard, un riche propriétaire
de Cordoue, le señor Gallardo, fut capturé sur cette
même route par des bandits qui exigèrent 30 000 francs
de rançon. L’argent fut payé et Gallardo rendu.
Vers six heures, nous atteignîmes Padul, bourgade assise dans

une jolie vallée plantée d’oliviers, de grenadiers et de vignes. Mais,
si la campagne est séduisante, la ville et les habitants ne le sont
guère, et, contre nos prévisions, nous ne devions pas y passer la
nuit.
Nous nous enquîmes d’une auberge. On nous indiqua la posada
du Paradis. Quel paradis ? celui des cochons, sans doute ; car la
demi-douzaine d’élus qui s’y ébattaient semblaient s’y trouver fort à
l’aise, en famille et comme chez eux. Rôdant de tous côtés, ils
flairaient les pots, remuaient du grouin les casseroles, se jetant dans
vos jambes, vous marchant sur les pieds.
Des muletiers allongés par terre sur leur couverture n’y prenaient
garde, et la matrone les contemplait d’un œil tendre comme une
couvée de petits poussins.
Naturellement rien à manger. « Pas même des œufs ?
— Vous ne manquerez pas d’en trouver dans la ville, » dit la
matrone.
Elle pousse l’obligeance extrême jusqu’à nous montrer du pas de
la porte une boutique de cordonnier où l’on nous en vendrait
sûrement.
Une petite fille qui se grattait alternativement la tête, le derrière et
le nez, est justement sur le seuil. Son papa est absent, mais cela ne
fait rien, dit-elle, et elle court tirer une douzaine d’œufs du fond d’une
armoire. Douze sous, prix raisonnable. Nous payons et nous partons
avec notre emplette, lorsqu’une sorte de vilain rustaud survient et
nous demande ce que nous sommes allés faire chez lui.
Nous lui montrons nos œufs. — Nos œufs ! Un instant.
« Combien les avez-vous payés ?
— Douze sous.
— La petite s’est trompée ! C’est vingt-quatre qu’il me faut. »
Nous le traitons de voleur et lui rendons sa marchandise.
L’hôtesse de l’auberge du Paradis, à qui nous racontons
l’histoire, nous regarde d’un mauvais œil. Évidemment ses
sympathies ne sont pas pour nous.
Sur ces entrefaites, un indigène qui vient d’apprendre l’arrivée
d’étrangers accourt nous offrir du bouc tout frais à deux réaux la livre
(50 centimes).
Nous lui achetons deux livres de bouc que nous remettons à
l’hôtesse, puis allons visiter les curiosités de l’endroit.
Sept heures.
Les chorizos sont depuis longtemps digérés, et cette promenade
supplémentaire a augmenté notre appétit. Le dîner doit être prêt, le
bouc a eu le temps voulu pour rôtir.
Nous entrons dans la chambre commune, salle à manger,
cuisine, étable, chenil, dortoir, et la première chose qui frappe nos
yeux, c’est notre bouc tout cru proprement mis dans une assiette et
entouré d’une belle guirlande de mouches.
« Eh bien, et le dîner ?
— Le dîner ? répète avec calme l’hôtesse.
— Oui, cette viande ? pourquoi supposez-vous que nous l’ayons
achetée ? Pour donner à souper à vos mouches ?
— Vous ne m’avez rien dit, réplique-t-elle. Je ne savais pas à
quelle heure vous rentreriez. »
Nous fîmes comme le conducteur du coche, nous déchargeâmes
à son adresse toute la provision de jurons, de sacres et d’injures que
nous avions recueillis çà et là, l’un et l’autre, dans nos diverses
pérégrinations à travers les milieux les plus variés, et le mari présent
en eut sa large part.
Bien que ce soulagement se fit dans la langue maternelle, ils
comprirent que nous ne les comblions ni d’éloges ni de protestations
d’amitié ; aussi sur le même ton ils ripostèrent.
Cependant, pris peut-être de remords, le mari, plus juste,
suggère l’idée d’envoyer notre bouc au four. Cela serait plus vite fait.
Le boulanger cuisait, en moins d’une heure nous pourrons nous
mettre à table. Convenu. On expédie le bouc. Mais l’heure se passe.
Le bouc ne revient pas. On envoie à sa recherche un petit drôle, fruit
des amours légitimes des maîtres de la posada. Le jeune chenapan
fait comme le bouc. On l’a vu jouer au toro sur la place. Il rentre
enfin tout essoufflé. « Et le bouc ? — Il n’est pas encore cuit, » dit-il.
Il s’assoit dans un coin, bâille et s’endort. On le secoue : « Va
chercher le bouc, petite canaille ! » Il sort en rechignant, et nous ne
le revoyons plus.
Cependant muletiers, âniers, paysans, contrebandiers,
colporteurs, maraîchers, mendiants, ont envahi la posada. Un grand
feu de branches, foyer primitif, flambe au milieu de la pièce. Chacun
fricote de son côté. Des parfums pimentés, alliacés, agréables,
flottent dans l’atmosphère au milieu des bouffées de fumée et
aiguisent notre faim.
Allongés sur un banc, nous assistons, l’estomac en détresse, aux
diverses confections d’odorantes et extraordinaires ratatouilles. Enfin
le sommeil nous gagne et nous fermons les paupières.
Quelle heure est-il ? La nuit est depuis longtemps venue, mais
nulle trace de bouc. Tous les clients, repus, sommeillent dans des
postures variées sur le sol caillouteux, tandis que le posadero et la
posadera, à cheval sur un banc, achèvent paisiblement à la même
gamelle une épaisse soupe aux pommes de terre et aux tomates.
Qui dort dîne est un méchant proverbe. Nous nous en
apercevons aux tiraillements de notre estomac ; cela et la vue de
ces hôteliers qui dévorent tranquillement en face de la faim de leurs
hôtes renouvelle notre colère :
« Et notre bouc ? nom de Dieu ! »
Ils haussent les épaules en gens qu’une telle question ne peut
intéresser.
Nous recommençons la sarabande, réveillant par nos jurons le
populaire endormi.
Le couple riposte ; les marmots crient ; les cochons grognent, une
mule brait lamentablement ; des malédictions sortent de tous les
coins.
On se lève, on gesticule, on lance en l’air bras et mains aussi
tragiquement que les gros mots. Une bagarre générale va suivre, et
nous allons sûrement être jetés dehors.
Subitement tout se calme, patron, matrone, hôtes, tombent à
genoux ou s’inclinent tête découverte. Une vive clarté venue du
dehors par la grande porte ouverte fait dans la salle une trouée
lumineuse, et des chants de jeunes filles, des bourdonnements
mâles, des glapissements de vieilles arrivent de la rue.
J’aperçois une vingtaine de lanternes suspendues à des bâtons,
puis des femmes enveloppées de noir, des hommes en cagoule, des
fillettes en blanc. Et cette foule bizarre s’agenouille, psalmodiant des
prières, les yeux levés vers l’intérieur de la posada sur une image
encadrée, accrochée à un pilier en face de la porte, et sous laquelle
vacille la flamme grêle d’une lampe : Saint Pierre, le front chauve
entouré d’un nimbe d’or, avec une barbe rouge, un manteau bleu et
les clefs du Paradis.
Après un fraternel échange d’Ave Maria et d’Oremus avec les
gens de l’auberge, la bande se relève et s’en va précipitamment
avec sa bannière, ses bâtons et ses lanternes, s’agenouiller et
psalmodier devant une autre porte et une autre image de saint.
C’est une confrérie de dévots qui fait ainsi à certaines époques le
tour de la bourgade. Comme il y a nombre de jeunes gens et de
jeunes filles qui processionnent ainsi par les nuits sombres, je
m’expliquais sans peine combien ces vieilles coutumes sont chères
aux habitants.
Cette visite apporta une diversion et un vent de calme. Les
dormeurs, un instant réveillés, se recouchent et, comme nous avons
renoncé à notre bouc, nous demandons à en faire autant. On nous
conduit à notre chambre. Mais là encore nouvelle dispute. Nous
avons demandé deux lits, et une paillasse unique, aux flancs
éventrés, gît lamentablement sur le sol.
Par la fenêtre ouverte, les étoiles scintillent au firmament
limpide ; une fraîche brise fait vaciller la lampe, toute chargée des
parfums salins de la Méditerranée voisine.
« En route, dis-je à mon compagnon, en reprenant mon sac, la
posada du Paradis n’aura pas ma nuit. »
L’aubergiste nous voit partir avec satisfaction ; des voyageurs
aussi exigeants l’incommodent.
Il fut honnête cependant, nous avions pris du pain et du vin, et
dans son compte il déduisit le prix de notre morceau de bouc,
puisque, dit-il, il lui resterait. Devant cette extraordinaire probité,
nous oublions nos rancunes et nous partons en lui serrant la main.
Au coin de la rue, nous rencontrâmes le boulanger se hâtant
lentement, suivant le précepte du sage. Il apportait à l’auberge le
quartier de bouc tout fumant.
XXXVII
MOTRIL ET MALAGA
Le jour se levait quand, des pentes de la Sierra de Lujor, nous

saluâmes la Méditerranée. Que de fois à l’époque des belles années
verdies d’espérance, j’avais rêvé sur la côte africaine en face de sa
grande nappe bleue ! A nos pieds Motril s’étendait dans la vallée, et
bientôt nous heurtâmes à une hôtellerie à l’enseigne de je ne sais
plus quel saint du cru — dans tous ces noms de célestes célébrités
la mémoire se perd — car l’Andalousie en fournit à elle seule de quoi
garnir tout le calendrier, puisqu’il suffisait jadis d’avoir fait rôtir
beaucoup de Maures et de juifs pour être promu d’emblée à la
dignité de saint de première classe. On nous ouvrit sans trop de
pourparlers et nous eûmes la bonne fortune de jouir chacun de notre
chambre et de notre cuvette. Un poulet aux tomates fumant et cuit à
point au réveil, effaça le regret du bouc de Padul, mit le comble à
notre satisfaction et nous fit rendre grâces au grand saint patron du
lieu.
La mer est à deux kilomètres. En gens arrivés au terme de leur
voyage et qui désormais veulent prendre leurs aises, nous les
franchîmes à l’aide d’un tramway, car il y a un tramway à Motril. Il
traverse des vergers, des champs de maïs, de cannes à sucre, des
roselières, des canaux d’irrigation débordés sur la voie et vous
dépose sur le port, c’est-à-dire dans une sorte de faubourg appelé la
Playa. Le vrai port de Motril est à deux ou trois lieues à l’est, dans
une anse, la Calahonda, assez large pour abriter une centaine de
navires. A la Playa on ne voit que des barques de pêche, que par les
mauvais temps on tire sur la plage, et quelques caboteurs.
La Carolina, vieux sabot faisant le service de Motril à Malaga, ne
levait l’ancre qu’à six heures, et il en était à peine trois. Que faire ?
Retourner en ville ? Elle n’offre rien d’intéressant. Mieux valait errer
sur la plage, suivre la longue ligne de roselières, gracieuse ceinture
des vergers qui descendent jusqu’au rivage. De petites cabanes de
jonc étaient disposées çà et là. Dans les unes, on buvait et
mangeait, dans d’autres, on louait abri et costumes aux baigneurs.
Nous nous munissons du caleçon réglementaire et courons prendre
un bain.
Deux señoras qui rafraîchissaient leurs charmes dans notre
voisinage, donnèrent à notre approche de tels signes d’inquiétude et
d’horreur que sur-le-champ nous reconnûmes des filles de la
pudique Albion.
Cependant, comme elles ne sortaient pas de l’eau, nous allâmes
nous sécher sur le sable, à quelque distance de ces naïades
effarouchées.
L’une, blond filasse, jaune et desséchée, l’autre, châtain clair,
grassouillette et jolie. Celle-ci ne semblait pas extraordinairement
farouche. Néanmoins sous prétexte de nous montrer son mépris et à
sa compagne son zèle de pudeur, elle tournait dédaigneusement le
dos ; mais, comme elle se baissait et se levait successivement,
suivant l’usage du beau sexe, qui paraît goûter ainsi plus
voluptueusement les caresses de l’onde, elle étalait et cachait tour à
tour des rotondités que n’eût pas désavouées la déesse callipyge, et
qu’une simple chemise ne pouvait guère dissimuler, tandis que
l’autre, chèvre austère, accroupie dans l’eau jusqu’au menton, ne
nous laissait voir qu’un visage chargé de couperose et de courroux.
Il n’est si attrayant spectacle dont à la fin on ne se lasse, et nous
allions regagner notre cabine de joncs, lorsqu’une mégère, attachée
au service des baigneuses, vint nous sommer avec majesté d’avoir à
déguerpir sur-le-champ.
« Je ne pense pas que vous soyez de décents cavaliers pour
offenser ainsi de vos regards des señoras qui prennent leur bain.
— Nous ne vous avons jamais dit que nous étions de décents
cavaliers. »
Elle s’en va furieuse et revient bientôt munie d’un grand peignoir,
et l’étendant comme un rideau entre nous et les baigneuses, elle les
fait sortir l’une après l’autre de l’eau, les conduisant à leur cabine,
entièrement dérobées à notre vue.
Le lendemain matin, étendu sur le gaillard d’avant, je me
réveillais devant un magique tableau. Sous les clartés empourprées
de l’aube et au travers d’une forêt de mâtures, Malaga se déroule
devant nous. Derrière la ville entassée, se dressent les hauteurs de
Gibralfaro, où flottent dans une buée d’or les rayons du soleil levant,
enveloppant d’une gloire la vieille forteresse phénicienne. Des villas
sans nombre sont parsemées sur la montagne ; et la gigantesque
cathédrale, énorme carré de pierre, domine le port et semble écraser
la ville.
Nous débarquons, et malgré l’heure matinale les quais sont
encombrés d’une foule bigarrée aux allures pittoresques, marchands
de poissons et de fruits, débardeurs, canotiers, matelots.
Les tavernes du port et des étroites rues adjacentes sont déjà
ouvertes et sur le seuil de l’une d’elles une jeune virago,
étonnamment mamelue, aux grands yeux hardis et noirs, nous
interpelle au passage :
« Des Anglais ! » s’exclame-t-elle, car tous les touristes sont
invariablement pris à l’étranger pour Anglais, et aussitôt à brûle-
pourpoint elle nous lâche son vocabulaire britannique :
« English spoken. Mylords. Roastbeef. Soda water. Pretty miss.
Brandy.
— Yes, brandy ! »
Elle passe derrière son comptoir et nous verse de cette
abominable eau-de-vie dont l’Allemagne empoisonne les deux
mondes en général et l’Espagne en particulier.
En face du comptoir, vrai bar anglais, rehaussé par une glace
italienne et des étagères mauresques chargées de flacons à
étiquettes germaniques, le mur est couvert de grandes affiches
enluminées, vantant les produits britanniques. Sur la table, des
couteaux portant l’estampille de Sheffield et sur un coin du comptoir
est un appareil à glace fabriqué à New-York.
« Vous n’avez donc rien de français ici ? »
Elle leva les yeux et les épaules comme si elle cherchait dans sa
mémoire.
« Nada ! » dit-elle.
Rien ! ou presque rien ; c’est à peu près de même partout en
Espagne. Dans ce pays où Anglais et Allemands ont pris dans le
commerce et l’industrie une si large place, nous sommes à peine
représentés.
Les Allemands surtout se sont implantés avec leur audace et leur
ténacité habituelles, inondant non seulement les marchés espagnols
de leurs produits, mais falsifiant les vins du cru.
Mon ami Robert Charlie a fait sous le titre le Poison allemand
une très patriotique campagne contre l’invasion de la bière
germanique ; il serait à souhaiter qu’un écrivain espagnol entreprît
une campagne analogue non contre l’invasion des vins allemands,
mais contre la falsification par les Allemands des vins espagnols.
Malaga, la ville la plus populeuse et la plus commerçante de
l’Andalousie, le premier port d’Espagne après Barcelone, est le
centre d’importation des denrées germaniques, principalement des
alcools, au moyen desquels l’Allemagne falsifie sur place tous les
vins de l’Andalousie.
Aussi, bien que la production vinicole ait considérablement
augmenté, puisque de vingt millions d’hectolitres qu’on récoltait il y a
quatorze ou quinze ans, elle s’élève aujourd’hui à plus de trente
millions, l’exportation, loin d’accroître dans les mêmes proportions,
n’a fait que diminuer, parce que, comme le constatait récemment le
journal El Liberal, « la majeure partie des vins espagnols qui ont
passé la frontière française ou ont été embarqués pour l’Amérique
ou les pays du Nord, n’étaient pas du vin, à proprement parler, mais
une infâme mixture fabriquée avec de l’alcool allemand et offerte sur
les marchés comme un produit de crus renommés. »
Avec de l’alcool amylique, des colorants provenant de la houille,
de l’extrait sec artificiel, de la glucose, un peu de moût de la plus
mauvaise qualité et des tonnes d’eau, les Allemands qui trafiquent à
Malaga inondent les marchés français et ceux d’Espagne de milliers
de barriques portant les marques des bons crus et pourvues des
meilleurs certificats de provenance [14] .
[14] On en a inondé les marchés français, tandis que
nos vignerons voyaient avec douleur leurs excellents vins
naturels leur rester pour compte dans leurs caves.
La sophistication, une fois en train, ne s’est pas
limitée au commerce extérieur. On fabrique également
des vins artificiels pour la consommation de Madrid et
des autres grandes villes, ainsi que l’a démontré le
laboratoire municipal, dont les analyses ont signalé dans
ces vins la présence de l’alcool amylique et d’autres
substances étrangères au jus de la treille et
généralement nuisibles. L’extrême bon marché de l’alcool
allemand facilite ces abus, et bien d’autres abus encore,
qui, non seulement compromettent la santé publique,
mais nuisent à la consommation des vins naturels et
ruinent le vigneron. La spéculation éhontée trouve
évidemment plus commode et plus avantageux d’acheter
une barrique d’alcool que huit barriques de vin, et avec
cette barrique d’alcool, de l’eau et d’autres ingrédients,
elle fabrique, sans tomber sous le coup des exigences
fiscales, dix ou douze barriques de vin (?). Ce qui lui vaut
un double bénéfice, puisque l’eau ne coûte rien et que le
fabricant n’a point eu de droits d’entrée à payer.
Que sera-ce, quand le bon marché des alcools
industriels étrangers s’aggravera de la prime de 60 francs
par hectolitre que le gouvernement allemand accorde à
l’exportation ?
On frémit en pensant aux difficultés et aux embarras
qui menacent notre commerce… Tandis que l’Allemagne
s’indemnisera de ses primes avec les millions gagnés sur
les nations qui lui prennent ses alcools industriels, et
principalement sur l’Espagne, nous verrons dépérir, de
jour en jour, notre production vinicole, diminuer nos
affaires avec l’étranger, augmenter, par conséquent, la
crise agricole, industrielle, commerciale et monétaire !
(El Liberal.)
Il résulte de cette audacieuse flibusterie une dépréciation

universelle des excellents vins de l’Andalousie, un appauvrissement
des producteurs et un renchérissement des denrées de première
nécessité.
N’est-ce pas une chose effroyable que cette concurrence
déloyale faite à toutes les races par la race saxonne ? Ce n’est pas
seulement par ses bières que l’Allemagne nous empoisonne, c’est
par ses alcools sophistiqués, ses vins artificiels vendus sous de
fausses marques et sous le couvert d’éhontés spéculateurs.
XXXVIII
L’AUBERGE DU GRAND SAINT IAGO
A la recherche d’une posada dans les prix doux — car si nous

touchons à la fin de notre voyage, nous touchons également à celle
de notre bourse — nous avisons un agent de police occupé à se
livrer à un outrage public aux bonnes mœurs.
« Je sais ce qu’il vous faut, nous dit-il, patientez un moment. »
Il termine paisiblement sa petite affaire au milieu de la rue, coram
populo et puellis, et tandis qu’il s’ajuste, un camarade le rejoint.
Nous voici déambulant par les calles étroites et tortueuses avec
nos sacs demi-vides pendant sur une épaule, nos faces brûlées, nos
souliers poudreux, nos triques de rôdeurs et nos vêtements qui
bâillent par plus d’une couture au soleil levant. Les deux agents qui
nous flanquent ne contribuent pas peu à nous désigner à l’attention
et si nous avions fait la gageure de passer pour deux compagnons
du fameux Melgarès, dont la respectable famille habite les environs
de Malaga, nous eussions gagné à coup sûr.
Aussi, dès les premiers pas, une troupe de polissons nous
escorte. Des hommes et des femmes se mêlent à la bande.
« Qu’est-ce que c’est ?
— Des ladrones.
— N’est-ce pas ceux qui ont attaqué la diligence de Motril ?
— Justement, ils viennent par le bateau de Motril.
— On les a arrêtés sur le port.
— Ah ! les gredins !
— Ils en ont bien la mine.
— Le garrot ! le garrot ! »
La foule grossit. On commence par lancer quelques cailloux.
Pour échapper au sort de la femme adultère de l’âge évangélique,
nous offrons à chaque cabaret que nous rencontrons les
rafraîchissements les plus choisis à nos guides. Ils refusent avec
dignité :
« Nous n’avons pas soif.
— Bah ! on boit sans soif.
— Les ivrognes, oui ; pas les Andalous. »
Au diable la sobriété des Andalous ! Nous débouchons dans un
petit carrefour en face d’une maison qui forme un angle. Enfin, c’est
là. Il était temps. Auberge du Grand Saint Iago. Encore un saint qui a
dû fricasser pas mal de juifs et de Maures ; mais nous bénissons son
nom ; il nous sauve des fureurs de la populace qui s’arrête surprise
et déçue de nous voir arrêtés à la porte d’une auberge au lieu de
celle de la prison.
La police frappe pendant cinq ou six minutes du pied et du poing
en criant à chaque coup d’une voix lamentable, mode andalouse de
s’appeler :
« Hé ! señora ! hé ! l’ama ! señora Mariquita ! »
La señora Mariquita se décide à paraître au balcon de l’étage
supérieur ; grosse commère qui a de beaux restes et les montre en
partie dans un déshabillé des plus sommaires.
« Des seigneurs voyageurs ! » crient les deux policiers.
Elle laisse tomber comme une reine un regard à la fois étonné et
dédaigneux ; dédaigneux sur des seigneurs qui payent aussi peu de
mine, étonné sur la foule qui les escorte, puis se décide à descendre
nous ouvrir.
Nous entrons ; les curieux se dispersent et les agents se retirent
après nous avoir recommandé aux bons soins de la señora comme
si nous étions de vieux amis et trempé par politesse leurs lèvres
dans un verre de liqueur que nous leur avons fait servir.
L’hôtesse qui, — elle nous l’apprit elle-même — est la veuve d’un
de leurs camarades, appelle à son tour d’une voix dolente : Barbara !
Barbara ! et nous confie, tandis qu’elle va achever sa toilette, à une
fort jolie nièce qui ne paraît avoir de barbare que le nom.
O Grand Saint Iago ! Tu restes un de mes meilleurs souvenirs
d’Espagne et bien que tu aies fait rôtir à petit feu un nombre illimité
de juifs, j’eusse souhaité de passer sous ton enseigne un nombre
illimité de jours !
Toi seul m’as réconcilié avec les posadas des Espagnes. Non
pas que la casa de la señora Mariquita fût absolument un centre de
sybaritisme, ni même un lieu de simple confort ; mais, si la femme du
vicaire de ma paroisse, fourvoyée là par hasard, eût été choquée de
la pauvreté de la chambre, de la dureté de la couche, de la voracité
des puces, de la grossièreté des draps, de l’exiguïté du pot à eau et
de la cuvette, son révérend époux se fût certainement épanoui à
l’éclat des yeux et du sourire de la chambrière, dont la brune beauté
et la piquante saveur lui eussent fait oublier un instant, ne fût-ce
qu’un instant, son chœur de blondes et bibliques chanteuses
d’hymnes.
Et la cuisine ! Quels condiments, quels piments, quel incendie !
Pour l’éteindre, trois brocs de malaga de diverses couleurs furent à
peine suffisants.
Sur les murs de la salle, asile de ces débauches, s’alignaient des
escouades de saints et de saintes à mine béate ou rébarbative ;
mais une nouvelle jeune fille, aussi jolie que la première et
répondant au doux nom de Cata, atténuait par son aimable présence
l’austérité de cette pieuse compagnie, tout en augmentant le légitime
désir de chacun de goûter aux joies célestes. La señora Mariquita
n’ignorait sans doute pas que pour un voyageur rien n’est plus
agréable que la variété, aussi avait-elle commis une de ses nièces
au service des lits, et la plus jeune à celui du buffet.
Malaga n’est pas seulement célèbre pour l’excellence de ses
vins, il l’est aussi pour la beauté de ses filles, et cette fois la
renommée aux cent bouches ne ment pas.
Yeux noirs éclatants et doux, blancheur mate du teint, visage
d’un charmant ovale, épaisse et luxuriante chevelure, lèvres si
rouges qu’on les croirait barbouillées de mûres, taille fine et poitrine
délicieusement agrémentée ; ajoutez à cela une exquise délicatesse
des mains et des pieds dont la cambrure reste découverte, et vous
aurez le croquis de Cata et de la généralité des Malaguègnes. La
plupart ont en outre un petit air réservé et sérieux sous lequel perce
le désir de plaire et la satisfaction de se sentir admirée. Voilà plus
qu’il n’est suffisant pour mettre à l’épreuve la vertu des saints. Ne
vous étonnez pas si la nôtre subit des assauts.
A notre baragouin castillan la niña riait comme une folle et ne se
lassait pas de remplir nos verres, que de notre côté nous ne nous
lassions pas de vider. Aussi bien avant le dessert, mon compagnon,
plus ferré que moi sur la langue de Don Quichotte, lui décocha ce
quatrain décroché d’un vieux livre :
Son tus labios dos cortinas

De terciopelo carmesi ;
Entre cortina y cortina,
Niña, dime que si.
Tes lèvres sont deux rideaux

De velours cramoisi ;
Entre rideau et rideau,
Fillette, dis-moi que oui.
Riant aux éclats, les mains appuyées sur ses seins, comme pour
en mieux accuser les contours, elle se laissa voler un baiser en
criant : no, no, no, puis se sauva, et deux secondes après nous
entendions sa tante et sa cousine, la préposée aux lits, joindre leurs
gammes à la sienne. Trilles moqueurs qui tombèrent sur notre
ardeur comme autant de douches glacées.
Le soir, pour nous consoler, nous allions assister à la malagueria,
mimique locale qu’on ne danse plus guère que dans les cabarets du
port et les concerts populeux ; sorte de pantomime amoureuse jouée
entre une jeune fille et un beau gars bien découplé, qui ne m’a pas
semblé différer essentiellement de celles déjà vues dans les villes
andalouses. Une chose m’a frappé dans toutes ces chorégraphies,
la différence marquée et caractéristique entre les danses
espagnoles et les nôtres. Chez nous, l’art chorégraphique est
devenu une savante acrobatie dont le nec plus ultra consiste à
s’écarter tant qu’on peut de la nature. Se tenir sur la plante de
l’orteil, s’élancer les bras en l’air comme si l’on voulait s’envoler dans
les frises, prendre des poses disloquées, faire des sauts de pie et un
compas de ses jambes, c’est ce qui plonge au troisième ciel tous les
dilettanti, amants forcenés de ces genres de tour.
Au risque de passer pour un philistin, j’avoue mes sympathies
pour des poses plus naturelles. Aux sauts périlleux de l’étoile
gymnasiarque, je préfère de beaux reins qui se cambrent, des flancs
qui voluptueusement ondoient, une taille qui semble plier sous
l’étreinte amoureuse, et, comme le disait avec son sens de l’art et du
beau l’immortel Gautier, « une femme qui danse et non pas une
danseuse, ce qui est bien différent ».
Les environs de Malaga seraient délicieux sans les nuées de
poussière qui enveloppent tout, bêtes et gens, villas et végétation. A
certains moments, cette poussière est d’une telle épaisseur que les
côtés des routes semblent recouverts d’une couche de neige. Les
arbres paraissent ornés d’un feuillage de carton et les bananiers,
dont les grandes feuilles pendent jusqu’à terre, ont l’air d’arbres en
zinc.
Nous prîmes le tramway pour aller jusqu’au Polo, village de
pêcheurs à quelques milles de la ville, et nous pûmes nous rendre
compte de cette atmosphère poudreuse qui, plus que la malpropreté
des rues de Malaga, empêche les étrangers d’y faire un long séjour.

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Jennifer A. Hart, MPAS, PA-C

John M. MacKnight, MD, FACSM

Previous editions copyrighted 2009.

Library of Congress Control Number: 2019934875

Content Strategist: Charlotta Kryhl

Last digit is the print number: 9 8 7 6 5 4 3 2 1

1600 John F. Kennedy Blvd.

To my past teachers, from whom I learned what it takes to be a PA; to my current

Thomas E. Brickner, MD Dennis Q. Chen, MD D. Nicole Deal, MD

David Diduch, MD Gregory C. Fanelli, MD Eric J. Gardner, MD

Michael Hadeed, MD Joel Himes, DO Chad D. Hulsopple, DO

Anish R. Kadakia, MD Amy Kite, MD Larry Lee, MD

John M. MacKnight, MD, FACSM Todd Milbrandt, MD, MS Nathaniel S. Nye, MD

Christopher J. Pexton, DO Tracy R. Ray, MD Andrew Schwartz, MD

Michael S. Sridhar, MD Marc Tompkins, MD Janet L. Walker, MD

Colton Wood, MD Seth R. Yarboro, MD Dan A. Zlotolow, MD

Chapter 1 How to Use This Book

Introduction • Medial collateral ligament: The primary knee stabilizer to

based on the differential attenuation of the beam by various

• Evaluation of bone pathology (fracture, tumor, arthritis,

• Accurate demonstration of urate acid crystals using

Ultrasonography • Foreign body detection (Fig. 3.15).

Fig 3.15 Ultrasonography: Foreign body. A small, echogenic

If normal but high degree of clinical suspicion

If no contraindication for MRI If MRI is contraindicated

MRI Bone scan

Fig 3.24 Skeletal trauma algorithm.

16 Fig 3.25 Focal lesion: Bone algorithm.

Radiography Still Conservative therapy

Fracture Normal Focal

CT MRI Bone scan

Fig 3.28 Low back pain algorithm.

Key Concepts • High-resistance techniques are generally considered more

Fig 4.1 Therapeutic exercise and modalities.

• Therapeutic US is typically avoided in the acute stages of

Chapter 5 Special Populations:

• Elderly adults have a decrease in bone mineral density,

• A screening evaluation should be done before initiating an

• The International Paralympic Committee was established in

BOX 6.1 Types of Disabilitiesa

Chapter 7 Special Populations:

• The increase in female participation is associated with

Vers six heures, nous atteignîmes Padul, bourgade assise dans

Le jour se levait quand, des pentes de la Sierra de Lujor, nous

Il résulte de cette audacieuse flibusterie une dépréciation

A la recherche d’une posada dans les prix doux — car si nous

Son tus labios dos cortinas

Tes lèvres sont deux rideaux

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