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MARATHON TRAINING
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In honor of the upcoming Boston Marathon I would like to briefly outline the basic steps involved in training for a marathon. Running a marathon can be extremely rewarding and challenging but it can also be a source of injury and frustration if you push your body to the limits and it breaks down. By educating yourself with the experiences of others that have successfully run marathons you can significantly increase your performance and decrease your risk of injury.
The first question to ask is, Am I capable of the intense training involved in marathon running or are there potential medical issues that may be aggravated by such activity? If there is any question about this the first step in training should be a visit to your primary care doctor. Possible complicating conditions could be high blood pressure, angina, asthma, diabetes, or poor circulation.
Next you have to decide what marathon you want to run so you can leave enough time to complete a thorough training schedule. Many of the larger marathons now require qualifying so don’t expect to run Boston, New York, or Washington D.C. your first time out. If you are a routine runner now you will need about 4 months to complete a build-up and taper schedule prior to the run. If you are not an avid runner you will need to start extremely slow and work your way to 20 miles per week before even entering a training schedule.
Most marathoners recommend a pre-marathon program that involves building up mileage over 3 ½ months. During this build up the runner must be very careful to allow rest days in between runs, continue daily thorough stretching, and pay close attention to any nagging aches and pains as signs of a more significant problem that may prevent the marathon. Expert runners also suggest picking one day a week to be the “long run” day. So while you are slowly building up the mileage of each run you will continue to advance the “long run” day up to the 22-23 mile range 4 or 5 weeks before the marathon. The remaining days runs should be between 4 and 10 miles and there has to be adequate rest between runs to allow for muscle recovery.
The final two weeks pre-race are the taper down period. This is where the runner slows down their mileage dramatically to allow their body to be completely prepared for the task at hand. This means limiting runs to every other day and slowing mileage to the 4-6 range. Always continue stretching daily and begin to prepare mentally and physically for the “big day”. Little things that can be helpful are to trim toenails, treat calluses or blisters, massage out any last minute kinks, and thoroughly prepare a strategy for the race.
On the day of the race wake up early enough to eat a small breakfast, drink some hydrating fluids (not coffee), use the bathroom, and get to the start line on time. Be prepared for all weather conditions. Finally make sure that you run your own pace. It is easy to get caught up in the mad dash at the beginning of the race but this may lead to early fatigue.
This is a very brief overview but there are many other sources of information out there. The local library is full of books that outline specific training schedules and diets. The Internet is also a free source of huge volumes of information. Just remember to be prepared, get educated, and have fun.
ACL Tears
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The anterior cruciate ligament or ACL is the most important stabilizer of the knee joint. It connects the thigh bone and shin bone together in the center of the knee joint and prevents forward movement of the shin during cutting or pivoting. Although it is not essential for activities like walking or even jogging in a straight line, as soon as any side to side movement is attempted the ligament is crucial to maintain stability.
The ACL has no ability to heal itself. Unlike an ankle sprain or some knee sprains where the ligament can scar and provide excellent support, when the ACL is torn completely the knee will never have the stability it needs to function normally. In addition, simply sewing the torn ACL back together has been shown to fail consistently. Instead, surgeons use tendons from the patient’s body or from an organ donor to create a new ligament that is then anchored into place using screws. The body will accept this new tissue and over time convert it to a strong “ligament” that is able to provide excellent stability.
In the distant past the importance of this ligament was not well understood by doctors so many athletes who tore their ACL over 25 years ago did not have any effort at surgical reconstruction. Those that went back to sports continued to have episodes where the knee “gave out” and over time this leads to tears in the shock absorbers of the knee and arthritis. In fact there is a whole generation of former athletes who are now in their 50’s who have early arthritis that started when they tore their ACL in high school sports.
Now, the ligament’s importance, and the consequences of going through life without an ACL are well understood and surgery for a torn cruciate ligament has become the standard. Over the last 25 years the surgery has gone from being a major procedure with a 4 or 5 day hospitalization and casting to an outpatient procedure with ability to walk right away. One thing that has not changed significantly is the 6-12 months that the body takes to strengthen and mature the transplanted tendon that is used to make a new ACL. This means that athletes cannot return to sports until their new “ligament” is strong enough to support their knee with sports.
Back Pain
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During the recent move of our office I was acutely reminded of how problematic back pain can be, so I have decided to re-visit this very common complaint. There is truly an epidemic of back trouble in this country and medical resources are being stretched to meet the demands of patients with disabling pain. In this column, I want to outline some of the more common causes for back pain and go over a few of the treatment options.
Muscular low back pain or “lumbar strain” is the typical backache that many younger, more active people will get when they have overdone things. Almost everyone has experienced this at some point. Pain is caused by muscles that are overworked and often poorly trained. These muscles can go into spasm, which produces severe pain and limits the ability to move. Usually this responds to a couple of days of rest followed by gradual resumption of activities. A brief course of anti-inflammatory medication and maybe a muscle relaxant will help. This episode, however, may be a warning of things to come if the patient does not improve their back conditioning, lose weight or change the way they use their back.
Chronic muscular back pain can become disabling and despite the lack of arthritic changes, disc changes, or spinal nerve problems, many people have been forced to change jobs or hobbies. There are thousands of treatments for chronic low back pain, but few have been shown to work scientifically. Most patients will try medications, some form of physical therapy, chiropractic or other non-traditional remedies (acupuncture, massage, herbals, etc.) Most doctors agree that the key is to maintain strength and flexibility of the spine while avoiding activities or injuries that cause pain. Most people can control the number of episodes of their back “giving out” but may not get rid of the problem completely.
The intervertebral disc is the gelatinous shock absorber that sits between two bones in the spine and provides flexibility and sponginess. A herniated disc (slipped, ruptured) occurs when a tear develops in the outer shell of the disc and some of the more liquid inner material leaks out. The disc material will often push backward onto the spinal cord or a spinal nerve, affecting the function of those nerves. This is what causes pain, numbness or even weakness in the foot or leg. Most patients will not require surgery in these circumstances; however, there are some serious warning signs that damage may become permanent without fast intervention. These include worsening muscle weakness in the leg, loss of bowel or bladder control, or myelopathy (sign of compression on the spinal cord itself). Conservative treatment includes rest, medications for pain, time, and possibly epidural steroid injections (put in the spine to shrink inflammation).
Finally, arthritis of the spine can take many forms. There can be wearing out of the disc spaces, wear of the small joints of the spine or loss of alignment of the spine. These can occur more often in the elderly and tend to get worse over time. It is important to keep the spine as strong and flexible as possible and to keep weight reasonable to decrease the load across the spine. Many patients can be managed with anti-inflammatory medications or gentle pain relievers. Others find relief with occasional chiropractic care, massage, an exercise regimen, magnets or over-the-counter pain blockers. If pain is severe, surgery to fuse the arthritic areas together so they no longer rub against each other may be helpful.
Overuse Injuries in Children
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Even though we think of children as having boundless energy and ability to go non-stop, it is possible for children to overdo it. Like adults, kids bodies need time to recover from athletic stress, and if they aren’t given that rest they can break down. Since children are still growing the way their body reacts to excessive activity is different than adults, but it can be quite serious.
Children’s bones are constantly growing both in length and width. In the long bones like the femur (thigh) and humerus (arm) there are growth lines at each end of the bone where cells are constantly laying down new layers of bone similar to the rings on a tree. In other areas like the heel, elbow, shoulder, and upper shin the bone grows through an apophysis. This is a separate growth center that widens the bone and eventually fuses with the main bone. These growth satellite areas are very susceptible to the stresses of sports because major muscle groups and tendons are constantly pulling on them when a body is in motion. So unlike adults who develop tendonitis or muscle strains from overuse, children develop inflammation and injury to these growth centers from excess activity.
The most common areas where children will have problems are the knee (Osgood Schlatter-previous article), shoulder and elbow (Little Leaguer’s injuries-previous article), and the heel (Sever’s Disease). In each of these areas a major tendon or group of muscles is pulling on the growing bone center during activity and can actually pull it apart if symptoms are ignored. These tendons are: the patellar tendon in the knee, the rotator cuff in the shoulder, the wrist and hand flexors in the elbow, and the Achilles tendon in the heel.
The mainstay of treatment for all of these overuse injuries is simple – rest. Often times a physician will prescribe an anti-inflammatory or even a brace. Once symptoms are under control the juvenile athlete can return to sports but it is important to monitor their activity level to avoid overuse injuries. In most cases kids can still be active but they may have to restrict the number of hours of participation per week. In addition symptoms that may be severe during growth spurts may decrease significantly during slower periods of growth. Finally, reassure your kids that they will outgrow the problem when their skeleton is fully mature between 16 and 20.
RUNNERS INJURIES
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In honor of the Marion Village 5K Road Race last weekend this article deals with the most common injuries that avid runners face during training. Most are not serious and can be treated with rest, appropriate stretching, and possibly anti-inflammatory medications. Since running is an extremely leg dependant sport the easiest way to classify injuries is by body part.
The foot and ankle is where the rubber meets the road, quite literally, and is the most common area of trouble. People who have excessively high arches (cavus feet) or people with low arches (flat feet) are more prone to develop problems. Running shoes are now made to accommodate for these extremes and can be a first line of defense. The foot is a complex interaction of ligament, bone, and tendon and shoe inserts or cushioning that can either pad areas that are overstressed or convert foot mechanics to a more normal range are very helpful.
Plantar fasciitis (heel and sole of foot), Achilles tendonitis, posterior tibial tendonitis (inner foot), and stress fractures top the list of maladies. Each of these is a form of overuse injury and is characterized by pain, swelling, and poor function. Early treatment may be as simple as altering your running style, resting briefly, or wearing the appropriate insert. More difficult cases may require medications, casting or bracing, cortisone injections, or rarely even surgery.
In the knee patellar tendonitis (front of knee), ileotibial band syndrome (outer side), or pes bursitis (inner side) are common overuse injuries. The key to treatment of these problems is early recognition and not ignoring symptoms. Again, rest and stretching tends to help quickly.
Sudden traumatic injuries can also be a problem with the knee. Tears of the shock absorbing cartilage (meniscus) can occur with twisting injuries in the younger runners and with even less force in older runners. These injuries are characterized by swelling not of the muscle and tendon around the joint but by fluid that collects in the joint itself. This may be difficult to distinguish but is important in treatment because many meniscus tears need surgery.
Finally, there are a few less common problems with the hips. Hamstrings tendonitis (back of the thigh), trochanteric bursitis (outer hip), and groin pulls are usually a result of poor stretching and overuse.
It is important to remember that all of these parts are interconnected and that an injury or poor alignment in one area can affect others. This is one reason why it may not be smart to continue running with an altered form to protect one injury at the expense of causing another. This also highlights why it is important to stretch all muscle groups around the foot and ankle, knee, and hip before running.
Jones Fracture
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Most of the time a broken bone in the foot does not pose a serious problem for the athlete. Most foot fractures do not require surgery or even casting. Although the break may take up to 6 weeks to heal, pain usually improves drastically after only a couple of weeks.
The Jones Fracture is drastically different, and it usually occurs in healthy aggressive athletes. A Jones Fracture is a break that occurs in the metatarsal of the small toe. The metatarsal is the bone that connects the ankle to the toes. The center of the bone has a very poor blood supply so its’ potential to heal a break is poor. The break often occurs with landing and twisting as during basketball and volleyball. It is usually accompanied by an ankle sprain. It is important to get both ankle and foot x-rays on patients who have pain or swelling that is suspicious for a foot fracture.
Since this bone has such a poor ability to heal, the treatment for Jones Fractures is very different from other foot fractures. They need to be treated with strict non-weight bearing and a cast for 6-8 weeks. There are even cases where healing can be further delayed or no healing can occur. This is called a delayed union or non-union.
In elite athletes surgery for a Jones Fracture is sometimes the answer. By placing a screw across the broken bone the athlete will have a shorter recovery time and a higher incidence of healing. These benefits need to be weighed against the risks of surgery. Several college and professional basketball players have had excellent results with this operation.
The Cortisone Myth
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For many conditions in Orthopedic Surgery and Sports Medicine a cortisone injection is part of the standard treatment. Cortisone may help inflammation, arthritis, bursitis, and tendonitis. It is a powerful anti-inflammatory medication, like an aspirin, given at the source of the problem. However many physicians have started taking a hard look at random injections given to relieve pain without consideration of the potential side effects and inadequate attempts at other treatments.
Cortisone is a generic term for any of the steroid-based anti-inflammatory injections used in medicine. These injections are very different from the steroids that bulk up some bodybuilders, and have all been used safely in Orthopedics and Rheumatology for years. Each is given at a specific dose based on how potent the individual drug is. Often injections will be combined with a numbing medication to dilute the Cortisone and ease the pain of injection.
Cortisone injections into tendons or around tendon coverings have become mildly controversial in the last 10 years. In the past it was quite common to inject tendons around the elbow, knee, heel, and wrist. Detailed microscopic studies of the tendons actually showed that injections could damage the structure and cause weakening in the tendon. This was seen in practices when some patients developed torn patellar tendons (knee), Achilles tendons (ankle), or extensor tendons in the wrist.
Many patients receive Cortisone to treat arthritis of one of the major joints of the body. The pain relieving effect is dramatic but usually temporary. This is appropriate for patients whose cartilage is fairly worn and the injections are being used as a way to treat pain and buy time before a joint replacement may be necessary. However there is some evidence that the Cortisone may actually damage whatever healthy cartilage is left in the joint and therefore should be used with care in patients with mild arthritis or in younger patients.
Finally, there are many excellent and safe uses for cortisone injections. There have been very few reports of problems with injections in the shoulder bursa, trigger fingers, elbow bursa, or hip bursa. The Cortisone is used to decrease pain and swelling and are often combined with rest or specific exercises to help with healing.
Little League Injuries
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Whether it’s Little League, Pony League, or T-Ball, spring is baseball season in the southeast coast. Along with the fun, laughs, and excitement of competition come a few injuries. The two most common at this age are irritation of the growth plates in the shoulder or in the elbow. These have been called Little Leaguer’s Shoulder and Little Leaguer’s Elbow.
Growing athletes have growth plates throughout their bodies. These are the areas where the bones are growing longer and wider, and they are not as strong as the surrounding regular bone. When these areas are stressed by athletic activities they can react by causing inflammation, swelling, and pain. In leg based sports like soccer, basketball, or football the knees or heels are usually the problem. In throwing sports, the shoulder and elbow have to generate high forces to launch the ball and are therefore commonly injured.
During throwing there is a great deal of power that needs to be built up in the muscles around the back and shoulder. During the acceleration and follow through phases of throwing these forces can damage the shoulder, elbow, and wrist. These forces can be higher during curve ball throwing, or in pitchers who throw side arm. In children of this age it is imperative to teach proper overhead throwing technique and position to avoid injuries.
Most commonly the stress on the growth plate will be felt in a child who is rapidly growing and who is throwing a lot. Pitchers are the most common position. These injuries can be thought of as mini-stress fractures that are occurring across the growing bone and never have enough time to heal.
The most important treatment is rest to allow the stressed bone to heal itself. Using a pediatric dose anti-inflammatory can help with pain and swelling. In some athletes an x-ray should be done to check the condition of the growth plate.
Usually it takes 2-4 weeks of strict rest before the athlete feels better. The athlete can then resume light throwing and progress back to full activity if there is no recurrence of pain. Some children cannot return to pitching or playing in multiple games per week without pain, and these kids should switch position and limit play based on their discomfort. The pain should never be ignored because in rare cases it can lead to growth problems in the arm.
THE ROLE OF ATHLETIC TRAINERS
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In this article I decided to discuss the important role that an athletic trainer can play in the care and rehabilitation of an athlete. After two years in practice I have been lucky enough to interact with most of the local high school and college trainers and can uniformly endorse their capability.
Athletic trainers are highly educated professionals that have obtained both a college degree and a certification from the National Athletic Trainers Association. They are required to continually update their knowledge by attending the latest courses, and many have personal experience with high level sports participation. They are the front line resource for many injured high school and college varsity teams.
For many young athletes the trainer will be the first professional who has a chance to evaluate and treat an injury. The on-field evaluation can exhibit findings that muscle spasm, swelling, or pain can mask during later exams by the physician. Occasionally a dislocation of the shoulder or knee cap will spontaneously correct and the most reliable information is the trainer’s exam. In less severe injuries the trainer may be able to tape, brace, or pad an athlete to allow them to return safely to a game. In more severe injuries the trainer may elect to use an ambulance for hospital transport or be able to contact a covering physician to arrange immediate evaluation. In sports like football and hockey the risk of injury is high enough that schools are required to have an athletic trainer readily available during games.
Probably the most important role of the trainer is rehabilitation of the athlete who has been evaluated by a physician. Specific instructions can be given for types and frequency of exercise or stretches, and a gradual return to play schedule can be set up. Often times the athlete will need access to special exercise equipment, taping, ice, or massage to allow quick return to play. It is crucial to have an objective person serving as a liaison between doctor and patient to prevent return to play before the athlete is safe and strong.
SHOULDER DISLOCATIONS
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Shoulder dislocations have been a common injury seen in emergency rooms and orthopedic offices this fall. This is an injury that often occurs in high school and college football players and can have devastating consequences for the individual.
The shoulder is a ball and socket joint with the humerus (upper arm bone) being round at the end and the glenoid (end of the scapula) being shaped like a shallow bowl. A shoulder dislocation occurs when enough force is transmitted to the shoulder to push the ball completely out of the socket. This can happen during tackling, blocking, or with falls onto the arm. Most commonly it happens when the arm is in an elevated position and the hand is rotated outward as in proper tackling position.
Unfortunately complications from shoulder dislocations are fairly common. In younger athletes below the age of 20 the rate of recurrent dislocation is 60 – 90%. As athletes get older the rate of recurrent dislocation goes down but the incidence of tears of the rotator cuff goes up dramatically. In a 50 –60 year old athlete the rate of rotator cuff tears caused during a dislocation is more than 50%.
Initial treatment for any dislocation is urgent relocation of the dislocated joint. Most of the time when the shoulder is dislocated the athlete will need to have the ball manually put back into the socket. This should be done by a professional, either a trainer or physician at the sideline, or by an emergency room physician. Occasionally in people who have had multiple dislocations they can relax and maneuver their shoulder muscles to allow the ball to relocate without help. People who have had chronic shoulder problems will often experience partial dislocations, called subluxations, which relocate spontaneously.
Following relocation of the joint the athlete should be evaluated by an experienced physician who can help recognize when one of the more serious complications could be present. In many individuals a MRI scan will be done to determine the amount of damage to the joint capsule and the rotator cuff. Most athletes can return to full sports activity after a dislocation but it requires a long period of recovery and rehab. It is important to regain the normal range of motion of the shoulder as well as the strength of all the major muscle groups around the shoulder.
There is some controversy about how to best treat a young athlete with their first dislocation. As stated earlier the re-dislocation rate can be up to 90% so some surgeons have gotten more aggressive about repairing ligament damage early. Many orthopedic surgeons will treat a first dislocation conservatively with rehab and wait to see if a second dislocation or subluxation occurs before considering an operation. Traditionally dislocation surgery has been done with full incisions but some athletes are good candidates for arthroscopic repair of their shoulders. This means that their incisions will be smaller and their recovery will be slightly faster. Regardless of the type of operation the athlete cannot return to contact sports for at least 6 months.
ANKLE SPRAINS
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Ankle sprains are among the most common injuries encountered by professional and recreational athletes alike and frequently contribute to lost playing time.
An ankle sprain is a tear in the ligaments that support either the inner or outer aspect of the ankle joint. This usually occurs when the athlete rolls the ankle inward after stepping in a hole or onto another players foot. As the foot rolls in (inverts) the ligaments connecting the outer bone of the ankle to the foot are stretched and torn to various degrees. A grade I injury is mild and will limit play for about 1 week. Grade II injuries are moderate and last 1-3 weeks, while a grade III sprain is severe and may limit the player for 6 weeks or more. Often bruising of the bones within the ankle can occur simultaneously. This can prolong the healing time of even more minor sprains.
Signs of an ankle sprain include pain, swelling, bruising, inability to bear weight, and a feeling of instability. Initial management should be with the RICE protocol, which stands for rest, ice, compression, and elevation. For minor injuries x-rays and evaluation by a physician may not be necessary, but for any significant problems consult your doctor.
Preventing sprains and returning to sports quickly are related issues. The muscles that control movement around your foot and ankle need to be kept strong to prevent injuries and to rehabilitate an injured ankle. A course of exercises designed to re-establish range of motion and strength is an essential part of returning to sports. Use of high top sneakers, ankle taping, and brace wear may be indicated in certain individuals.
Occasionally an athlete will develop chronic ankle instability, where long after healing of a sprain (or multiple sprains) the ankle still feels like it gives way or is loose. This is often caused by incomplete rehab of an injury or may be a sign of chronic stretching of the ligaments in the ankle. Occasionally players need to wear a functional brace to help support the ankle during sports. In more severe cases the chronically stretched ligament has to be surgically shortened or substituted for.
Frozen Shoulder
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Frozen shoulder is a term used to describe patients who have developed thickened and scarred down capsule around their shoulder joint, which severely limits their range of motion. When someone has frozen shoulder pain can be quite severe but the most striking finding is the inability to move the arm upward or outward. In fact limitations in elevation or external rotation of the arm confirm the diagnosis and are used to monitor progress with treatment.
In a few patients, especially people with diabetes, frozen shoulder can occur without any other cause. When it is the primary problem the onset of symptoms may be quite rapid and deterioration takes place over just a few short weeks. If the problem is ignored too long permanent losses may occur.
In most other patients frozen shoulder is a secondary diagnosis and the primary problem is rotator cuff tendonitis or tear, or capsular injury from a shoulder dislocation. In these patients there may be a history of injury or the pain may start without a trauma. The initial problem is pain, but over a longer period of time people stop using their shoulder because of the pain. If someone stays in a protected position for too long, such as wearing a sling all the time, the shoulder will scar down in that position. The patient then has two problems, the initial source of pain and a frozen shoulder.
Treatment for frozen is usually successful when initiated early. Most people are too scarred and tight to do much movement of their shoulder independently and will require the help of a therapist. Pain medication and anti-inflammatory medication help provide comfort to allow more motion. Often a cortisone injection will provide enough pain relief to get the shoulder moving. Even with good conservative treatment frozen shoulder may take 3 to 12 months to completely resolve. The key is to maintain steady, slow progress.
Unfortunately many people do not respond well to the early treatment and despite aggressive efforts they remain stiff and even lose some motion. If patients are not making progress surgery should be done to prevent severe loss of motion. The goals of the surgery are to correct the primary problem, break up any scar tissue or adhesions, and to assure full motion after the surgery is done. Usually these goals can be achieved by combining an aggressive manipulation of the shoulder with an arthroscopy to break adhesions and evaluate the rotator cuff. Even under the best circumstances some permanent loss of shoulder motion should be expected, but typically patients will regain a functional range that allows them to use their arm comfortably in daily activities.
CHONDROMALACIA PATELLAE
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“Chondromalacia Patellae” is a disorder characterized by pain and crunching in the front of the knee. Chondromalacia is the medical term used to describe worn out or arthritic cartilage. In many people this wearing out starts in or is isolated to the knee cap.
Cartilage comes in many forms but the most important cartilage in the knee is the smooth glistening stuff that caps the 3 bones in the knee. This cartilage can be thought of like the tread on a tire and over years of activity it can wear down. In many people the damage can affect all of the surfaces evenly, but in most the wear will be uneven and the symptoms produced correlate with what area wears first. In many women the knee cap wears earlier while in many men the inner compartment of the knee wears first. In some people who have had an injury to their cartilage the knee will wear out in patches similar to pot holes in an otherwise smooth road.
Symptoms of chondromalacia patellae include pain over the front of the knee, catching or grinding behind the knee cap especially with deep bending, and knee swelling after activities. Stair climbing or activities that involve frequent and deep knee bending are the worst, and biking can be very painful. Usually people are asymptomatic with daily living activities but when they exercise, garden, or have to do climbing the knee acts up.
Treatment of arthritis of the patella usually starts with some very conservative measures. In many people, their problem is caused by a tendency for the knee cap to ride slightly out of center on the thigh groove. These patients need strengthening of the quadriceps muscles on the front of the thigh; especially the inner thigh group called the VMO. In some people simply changing their sports or daily activities will be quite helpful. They must avoid stairs, step aerobics, stair master, biking, and deep bending exercises like squats and lunges. Usually exercises that don’t involve bending, such as swimming, walking, Nordic Track, or weight lifting won’t cause as much pain.
Some people need more aggressive treatment with medications like anti-inflammatories, Glucosamine, or pain pills. Often an injection with cortisone will provide temporary relief, while a series of injections with a new synthetic joint fluid may provide up to a year of help. A few patients will go on to need surgery. Usually this will be an arthroscopy to smooth the surface of the patella and release any tight ligament structures causing pressure. This helps symptoms but does not cure the underlying arthritis. In rare instances operations can be done to remove the knee cap entirely or move the knee cap to reduce pressure on it. Some day many years from now we may be able to inject cartilage into the knee and have new smooth surfaces grow but that is far in the future.
FOOTBALL STINGERS
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Early fall brings back football season and many young athletes are experiencing the fun and competition that comes with organized sports. Some of those same football players have now experienced a "burner" or "stinger" for the first time. These common injuries occur when the athlete is tackling or falling and the neck gets bent away from the shoulder being hit. Stingers can be very frightening because not only do they cause pain in the neck and shoulder, but they can also cause tingling, numbness, or weakness in the arm and hand. Occasionally there is a short period of paralysis of the entire arm.
Burners are caused when the group of nerves that supply sensation and strength to the arm are stretched or compressed by the beding of the neck. The nerves can sustain injury to a varying degree and recovery can take a few seconds or sometimes months. Grade 1 injuries are the most common and involve very mild stretching of the nerves, with recovery usually very quickly. Grade 2 injuries involve some tearing of nerve fibers and can take a few weeks or even months to recover. Grade 3 injuries are extremely rare and involve the nerves being severed. Usually surgery is required and full recovery is unlikely.
When a player initially injures his neck and has a stinger, the most important step is to be sure that there is no injury to the bones of the neck or spinal cord itself. Tenderness around the spine or symptoms that involve the legs are warning signs that the injury may be very serious and that cervical bracing and EMS services are needed. Most athletes whose symptoms resolve spontaneously can return to play either that day or the following game. If any numbness, pain, or weakness persists the athlete must stay out and be evaluated by a physician before returning.
Recurrent stingers are a problem for some football players. Usually a more serious problem with the neck or shoulder is the cause, but poor tackling technique can also be to blame. Consultation with a doctor is important in this group.
MINIMAL INCISION KNEE REPLACMENT
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Minimal incision knee replacement is a surgical procedure designed to replace only the portion of the knee that has lost it's smooth articulating surface, not the entire knee joint. Osteoarthritis often effects one of the articulating surfaces of the knee while sparing others. A partial knee relacement provides a new articulating surface for that portion of the knee that has "worn down."
The new implant is designed to relieve weight bearing pain, rebalance the knee, improve knee function, and delay or eliminate the need for a total knee replacement. Patients who will benefit most from the minimal incision partial knee replacment procedure are those who suffer from pain while standing; pain when walking short distances; pain when changing positions such as sitting to standing; or those who have persistent knee swelling, locking, or giving way.
The minimal incision knee replacement requires a smaller incision compared to a total knee replacement. The partial knee replacement technique also allows the major ligaments of the knee to remain intact while replacing the "worn" articulating surface. A total knee replacement procedure involves replacing all joint surfaces and ligaments with metal and plastic due to the extent of joint surface damage.
Hospital stay is drastically reduced with minimal incision partial knee replacement. Patients are discharged anwhere from 6 to 24 hours following surgery depending on indidual circumstances. Rehabilitation is quicker compared to a total knee replacement procedure due to less extensive surgical trauma and discomfort. Walking is begun the same day as surgery.
Talk to Dr. Johnson, Dr. Heacox and Dr. Baltz at Wareham Orthopedic Associates about your knee pain and see if you are a candidate for this minimal incision knee replacement.
Meniscal Tears
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One of the most common injuries in all sports is a tear of the shock absorbing cartilage in the knee called the meniscus. It usually occurs when an athlete twists, hyperflexes, or hyperextends the knee. Many are from contact, but non-contact falls and twists can also tear the meniscus. Most large tears will become immediatly symptomatic and swell drastically. Some very small fraying tears can produce symptoms only when the knee is in a certain position or activity. In younger athletes the injury is usually quite obvious and there can be torn ligaments or fractures that accompany the meniscal injury. In older people the meniscus is more brittle and friable and a tear can occur with a deep knee bend or getting out of a low chair.
Small meniscal tears have a good chance of healing themselves and becoming asymptomatic. Large tears, however, will not heal spontaneously and can damage the joint surfaces by flipping in and out of the joint. Often patients with large tears will sense a popping , clicking, or giving way as the tear flips around. Most patients also experience swelling, pain, difficulty with bending or stairs, and trouble with twisting of the knee.
Treatment for meniscal tears varies greatly depending on the size and location of the tear, age of the patient, underlying arthritis, activitiy level, and ligament injuries. Very young active athletes almost all sustain large tears and require surgery. The ideal operation is to repair the meniscus so that it can heal and remain functioning as a shock absorber. Some times the tear is frayed and the tissue cannot be fixed so removal of the torn portion, leaving as much intact remnant as possible, is the best option. In patients over 40-50 years old studies have shown that the rate of healing of repaired menisci is very low so surgeons often will perform removal in this group. Regardless of the type of treatment, with modern technology the operation can be done entirely through a scope, minimizing incisions and recovery time.
Osgood Schlatter Disease
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Several times in the last few weeks I have seen adolescent athletes with anterior knee pain after playing sports. The confused and worried looks I get from parents asking "Osgood what?" is what prompts this article.
Osgood Schlatter is a very common condition that occurs in the knees of many adolescent athletes. It usually affects males between 10 and 15 years old and is characterized by pain along the front of the knee. Most kids will still be able to participate in daily activitiies like school or household chores but after extended periods of running during sports or neighborhood play they develop pain. Many will develop a small bump over the front of the shin just below the knee cap which is sore to touch and may be growing. In days past, parents would often refer to this as "growing pains" and they treated it with rest and over the counter medications.
The actual cause of Osgood Schlatter is irritation or even fragmentation of the growing bone of the anterior shin. The bump on the front of the shin is called the tibial tubercle and it is responsible for making the top of the shin bone wider as we grow. The patellar tendon, which comes from the knee cap and hooks into this area of bone, is constantly pulling on this growing area of bone. During times of rapid growth or in kids who are highly active the forces pulling the growth area apart are too much and the the growing bone reacts by producing pain and swelling. In severe untreated cases the tibial tubercle can actually be pulled off when the pulling forces exceed the strength of the growing bone.
Most cases of Osgood Schlatter never get this far. Treatment initiated early is usually very effective in limiting symptoms and preventing long term problems. The first steps are rest and anti-inflammatories. Although this frustrates most athletic adolescents it is mandatory to allow a brief time for the growing bone to heal and recover. Most kids with Osgood Schlatter can return to be reasonably athletic and active. Common sense is generally the rule and if kids need to limit their games or practices or possibly sit out certain times in the season this is usually a good compromise. Using ice and anti-inflammatories during the season also helps.
The most important key is not ignoring the symptoms. Athletes that continue to play and struggle through their pain may end up doing permanent damge to the growing area of bone in the knee. This can lead to surgery, chronic pain, or even arthritis.
It is best to be evaluated by your doctor so that a professional can determine what period of rest is needed, whether xrays are needed, and if more aggressive treatment with a brace or cast might be the answer.
Shoulder Bursitis
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Shoulder pain is one of the most common complaints the orthopedic surgeon sees. Overhead athletes (tennis, volleyball, swimming)frequently suffer but people can even develop shoulder problems from the way they sleep. A typical complaint is that the shoulder is most painful at night and will wake the person up several times during sleep.
The usual cause for these shoulder pains is bursitis, or what some doctors call rotator cuff tendonitis or impingement. The most common group affected is between the ages of 35 to 55, and usually there is not a major injury or trauma that leads to the pain. Often times people will be involved in a repetitive overhead activity or tend to sleep with their arm up overhead or on that side. Both sports and job activities can be the source of the repetitive motion (for example plumbers, contractors, painters).
People usually are reasonably comfortable when the arm is at their side but will get bursts of stabbing pain when the arm is raised forward or to the side. Often patients feel the pain down the side of the arm and even radiating toward the elbow.
As with any overuse injury the key to cure lies in rest and the appropriate non-surgical treatment. Anti-inflammatories are usually helpful, along with limiting use of the shoulder for a period of time. Exercises designed to stimulate healing of the iritated rotator cuff tendons are also essential. Frequently the orthopedic surgeon will offer a cortisone shot into the shoulder to relieve pain and allow the patient to participate in therapy.
About 90% of people will have improvement or complete resolution of their symptoms with a course of appropriate treatment. However, the remaining 10% may not respond to the conservative treatment and could elect for surgical treatment. This usually means an arthroscopy with trimming of the rotator cuff, removal of any bone spurs, and removal of the inflamed bursa. Success with this operation is very good.
In some people that have persistent pain or that have a trauma that initially started the pain the physician usually needs to be sure there is not a complete tear of the rotator cuff. This problem almost always requires surgical repair. Surgery for a tear can often be done with a scope but the recovery time to allow the torn rotator cuff tendons to heal is 2 to 3 months.
Overuse Injuries
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Spring is in the air, the Crocus are blooming, and athletes around the south coast are coming out of hibernation to re-claim their sports. This is a critical time of year for most recreational athletes because often times the excitement of getting back outside outweighs the realization that you are not in the same kind of shape you were last fall. Spring is a time which brings some athletes a smile but many others tendonitis, bursitis, or a sprain.
It is important for "weekend warriors" to understand that if they haven't been keeping in shape over the winter, spring is a time to start at the beginning. The example that best illustrates this is a runner who may have been doing 5 miles four times a week at the end of last fall. The goal during spring should be to start at a very low level, maybe 1-2 miles two or three times a week. This runner has to slowly progress his mileage, pace, and frequency until he has achieved his ultimate goal of 20 miles per week. The progression needs to be gradual and spread over a reasonable amount of time (generally 3-8 weeks). Most of all it is important to pay attention to your body signals and not move on to higher levels of training if you are having pain or difficulties. This model applies to any sport.
The most common problems that affect spring time athletes are bursitis, tendonitis, or sprains. Bursitis is inflammation and irritation of one of the fluid filled sacks that cover bony spots on our bodies. Trouble spots include the inner knee, the point of the hip, and the back of the elbow. Often swelling is impressive and pain can be tremendous. Rest, anti-inflammatories, and occasionally a cortisone shot are the mainstays of treatment.
Tendonitis is an irritation of one the the hundreds of muscle-tendon units that power our bodies. These can truly occur anywhere in the body however, the rotator cuff, outer elbow, wrist, achilles, and patellar tendons lead the way. Treatment is very similar to bursitis.
Finally sprains are much more common in the spring than other times of year. Ligaments around the joints of the body haven't been properly stretched and don't have the muscle support they need. This generally leads to partial or even full tearing when the ligament is improperly loaded. Examples of this are the ankle, the wrist, and the ACL in the knee. Each joint in the body has two main support systems - the ligaments which act like check reins and the muscles which control joint movement and keep it in normal range. If muscles are not properly trained to handle the loads put on them by overly aggressive springtime athletes the ligaments may be stretched or even torn. Prevention is the ideal medicine for sprains. However, once they have occurred treatment is usually non-surgical, although some are serious enough to mandate surgical correction.
The key to enjoyable and safe spring sports is common sense. Set your athletic goals high but always keep them in check by knowing your limitations. As the warm weather continues you will be able to continue raising the bar and challenging yourself more.
Carpal Tunnel Syndrome
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Carpal Tunnel Syndrome is a very common problem which affects the nerve supply to the hand and wrist. Athletes and non-athletes alike are prone to developing problems with numbness, tingling, and pain in their hands and wrists. This is often seens in bicyclists, racquet players, bowlers, hair dressers, dental hygeinists, and factory workers.
The median nerve supplies sensation to the palm side of the wrist and hand, as well as the thumb, index, long, and ring fingers. Carpal tunnel syndrome occurs when the nerve is pinched under a connective tissue band in the wrist. The nerve reacts to this excessive pressure by producing pain, numbness, and tingling in the areas which it supplies. In classic carpal tunnel the small finger and back side of the hand are not affected but crossover between the nerves in the forearm can confuse the picture.
Often symptoms will be worst when the person is using their hand for repetitive activities or holds the wrist in one position for a long time. Patients often say they need to shake their hand or hold it down for a period of time to get sensation back. At night patients are often awoken due to pain and numbness.
Initial care of carpal tunnel should include trying to identify the cause of the symptoms. Conditions which cause fluid retention or injuries to the wrist can be a source. If work or recreational activitieS are to blame then limiting these painful activities can help. Use of anti-inflammatory medications or a "cortisone" shot into the wrist can also decrease swelling and inflammation and help. Use of a splint during activities and at night is often useful.
Surgery to treat carpal tunnel is indicated if the pain and numbness have become limiting and conservative treatment has not helped. In addition surgery should be considered if weakness of the muscles supplied by the median nerve has developed. This weakness may not get better but surgery can prevent further loss of strength.
Thumb Sprains
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One of the most common injuries seen during ski season is a thumb sprain. These are usually caused by a fall where the pole gets twisted or jammed and the thumb is bent backward or sideways. Anyone who has done a lot of skiing on moguls has had at least a minor torque injury to their thumb.
The joint at the base of the thumb is usually the one injured. This joint is between the metacarpal(bone at the base of each finger) and the first phalanx(bone between the two large knuckles). The joint has a series of ligaments around it providing stability. The ligament on the inner side is typically injured, called the ulnar collateral ligament. As with any other ligament sprain, injury can range from a minor stretch to complete tearing and can even involve pulling a small fragment of bone off with the ligament.
Grade 1 thumb sprains are minor incomplete tears of the ligament and respond to conservative treatment very well. Grade 2 tears involve incomplete but substantial tearing where the joint shows mild looseness. Grade 3 tears are complete ligament ruptures and indicate very little stability left in the joint.
Initial treatment for any sprain should involve ice, elevation, rest, and anti-inflammatory medications. If pain persists or instability is present, xrays and evaluation by a doctor are appropriate. A period of bracing and or casting may be necessary.
Grade 3 sprains and those where a bone fragment has been pulled off usually require surgery. This is because the chances for spontaneous healing are low. The procedure is designed to reattach the ligament back to the area of bone it was torn from.
Occassionally athletes will have chronic instability of their thumb joint from one or more old injuries. This is common among basketball players and skiers. When the person tries to grip tightly pain will develop over the inner aspect of the thumb due to looseness. Surgery to recreate a new ligament using a tendon from the wrist can often be helpful.
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