Patient Education

Shoulder Anatomy                                                                   Knee Anatomy                                                                         Basketball Injuries                                         
Tennis Elbow                                                                     Youth Baseball Injuries                                                     Runner's Knee                                     Meniscus Tears                                                                 Patellar Mal-alignment                                                        Degenerative Knee Changes


 Shoulder Joint Anatomy

The scapula, also known as the shoulder blade, is a large, flat bone located on each side of the upper back. The scapula has connections with the clavicle (or collar bone), the humerus (or upper arm bone), and is firmly attached to back by strong muscles. The scapula is a triangular shaped bone with four main structures, or prominences, that serve as key attachment points for bones, ligaments, and muscles. These prominences are located in such a way as to provide mechanical leverage for ligaments and muscles as they perform complex joint movements. Other flat areas on the scapula, called fossas, serve as attachment points for muscles of the rotator cuff.

The front or anterior slide of the scapula is dish-like in nature, and serves as the origin for the subscapularis muscle - a broad flat muscle whose fibers go across the shoulder joint and attach on the upper arm bone, contributing the anterior or front portion of the rotator cuff (the sheath of musclo-tendinous tissue that surrounds the shoulder joint).

This anterior or front view of the shoulder joint shows the humerus separated from the scapula. Both the head of the humerus and the glenoid fossa are covered with smooth articular cartilage and allow the bone surfaces to articulate or move freely on one another. In the normal shoulder joint this results in pain-free, frictionless movement.

The shoulder joint is one of the body's most flexible and mobile joints, allowing the arm to be positioned and moved in almost any direction.
In addition, the shoulder joint allows the arm to be rotated inward (internal rotation) or outward (external rotation) to help place the flexed forearm in a better position to accomplish any given task.
The head of the humerus, also called the humeral head, is almost spherical in shape and rotates freely in the glenoid fossa of the scapula. The shoulder joint's flexible ligaments, the rotator cuff, and the other muscles that cross this joint all add to the shoulder's stability and its extraordinary range of motion.

The dorsal or back side of the scapula contains two major areas - one is located above and one is located below the scapular spine. The area above the spine is called the supraspinatus fossa and serves as the origin for the supraspinatus muscle. The large area below the spine is termed the infraspinatus fossa; it serves as the origin for the infraspinatus muscle.

Like the subscapularis muscle, both of these posterior-based muscles insert on the humerus through the strong rotator cuff, and serve to stabilize the shoulder joint. The rotator cuff is the anatomical confluence of these three muscles as they attach to the head of the humerus.

This cuff, sometimes mistakenly called rotator "CUP" by patients, is one of the most important stabilizers of the shoulder joint. Any problem with this tendinous cuff may severely limit such activities as raising your arm above your head, reaching behind you, or doing forceful lifting. Continuing with sports-related activities or aggressive workouts may increase your risk of developing further problems.

As opposed to the hip joint (a true ball and socket joint), the shoulder joint is a much shallower joint, and offers less structural support than is seen in the hip. The shoulder joint's anatomy has sometimes been compared to that of a golf ball and golf tee, with the head of the humerus being compared to the golf ball, and the scapula's glenoid fossa being the tee. The cross-sectional MRI of the shoulder joint, as seen below, shows this unique anatomical relationship in detail.
The illustration on the right depicts a lateral or side view of the scapula, showing the glenoid fossa and the soft tissue ring around it called the glenoid labrum. For clarity the humerus has been removed in this figure in order to show the joint capsule and muscles of the rotator cuff more clearly.

With the humeral head removed, one can readily see the location of the many soft tissue structures that make up the shoulder joint. Because of the lack of bone support in this shallow joint, the soft tissue element's importance cannot be overstated. It is evident that these structures add a great deal of stability to this unique joint.

 Knee Joint Anatomy

Understanding knee joint anatomy is important for knee-injured patients and their immediate family members, who might be assisting in the patient's recovery process. This basic knowledge may also help relieve some of the initial apprehension regarding the injury and treatment. The rehabilitation process will be enhanced if the patient is aware of what structures were damaged by the initial injury, and what measures were undertaken to restore stability and function.

The following is an illustrated overview of the anatomy of the knee. Front and back views of the knee seen on the right side of this page will provide important information about the main structures that provide knee joint stability.

The lateral view of the knee is drawn in a midlateral section to give a clearer view of the menisci and femoral condyles. The blue areas represent bursae. The Medial and Lateral Meniscus, as seen on the left, serve to support the articular condyles of the distal femur and provide near frictionless knee flexion. The two concave surfaces formed by the menisci cradle and support the femur.

 Basketball Injuries

Basketball is a physically demanding contact sport.  Due to the repetitive and forceful nature of running, jumping, twisting and direct contact, the relation between injury and sport often parallel each other.  Some of the most common basketball injuries involve the knee, ankle and foot.  These may include tear to the meniscus, ACL sprains or tears, patellar tendonitis, ankle sprains, and metatarsal fractures of the foot. 

An ankle sprain is a common occurence in basketball.  This injury causes a stretch or tear to one or more of the ligaments in the ankle.  Sprains are graded on a I to III grading scale based on ligament damage, with a Grade III sprain being the most severe.  The most common mechanism of injury involves stepping or landing on someone else's foot.  The result is a twisting injury to the ankle.  Symptoms may include sudden pain, swelling, discoloration, and an inability to move the ankle properly.
If symptoms persist, derformities are noted, or pain intensity is high, x-rays may need to be taken to rule out any bone fractures.  Initial treatment for ankle injuries should include protection from further injury, rest, ice, compression and elevation.  It may be necessary for the player to wear an ankle brace and/or tape to prevent further injury.  A Sports Medicine physician's role in the process in important and may offer the player, parents and coaches valuable reassurance.  Restoration of motion, strength and proprioception are essential for the athlete to return to activity safely.

Another common injury in the ankle/foot complex involves fractures to the metatarsal bones in the foot.  A simple stress fracture in one of the metatarsals is most often treated with non-operative measures such as rest, protected weight-bearing and strengthening.  However, fractures of the 5th metatarsal are among the most difficult to treat.  Surgical intervention may be necessary in those fractures with delayed healing, or those fractures more severe in nature.

 Tennis Elbow

Tennis Elbow, also called lateral epicondylitis, is a very common form of tendinitis that occurs in at a specific area on the lateral elbow. The cause of this condition is believed not to be inflammatory in nature, but may be related to sustained overuse of the forearm, called repetitive trauma. In some instances, the condition may be work-related, or sports-related as well. Although the name implies a direct correlation with the sport of tennis, you do not have to play tennis to get this condition.

Sports-related activities such as racquetball, squash, tennis, and even golf may strain the extensor muscles as they attach to the elbow. In addition, carrying heavy loads with the arms extended and palms facing up may cause tennis elbow symptoms. Repeatedly extending the wrists and fingers also may cause symptoms.

The tenderness and degenerative changes to this area on the outside of the elbow occur at the point of attachment of the tendons and muscles that straighten out the wrist and fingers. These extensor tendons arise from the lateral epicondyle (or outside elbow bump), and receive small, traumatic tears over time, leading to this painful condition.Examination of the lateral elbow area in a patient with Tennis Elbow will reveal soreness in a rather defined area over the elbow’s lateral epicondyle. When diagnosing Tennis Elbow, it is important to rule out nerve compression or bone fractures that may have occurred in this area.

Treatment methods for Tennis Elbow will depend upon the severity of the patient’s symptoms. Sometimes oral anti-inflammatory medications may provide relief of mild Tennis Elbow symptoms. In addition, an injection into this area with a cortico-steroid medication may also improve symptoms. Usually a long wrist splint that keeps the hand in a neutral position will limit the movements of the hand and allow the symptoms to subside. Sometimes a lateral forearm band (also called a Tennis Elbow band or splint) may relieve symptoms by providing support and placing mild pressure on the extensor muscle area.
When conservative measures are not effective in relieving symptoms, surgery may be recommended. During surgery a small incision is made over the lateral elbow area, allowing the surgeon to explore the extensor tendon origin on the humerus (upper arm bone). Degenerative tissue is removed at this time.

 Youth Baseball Injuries

Spring signifies the start of the youth or little league baseball season.  These young players are excited not only because baseball season marks the ending of the formal school year, but also because youth sports give these participants a chance to get outside, enjoy the warmer weather, and compete in the all-American past time - baseball.  However, players, coaches and parents need to be aware of potential injuries that might occur during these activities, and take precautions to insure safety.
The Consumer Product Safety Commission estimates that 160,000 individuals in the United States are treated each year for injuries sustained in youth baseball. Fractures to the upper and lower extremity made up a significant number of these reported injuries. These numbers do not include those “minor” injuries that were never reported, or the injuries that were “treated” by the coaches or parents.

It is important to remember that complications from fractures or other injuries can be avoided or at least minimized, if medical attention is sought soon after an injury has occurred. If the injury truly is only a minor sprain or strain, one visit to the sports medicine doctor is usually all that is necessary. A parent's time and money are well-spent having this reassurance.
Knowing that your child's “twisted ankle” may be only a minor sprain gives the parent a certain peace-of-mind not often present in a self-diagnosis.  If the injury is determined to be more severe in nature (such as a fractured bone), then the parent will have provided the best chance for their child to have a full and quick recovery.

 Patellar Mal-alignment

Repetitive overuse of the knee joint (as in Runner's knee) as well as alignment problems of the kneecap, may lead to inflammation and degenerative changes to the underside of the patella. The patella’s smooth cartilage surface that is designed to glide on the end of the femur may become rough due to the degenerative changes. This knee shows inflammation and degenerative changes to the underside of the patella. The once smooth cartilage has become pitted and worn due to the malalignment. In the normal condition the patella maintains a centralized position on the articular condyles of the femur throughout knee joint flexion. Alignment problems exist when the patella subluxes laterally during flexion as seen on the far left.

 Runner's Knee

Estimates indicate that as many as 15% of U.S. adults take part in a regular running or jogging exercise program. The majority of these individuals remain healthy, and will have no significant problems relating to their knees or other musculoskeletal joints. However, some individuals who run regularly do develop a painful condition known as “Runner’s Knee,” also called Patello-femoral Pain Syndrome. Simply stated, this malady can be described as pain under the kneecap. This condition is not the result of just one traumatic injury or episode, but it is most commonly due to the long-term, repetitive motion stresses of running.

The patella (or kneecap) is the disc-shaped bone located on the anterior or front aspect of the knee joint, and is connected to a large muscle group in the thigh (the quadriceps) by a very thick tendon. In addition, it also is attached to the lower leg bone (the tibia) by way of a strong ligament called the patellar ligament. The peculiar shape of the underside of the patella allows it to fit snugly into the groove between the condyles in the end of the femur. During flexion and extension of the knee joint, the patella glides smoothly in this groove throughout the knee’s arc of motion, The leg’s quadriceps mechanism is described as the extension or straightening motion of the lower leg in response to the contraction of the quadriceps muscles in the thigh. Kicking a ball is a perfect example of this mechanism. The patella is located within the tendon/ligament interface of this mechanism, and serves as a fulcrum at the knee joint.

The repetitive motion of the patella sliding over the condyles of the femur in such fitness activities such as running, jogging, and even walking, may result in a painful inflammation or irritation of the underside of the kneecap. Many conditions with names such as overuse synovitis, patellar tendonitis, and tenosynovitis all are associated with the repeated stresses incurred from running.
This syndrome may also be caused by the way the kneecap aligns itself on the anterior knee during flexion and extension. Alignment problems of the patella at the knee may be caused by anatomical relationships in other parts of the body such as the hips, thighs, or even feet. In most cases of patellar malalignment, the patella subluxes (slips laterally), and may actually dislocate in some individuals. A special x-ray view of the knee called a merchant's view will help identify this lateral displacement.
Treatment for Runner’s Knee may include rest, anti-inflammatory medication, physical therapy and strengthening exercises, knee bracing, orthotics (shoe inserts), or use of an infra-patellar sleeve or strap. Chronic, long-term problems such as continued pain, patellar tendonitis, malalignment, and degenerative changes in the knee joint may require arthroscopic or more traditional surgery.



 Meniscus Tears

The knee has two cartilage disks, called menisci, that are attached to the top portion of the tibia (the large lower leg bone). The lateral meniscus is located on the outer side of the knee joint, and the medial meniscus is on the inner side. These two wedge-shaped discs form a cradle for the cartilage covered condyles of the femur. The menisci absorb shock, and serve to cushion the knee. An injury to a meniscus may take the form of a small or large tear, a split in the disc, or a frayed or roughly torn area. This illustration depicts a large tear in the medial meniscus. The knee's lateral meniscus is intact and has a normal crescent-shaped appearance.


 Degenerative Changes to the Knee

Alignment problems, wear and tear to the knee joint, and systemic diseases such as osteoarthritis, may contribute to degenerative changes to the joint surfaces of the femur (thigh bone) and the tibia (large lower leg bone). Advanced stages of degeneration include the formation of bone spurs call osteophytes. Pointed bone prominences, called osteophytes, occur in response to the joint degeneration. These growth are frequently seen in those joints undergoing arthritis changes. The normally smooth articular cartilage is worn away due the joint instability and inflammatory process.
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