Weight Lifting Injuries

Statistically, more and more people are working out using weights and weight  bearing exercise than ever before.  Whether it’s to achieve those major biceps for men or to tone and stave off the ravages of osteoporosis for women,  fitness with weights is at all an all time high.  So, unfortunately, are serious shoulder injuries, most of which occur with upper arm strengthening.

One common problem  is an injury to the A-C joint  The A-C Joint is the small accessory joint at the top of the shoulder. You can feel it — it is the small bump at the end of your collarbone. A-C stands for Acromio-Clavicular. The acromion is a flat bone at the top end of the shoulder blade. It is nature’s shoulder-pad — a square shaped bone that you can feel at the top of your shoulder.  The clavicle is the collarbone. Between the end of the clavicle and the acromion is the A-C joint which plays a major supporting role in the function of the shoulder.”

Both those who work out and their fitness trainers can stress the A-C joint when they do bench-presses and overheads because any exercise that uses a substantial amount weight to move the arm also involves stress to the shoulder.  Both of these lifts strengthen the powerful deltoid muscle which lies along the acromion and the clavicle and thus, the stress of heavy lifting can be transmitted to the small A-C joint. People who lift weights for years may injure the A-C joint and develop arthritic degeneration in the area. My patients frequently complain of pain and popping  at this joint.   I can even hear the pop on examination before x-ray or MRI confirms the injury or arthritic condition.”

The bad news on A-C  joint degeneration is that  once the damage occurs, it cannot be reversed. There is no cure for arthritis. One solution might be to curtail or give up overhead lifting, but this is usually not an option for dedicated weight lifters.  They may abstain from or limit weight lifting, but usually only for short periods of time and rarely long enough to stabilize a serious joint condition. Anti-inflammatory medicines like Aleve, Celebrex and Advil  may relieve pain but their effects may only be temporary.  A cortisone injection into the A-C  joint may also help, albeit temporarily. And neither will relieve the ‘popping’ of the joint.  That said, both therapies  should be tried prior to surgical intervention.

When A-C joint surgery is indicated, both the pain of the injury and the ‘popping’ sound can be cured with comparatively minor surgery. Quite simply, the end of the collarbone is removed. The painful arthritis and the pressure at the joint are relieved. This often ends both the pain and the popping.  The surgery can be done either arthroscopically or through a very small incision at the top of the shoulder. Recuperation is relatively quick usually two to three weeks to return to normal activity .  The good news for the gym set is that there is usually little or no postoperative impairment to the shoulder and patients can happily resume weight lifting and other sports. Some lifters may note slight loss of maximum bench press strength, but this will be offset by relief of painful popping.

Weight lifters can also develop muscular injuries from overuse or overdoing it! One common condition is bicepital tendinitis.  “The biceps muscle bends the elbow and it’s long tendon lies in a groove in the front of the shoulder. Tendinitis or inflammation of the tendon can occur with bench presses and ‘dips’.  Treatment consists of pain and/or anti-inflammatory medication ; Physical therapy can be useful.  Sometimes, a cortisone injection. is necessary

Older lifters may even rupture the tendon. Sharp pain and a popping sensation may be felt in the front of the shoulder. The pain will eventually subside and usually there will be little or no lasting disability so surgery is rarely necessary.

Another muscle that can tear with excessive stress during bench presses is a tear to the so-called “pecs” – the pectoralis major muscles. A partial tear can be treated with rest and therapy and should heal on it’s own. A complete tear may require surgical repair.

Working out with weights is an important part of many people’s lifestyles. It is, for the most part, an excellent way to help stay fit and an anti-aging boost.  That  said, it must be approached with care in order for people to gain the maximum benefit from work-outs.”  In short, take care of your arms and shoulders and they will help take care of you.  If not, your upper body fitness is at serious and potentially permanent risk due to injury.

 Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

 

 

 

 

 

 

 

 

MUSCLE STRAINS / RICE

Hamstring Pain:  R.I.C.E.

Pulls or strains of the hamstring muscles are one of the most common sports ailments.  They occur often in running sports and are frequently caused by quick starts and stops—as in sprinting, baseball, basketball, tennis, etc.

The hamstring consists of three large muscles in the back of the thigh.  They begin at the pelvis and end just below the knee.  If you straighten and tense your knee, the fleshy part of the muscle can be felt behind the thigh.  If you run your hand behind the knee, you will feel the lower hamstring tendons on each side.  The hamstrings bend the knee.  The opposite muscle in front of the thigh is the powerful quadriceps which straightens the knee.  This muscle is approximately one-and-one-half time stronger than the hamstrings.  People with weak hamstrings are more prone to injury.

Muscles tear as a result of sudden changes in tension.  For example, a sudden start or stop can stress the muscle.  This is why sprinters are more susceptible.

When a hamstring tears, the runner feels a sudden pain in the back of his thigh.  The sensation of a “rip” or “tear” is also common.  Pain will increase over the following hours and swelling and/or a large black and blue spot (ecchymosis) may also occur from the bleeding of the injured muscle.

 

There are three grades of muscle tears:

Grade I:  (mild strain)  Less than 10% of the muscle is torn.

Grade II:  (moderate tear)  Up to 50% of the width of the muscle is torn.

Grade III:  (severe)  Over half of the width of the muscle is torn.

If you think you have injured the hamstrings, it is best to stop playing or exercising.  Treatment can be summed up with the acronym RICE, which stands for:

  1. Rest—crutches may be necessary.
  2. Ice—to stop swelling and relieve pain.
  3. Compression—apply an Ace bandage to lessen swelling.
  4. Elevation—helps decrease the swelling.

Treatment

Several days later, a warm whirlpool is soothing and aids in the healing process by increasing the blood flow to the injured muscle.  Mild strains will heal in a couple of days, while Grade II injuries may take up to two weeks to heal.  Grade III injuries take even longer (three to four weeks).  You can return to sports when it is no longer painful to tense the muscles.  Before you start running, it is best to rehabilitate the knee.

Initially, gentle motion to the knee should be done to regain motion.  Next, when the pain subsides, work out with light weights to re-strengthen the hamstrings.  A simple exercise is to lie face down and bend the knee with an ankle weight attached to the lower leg.  Hold for a few seconds and then relax.  It is best to start with two to three pound weights and gradually increase the amount every week.

Before returning to full activity, you should first do slow, easy running or jogging.  Running speeds can later be increased.

Prevention:

Hamstring pulls can frequently be prevented by proper warm-ups and preliminary stretching exercises.  The warm-ups increase blood supply to the muscles, making them less likely to tear.  The following are good hamstring-stretch exercises.

  1. Lie on your back.  Bring one leg up to your chest with the hip and knee bent.  Cup your hands behind the knee and push knee against the hand, straightening the knee.  Hold the stretch for five seconds.  Repeat the exercise five times.  Then do the opposite leg.
  1. Kneel down with one knee and straighten the opposite leg in front of you.  Bring your upper torso over the outstretched leg, keeping your arms at your side and your back straight.  Hold the stretch for three to five seconds.  Repeat five times.  Next, stretch the opposite leg.

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

Knee replacements

 

 

 

 

 

 

 

 

Joint replacements without question are one of the major medical innovations of the past hundred years.

A Total Knee Replacement (TKR) replaces an arthritic knee joint. The femoral (thigh) component is metal; The lower tibial (upper leg ) component is high grade polyethylene plastic; Commonly, the arthritic knee cap surface is also replaced with a plastic button.Thus, the new joint is metal bearing on plastic. While some TKR’s are designed for bony ingrowth to secure them to the bone, most are attached with a medical acrylic cement.

The arthritic joint surfaces are removed -by cutting the old joint out with a power saw. We use guides to insure accurate cuts and the above components fit into these cuts -held by the cement.

Total Knee Replacements  have evolved over my career. During my formal orthopedic training and my fellowship in Joint Replacement Surgery at Boston’s Massachusetts General Hospital, this procedure was relatively new and the technique was not as streamlined as it is today. For example, then, many of the saw cuts to remove bone were eyeballed and were made freehanded. Today the cutting guides are much better perfected and easier to use ,so that the cuts are much more accurate and components fit much better than in the past. This leads to better fitted and more secure components, thus resulting in better longevity.

Years ago, we told patents that the TKR would only last around a dozen years. Today, a TKR could last 25-30 years.

The surgery is major and patients need to stay in the hospital for several days. Physical Therapy are recommended for 2-4 weeks and full recovery may take several months. Like any surgery there are potential, albeit,rare complications. But most people do very well and ultimately are very pleased . With a relatively pain free knee, they can get their lives back.

Who needs a Knee Replacement ? Usually people who are at least in their 50’s.  In rare circumstances, younger people with severe arthritis may need a TKR, but we try told hold off on older patients as the components do not last forever. In younger patients, the likelihood of a second revision operation later in life is likely where as it is less likely in a 60 year old. Obviously, one should have advanced arthritis and joint destruction on an x-ray.(see photo below )

 

Knee with severe Osteoarthritis

 

 

 

 

 

 

 

 

 

But, the main  indications are pain and limited function. Unable to walk more than a few blocks or around a Mall without increased pain is the usual indication.

I have been performing Total Knee Replacements for years and most of my patients have been very happy with my care and with the results. If you think that you need one, come in to see me and I will discuss the operation in greater detail.

 

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

 

 

Ski Injuries

Preventing Common Ski Injuries

Once again, many are heading north to the slopes and most will return invigorated, tanned, and happy.  Some, unfortunately, will return with slings or crutches, pale and unhappy.  Here are some common ski injuries and how to avoid.

Well over half of the ski injuries involve the lower extremities, and most of these favor the knee and leg.

Knee Injuries

Knee sprains are by far the most common injuries.  The ligaments along the inside of the knee are injured when a skier catches the inner edge of a ski in the snow and the foot rotates outward as the body continues forward.  Stress is then placed on the inner side of the knee, which is forced into a “knock-knee” position as the skier falls.  The ligament will be stretched (sprained) if the force is minimal and if the bindings release.  Otherwise, the ligament can be completely torn.  Another potentially dangerous position is the “snow plow”—where both knees are knocked and the body weight is placed on the inner edge of the ski.  A fall will place direct force against the inside of the knee.

Catching the outer edge of the ski may injure the ligament that lies along the outside of the knee.  This can occur if the tips of the skis accidentally cross and the skier falls sideways.  The leg on the side of the fall will twist inward and will remain straight.  Stress is placed on the outer ligaments.

The new shorter, shaped skis place more stress on the knees than the former, longer skis.

Especially stress on the medial collateral ligiment(MCL).

Prevention of these injuries mainly centers around adequate bindings.  It has been reported that a high percentage of lower extremity injuries result from a failure of bindings to release.  Quality bindings properly mounted and maintained will prevent many knee injuries.  Various knee braces can also be worn and, to some extent, can provide protection.  A brace with metal sidings and hinges can comfortably be worn under ski pants and allow an acceptable degree of knee mobility.

Fractures

Another common injury is the tibial fracture—or broken leg.  This occurs when the leg is forced against the hard boot top during a fall.  The leg can also break when the bindings fail to release and the leg is twisted.  This torque can snap the bone.  Again, proper bindings are the best insurance against this unfortunate and incapacitating injury.

Shoulder Dislocations

If inadequate bindings are a cause of knee and leg injuries, faulty pole technique can contribute to upper extremity injuries—specifically the shoulder or thumb.

Shoulder dislocations are very commonly treated at base clinics.  The shoulder can dislocate when a backwards force is applied to the outstretched arm and the shoulder is levered forward.  Thus, a skier who falls on his outstretched (abducted) arm may sustain this injury.  Frequently, however, the arm is levered by a planted pole; as the body continues forward, the arm is forcibly stretched and rotated outward, aggravating the injury and making a dislocation more likely.  Slalom racers who grasp too long on their planted poles are especially susceptible to this type of injury.

A shoulder dislocation is very painful and requires immediate setting to relocate the joint.  Multiple dislocations can eventually produce a damaged, unstable shoulder, and surgery will frequently be required to repair it.  One way to avoid this injury is to be aware of the mechanism and try to eliminate excessive pole planting.  Poles with strapless hand grips, which release better from the skier’s hand, may also prevent this injury.  If a skier has a dislocated shoulder, he or she might consider a brace to check excessive shoulder stretching.  These braces are custom made, but they are light, comfortable, and usually don’t interfere with normal skiing.  They can be worn inconspicuously under the ski jacket. ( I have personal experience on this matter, as I dislocated my shoulder twice while skiing—once on a bunny trail at Stratton-when I first learned to ski—but again, and less embarrassingly, on a real black diamond trail—Nosedive—at Stowe, a few years later. I successfully skied down Nosedive without falling and ,of course, at the bottom on level terrain, slipped and fell. I had a custom made brace made which I wore thereafter and never again dislocated my shoulder.)  

Thumb Injuries 

The other notorious injury caused by ski poles is damage to the ligament on the inside of the thumb.  Since the pole is grasped between the thumb and the index finger, sudden force along the pole can jam the handle of the pole into the base of the thumb and injure the ligament.  This is a serious injury which is treated with a cast and perhaps surgery.   Pole straps incorrectly positioned can result in greater risk of this accident.  A strap held around the palm just below the base of the thumb can be stretched.  The strap should properly lie around the wrist, well away from the thumb.  The risk of thumb injuries may also be decreased—although not eliminated—by using poles with a strapless type of hand grip.

Finally, here are five useful tips for prevention of ski injuries:

  1. Service your bindings at the start of each ski season.
  2. Stay fit prior to the ski vacation.
  3. Do warm-up exercises before you go out.
  4. Quit whenever you feel tired.
  5. Don’t be a daredevil.

 

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

Shoulder Separations

SHOULDER SEPARATIONS

 

One common shoulder injury that is frequently confused with a dislocation is the shoulder separation.  Many people believe them to be the same injury, but the two are completely different.

Shoulder separations refer to a disruption of the ligaments which hold the collarbone to the shoulder blade.  When these ligaments are ruptured, the collarbone rises out of place from the shoulder and “separates.”  Medically, this is referred to as an Acromio-Clavicular separation.  As the clavicle (collarbone) attaches to the acromion (side extension of the shoulder blade), it is held by three ligaments.  These ligaments stabilize the clavicle and hold it down toward the top of the chest.  Injury to these ligaments “springs” the collarbone upward from its normal position.

Run your hand along your collarbone; as the shoulder is approached, you will feel a small bump—this is the acromio- clavicular (A-C joint).  A-C separations usually occur from a direct force as one falls violently onto the point of the shoulder.  The shoulder is forced downward as the ligaments holding the collarbone tear.  The injury is common in contact sports, such as football, rugby, hockey, and lacrosse.  Football players who carry the ball, such as backs and ends, are more susceptible because their shoulders are directly hit when they are tackled.  However, the improvement and effectiveness of shoulder pads over the years has diminished the incidence of this injury in football in contrast to rugby where the occurrence rate remains higher.

A shoulder separation is quite painful, and the athlete is unable to lift his arm without discomfort.  The A-C joint is swollen and tender to touch.  Complete separations produce a prominent deformity with an enlarged “bump.”  If there is any doubt about the diagnosis, stress x-rays can be performed to confirm that the joint has separated.  The patient is asked to hold a heavy weight with the arm at the side.  The weight pulls the shoulder blade down, and the collarbone will displace upward.

Like many other orthopaedic injuries, A-C separations are categorized into three degrees of severity.  A first degree separation is merely a sprain without serious ligament damage.  The joint is tender and swollen, but there is no separation.  Treatment consists of ice applications and use of a sling for 3-7 days.  Athletics can later be resumed when the pain subsides, and full shoulder motion is restored.  Little rehabilitation is necessary, and the prognosis is excellent.

In the second degree separation, the injury is greater, and there is complete disruption of the ligaments which surround the A-C joint. However, the ligaments holding the collarbone to the shoulder blade are not torn, and consequently there is only minor displacement of the collarbone.  The A-C “bump” is more prominent, and the separation can be felt.  This injury is also treated with a sling, but immobilization is required for two to three weeks to allow the joint to heal.  During this period, gentle motion exercises are allowed to prevent shoulder stiffness.  Later, shoulder strengthening exercises are recommended.  The athlete can return to sports in four to six weeks if the pain has subsided, and if there is clinical evidence of healing.

A third degree A-C separation represents a complete dislocation of the joint and rupture of all ligaments.  The collarbone displacement produces a large painful deformity.  The treatment of this injury is controversial.  Some orthopaedists believe that no treatment is necessary, and therefore no attempt is made to reduce the separation.  The rationale of this treatment is based on the belief that the separation does not really cause any permanent disability of the shoulder after the initial pain has subsided.  The patient rests with a sling for one to two weeks and later resumes activity when there is no longer any pain.  There is merit to this approach, as many patients regain useful function of their shoulder even with a permanent deformity.

The other school of thought is that the separation must be set and held either with a brace or by surgery.  The brace is a special sling with a pad which exerts pressure over the collarbone, pushing it down.  The sling could be effective, but it is very uncomfortable and must be worn constantly for six weeks.  Unfortunately, this treatment requires a rather stoical and reliable patient and, frequently, this treatment option is not practical.

Surgery consists of returning the collarbone to its normal position and holding it in place with a screw, pin, or wire.  The ruptured ligaments are also repaired.  The athlete will miss competition for approximately 12 weeks.

However, surgery may be performed in certain instances—depending on the severity of the displacement and individual requirements of the athlete relating to his sport.

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

Shin Splints

 

The term “shin splints” is commonly used to describe leg pain or aches, but it specifically refers to pain along the inner border of the tibia—the large bone of the leg.  It usually occurs in novice or poorly-conditioned runners, and the main treatment is rest.  The exact cause of shin splints is somewhat controversial because there are several different reasons for the pain to occur:

OVERUSE SYNDROME 

Overuse of a muscle refers to stress or sprain of a muscle from too much exercise.  The overuse syndrome can also be caused by wearing inadequate shoes or by running on hard or sloped surfaces.  The basic postural problem producing this is pronation of the foot.  Pronation is a medical term which means outward tilting of the foot.  People with flat feet or dropped arches have pronated feet.  Stretching the foot outward places increased pull on the muscles that run along the inner border of the ankle and under the arch.  These muscles originate along the inner side of the tibia.  The major muscle–the posterior tibial muscle–helps hold up the arch.  As a result of pounding on the arch and, thus, constant tugging on the muscle, the muscle belly is stretched and even torn away from the bone.  Pain and inflammation result.

The pain may initially occur after running.  Persistent running with the injury will only aggravate it and produce pain during activity and later with normal walking.

Treatment consists of rest and application of ice to the leg.  Telling a serious runner to rest is about as undesirable as suggesting that he purchase a bicycle, but, like it or not, rest is most important for healing to occur.  The period of rest may vary, but usually two to three weeks are required.

Once a runner has recovered, attempts are made to prevent future injuries.  Firm, well-constructed shoes with arch supports are recommended.  The arch support helps tilt the foot inward and corrects the pronation.  If the standard supports in the shoes are not sufficient—and they may not be for excessively pronated feet—custom-made inserts or orthotics should be obtained. I usually recommend first trying less expensive standard inserts which can be purchased in any running store. Changes in running environment from hard to softer surfaces, such as a track, and away from uneven ground, will also help.

Also, I see many patients who have one leg that is around a ½ inch shorter than the other. It is a minor discrepancy and frequently, we do not know why this occurred. However, it can cause problems with the back, knees, or ankles. And it can also cause shin splints. The treatment is simple—a shoe lift or insert for the shorter leg.

TIBIAL STRESS FRACTURE

Another cause of leg pain is a stress fracture of the tibia.  This is a small crack or hairline fracture of the bone.  It occurs from the pressure of constant pounding.  Localized pain results.  The fracture may not become evident on x-rays for several weeks and sometimes a bone scan is necessary to make the diagnosis.  The treatment is absolute rest from running until the fracture heals.  A cast is sometimes required, but in some instances, protection with crutches is sufficient.

 COMPARTMENT SYNDROME

A third –and rare reason — for shin splints is a “compartment syndrome.”  Muscles are covered under the skin by a tissue called fascia.  An analogy is the encasement of a sausage.  Muscles enlarge when they are exercised, and in the leg, muscle expansion produces increased pressure in the compartment.  The muscles become too tight under the skin and swelling results.  The nerves and blood vessels adjacent to the muscles also become crowded and pinched, producing discomfort.  Treatment consists of rest and ankle exercises, but in severe cases, surgery may be necessary to slit the fascial covering of the compartment and relieve pressure on the muscles.  The surgery is fairly simple and usually effective.

To conclude, proper conditioning is important because shin splints frequently occur during training or in individuals who are unfit.  Thus, increases in exercise and activities should be gradual.  Proper shoes and orthotics may prevent overuse syndromes, but they will have little effect on stress fractures or compartment syndrome.  And, finally, the importance of rest cannot be overemphasized.

 

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

Rotator Cuff Injuries

The Rotator Cuff – not rotary cuff, as some people call it – is a broad tendon that covers the humeral head –or ball of the shoulder joint. The shoulder is a ball and socket joint. Both are very shallow and the joint would be unstable were it not for multiple muscles and ligaments which hold the ball and socket together. The fact that the joint is shallow allows for better and circular motion of the shoulder.

The rotator cuff is actually a broad tendon which, to me, looks like a bathing cap-covering the ball of the shoulder like a cap covers one’s head. Four muscles converge into the cuff –the subscapularis, the supraspinatus, the infraspinatus, and the teres minor. The tendon attachments of the middle two muscles (the supraspinatus and the infraspinatus) are more commonly torn.

These muscles allow internal and external rotation of the shoulder and assist the larger muscle that covers the shoulder-the deltoid – with abduction(raising the arm sideways and upwards). The deltoid abducts the arm, but cannot do so without the assistance of the rotator cuff muscles. This is why patients with a strong, normal deltoid but with a large rotator cuff tear frequently cannot lift their arm.

I mainly see three rotator cuff conditions:

1. TENDONITIS or TENDONOSIS.

Tendonitis means that the cuff tendon is inflamed and clinically there is tenderness and pain on movement. Overhead elevation produces pain –a positive Impingement Sign. Under arthroscopic visualization, the cuff looks scarred and irregular. Calcium deposits may occur.

Depending on the severity of this condition, I try to initially treat this problem with rest, therapy, and anti-inflammatory medications. Frequently, I give a cortisone injection ,which commonly works.

If these conservative measures, fail, the last resort could be arthroscopic surgery to smooth and clean out the scar tissue. This is usually successful and the recovery time is short –most of my patients regain full motion within a week or two.

2. PARTIAL ROTATOR CUFF TEAR

This is commonly associated with tendonitis ( above) and the treatment is the same. I first recommend conservative treatment. If surgery is later performed, I usually smooth and clean out the scar tissue adjacent to the partial tear and it probably heals without surgical repair or opening up the shoulder. 

3. COMPLETE ROTATOR CUFF TEAR

This is a full thickness tear – a complete tear: the size of the tear is commonly the size of a dime but frequently larger. Usually, although, not always, the patient cannot raise his or her arm, or if they can, they do so with pain. The tear could be caused by chronic use and wear in an older person. In younger people or in workers who do heavy labor, it can be caused by an acute wrenching injury. Falling directly on the shoulder can tear the rotator cuff. Throwing hard can do it. Or some injury that jams the arm — thus transmitting force towards the shoulder– can tear it.

These are serious injuries. The treatment is frequently surgical –commonly with a skin incision. The tear is stitched together. Sometimes, it can be repaired arthroscopically, but usually a small mini incision is necessary. Post operatively, a sling to rest the arm and to allow the repair to heal is needed for 3-4 weeks. And then, physical therapy to rehab the shoulder –for 2-3 months – or longer. No picnic!

But, the results are frequently good, although there are no guarantees. Much of the success of this surgery depends on the patient. Patients must adhere to their doctor’s orders, lest they re-tear the repair in the vital post-operative period. And, if they do not follow-through with their rehab program, they may develop stiffness, a frozen shoulder, or weakness. And in older patients with poor circulation, the repair may not heal ;  also,  in patients who smoke or have diabetes.

Some people with large tears, paradoxically, have surprisingly decent shoulder motion. If these patients have relatively little pain, they theoretically could avoid surgery if they can live with this condition. But, most people with rotator cuff tears have trouble and require surgery.

Is there treatment besides surgery ?  Probably not.  Physical therapy could be offered for the patient in the paragraph above, but therapy will not heal the tear. Large tears most probably will not heal, so surgery is usually indicated for these.

 

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

Meniscus Tears

MENISCUS TEARS

 

Since we can all laugh at ourselves, I will share an old crack about Orthopedists—strong as an Ox and twice as smart.

Well, maybe there was a time when many muscular medical students in the lower half of their class went into orthopedic surgery, but that certainly has changed. The orthopedists that I have known throughout my career have been plenty smart.

To prove this, two of the major medical advances of the past hundred years have been in our field: total joint replacements and arthroscopic surgery.

Presently, other surgeons do arthroscopic type surgery –general surgeons now remove the gall bladder and the appendix with a laproscope, thus avoiding the large abdominal incisions of the past. Yet, orthopedic knee and shoulder arthroscopic (arthro meaning joint) surgery was routinely performed decades before general surgeons started doing similar surgery on the belly.

When I trained in the 70’s, a patient with a torn meniscus(torn cartilage) would have the knee cut open with a two-three inch incision at surgery and the entire meniscus would be removed. The patient would eventually go home two to five days later on crutches and require a month or two to recover.

Now the meniscus tear is treated in an outpatient surgical center requiring only several hours stay. The tear is removed with micro instruments through three tiny ¼ inch cuts (one stitch each) and most of my patients are walking without crutches, or a limp, for that matter, within a week of the surgery.

What a great medical advance in the past thirty years!

Nor, do we remove the entire meniscus as we used to. This is bad and can eventually cause degenerative arthritis as the result of bone on bone contact. Now, we only remove the portion of the meniscus that is torn and we preserve the uninvolved remainder. This works out just fine, and most people do very well and recover quickly. Sometimes, rarely, the meniscus tear can be repaired.

The knee has two meniscui –medial and lateral. They are half-moon shaped. They have various functions, but they are basically shock absorbers to prevent bone on bone contact in the knee joint. They are rubbery in quality and with stress, torque, or a twisting mechanism, they can be torn. A torn meniscus can cause pain, clicking, or interfere with motion(locking –as the knee can get stuck and unable to fully extend).

The perimeter of the meniscus does have blood supply (red zone) and tears in this outer rim and be repaired and can heal. More commonly, the tears are through the inner, avascular 2/3’s of the meniscus and are not repairable. These tears are simply removed.

My patients go home on crutches and pain killers after the surgery and most can walk without crutches within 4-5 days. Almost all walk normally and bend their knee fully two weeks later when the stitches are removed. Some require physical therapy; many do not. But knee exercises hasten the recovery. I have had patients return to sedentary work within days of the surgery, but full return to sports can require weeks or even months.

Younger people do great. Older individuals with arthritis in their knee may not fare as well as due to the arthritic pain, but many improve enough to be satisfied.

 

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

Ankle/Achilles Injuries

ANKLE /ACHILLES INJURIES

SPRAINS 

I have treated many people ,who, after twisting their ankle, were told by either a family doctor or emergency room person, that it ” is only a sprain.”

The ankle is wrapped in an Ace bandage and the patient is advised to see a specialist if no better in a week or two. The implication is that this injury is no big deal.

This attitude always upsets me because ankle sprains are commonly potentially serious injuries. In my opinion, if not aggressively treated early on, they may not sufficiently heal and could cause ongoing and chronic trouble in the future.

A sprain is a stretch injury or tear of a ligament. A ligament is a tight, fibrous cord that holds joints together and provides stability. A force that stretches a ligament can cause merely a stretch injury ( Grade 1 ), a partial tear of the ligament ( Grade 2 ) , or a complete rear or rupture ( Grade 3 ).

There are two groups of ankle ligaments. On the inner or medial side of the ankle is the broad and thick Deltoid ligament. On the outer or lateral side are two lateral ligaments. The lateral ligaments are injured more often-probably because the foot has a greater tendency to twist inward.

A mild sprain causes some discomfort and localized swelling, but the patient can usually walk. A more severe sprain –in which the lateral ligaments are either partially or completely torn is much more serious. There is greater swelling and the patient can barely walk. It is because of these injuries, that I believe ankle sprains require urgent attention by an orthopedist. A delay of several weeks in addressing a Grade 2 or Grade 3 ligament tear could result in a permanently lax ankle–prone to re-injury.

First, an x-ray needs to be performed to rule-out the possibly of a fracture. And, sometimes a stress x-ray–performed while pressure is placed against the ankle—is required. A positive stress x-ray will indicate ankle joint tilting or instability. In extreme cases, I may order an MRI to deteremine if a ligament is torn and to what extent.

We all have out different ways of treating a sprain and, with the exception of pure neglect, there may be no right or wrong way. The practice of medicine, after all, is an art.

I prefer to treat simple sprains by wrapping the ankle with 2 inch white sports tape which I leave on for a week. This is in effect,a soft cast, and it gives support and controls swelling. My patients usually feel much better and have less pain once the tape is applied. Many can suddenly walk again. If the sprain is worse, say, Grade 2, I may supplement the tape with a brace like an aircast.

I recommend anti-inflammatory medication for a week or so and later, I may order physiotherapy.

I personally rarely use an ace bandage to treat an ankle sprain.

Most people with Grade 1 sprains recover within three weeks but some can take longer.

I also may treat people with Grade 2 sprains in a similar manner, but if there is ankle looseness and laxity, I very well may recommend a solid cast for three weeks to allow the ligament to heal. This may be somewhat inconvenient for the patient, but allowing the ligament to heal in its normal length and tension may save that patient future injuries and aggravation.

A Grade 3 complete tear –confirmed by an MRI – should either be treated in a cast or with surgical repair. The latter would be my preference in many cases, but this decision is ultimately tailored to an individual patient’s requirements.

Recently a saw a man in his late thirties who complained of recurrent ankle sprains. A stress x-ray in my office indicated severe laxity. I told him that unless he wanted to live with this, reconstructive surgery would be the only feasible treatment to stabilize the ankle. He initially injured his ankle years before while playing college football, and it was my impression– from speaking to him–that he never received adequate treatment early on after he sprained his ankle. Thus, the outcome did not surprise me. The torn ligament probably never healed.

The deltoid ligament on the inner side of the ankle is basically treated the same, but because it is a broader ligament and is an important stabilizer of the ankle, I am more inclined to treat deltoid injuries in a cast or surgically, if they are completely torn.

 

ACHILLES TEARS

There are three muscles in the calf. All converge into a large broad tendon above the back of the ankle—the Achilles Tendon.

I refer to these muscles –the Gastronemius, the Soleus, and the Plantaris as the three bears.

The planteris—the baby bear – is a long thin muscle / tendon and it is of little significance. It is famous because many people tear it –frequently in a tennis or basketball game. People with an acute planteris tear develop stabbing calf pain. Some describe a feeling that they were struck in the calf by a tennis ball. They limp and may have pain for several weeks.

There is no treatment except RICErest, ice, compression, elevation. To this I would add anti-inflammatory medication and possibly physiotherapy. Since people complain of calf pain, an ultrasound to rule out a blood clot may be considered depending on the patient’s history.

These usually heal completely in a few weeks with no residual problems or lasting impairment. Surgery is never necessary.

A rupture of the Achilles tendon is a different story.

Frequently, this is a sports injury as the heel forcibly extends. Severe stress and tension is placed on the stretched Achilles tendon. A rip, pop, or tear is felt or even heard. The victim can walk but limps noticeably as the foot drags. The diagnosis is easily made on the field, court, or in the office. A gap can be felt in the tendon and ankle motion is compromised. X-rays and an MRI are not really necessary. But, an MRI could be ordered –if for no other reason but to satisfy the patient that surgery is necessary.

These injuries can certainly be treated in a cast with the foot fully tipped down like a ballet dancer en pointe. The tendon should come together and it should heal.

But today, most orthopedists—myself included – recommend surgery. The procedure is fairly routine and the incision does not need to be very large. No, it cannot be performed arthroscopically. With surgery, the tear is brought together and stitched under direct visualization. And the success rate for healing is high.

A post operative cast for a few weeks is still necessary, but I have lately been replacing the cast with a brace–sooner– after a few weeks, and this helps the patient regain motion earlier. The overall recovery is not quick, but the results are usually excellent.

 

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

ACL

ACL

( ANTERIOR CRUCIATE  LIGAMENT )

INJURIES

Several years ago, I saw a middle aged patient for a second opinion regarding his knee. Another orthopedist told him that he needed surgery to replace a torn anterior cruciate ligament (ACL). I examined his knee –everything appeared normal. There was no laxity or looseness. What sort of problems are you having with it, I inquired? “None,” he replied.

“Then why do you want surgery?” I responded.

“Because it is torn”.  The other doctor warned him that he might have future problems.

In a situation like this, I always wonder who is loonier –doctor or patient. Not everyone who tears an ACL needs reconstructive surgery, but more about this later.

The cruciate ligaments –anterior and posterior – are important central ligaments within the knee joint ( see diagram below). Like a cruciate screw head, they are in the center of the knee and they add stability. The ACL prevents the tibia (leg bone) from translating forward on the femur (thigh bone). The ends of these two bones form the knee joint. The PCL prevents backward instability. Also, the ACL restrains abnormal knee rotation.

The ACL is more commonly injured. The trauma is usually substantial-not from a minor sprain. Tears can occur from pivoting on one foot while running, decelerating, changing direction, or after landing from a jump. Blunt trauma like a clip in a football game while the victum’s foot is planted can do it as well. Or a ski injury—a twist to the knee or a fall– as the ski bindings fail to release.

A pop is commonly felt and may be heard. Swelling gradually occurs and the knee can blow up. If the knee is drained with a needle, blood is removed. This combination of a pop and bleeding tells me that the knee injury is more serious than a slight sprain.

On exam, we may find a positive drawer sign. The tibia displaces forward just like a dresser drawer is pulled out.

X-rays need to be performed to rule out a fracture and sometimes a chip fracture can be diagnosed. The ligament is not visualized on a routine x-ray and therefore, the next step is an MRI to make the diagnosis. We need to learn if the cruciate is indeed torn or if there is an associated meniscus tear. And,  if the ACL is torn: to what extent and where?

“us” above-middle – is the ACL : from an early 20th Century German Textbook. 

If it is torn right off of the bone in children, it is frequently directly repairable.Surgery should be performed fairly soon (it is no emergency, though). Frequently, when the injury occurs  lower down on the ligament at the tibial attachment, a sizable chunk of bone is broken off and this should be –and can be fairly easily – surgically repaired. This ligament fracture  is more common in children, but can be seen in teens or adults.

The most common problem is an ACL tear through the mid-portion of the ligament. Here the blood supply is frequently skimpy. Think of the ACL circulation as an hour glass. It is better at the top and bottom, but thin in the middle. Thus, repairing the ligament is this level will commonly not succeed. Most ACL tears are in the mid portion of the ligament and not repairable. I do not recommend attempting to repair the ligament if it is torn here. Moreover, the arthroscopic appearance of the torn ligament is that of a rag mop, and it would be like trying to stitch together scrambled eggs—an exercise in futility!

So, given that most people tear the ACL in an area that is unrepairable—what to do? The ACL reconstruction is a great operation. Performed mainly arthroscopically, a graft is inserted through a tunnel in the tibia into the knee joint and secured with a screw into the femur –thus replacing the torn and functionless ligament. But the operation is not without potential risks-infection, stiffness, graft failure, etc. and the recuperation is relatively lengthy. Athletes who have this operation are out for the remainder of the season.

Who requires this operation? Certainly athletes involved in high school, college, or professional sports or athletes who have to cut, pivot, or jump. Or, older patients who participate in intense sports. Also, people who have a very prominent drawer sign with pain or people who later develop a trick knee that buckles and gives way— at risk for producing a new injury.

So getting back to our friend in the first paragraph, should you have the ACL reconstruction because—like Mount Everest—it is there ? ( the surgery is available ) Or are there alternatives. In this respect—and again this is my opinion – I tend to be more conservative than some of my colleagues.

Not everyone requires the operation. And, this is not just my opinion, but a stated fact in the orthopaedic literature. In a study in 1993 involving almost 300 patients, 62 were able to function satisfactorily without an ACL.

This has clearly been my experience with my patients. Many patients with an ACL tear have stable knees as other surrounding structures of the knee  may also provide stability. If these patients have reasonably stable knees and, like the man above, few or no symptoms, I do not encourage reconstructive surgery. Instead, I rehab their knee with an intense exercise and strengthening program –emphasizing the hamstring muscles and a custom made brace for sports that stabilizes the knee. Most patients consider this brace to be comfortable and it worn by many athletes. I have had many patients who have returned to various sports and skiing after this treatment and most have done very well. For example, an attorney friend that I treated about twenty years ago, has had no long term trouble and has long since returned to skiing black diamond trails while wearing his brace.

After an ACL injury is diagnosed by an MRI, I do recommend standard arthroscopic surgery to evaluate the knee. Basic arthroscopy is a relatively minor procedure and the recovery is quick. I want to see the extent of the tear or if the ACL is repairable. Sometimes the MRI is incorrect and the tear is not as bad as reported. Sometimes there is an associated meniscal tear which I treat. I also believe that washing our the knee and removing blood clots and the scarred damaged rag mop of a ligament relieves pain and hastens recovery and rehab. This has been my overwhelming experience. If the ACL is completely torn and un-repairable, it is of absolutely no use. A wad of scar tissue forms-we call it the ACL stump- and it can probably produce some knee discomfort. Therefore, I remove the scarred stump as it is functionless.

Next, I sent my patients for PT to rehab their knee. Most feel better after this minor operation and are walking normally within two weeks. A brace is custom made and eventually they return to sports and, hopefully, a normal lifestyle. They are watched carefully. If their knee loosens up; if they re-injure their knee; if they simply do not do well –if their knee still goes out or buckles, I recommend a reconstruction. One valid criteria –for me – is how do they do during normal, daily activity. If a patient can, say, ski successfully while wearing a brace, but if his or her knee constantly buckles while going up steps, this is unacceptable. One realistically cannot constantly wear a brace. So, this patient should consider an ACL reconstruction.

Again, 60-70 % of these patients can avoid this operation. If someone is middle aged, a weekend athlete-golf or doubles tennis, etc. – or has a sedentary job, it is certainly reasonable to first try the conservative approach. Especially if their knee is fairly stable.

What patients do I recommend have a reconstruction early on ? A young athlete. Perhaps someone in their late teens or in their 20’s – 30’s who plays organized contact sports, skis, or plays competitive tennis. Someone who has 60 years ahead of them probably should have the surgery. Or, a policeman, fireman, or construction worker who may not be able to wear a brace and who may perhaps be in harm’s way if they cannot rely on their knee function.

Thus, every individual case needs to have treatment recommendations tailored to their medical exam findings and their future requirements.

Why do some doctors believe that everyone (outside of the elderly population) should have an ACL reconstruction? There is a feeling that re-injuries will occur and eventually lead to the development of osteoarthritis of the knee. While, this view may be valid, I do not believe that this is always the case. Many of my patients have done well with rehab/bracing and have not re-injured their knees. Nor, have follow-up x-rays years later demonstrated arthritis. Moreover, whenever I do a total knee replacement on someone –with severe arthritis: obviously–I almost always find an intact ACL. So, if isolated ACL tears always lead to osteoarthritis, why don’t more people undergoing total knee replacements have absent ACL’s ? Finally, some recent studies have shown that ACL reconstructive surgery does not necessarily prevent osteoarthritis in the long term.

Again, the above opinions are mine and do reflect my bias, albeit based on thirty years of experience in treating these injuries. Medicine can be in art and sometimes there is no right or wrong opinion.

But if you injure your ACL at least be informed about your condition and your options. Possibly seek a second opinion before rushing into reconstructive surgery. And remember, an ACL reconstruction is not an emergency operation in most cases. In fact, many orthopedists recommend delaying the procedure for a few weeks after an injury so that the knee swelling can decrease and the knee can somewhat recover from the insult. So, in most cases, there is no rush.

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.