Essential Orthopaedics 2Nd Edition Mark D Miller full chapter pdf docx

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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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Design Direction: Brian Salisbury
Printed in China
Last digit is the print number: 9 8 7 6 5 4 3 2 1
1600 John F. Kennedy Blvd.

Ste 1600
Philadelphia, PA 19103-2899
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.
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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
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risk of injury in professional baseball players. Orthop J Sports Med.
• Core exercise should be supplemented by some
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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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at the Italian opera in Paris; but the only foundation for such a report
seems to be that it was not uncommon for violinist composers of that
period to enlist the aid of their friends in writing for the orchestra.
Viotti was a broadly educated musician, whose experience with
orchestras was wide.
Second in importance to the concertos are the duets for two violins
written during his stay in Hamburg. These are considered second in
musical charm only to Spohr’s pieces in the same manner. That
Viotti was somewhat low in spirit when he was at work on them,
exiled as he was from London and Paris, is shown by the few words
prefixed to one of the sets, ‘This work is fruit of the leisure which
misfortune has brought me. Some pieces came to me in grief, others
in hope.’
Viotti had a brilliant and unrestricted technique. He was among the

greatest of virtuosi. But little of this appears in his music. That is
distinguished by a dignity and a relative simplicity, well in keeping
with the noble traditions inherited from a country great in more ways
than one in the musical history of the eighteenth century. But as far
as form and style go he is modern. He undoubtedly owes something
to Haydn. Moreover, Wasielewski makes the point that there is no
trace in his music of the somewhat churchly dignity one feels in the
sonatas of Corelli and Tartini. Viotti’s is a thoroughly worldly style, in
melody and in the fiery but always musical passage work. He is at
once the last of the classic Italians and the first of the moderns,
standing between Corelli and Tartini on the one hand and Spohr,
David, and Vieuxtemps on the other.
The list of the men who came to him for instruction while he was in
Paris contains names that even today have an imposing ring. Most
prominent among them are Rode, Cartier, and Durand. And among
those who were not actually his pupils but who accepted him as their
ideal and modelled themselves after him were Rodolphe Kreutzer
and Pierre Baillot. These men are the very fountain head of most
violin music and playing of the nineteenth century. They set the
standard of excellence in style and technique by which Spohr and
later Vieuxtemps ruled themselves.
IV
Before considering their work, the development of violin music in
Germany during the eighteenth century must be noticed. The
influence of the Italians was not less strong here than in France.
Both Biber and Strungk had come under it in the late seventeenth
century, Strungk being, as we know, personally acquainted with
Corelli and at one time associating closely with him in Rome. The
German violinists of the eighteenth century either went to Italy to
study, or came under the influence of various Italians who passed
through the chief German cities on concert tours.
The most conspicuous of them are associated with courts or cities

here and there. For instance, early in the century there is Telemann
in Hamburg; a little later Pisendel in Dresden; J. G. Graun in Berlin;
Leopold Mozart in Salzburg; the gifted Stamitz and his associates
Richter, Cannabich and Fränzl in Mannheim; and the most amiable if
not the most gifted of all, Franz Benda, here and there in Bohemia,
Austria and Saxony. Though these and many more were widely
famous in their day as players, and Mozart was influential as a
teacher, little of their music has survived the centuries that have
passed since they wrote it. The eighteenth century was in violin
music and likewise in opera, the era of Italian supremacy; and in
violin music we meet with little except copies outside of Italy.
Georg Philipp Telemann, it is true, wrote that he followed the French

model in his music; but as Wasielewski says, this applies evidently
only to his vocal works and overtures, for his violin compositions are
very clearly imitations of Corelli’s. All his music, and he wrote
enormous quantities in various branches, is essentially
commonplace. Between 1708 and 1721 Telemann occupied a
position at the court of Eisenach. It was chiefly during these years
that he gave himself to the violin and violin music. Afterwards he
went to Hamburg and there worked until his death in 1767.
Johann Georg Pisendel is a far more distinguished figure. He was

born on the twenty-sixth of December, 1687, at Carlsburg in
Franconia, and died in Dresden, after many years’ service there, in
November, 1755. While still a boy the Marquis of Anspach attached
him to his chapel, on account of his beautiful voice. In the service of
the same prince at that time was Torelli, the great Italian composer
for the violin; and Pisendel was his pupil for a considerable period.
Later in life he was able to journey in Italy and France, and was
apparently at one time a pupil of Vivaldi’s in Venice. From 1728 to
the time of his death he was first violin in the royal opera house at
Dresden. His playing was distinguished by care in shading, and in
his conducting he was said to have laid great importance upon ‘loud
and soft.’ As a composer he is without significance, though some of
his works—concertos and sonatas—have been preserved. But his
influence served to educate violinists in that part of Germany, so that
little by little Germans came to supplant the Italians in that branch of
music, and to find occupation in connection with the opera house
orchestra, which had been up to that time almost entirely made up of
Italians.
Most conspicuous among those who were actually his pupils was
Johann Gottlieb Graun, brother of the still familiar Carl Heinrich. But
Graun was not content with instruction in Germany alone, and
betook himself to Tartini in Padua. After his return to his native land,
he eventually found his place at the court of Frederick the Great,
who was still crown prince. With him at this time were Quantz, the
flute player, and Franz Benda. After the accession of Frederick to the
throne of Prussia, Graun was made first violin and concert master in
the royal orchestra; and he held this place until his death in 1771.
His compositions, like all others for the violin at this period, are
hardly more than imitations of the Italian masterpieces. And like
Pisendel, his importance is in the improvement of the state of
instrumental music in Germany, and especially of the orchestra at
Berlin.
His successor in this royal orchestra was Franz Benda, who, not only
by reason of the romantic wanderings of his life, is one of the most
interesting figures in the history of music in Germany during the
eighteenth century. His father, Hans Georg, had been a sort of
wandering player, as well as a weaver; and his brothers, Johann,
Georg, and Joseph, were all musicians who won a high place in their
day. Georg was perhaps the most distinguished of the family, but in
the history of violin-music Franz occupies a more important place.
The Bendas were Bohemians, but most of them settled in Germany

and accepted German ideals and training. Franz Benda, after a
changing career as a boy singer in various places, finally came
under the influence of Graun and Quantz in the crown prince’s
orchestra, at Rheinsberg. The principal instruction he received upon
the violin came from Graun, who was himself a pupil of Tartini’s; so,
although Benda shows the marks of an independent and self-
sufficient development, not a little of Italian influence came close to
him. He remained in the service of the Prussian court from 1733,
when Quantz befriended him, until his death as an old man in 1786.
His playing was admired for its warm, singing quality, which showed
to such advantages in all slow movements that musicians would
come long distances to hear him play an adagio. Burney heard him
in 1772 and was impressed by the true feeling in his playing. Burney,
too, mentioned that in all Benda’s compositions for the violin there
were no passages which should not be played in a singing and
expressive manner. He went on to say that Benda’s playing was
distinguished in this quality from that of Tartini, Somis, and Veracini,
and that it was something all his own which he had acquired in his
early association with singers.
He had indeed been a great singer, and he gave up public singing

only because after singing he was subject to violent headache. He
trained his two daughters to be distinguished singers of the next
generation.
His works for the violin are numerous, but only a small part of them
was published, and this posthumously. In spite of the often lovely
melodies in the slow movements they have not been able to outlive
their own day. Wasielewski calls attention to the general use of
conventional arpeggio figures in the long movements, which,
characteristic of a great deal of contemporary music for the violin,
may have been written with the idea of offering good technical
exercise in the art of bowing.
Among Benda’s many pupils the two most significant are his own
son, Carl, and Friedrich Wilhelm Rust. The former seems to have
inherited a great part of his father’s skill and style. The sonatas of the
latter are among the best compositions written in Germany for the
violin in the second half of the eighteenth century. Rust died in
February, 1798. His name is remembered as much for his sonatas
for pianoforte as for his violin compositions. Another pupil, Carl
Haack, lived until September, 1819, and thus was able to carry the
Benda tradition over into the nineteenth century. On the whole Franz
Benda may be said to have founded a school of violin playing in
Berlin which has influenced the growth of music for that instrument in
Germany. Its chief characteristic was the care given to simplicity and
straightforwardness, especially in the playing of slow movements
and melodies, which stands out quite distinctly against the current of
more or less specious virtuosity running across the century.
Johann Peter Salomon (1745-1815) has been associated with the

Berlin group, though his youth was spent in and about Bonn, and his
greatest activity was displayed as an orchestral conductor in London.
It was he who engaged Haydn to come to London and to compose
symphonies specially for a London audience; and he occupies an
important place in the history of music in England as one of the
founders (1813) of the Philharmonic Society. He published but little
music, and that is without significance.
One of the outstanding figures in the history of violin music in

Germany is Leopold Mozart, the father of Wolfgang. He is hardly
important as a composer, though many of his works were fairly well
known in and about Salzburg where the greatest part of his life was
spent; but his instruction book on playing the violin marks the
beginning of a new epoch in his own country. This was first
published in Augsburg in 1756, was reprinted again in 1770, 1785,
and in Vienna in 1791 and 1804. It was for many years the only book
on the subject in Germany.
Much of it is now old-fashioned, but it still makes interesting reading,

partly because he was far-seeing enough to seize upon fundamental
principles that have remained unchanged in playing any instrument,
partly because the style is concise and the method clear, partly
because of the numerous examples it contains of both good and bad
music. Evidently his standard of excellence is Tartini, so that we still
find violin music in Germany strongly under the influence of the
Italians. But the great emphasis he lays upon simplicity and
expressiveness recalls Benda and his ideals, so that it would appear
that some wise men in Germany were at least shrewd enough to
choose only what was best in the Italian art. Among the many
interesting points he makes is that it takes a better-trained and a
more skillful violinist to play in an orchestra than to make a success
as a soloist. Evidently many of the German musicians distrusted the
virtuoso. Emanuel Bach, it will be remembered, cared nothing for
show music on the keyboard. C. F. D. Schubart, author of the words
of Schubert’s Die Forelle, said that an orchestra made up of virtuosi
was like a world of queens without a ruler. He had the orchestra at
Stuttgart in mind.
V
Meanwhile about the orchestra at Mannheim there was a band of
gifted young men whose importance in the development of the
symphony and other allied forms has been but recently recognized,
and now, it seems, can hardly be overestimated. The most
remarkable of these was J. C. Stamitz, a Bohemian born in 1719,
who died when less than forty years old. His great accomplishments
in the domains of orchestral music have been explained elsewhere
in this series. In the matter of violin music he can hardly be said to
show any unusual independence of the Italians, but in the meagre
accounts of his life there is enough to show that he was a great
violinist. He was the teacher of his two sons, Carl (1746-1801) and
Anton (b. 1753), the latter of whom apparently grew up in Paris,
where the father, by the way, had been well known at the house of
La Pouplinière. Anton, as we shall see, was the teacher of Rodolphe
Kreutzer, already mentioned as one of the great teachers at the
Paris Conservatory in the first of the nineteenth century.
Christian Cannabich, a disciple if not a pupil of Stamitz, was likewise

a famous violinist, but again like his master, was more influential in
what he accomplished with the famous orchestra at Mannheim than
in his playing or composing for the violin. He seems to have spent
some years in Naples to study with Jomelli, and the Italian influence
is evident in all he wrote for the violin. Wilhelm Cramer, the father of
the now more famous J. B. Cramer, was another violinist associated
with the Mannheim school, until in 1773 he went to London on the
advice of Christian Bach. Here he lost one place after another as
conductor, owing now to the arrival of Salomon, now to that of Viotti.
He died in 1799 in great poverty.
Others connected with the orchestra at Mannheim are Ignaz Fränzl,

whose pupil, F. W. Pixis, became the teacher of Kalliwoda and Laub,
and whose son Ferdinand (1770-1833) was a distinguished violinist
in the next century; and Johann Friedrich Eck (b. 1766) and his
brother Franz. Their father was, like Stamitz, a Bohemian. Indeed
Stamitz seems to have induced Eck the elder to leave Bohemia and
come to Mannheim. Franz Eck is most famous today as one of the
teachers of Ludwig Spohr.
In Vienna the Italian influence was supreme down to nearly the end
of the century. The first of the Viennese violinists to win an
international and a lasting renown was Karl Ditters von Dittersdorf (b.
1739), the friend of Haydn and Gluck. Though two of his teachers,
König and Ziegler, were Austrians, a third, who perfected him, was
an Italian, Trani. Through Trani Dittersdorf became familiar with the
works of Corelli, Tartini, and Ferrari, after which he formed his own
style. Practically the first German to draw a circle of pupils about him
was Anton Wranitzky (b. 1761). Among his pupils the most
distinguished was Ignaz Schuppanzigh, who, as the leader of the
Schuppanzigh quartet, won for himself an immortal fame, and really
set the model for most quartet playing throughout the nineteenth
century. He was the son of a professor at the Realschule in Vienna.
From boyhood he showed a zeal for music, at first making himself a
master of the viola. At the time Beethoven was studying counterpoint
with Albrechtsberger he was taking lessons on the viola with
Schuppanzigh. Later, however, Schuppanzigh gave up the viola for
the violin. His most distinguished work was as a quartet leader, but
he won fame as a solo player as well; and when the palace of Prince
Rasoumowsky was burned in 1815, he went off on a concert tour
through Germany, Poland and Russia which lasted many years. He
was a friend not only of Beethoven, but of Haydn, Mozart, and of
Schubert as well; and was the principal means of bringing the
quartet music of these masters to the knowledge of the Viennese
public. He died of paralysis, March 2, 1830. Among his pupils the
most famous was Mayseder, at one time a member of the quartet.
What is noteworthy about the German violinist-composers of the

eighteenth century is not so much the commonness with which they
submitted to the influence of the Italians, but the direction their art as
players took as soon as they began to show signs of a national
independence. Few were the match of the Italians or even the
French players in solo work. None was a phenomenal virtuoso. The
greatest were most successful as orchestral or quartet players; and
their most influential work was that done in connection with some
orchestra. This is most evident in the case of the Mannheim
composers. Both Stamitz and Cannabich were primarily conductors,
who had a special gift in organizing and developing the orchestra.
Their most significant compositions were their symphonies, in the
new style, in which they not only gave a strong impetus to the
development of symphonic forms, but brought about new effects in
the combination of wood-wind and brass instruments with the
strings. Leopold Mozart’s opinion that a man who could play well in
an orchestra was a better player and a better musician than he who
could make a success playing solos, is indicative of the purely
German idea of violin music during the century. And it cannot be
denied that great as Franz Benda and Johann Graun may have been
as players, they contributed little of lasting worth to the literature of
the violin, and made practically no advance in the art of playing it.
But both were great organizers and concert masters, and as such
left an indelible impression on the development of music, especially
orchestral music, in Germany.
VI
Before concluding this chapter and passing on to a discussion of the
development of violin music in the nineteenth century a few words
must be said of the compositions for the violin by those great
masters who were not first and foremost violinists. Among these,
four may claim our attention: Handel, Bach, Haydn, and Mozart.
Handel is not known to have given much time to the violin, but it is
said that when he chose to play on it, his tone was both strong and
beautiful. He wrote relatively little music for it. Twelve so-called solo
sonatas with figured bass (harpsichord or viol) were published in
1732 as opus 1. Of these only three are for the violin: the third, tenth,
and twelfth. The others are for flute. Apart from a few characteristic
violin figures, chiefly of the rocking variety, these solo sonatas might
very well do for clavier with equal effect. There is the sane, broad
mood in them all which one associates with Handel. In the edition of
Handel’s works by the German Handel Society, there are three
additional sonatas for violin—in D major, A major, and E major.
These seem to be of somewhat later origin than the others, but they
are in the same form, beginning with a slow movement, followed by
allegro, largo, and final allegro, as in most of the cyclical
compositions of that time. One cannot deny to these sonatas a
manly dignity and charm. They are in every way plausible as only
Handel knows how to be; yet they have neither the grace of Corelli,
nor the deep feeling of Bach. One may suspect them of being, like
the pieces for clavier, tossed off easily from his pen to make a little
money. What is remarkable is that sure as one might be of this, one
would yet pay to hear them.
There are besides these solo sonatas for violin or flute and figured
bass, nine sonatas for two violins, or violin and flute with figured
bass, and seven sonatas, opus 5, for two instruments, probably
intended for two violins.
Among the most remarkable of J. S. Bach’s compositions are the six

sonatas for violin without any accompaniment, written in Cöthen,
about 1720. These works remain, and probably always will remain,
unique in musical literature, not only because of their form, but
because of the profound beauty of the music in them. Just how much
of a violinist Bach himself was, no one knows. He was fond of
playing the viola in the court band at Cöthen. It can hardly be
pretended that these sonatas for violin alone are perfectly adapted to
the violin. They resemble in style the organ music which was truly
the whole foundation of Bach’s technique. In that same organ style,
he wrote for groups of instruments, for groups of voices, for clavier
and for all other combinations.
On the other hand no activity of Bach’s is more interesting, and

perhaps none is more significant, than his assiduous copying and
transcribing again and again of the violin works of Vivaldi, Torelli, and
Albinoni. Especially his study of Vivaldi is striking. He used themes
of the Italian violinists as themes for organ fugues; he transcribed the
concertos of Vivaldi into concertos for one, two, three, or four
harpsichords. And not only that, practically all his concertos for a
solo clavier are transcriptions of his own concertos for violin.
But the polyphonic style of the sonatas for violin alone is peculiarly a
German inheritance. Walter and Biber were conspicuous for the use
of double stops and an approach to polyphonic style. Most
remarkable of all was a pupil of the old Danish organist, Buxtehude,
Nikolaus Bruhns (1665-1697), who was able to play two parts on his
violin and at the same time add one or two more with his feet on the
organ pedals. Though Corelli touched gently upon the polyphonic
style in the movements of the first six of his solo sonatas, the
polyphonic style was maintained mostly by the Germans. As Bach
would write chorus, fugue, or concerto in this style, so did he write
for the violin alone.
Of the six works the first three are sonatas, in the sense of the
sonate da chiesa of Corelli, serious and not conspicuously
rhythmical. The last three are properly suites, for they consist of
dance movements. The most astonishing of all the pieces is the
Chaconne, at the end of the second suite. Here Bach has woven a
series of variations over a simple, yet beautiful, ground, which finds
an equal only in the great Passacaglia for the organ.
The three sonatas of this set can be found transcribed, at least in

part, by Bach into various other forms. The fugue from the first, in G
minor, was transposed into D minor and arranged for the organ. The
whole of the second sonata, in A minor, was rearranged for the
harpsichord. The fugue in the third sonata for violin alone exists also
as a fugue for the organ.
There are besides these sonatas for violin alone, six sonatas for
harpsichord and violin, which are among the most beautiful of his
compositions; and a sonata in E minor and a fugue in G minor for
violin with figured bass. It is interesting to note that the six sonatas
for harpsichord and violin differ from similar works by Corelli and by
Handel. Here there is no affair with the figured bass; but the part for
the harpsichord is elaborately constructed, and truly, from the point
of view of texture, more important than that for the violin.
Bach wrote at least five concertos for one or two violins during his
stay at Cöthen. One of these is included among the six concertos
dedicated to the Margrave of Brandenburg. All of these have been
rearranged for harpsichord, and apparently among the harpsichord
concertos there are three which were originally for violin but have not
survived in that shape. The concertos, even more than the sonatas,
are not essentially violin music, but are really organ music. The style
is constantly polyphonic and the violin solos hardly stand out
sufficiently to add a contrasting spot of color to the whole. Bach’s
great work for the violin was the set of six solo sonatas. These must
indeed be reckoned, wholly apart from the instrument, as among the
great masterpieces in the musical literature of the world.
Haydn’s compositions for violin, including concertos and sonatas,

are hardly of considerable importance. His associations with
violinists in the band at Esterhazy, and later in Vienna with amateurs
such as Tost and professionals like Schuppanzigh, gave him a
complete idea of the nature and the possibilities of the instrument.
But the knowledge so acquired shows to best advantage in his
treatment of the first and second violin parts in his string quartets, in
many of which the first violin is given almost the importance of a solo
instrument. Eight sonatas for harpsichord and violin have been
published, but of these only four were originally conceived in the
form.
The young Mozart was hardly less proficient on the violin than he
was on the harpsichord, a fact not surprising in view of his father’s
recognized skill as a teacher in this special branch of music. But he
seems to have treated his violin with indifference and after his
departure from Salzburg for Paris to have quite neglected his
practice, much to his father’s concern. The most important of his
compositions for the violin are the five concertos written in Salzburg
in 1775. They were probably written for his own use, but just how
closely in conjunction with the visit of the Archduke Maximilian to
Salzburg in April of that year cannot be stated positively. Several
serenades and the little opera, Il re pastore, were written for the fêtes
given in honor of the same young prince. The concertos belong to
the same period. In Köchel’s Index they are numbers 207, 211, 216,
218, and 219. A sixth, belonging to a somewhat later date, bears the
number 268. Of these the first in B-flat was completed on April 14,
1775, the second, in D, June 14, the third, in G, September 12, the
fourth, in D, in October, and the fifth, in A, quite at the end of the
year.
The sixth concerto, in E-flat, is considered both by Jahn and Köchel

to belong to the Salzburg period. It was not published, however, until
long after Mozart’s death; and recently the scholarly writers, Messrs.
de Wyzewa and de St. Foix, have thrown considerable doubt upon
the authenticity of large parts of it. According to their theory[50] the
opening tutti and the orchestral portion at the beginning of the
development section are undoubtedly the work of Mozart, but of the
mature Mozart of 1783 and 1784. Likewise the solo passages in all
the movements seem to bear the stamp of his genius. But apart from
these measures, the development of the solo ideas and the
orchestral accompaniment were completed either by André, who
published the work, or by Süssmayer, who was also said by Mozart’s
widow to be the composer of a mass in B-flat, published by C. F.
Peters as a composition of Mozart’s.
In addition mention should be made of the concertos introduced

between the first and second movements of various serenades,
according to the custom of the day. Most of these are of small
proportions; but one, in G major (K. 250), written in Salzburg some
time in July, 1776, has the plan of an independent composition.
It was the custom for a master like Schobert in Paris, or Mozart in

Vienna, to ‘accompany’ the young ladies who played pianoforte or
harpsichord sonatas of his composition and under his instruction with
music on the violin. There are many sonatas for harpsichord
published by Schobert, with a violin part ad libitum. This in the main
but reinforces the chief melodic lines of the part for harpsichord or
pianoforte; and works with such a violin part, ad libitum, are not at all
violin sonatas in the sense of the term accepted today, i.e., sonatas
in which violin and piano are woven inextricably together. They are
frankly pianoforte or harpsichord sonatas with the ‘accompaniment’
of a violin.
On the other hand, we have found the violin masters like Corelli and
Tartini writing sonatas for violin, with figured bass for harpsichord,
lute, or even viol. Such sonatas were often called solo sonatas, as in
the case of those of Handel, recently mentioned. The accompanying
instrument had no function but to add harmonies, and a touch of
imitation in the written bass part, here and there.
Between these two extremes lies the sonata with harpsichord
obbligato, that is to say, with a harpsichord part which was not an
accompaniment but an essential part of the whole. In these cases
the music was generally polyphonic in character. The violin might
carry one or two parts of the music, the harpsichord two or three.
Very frequently, if the instruments played together no more than
three parts, the composition was called a Trio. The sonatas by J. S.
Bach for harpsichord and violin are of this character. Though the
harpsichord carries on more of the music than the violin, both
instruments are necessary to the complete rendering of the music.
Mozart must have frequently added improvised parts for the violin to
many of his sonatas written expressly for the keyboard instrument.
Among his earliest works one finds sonatas for clavecin with a free
part for violin, for violin or flute, for violin or flute and 'cello. Oftenest
the added part does little more than duplicate the melody of the part
for clavecin, with here and there an imitation or a progression of
thirds or sixths. But among his later works are sonatas for pianoforte
with added accompaniment for violin in which the two instruments
contribute something like an equal share to the music, which are the
ancestors of the sonatas for violin and piano by Beethoven, Brahms,
and César Franck. Among the most important of these are six
published in November, 1781, as opus 2. In Köchel’s Index they bear
the numbers 376, 296, 377, 378, 379, and 380. The greatest of them
is that in C major, K. 296, with its serious and rich opening adagio, its
first allegro in Mozart’s favorite G minor, and the beautiful variations
forming the last movement. Four more sonatas, of equal musical
value, were published respectively in 1784, 1785, 1787, and 1788.
VII
Looking back over the eighteenth century one cannot but be
impressed by the independent growth of violin music. The Italians
contributed far more than all the other nationalities to this steady
growth, partly because of their native love for melody and for sheer,
simple beauty of sound. The intellectual broadening of forms, the
intensifying of emotional expressiveness by means of rich and
poignant harmonies, concerned them far less than the perfecting of a
suave and wholly beautiful style which might give to the most singing
of all instruments a chance to reveal its precious and almost unique
qualities. This accounts for the calm, classic beauty of their music,
which especially in the case of Corelli and Tartini does not suffer by
changes that have since come in style and the technique of
structure.
The success of the Italian violinists in every court of Europe, both as

performers and as composers, was second only to the success of
the great singers and the popular opera composers of the day. Their
progress in their art was so steadfast and secure that other nations
could hardly do more than follow their example. Hence in France and
Germany one finds with few exceptions an imitation of Italian styles
and forms, with a slight admixture of national characteristics, as in
the piquancy of Cartier’s, the warm sentiment of Benda’s music.
What one might call the pure art of violin playing and violin music,
abstract in a large measure from all other branches of music, was
developed to perfection by the Italian violinist-composers of the
eighteenth century. Its noble traditions were brought over into more
modern forms by Viotti, henceforth to blend and undergo change in a
more general course of development.
Perhaps only in the case of Chopin can one point to such a pure and
in a sense isolated ideal in the development of music for a single
instrument, unless the organ works of Bach offer another exception.
And already in the course of the eighteenth century one finds here
and there violin music that has more than a special significance. The
sonatas for unaccompanied violin by Bach must be regarded first as
music, then as music for the violin. The style in which they were
written is not a style which has grown out of the nature of the
instrument. They have not served and perhaps cannot serve as a
model for perfect adaptation of means to an end. Bach himself was
willing to regard the ideas in them as fit for expression through other
instruments. But the works of Corelli, Tartini, Nardini and Viotti are
works which no other instrument than that for which they were
written may pretend to present. And so beautiful is the line of melody
in them, so warm the tones which they call upon, that there is
scarcely need of even the harmonies of the figured bass to make
them complete.
In turning to the nineteenth century we shall find little or no more of

this sort of pure music. Apart from a few brilliant concert or salon
pieces which have little beyond brilliance or charm to recommend
them, the considerable literature for the violin consists of sonatas
and concertos in which the accompaniment is like the traditional half,
almost greater than the whole. In other words we have no longer to
do with music for which the violin is the supreme justification, but
with music which represents a combination of the violin with other
instruments. Glorious and unmatched as is its contribution in this
combination, it remains incomplete of itself.
FOOTNOTES:
[48] See A. Schering: Geschichte des Instrumentalkonzerts.
[49] Die Violine und ihre Meister.
[50] See ‘W. A. Mozart,’ by T. de Wyzewa and G. de St. Foix, Paris, 1912.
Appendix II, Vol. II, p. 428.
CHAPTER XIII
VIOLIN MUSIC IN THE NINETEENTH
CENTURY
The perfection of the bow and of the classical technique—The
French school: Kreutzer, Rode, and Baillot—Paganini: his
predecessors, his life and fame, his playing, and his compositions
—Ludwig Spohr: his style and his compositions; his pupils—
Viennese violinists: Franz Clement, Mayseder, Boehm, Ernst and
others—The Belgian school: De Bériot and Vieuxtemps—Other
violinist composers: Wieniawski, Molique, Joachim, Sarasate, Ole
Bull; music of the violinist-composers in general—Violin music of
the great masters.
The art of violin music in the nineteenth century had its head in
Paris. Few violinists with the exception of Paganini developed their
powers without the model set them by the great French violinists at
the beginning of the century. Most of them owed more than can be
determined to the influence of Viotti. Even Spohr, who with more or
less controversial spirit, wrote of the French violinists as old-
fashioned, modelled himself pretty closely upon Rode; and therefore
even Spohr is but a descendant of the old classical Italian school.
The technique of playing the violin was thoroughly understood by the

end of the eighteenth century. Viotti himself was a brilliant virtuoso;
but, trained in the classic style, he laid less emphasis upon external
brilliance than upon expressiveness. The matters of double stops,
trills, runs, skips and other such effects of dexterity were largely
dependent upon the fingers of the left hand; and this part of
technique, though somewhat hampered by holding the violin with the
chin upon the right side of the tailpiece, was clearly mastered within
reasonable limits by the violinists of the middle of the century, Tartini,
Veracini, Nardini, Geminiani, and others. Indeed Geminiani in his
instruction book recommended that the violin be held on the left side;
and in range of fingering gave directions for playing as high as in the
seventh position. Leopold Mozart, however, naturally conservative,
held to the old-fashioned holding of the instrument.
The technique of bowing, upon which depends the art of expression

in violin playing, awaited the perfection of a satisfactory bow. Tartini’s
playing, it will be remembered, was especially admired for its
expressiveness; and this, together with certain of his remarks on
bowing which have been preserved in letters, leads one to think that
he may have had a bow far better than those in the hands of most of
his contemporaries. Whether or not he made it himself, and indeed
just what it may have been, are not known. Certainly it must have
been better than the bows with which Leopold Mozart was familiar.
The clumsy nature of these may be judged by the illustrations in his
instruction book.
The final perfection of the bow awaited the skill of a Frenchman,

François Tourte (1747-1835), who has properly been called the
Stradivari of the bow. It was wholly owing to his improvements that
many modern effects in staccato, as well as in fine shading,
particularly in the upper notes, became possible. He is supposed not
to have hit upon these epoch-making innovations until after 1775;
and there is much likelihood that he was stimulated by the presence
of Viotti in Paris after 1782. No better testimony to the service he
rendered to the art of violin playing can be found than the new
broadening of violin technique and style accomplished by men like
Viotti, Kreutzer, Baillot, Rode, and Lafont, who availed themselves
immediately of the results of his skill.
I
Something may now be said of these men, whose activities have
without exception the glaring background of the horrors of the
French Revolution. Though Kreutzer was of German descent, he
was born in Versailles (1766) and spent the greater part of his life in
and about Paris, intimately associated with French styles and
institutions. Apart from early lessons received from his father, he
seems to have been for a time under the care of Anton Stamitz, son
of Johann Stamitz. At the Chapelle du Roi, to which organization he
obtained admittance through the influence of Marie Antoinette, he
had the occasion of hearing Viotti. The great Italian influenced him
no less than he influenced his young contemporaries in Paris.
Concerning his activities as a composer of operas little need be said,
though one or two of his ballets, especially Paul et Virginie and Le
Carnaval de Venise, held the stage for some years. As a player he
ranks among the most famous of the era. His duets with Rode
roused the public to great enthusiasm. In 1798 he was in Vienna in
the suite of General Bernadotte, and here made the acquaintance of
Beethoven. Subsequently Beethoven dedicated the sonata for violin
and piano (opus 47) to Kreutzer.
By reason of this and his book of forty Études ou caprices pour le

violon, he is now chiefly remembered. His other compositions for the
violin, including nineteen concertos and several airs and variations,
have now been allowed to sink into oblivion. To say that the
concertos are ‘more brilliant than Rode’s, less modern than Baillot’s’
distinguishes them as much as they may be distinguished from the
compositions of his contemporaries. They are dry music, good as
practice pieces for the student, but without musical life. But Kreutzer
was a great teacher. He was one of the original professors of the
violin at the Conservatoire, and with Baillot and Rode prepared the
still famous Méthode which, carrying the authority of that sterling
institution, has remained, almost to the present day, the standard
book of instruction for the young violinist. His own collection of forty
studies likewise holds still a place high among those ‘steps to
Parnassus’ by which the student may climb to the company of
finished artists.

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

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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

Viotti had a brilliant and unrestricted technique. He was among the

The most conspicuous of them are associated with courts or cities

Georg Philipp Telemann, it is true, wrote that he followed the French

Johann Georg Pisendel is a far more distinguished figure. He was

The Bendas were Bohemians, but most of them settled in Germany

He had indeed been a great singer, and he gave up public singing

Johann Peter Salomon (1745-1815) has been associated with the

One of the outstanding figures in the history of violin music in

Much of it is now old-fashioned, but it still makes interesting reading,

Christian Cannabich, a disciple if not a pupil of Stamitz, was likewise

Others connected with the orchestra at Mannheim are Ignaz Fränzl,

What is noteworthy about the German violinist-composers of the

Among the most remarkable of J. S. Bach’s compositions are the six