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Expert Advice

Read our Expert Advice columns which can be viewed each Saturday in the community edition of The Arizona Republic.

As always if you have any questions, please do not hesitate to contact us.

I have been told I have a frozen shoulder. What does that mean?

Appeared in The Arizona Republic on 1/3/09

Frozen shoulder also called adhesive capsulitis is a process that involves thickening and contracture of the capsule surrounding the shoulder joint.

In most cases there is no known cause, however, frozen shoulder can occur after surgery or injury to the shoulder.

    • Most commonly affects people in their fifth and sixth decades.

    • Prevalent in 2-5% of the general population.

    • More common in diabetics (10-20%). Can often be a presenting symptom of diabetes.

    • More common in: females, non-dominant extremities, and those with sedentary occupations.

The hallmark of the disorder is restricted motion or stiffness in the shoulder. The affected individual cannot move the shoulder normally. Motion is also limited when someone else attempts to move the shoulder for the patient.

Frozen shoulder usually resolves spontaneously although recovery can take as long as 18 months.

Initial treatment measures include anti-inflammatory medications, physical therapy, and sometimes injections into the shoulder joint itself. Surgical intervention can speed the recovery process.

In general, surgery consists of manipulation under anesthesia, which involves putting the patient to sleep and forcing the shoulder to move. This process causes the capsule to stretch or tear.

Newer techniques use minimally invasive arthroscopy to surgically release the contracted tissue and restore motion and have shown superior results.

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I sprained my ankle and it still hasnt healed. Is it time to see a doctor?

Appeared in The Arizona Republic on 1/17/09

Yes. Uncomplicated ankle sprains will often resolve with simple measures such as rest, ice, compression, and elevation (RICE therapy).

Persistent swelling, tenderness, bruising, or difficulty bearing weight on the ankle should alert you to a more serious underlying injury and should be promptly evaluated by your doctor.

Sprained ankles are probably the most common musculoskeletal injury occurring nearly 25,000 times per day.

A sprained ankle happens when the ankle is rolled or twisted putting the supporting ligaments under stretch.

Ligaments are elastic like rubber bands and have a certain amount of natural give to them.

When that give is exceeded, the ligament begins to tear either partially or completely. Your doctor can help differentiate a complete tear based on examining your ankle and sometimes ordering x-rays.

Most ankle sprains can be treated with RICE therapy, however, more severe injuries may require immobilization, therapy, and bracing to promote recovery.

Bracing has been shown to be more effective than taping in preventing recurrent ankle injuries and should be prescribed by your physician.

Proper rehabilitation is critical to preventing chronic ankle instability and consists of balance and strengthening as well generalized core conditioning.

Untreated or undertreated ankle sprains can progress to chronic pain and instability of the ankle. These conditions often require surgery to correct.

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I have been told I have tennis elbow but I don't play tennis. Is that possible?

Appeared in The Arizona Republic on 1/31/09

Yes. Tennis elbow or lateral epicondylitis can occur in anyone although it is most common among those aged 30 to 50.

Tennis elbow can affect as many as half of athletes in racquet sports. However, most patients with tennis elbow are not active in racquet sports. Most of the time, there is not a specific traumatic injury before symptoms start.

Tennis elbow is a degenerative condition of the tendon fibers that attach on the bony prominence (epicondyle) on the outside (lateral side) of the elbow.

Common activities that lead to epicondylitis are both recreational (tennis, especially groundstrokes; racquetball; squash; and fencing) and occupational (meat cutting, plumbing, painting, raking, and weaving).

Initial treatment should be non-operative and may consist of bracing, anti-inflammatory medication, and physical therapy.

It can often take twice as long to treat tennis elbow as symptoms have been present for so prompt diagnosis and initiation of medical treatment are important

More aggressive treatment may involve cortisone injections into the painful part of the elbow. Often a series of two or three injections is required.

For refractory or unresponsive cases surgery may be necessary. Traditionally an open incision is made on the outside of the elbow and the diseased tendon fibers removed. Newer minimally invasive arthroscopic techniques have been developed which allow your surgeon to treat any additional problems about the elbow as well.

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It hurts when I run. Is it time to see a doctor?

Yes. In general, activity related pain with running may be a sign of a stress overload injury and should be evaluated by a sports medicine specialist.

  • Soreness or generalized fatigue following vigorous running activities is common and should dissapear with adequate rest. Never try to run through the pain.

Overuse injuries in runners may be divided into two causes: extrinsic and intrinsic. Extrinsic factors, those under our control to modify, account for rougly three-quarters of all overuse injuries in runners.

  • Extrinsic factors basically amount to training errors or equipment issues.
  • Training errors include running frequency, distance, speed, length of time and proper warm-up or warm-down.
  • Equipment issues include the condition of the running shoes, inserts or orthotics and, of course, the contour and composition of the running surface.

Intrinsic factors, those mostly non-modifiable factors, account for the remaining quarter.

  • These include anatomic factors such arch height, length lengths and alignment and overall flexibility.

Risk factors that have been positively identified with an increased risk of injury include: a history of prior injury, novice runners, those involved in competition, and a sudden increase in weekly distance.

Risk factors that have been shown to have no association with an increased risk for injury include: age, gender, body mass, running on hilly terrain, or the time of day or year when running takes place.

In addition to evaluating and treating your injury, a sports medicine specialist can thoroughly evaluate your training habits and intrinsic risk factos to identify areas for change that can help you to avoid recurrence of your injury.

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I have been hearing a lot about ACL injuries. What is all the "fuss" about?

A number of high profile athletes have recently undergone surgery for a torn ACL including golf's Tiger Woods and football's Tom Brady.

The ACL which stands for anterior cruciate ligament is one of four main stabilizing ligaments around the knee.

It connects the femur or thigh bone to the tibia or shin bone. Its principal role is to resist forward displacement of the tibia.

It is estimated that approximately 80,000-100,000 ACL injuries will occur each year.

The ACL is most commonly injured during noncontact athletic activities. Injuries occur as a result of a sudden unanticipated decceleration or change in direction such as seen with quick cutting or pivoting maneauvers.

Female athletes sustain ACL injury rates that are approximately 5 times or more greater than their male counterparts.

The ACL is also frequently injuried during workplace activities particularly those that frequently involve carrying heavy loads with repeated changes of direction.

Being locate deep within the knee joint itself and bathed with the joint fluid, a torn ACL will not heal itself. It is also not possible to "fix" or repair a torn ACL - a new ligament must be reconstructed.

  • Reconstruction involves removing the old ligament and creating a new one called the graft and fixing it to tunnels drilled into the bone.

Although non-operative treatment is possible, a torn ACL is most often treated surgically.

  • The mainstay of nonoperative treatment involves activity modifications and limitations and sometimes bracing which most people find unacceptable.
  • Without surgery, the ACL deficient knee is suseptible to cartilage tears and premature arthritis which may not be so easy to correct.

Graft choices include harveting part of your own knee also called an autograft and obtaining a donor cadaver graft also called an allograft.

  • Recent evidence has indicated that the failure rate for cadaver graft tissue may be as high as 24%.

Surgery is often performed on an outpatient basis and most times full weight bearing is permitted right after surgery.

Rehab for a reconstructed ACL may take 6 months or more and return to full athletics should occur somewhere between 6 to 9 months after surgery.

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I have been told I have a knee ligament sprain. What can I expect?

There are four main stabilizing ligaments around the knee.

  • One connecting the inside of the thigh bone to the inner aspect of the shin bone (MCL).
  • One connecting the outer aspect of the thigh bone to the smaller bone of the leg (LCL).
  • Two that cross deep within the knee and connect the thigh bone to the shin bone (ACL and PCL).

A sprained ligament is one that is stretched and loose but not yet completely torn.

  • It is important to identify a completely torn ligament as not only does the treatment differ but they are often associated with other damage to the knee.

Most knee ligament sprains can be treated nonoperatively with bracing, protected weight bearing, restriction from activities, and physical therapy.

Sprains of the anterior cruciate ligament or ACL are extremely rare. Most often this ligament either partially or completely tears. A torn ACL is frequently associated with instability of the knee and should be evaluated by a sports medicine surgeon. Even partially torn ligaments can lead to serious long-term problems.

Most of us can live without a PCL and treatment should be individualized based on your activity level and work demands.

  • One note of caution, PCL injuries often occur during violent injuries or accidents. They can be a sign of more seriours damage to the knee such a dislocation and should be promptly evaluated.

While an isolated LCL sprain will usually heal without surgery, injury to this ligament is often a sign of deeper injury to the entire complex of stabilizing structures at the back corner of the knee. Prompt identification of this more complex pattern of injury is crucial as early surgical intervention is more optimal than delayed reconstruction.

Knee ligament injuries should be evaluated by a physician with experience in treating these potentially complex injuries.

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I don't consider myself an athlete. Would I still benefit from evaluation by a sports medicine specialist?

YES. Many workplace injuries particulary to the elbow, knee, and shoulder mimic injuries that occur during athletic competition. Sports medicine specialists have additional training and expertise in diagnosing and treating these conditions whatever their cause.

Sports Medicine Physicians are ideal physicians for the non-athlete as well, and are excellent resources for the individual who wishes to become active or begin an exercise program. For the "weekend warrior" or "industrial athlete" who experiences an injury, the same expertise used for the competitive athlete can be applied to return the individual as quickly as possible to full function.

Sports Medicine Physicians are dedicated to providing comprehensive and quality care to the active individual.

Just as a sports medicine specialist is focused on returning an athlete to safe competition as quickly as possible, they are also aware of the need to return you to work in as safe and quick a manner as possible. Lost time from work has as much, if not more, impact as time lost from sports.

Sports medicine specialists often make use of a network of other professionals to help quickly and accurately diagnose and rehab injuries as quickly as possible.

Sports Medicine Surgeons specialize in the non-operative and operative treatment of musculoskeletal sports conditions. Individuals with advanced expertise in sports medicine are trained to detect subtle conditions that often limit optimum performance and to employ advanced therapies including surgery to restore that potential.

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My doctor told me I have "arthritis". What are my options? (Are there options other than total joint replacement?)

The most common form of arthritis is the degenerative type also called osteoarthritis.

Osteoarthritis is not a disease in the traditional sense. It is a wearing away of the gliding (articular) cartilage that covers the joints much like getting a cavity in the enamel of your tooth that exposes the underlying bone.

Many new options exist today for the treatment of arthritis both surgical and non-surgical.

The focus of sports medicine surgeons is on joint preservation using techniques that help preserve or, in some cases, even restore the cartilage which helps conserve function.

Although highly successful and with a proven track record, joint replacement often comes at the expense of decreased activity levels as modern implants are not able to withstand the rigors of competitive athletics.

Patients 50 years or younger present a special challenge. New methods exist to treat localized "cavities" by repairing and in some cases replacing the native cartilage before the wear becomes widespread and progresses to generalized arthritis.

Led by the baby-boomers, a generation that grew up exercising and staying fit, patients are demanding options to retain their active lifestyles. They no longer want to settle for options that limit the activities that define their live to the max lifestyle.

The baby boomers are a generation that is accustomed to getting what they want and what they want is to maintain their fitness levels well into their 60's and 70's.

They baby boomer generation possesses a competitive drive that has led to numerous scientific advancements and they expect these advancements in medicine to take care of them as they mature.

This active, competitive spirit has been passed on to their offspring and subsequent generations are now accustomed to visits to the orthopedists office to repair or replace torn ligaments, treat tendonitis, and, of course, preserve their joints.

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Is my adolescent son at risk for an elbow injury playing baseball?

The incidence of elbow injuries (particularly those requiring surgery) has been rising exponentially during this decade.

This may be in part due to better understanding of injury mechanisms, better recognition of injuries by coaches, parents, and pediatricians, and more prompt referral to a sports medicine orthopaedic surgeon.

Based on research conducted at the American Sports Medicine Institute in Birmingham, Alabama the following risk factors have been identified:

  • Year-round throwing - 69% of injured players had less than 2 months off from throwing during the year. Most played competitively 8 or more months during the year.
  • Seasonal Overuse - 62% exceeded their recommended pitch counts and maximum number of recommended innings per season.
  • Event Overuse - Throwing too much or too often without adequate rest. Seen frequently during summer tournament or showcase season. Also seen in pitchers who throw back to back days or multiple games over a short span such as a weekend exhibition.
  • Early breaking pitches - 2/3 of injured pitchers threw breaking balls before their arms had matured.
  • Velocity > 80 mph - At 80mph the forces of throwing approach the "redline" of breaking force in the ligamentous restraints of the elbow. Too much emphasis on the radar gun.
  • Inadequate warm-ups - "star" pitchers are often among the best players on their team and are frequently sent from a fielding position to the pitching mound during a game without proper time for warming up their pitching motion.
  • Showcases - Talent competitions in which players are asked to demonstrate throwing skills repeatedly often without adequate rest or warm-up.

Summer has proven to be the season with the highest number of risk factors and, in fact, most elbow injuries requiring surgery occur during summer.

Signs to look for include: elbow or arm fatigue that does not resolve with a day of rest, elbow pain with cocking or ball release during throwing, elbow pain that does not resolve with ice and over-the-counter anti-inflammatory medications, loss of velocity and/or control, and change in pitching mechanics that occur as a result of trying to "adapt" to the pain.

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I injured my knee playing sports; do I need to see a doctor?

The knee is a complex joint stabilized by many ligaments, tendons, and cartilage structures. These structures are all vulnerable to injury during the accelerations seen during athletic activity.

Of course, the bone itself can be broken (fractured) during violent collisions and should be treated immediately at the nearest emergency room.

Immediate swelling is often a sign of serious ligament injury such as disruption of the ACL.

Persistent swelling (lasting for more than several hours to days) is frequently the only sign of occult damage to the knee and should be investigated by a sports medicine specialist.

Inability to bear weight on the knee.

Pain with activities such as kneeling, squatting, or stair climbing.

Inability to fully straighten the knee.

Feeling like something is loose or "floating" in the knee.

Feeling the knee get stuck or caught during motion.

Persistent popping or crunching noise during motion.

Many knee injuries will, of course, resolve on their own but it is always best to seek medical attention if any question arises.

Sports medicine orthopaedic surgeons while usually performing complex knee ligament reconstructions are capable of treating knee injuries with a variety of non-operative techniques as well including therapy and supervised rehabilitation.

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I dislocated my shoulder, now what?

The shoulder is a ball and socket joint that relies on additional ligaments, tendons, and cartilage for stability. Injuries to these structures are common following a traumatic dislocation.

Do not attempt to put the shoulder back in place yourself. You may cause irreparable damage.

Immediately seek medical attention. Time is of the essence as the longer a shoulder remains dislocated the harder it is to put back in place (reduce) and the more likely surgery will become necessary.

Following reduction, you may be immobilized for several weeks before beginning a supervised rehabilitation program.

The risk of recurrent dislocation is inversely proportional to your age. That is, the younger you are when you first dislocate your shoulder the more likely it is to happen again.

Younger, more active patients often benefit from early operative intervention to remain at their desired work or activity levels.

Patients over 40 are more likely to have an associated rotator cuff tear and require additional evaluation.

Contact or collision athletes such as football or hockey players and wrestlers present a special challenge and should be managed by a sports medicine specialist.

In addition to plain x-rays, special tests such as MRI or CT scans may be necessary to help define the extent of the damage including Hill-Sachs fractures (impactions of the back of the ball caused by hitting the front of the socket on the way out) and Bankart lesions (torn cartilage from the front of the socket pulled off by the dislocation).

Atraumatic dislocations (those that occur from routine daily activities rather than during athletic activities) require a specialized approach to treatment.

If left untreated, shoulders can become loose in which they sublux (partially dislocate) rather than come completely out of the socket and are frequently quite painful and potentially disabling.

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I tore my knee cartilage. What does this mean? (part I)

Appeared in The Arizona Republic on 2/7/09

First, it is important to understand that there are two different types of cartilage in the knee

The meniscus, or shock absorbing cartilage, is a firm rubbery like substance (like your ear lobe) that sits between the end of the thigh bone and the top of the shin bone. It acts as a cushion to help absorb the impact forces of walking, running, or jumping.

The second type of cartilage is the articular or gliding cartilage that lines the ends of the bones.

Most commonly a torn cartilage implies damage to the meniscus.

Meniscus tears can occur from either a direct twisting or pivoting type injury or from a gradual wearing out also called a degenerative type tear.

You might experience a "popping" sensation when you tear the meniscus. Most people can still walk on the injured knee and many athletes keep playing with a meniscal tear. When symptoms of inflammation set in, the knee typically feels painful and tight. For several days you will likely experience:

    • Stiffness and swelling

    • Tenderness in the joint line

    • Collection of fluid ("water on the knee")

    • Catching or locking of your knee

    • Knee buckling

Most cartilage tears will not heal themselves. If nonsurgical treatment fails and the knee remains painful and function remains limited, surgery to remove the torn portion is indicated.

This minimally invasive surgery is performed using the arthroscope (a miniature camera) and is among the most common surgeries performed in the United States.

It is possible to repair the meniscus in special circumstances if rapid surgical attention is received. Young, active athletes should be promptly evaluated by a sports medicine specialist so that an attempt to save the cartilage can be undertaken in a timely manner.

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I tore my knee cartilage. What does this mean? (part II)

Appeared in The Arizona Republic on 2/14/09

First, it is important to understand that there are two different types of cartilage in the knee

The meniscus, or shock absorbing cartilage, acts as a cushion to help absorb the impact forces of walking, running, or jumping.

Lining the ends of the bones is the articular cartilage, or gliding cartilage. It functions much like the enamel on your tooth. It serves to create a smooth, almost frictionless surface for the bones to slide past one another during normal motions. When injured it begins to develop a hole in it much like a cavity in your tooth. A complete cavity will expose the underlying bone.

Although not as common as a meniscal tear, damage to the articular cartilage is more serious.

Loss of the gliding cartilage leads to an irregular surface causing pain with motion.

Unfortunately when the articular cartilage is damaged there is no way for the body to replace it.

When the joint surface begins to completely wear out and deteriorate, we call that degenerative arthritis or osteoarthritis.

It is important to seek early treatment for articular cartilage injuries to prevent rapid wear and deterioration of the joint surface which lead to irreversible arthritis.

New surgical options for cartilage repair have been devised. These treatments attempt to prevent the almost inevitable spread of the arthritis and delay the need for a knee replacement.

Options include:

    • Marrow stimulation. An attempt to have the body fill in the lesion with a scar tissue that is less durable that the native cartilage.

    • Cartilage grafting. Viable cartilage and bone plugs can be harvested from either a healthly area of the knee or from a donor knee and transplanted into the defect.

    • Cartilage replacement. Cartilage cells are harvested from your knee and amplified in the lab before reimplanting them into the defect.

    • Limited or partial resurfacing. Artificial metal and plastic components can be used to replace just the worn out portions of the knee or shoulder.

    • Partial knee replacement. Essentially one of the three knee compartments that is worn out is replace preserving much of the knees normal ligament and bone structures.

As with all medical and surgical treatments these options require careful discussion with your medical professional to weight the pros and cons of each choice. A treatment plan tailored to your individual lesions is absolutely critical.

Sports medicine trained orthopaedic surgeons often have additional training and expertise in treating these advanced problems.

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What is arthroscopy and how can it help me?

Appeared in The Arizona Republic on 2/21/09

Arthroscopy is the use of a miniature fiberoptic camera (commonly 4 millimeters in diameter) to view inside a joint most commonly the shoulder, knee, and elbow.

Smaller cameras have been developed to allow access to other joints such as the ankle. Arthroscopy does not involve the use of lasers.

By allowing the surgeon to directly see inside the joint, many conditions and otherwise hidden lesions can be viewed.

Special instruments have been developed along with the cameras that allow the surgeon to work inside the joint as well.

The camera and instruments are introduced through multiple small stab wounds about the width of a writing pen rather than through a traditional incision.

Since the joints are often located deep within the body, this allows preservation of normal overlying tissues. Traditional open surgery often requires violating this tissue in order to reach the joint.

Although surgery can never be risk free, preservation of normal tissue often eliminates whole categories of potential complications.

Of course, if cosmesis is a concern, these small wounds are less noticeable and often heal with minimal scarring.

Many conditions that once required a large incision and a lengthy hospital stay can now be performed using these minimally invasive tools.

Recovery is often faster following arthroscopic surgery largely because there is less pain involved.

A skilled arthroscopic surgeon can often see better and achieve more optimal access to the tissue than with a traditional open technique.

Arthroscopic surgery is often performed on an outpatient basis meaning you will be sent home from the hospital the same day.

Sports medicine trained orthopaedic surgeons often have additional training and expertise in these advanced procedures.

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I have been told I have shoulder arthritis and that nothing can be done. Is this true?

Appeared in The Arizona Republic on 2/25/09

Shoulder arthritis, like arthritis of the knee and hip, can be a difficult problem to treat. However, the good news is that there are options.

Fortunately end stage arthritis of the shoulder is not as common as that of the hip and knee.

Because we are so dependent on our shoulder to help position our arms and hands for work, recreation, and even daily activities, however, shoulder arthritis can be just as disabling.

The most common form of shoulder arthritis is the degenerative type or osteoarthritis which typically affects people over the age of 50. Other type include post-traumatic arthritis which develops after major injury to the upper arm or shoulder girdle or cuff-tear arthropathy which develops from unrepaired rotator cuff tears.

The most common symptom of arthritis of the shoulder is pain, which is aggravated by activity and progressively worsens.

Limited motion is another symptom. It may become more difficult to lift your arm to comb your hair or reach up to a shelf. You may hear a clicking or snapping sound (crepitus) as you move your shoulder.

As the disease progresses, any movement of the shoulder causes pain. Night pain is common and sleeping may be difficult.

Nonsurgical treatment includes: activity modifications, physical therapy, moist heat, anti-inflammatory medications, injections, and icing the shoulder after vigorous activity.

Surgical treatment often involves a total shoulder replacement in which the ball and socket are replaced by metal and platic components. Success matches that seen with hip and knee replacement surgery.

New options include replacements limited to just the diseased portions (resurfacing) and reverse shoulder replacements for rotator cuff deficient shoulders that have been previously untreated.

If your shoulder arthritis has been untreated, you should seek consultation with an orthopaedic surgeon specializing in shoulder replacement and the treatment of shoulder arthritis.

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My rotator cuff is torn. Should I have it repaired?

Appeared in The Arizona Republic on 3/7/09

The answer is most likely yes.

The rotator cuff is a set of four small muscles that surround the ball and socket of the shoulder joint and help spin the ball in the socket during motions in which the arm is raised away from the body.

They are important in providing stability to the joint and preventing abnormal stresses with motion that could lead to premature arthritis.

Once torn, the tendons that attach the muscle to the bone are not capable of repairing themselves.

Although nonsurgical treatments such as activity modifications, physical therapy, anti-inflammatory medications, and even injections can be effective in relieving the pain of a rotator cuff tear, they can not prevent the degeneration of the muscle that occurs following detatchment of the tendon.

Surgery attempts to restore the anatomy, repair the tendon to the bone, and preserve the muscle quality.

During surgery any contributing factors such as bone spurs on the undersurface of the shoulder blade (acromion) or inflammatory tissue (bursitis) may be removed as well.

Traditional surgery involves a large open incision on the front of the shoulder and detachment of the deltoid muscle followed by repair of the rotator cuff.

Mini-open incisions have largely replaced traditional techniques and involve a smaller incision without detachment of the muscle.

Newer techniques can be performed in a minimally invasive fashion through the use of an arthroscope (miniature fiberoptic camera).

These techniques allow for better visualization and mobilization of the tissue, repair and treatment of any associated pathology, less risk of complications, and the promise of a faster recovery from surge ry but require considerable expertise to perform.

Since most people desire to maintain their quality of life and preserve their activity levels, most of us would benefit from prompt repair of a torn rotator cuff.

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I have been told my bone is "fractured". Does this mean it is not broken?

Appeared in The Arizona Republic on 3/21/09

Unfortunately, no. A fracture is just the medical term for a break. They mean the same thing.

Fractures, or breaks, can be described in a number of ways. Terms such as incomplete, complete, compound, displaced, greenstick, buckle, or separated are all used to describe a fracture. However, the bone is still broken.

Compound or open fractures occur when the bone protrudes through the skin and communicates with the outside world. This situation represents a true medical emergency and prompt attention at an emergency room is needed.

In order to promote healing and reduce discomfort, most broken bones need to be immobilized. Typically this involves a cast, a splint, or a brace. The choice of immobilization depends on many factors and should be made by an orthopaedic specialist after initial stabilization from the emergency room.

Casts involve the most immobilization and protection of the fracture but also require the most care and upkeep. If appropriate, a brace can be worn after sufficient healing is evident on the x-rays. Braces are often, more comfortable, and can be removed under controlled conditions for activities such as showering and bathing.

Fortunately, for most of us, the healing process begins immediately after the break occurs. Full healing can take anywhere from 6 to 12 weeks or longer depending on the severity of the break and the exact bone that is involved.

The pain from a fractured bone often subsides long before the break is fully healed. A healing bone has to mature enough to be able handle the stresses of normal use particularly a return to sports. This may take some time and rehabilitation even after the cast or other immobilization is removed.

Of course many fractures cannot be stabilized by the above methods and will require surgery to promote proper healing.

Following a break, the timing of surgery is very critical to ensuring an optimal outcome. Prompt follow-up with an orthopaedic surgeon is advisable.

Without proper treatment a bone can develop a nonunion in which it fails to heal at all or a malunion in which it heals in an awkward position that compromises function. These are difficult problems to correct. Although the chance of developing these problems cannot be eliminated completely, prompt attention and treatment can help minimize the risks.

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I have been told I have "bursitis". Is this serious?

Appeared in The Arizona Republic on 4/4/09

A bursa is a fluid filled sac that provides a cushion between a prominent bone and either a tendon or the overlying skin. Normally only a tiny trace amount of fluid exists.

The most common locations for a bursa are:

    • On the outside of the hip bone (greater trochanteric bursa)

    • Underneath the point of the shoulder blade (sub-acromial bursa)

    • In back of the elbow (olecranon bursa)

    • In front of the kneecap (pre-patellar bursa)

When irritated either by a direct blow or too much repetitive pressure, the bursa becomes inflamed and swells with fluid. We call this condition bursitis.

If left untreated, the bursa fluid may become infected. If you suspect an infection or develop redness around the swelling or a fever, you should immediately seek medical attention.

Most commonly bursitis can be treated by draining the fluid with a needle (done right in the doctor's office) and by applying a compression wrap to help prevent the reaccumulation of fluid.

Oftentimes a steroid injection ("cortisone" shot) is used as well to help reduce the inflammation and help the tissue to heal.

Rarely surgery is required to remove or excise an inflamed bursa that does not respond to simple drainage.

One notable exception is bursitis of the shoulder, which is often better treated with surgery if it involves impingement of the underlying rotator cuff (shoulder) muscles.

A visit to an orthopaedic surgeon can help decide which treatment is best suited for your particular situation.

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Should I see a sports medicine surgeon for my injury or a general orthopaedic surgeon?

Appeared in The Arizona Republic on 4/18/09

Both are well trained in musculoskeletal medicine. Sports Medicine Specialists are orthopaedic surgeons with additional training in the unique injuries and recovery cycle of athletes. Sports Medicine Surgeons specialize in the non-operative and operative treatment of musculoskeletal sports conditions. Individuals with advanced expertise in sports medicine are trained to detect subtle conditions that often limit optimum performance and to employ advanced therapies including surgery to restore that potential.

Many sports injuries can be managed without surgery and Sports Medicine Specialists can expedite referral to appropriate rehabilitative care and ancillary services as needed.

Orthopaedic sports medicine specialists have advanced specialty training that makes them proficient in the following areas:

    • Treatment options, both surgical and non-surgical, as they relate to sports-specific injuries and competition.

    • On-the-field evaluation and management of sports medicine related illnesses and injuries with detailed knowledge of sports-specific musculoskeletal injuries and medical problems.

    • "Return to play" decisions in the sick or injured athlete

    • Coordination of medical care within athletic team settings including other health care professionals, such as athletic trainers, physical therapists, and non-orthopaedic physicians.

    • Soft tissue biomechanics, injury healing, and repair.

    • Principles and techniques of rehabilitation that enable the athlete to return to competition as quickly and safely as possible.

    • Knowledge of athletic equipment and orthotic devices (braces, foot orthoses, etc.) and their use in prevention and management of athletic injuries.

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What is "Tommy John" surgery and should I be concerned?

Appeared in The Arizona Republic

Orthopaedically, the arm bone or humerus is connected to the ulna (the forearm bone on the pinkie side) across the elbow by a band of tissue called the ulnar (or medial) collateral ligament.

Injury to this ligament occurs from repetitive throwing most notably in baseball pitchers and javelin throwers.

Surgery to reconstruct this ligament was first performed on a professional baseball pitcher named Tommy John who was able to successfully return to the pitcher's mound.

Throwing in excess of 80mph produces forces that approach the "redline" for the ligament in the mature elbow.

Repetitive maximal stress to the ligament can cause it to tear or to stretch out and become incompetent.

Once this occurs the ligament will not heal itself properly and cannot be fixed.

While it is certainly possible to live and function without an ulnar collateral ligament, it is essential to throwing and must be reconstructed.

Similar to an ACL injury in a knee, a new ligament must be fashioned out of a donor graft. In the case of the elbow, graft choices are most commonly harvested from the forearm or leg.

Elbow pain with throwing, particularly medial (or inside) pain, is a sign of a serious problem and should prompt immediate cessation of throwing and rapid evaluation by a sports medicine orthopaedic surgeon.

Injuries to the ulnar collateral ligament as well as the incidence of "Tommy John" surgery to correct them in youth and adolescent baseball pitchers are becoming epidemic. Guidelines for pitch counts and number of innings pitched by age bracket such as those found at USA Baseball should be adhered to.

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I separated my shoulder. What does this mean?

Appeared in The Arizona Republic 5/2/09

A shoulder separation is term used to describe a disruption of the acromioclavicular (or AC) joint. This is the connection between the collar bone (clavicle) and the end of the shoulder blade (acromion).

It is often confused with a true shoulder dislocation in which the ball comes out of the socket but is often less serious.

Typically the AC joint separates as a result of a direct fall onto the point of the shoulder or from a blow underneath the shoulder pads in football.

You may notice a deformity on the top of the shoulder near the end of the collar bone but mild cases may present only with pain particularly with reaching overhead or across the body.

AC separations should be evaluated by an orthopaedic surgeon and are graded based on the xray results.

Mild grades (I-III) are often treated non-operatively with rest, ice, oral anti-inflammatory medications and possible physical therapy.

More severe (IV-VI) grades require surgery, sometimes urgently, to avoid complications.

Even with complete disruptions (grade III), a trial of non-operative treatment is often warranted. Heavy manual laborers or athletes, however, may opt for immediate surgical reconstruction.

A thorough evaluation for associated injuries is necessary as diagnosis of these problems is often delayed.

Results are good even with delayed surgical intervention. In less active individuals trimming the end of the collarbone (which can be done arthroscopically) is all that is often necessary while in more active individuals it is often necessary to reconstruct the torn ligaments.

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I have been told I tore my biceps tendon. Now what?

Appeared in The Arizona Republic on 5/16/09

First it is important to distinguish whether the tear is of the proximal part (near the shoulder) or the distal biceps (where the tendon inserts near the elbow).

The biceps consists of two muscle bellies much like a bicycle has two wheels. Near the shoulder these muscle bellies arise from two distinct tendons, a long and a short head.

The long head frequently tears spontaneously particularly in older individuals while the short head almost never does so.

Tears of the long head proximally may present with a deformity to the muscle that resembles that of the cartoon character "Popeye the sailor".

Tears of the long head do not cause any functional or strength deficits after the initial pain subsides and rarely require surgery to repair them.

It is important, however, to have a thorough evaluation by your physician to ensure that there is no other associated damage such as rotator cuff tears or tears to the cartilage rim which surrounds the shoulder socket. These associated conditions often require surgical repair.

In contrast, tears of the biceps near the elbow are a more serious problem. Near the elbow the muscles converge to form just one tendon that attaches to the forearm and helps bend and rotate the elbow.

Left alone, distal tears near the elbow will not heal and may lead to significant functional limitations depending on your age, occupation, and activity level.

Prompt evaluation is of the essence if you suspect a distal rupture in order to undergo timely surgical repair.

Without timely intervention, the muscle will begin to contract and scar down making repair next to impossible and reconstruction very difficult.

A sports medicine trained surgeon will often employ the latest techniques of repair and rehabilitation to speed your recovery.

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