by Phillip Parr, M.D.

The emphasis on cardiovascular fitness has led to an increase in the number of overuse injuries of the lower extremities, including shin splints, plantar fasciitis and Achilles tendonitis. Achilles problems are a particular problem to both elite runners and middle-aged joggers.

Injuries to the Achilles are the result of its unique anatomy and the phenomenalforces running exerts on it. It’s the largest and longest tendon in the body, and it tends to twist as it courses from its attachment to the gastrosoleousmuscle complex (the calf) to its insertion in the calcaneus (the back of theheel). This twisting results in an area of poor circulation two to six centimetersabove the tendon’s insertion at the heel – where most Achilles injuriesoccur.

Repetitive overload of the tendon, from running or jumping, or both, causes a gradual breakdown in the cross-links of the collagen (a strong, fibrous protein), with progressive disorganization and disruption of the fibers. In an attempt to heal the fibers, the body launches the inflammatory process, which results in the familiar swelling and tenderness in the area. Anatomic variations, such as forefoot varus, rigid ankles and razor-thin tendons, predispose some athletes to Achilles tendon problems.

Conservative Care

In most cases, Achilles tendonitis will respond to conservative treatment. Because persistent overload of an acutely or chronically inflamed tendon may lead to rupture, the best treatment is rest. Regular post-run icing can be helpful as both a treatment and a preventative measure, reducing swelling and allowing damaged fibers to heal better between workouts. Heel lifts can take some of the pressure off the tendon, providing short-term relief, although it’s best not to become dependent on such devises. Orthotics correct forefoot malalignment, increase cushioning and may also elevate the heel slightly. The use of anti-inflammatory medications, ultrasound and electrical stimulation can also be helpful.

Once the tendon is rested and healed enough to tolerate some stress, the most effective long-term treatment and prevention is lower-leg stretching. This can lengthen the calf muscle and thus relieve a great deal of tension on the tendon. A homemade incline board or one of several such commercial products can be extremely helpful for this kind of stretching.

Disabling symptoms that continue after an adequate period of conservative care may indicate a partial tear of the tendon. Ossification (hardening) within the tendon, which is often visible on an x-ray, always indicates a partial tear. If no ossification is present, an MRI may show partial disruption of the tendon.

Surgical Options

An athlete who has had Achilles tendonitis symptoms for quite a while – more than six months – and who doesn’t respond adequately to conservative treatment may be a candidate for surgery. The surgical procedure itself usually takes only a few minutes and is straightforward. Runners who have no tears of the tendon fibers may benefit greatly from having the thickened, chronically inflamed tendon sheath stripped; this decompresses the tendon. Assuming the athlete takes measures to avoid traumatizing the area again, the sheath will then grow back in a healthier form. The prognosis is excellent. Many runners report, after a period of rehab, that they are able to run pain free for the first time in years. Preventative icing and stretching measures can help to keep the problem from recurring.

Runners who have partial tears benefit from the excision of the torn fibers and repair of the tendon. One surgical trick is to incorporate the healthy plantaris tendon – a small, ribbon-like tendon that courses along the medial (inner) side of the Achilles – into the repair, thus reinforcing the tendon with healthy tissue.

Runners thinking about Achilles surgery should be aware that the post-operative course can be long and requires therapy. Working on strengthening the tendon in the eccentric phase – when the tendon or muscle lengthens while it contracts – is necessary to regain tensile strength and to organize the tendon fibers so that they work smoothly again. Most athletes will be able to return to previous levels of running and jumping six to eight months after surgery. With intense therapy and willingness to endure the discomfort levels required, some runners have been able to begin training again in much less time, sometimes in as little as two months.

The Pinch Test

Achilles tendonitis is easily diagnosed by clinical exam. In the acute phase, the tendon is constantly swollen and extremely painful to the touch. Runners familiar with the problem are only too aware of how a relatively gentle pinch test can make them jump up out of their seats. In more chronic cases, the tendon may be enlarged and nodular, though perhaps less tender. This phase is known as tendonitis.



Photo: Freedigitalphotos.net- Ambro

http://www.freedigitalphotos.net/images/view_photog.php?photogid=1499

By: Andrew F. Rocca, M.D. 

Do you experience shoulder pain performing everyday tasks such as vacuuming and lifting? If so, you may have a rotator cuff tear. Rotator cuff tears are a common source of shoulder pain in adults. They are most frequently injuries from wear, rather than trauma. Our busy lives and everyday activities take their toll on our tendons, ligaments, and joints over time. Consequently, as our bodies age, we become more prone to these wear-type injuries. If you are suffering from shoulder pain, a rotator cuff tear may be the problem.

Winter-sports heighten in popularity as people begin to hit the ski slopes over winter vacation, and therefore increase their chances of acquiring common musculoskeletal injuries. Both adults and children, from the advanced to the novice, can prevent injuries by being cautious, aware and realistic of their athletic ability, limitations and surroundings.

Winter sports-related injuries that resulted from activities such as snow skiing, sledding and snowboarding accounted for more than 144,200 visits to hospital emergency departments in 2009.

To prevent winter sports-related injuries this holiday season, the American Academy of Orthopaedic Surgeons suggests the following safety tips:

• Wear appropriate protective gear, including goggles, helmets, gloves, and padding. For warmth and protection when playing outside, wear several layers of light, loose and water- and wind-resistant clothing. Layering allows you to accommodate your body's constantly changing temperature.
• Warm up muscles with light exercise for 10 minutes. Begin your lifting routines with manageable weights and do not overdo aerobic activities. Replenish fluids to prevent dehydration.
• Know and abide by all rules of the winter sport in which you are participating. Make sure equipment is in good working order and used properly. When hitting the slopes, take a lesson (or several) from a qualified instructor. Learn how to fall correctly to reduce the risk of injury.
• Seek shelter and medical attention immediately if you or anyone with you is experiencing hypothermia or frostbite when in the cold.

Source: http://orthoinfo.aaos.org/topic.cfm?topic=A00367

Photo: Freedigitaphotos.net-

http://www.freedigitalphotos.net/images/Outdoor_Sports__Land_g220-Skiing_p463.html

Give the gift of health and safety to you and your family and avoid injury-prone situations in effort to prevent bone, join and muscle injuries this holiday season. Numerous people traveling this time of year can expose themselves to risks that they can easily and unknowingly be unaware of when transporting luggage.

According to the U.S. Consumer Products Safety Commission, more than 54,000 people were treated in hospital emergency rooms, doctor’s offices, clinics and other medical settings for injuries related to carrying luggage in 2009. Injuries to the back, neck and shoulder can be caused by struggling with heavy, over-packed luggage.

To prevent lifting injuries this holiday season, the American Academy of Orthopaedic Surgeons suggests the following safety tips:

• Pack light and use luggage with wheels when traveling.
• Take care when placing luggage in an overhead compartment. First, lift it onto the top of the seat. Then, with hands situated on the left and right sides of the suitcase, lift it up. If your luggage has wheels, make sure the wheel side is set in the compartment first. Once wheels are inside, put one hand on top of the luggage and push it to the back of the compartment. To remove the luggage, reverse this process.
• Do not rush when lifting or carrying a suitcase or heavy package. If a piece of luggage is too cumbersome when traveling, either check it or ask for help. At the mall, minimize heavy loads by making frequent trips to the car.
• Always use proper lifting techniques. When lifting, bend at your knees and lift with your leg muscles, not your back and waist. Avoid twisting or rotating your spine.

Source: http://orthoinfo.aaos.org/topic.cfm?topic=A00367

With fall now in full swing and the holiday season just around the corner, many people are beginning to break out ladders hanging around their homes. Ladders are an easy and convenient tool used to clean gutters on the roof, hang holiday lights and decorations and aid in reaching those out-of-the-way objects in closets and attics. According to the U.S. Consumer Product Safety Commission, more than 532,000 people were treated in hospital emergency rooms, doctor’s offices, clinics and other medical settings in 2007 because of injuries related to ladders use. The majority of these injuries are cuts, bruises and fractured bones.

Orthopaedic surgeons who treat these injuries, and the American Ladder Institute know that numerous injuries could be avoided by following the safety guidelines on the use of ladders. For more information on ladder safety, read the following tips below from the American Academy of Orthopaedic Surgeons:

Use the Correct Ladder:

Use a ladder of proper length to reach the working height you need. Inside a house, that probably needs a low stepladder; outside, you may need a taller stepladder, and for some projects, an even taller single or extension ladder. Use a ladder according to use and working load – the combined weight of the climber and the load being carried.

Inspect the Ladder:

Always inspect the ladder before you use it. Never use the ladder if it is damaged, broken or bent.

Do not make a temporary repair of broken or missing parts and then use the ladder. The temporary repair could fail while you are high off the ground. A ladder should be free from grease, oil, mud, snow and other slippery materials before using.

Moving the Ladder:

You should carry a single or extension ladder parallel to the ground. Hold the side rail in the middle of the ladder so you can balance the load. You should get help moving a very long ladder. Remember to always carry a stepladder in the closed position.

Setting up the Ladder:

Before you use a single ladder, extension ladder, or stepladder outside the house, make sure it will not hit electrical wires, tree limbs or any other obstructions when it is extended.

To ensure that the ladder is stable, place the feet of the ladder on firm, even ground.

The bottom of the ladder should be 1 foot away from the wall for every 4 feet that the ladder rises. For example, if the ladder touches the wall 16 feet above the ground, the feet of the ladder should be 4 feet from the wall. If you are going to climb onto a roof, the ladder should extend 3 feet higher than the roof. The upper and lower sections of an extension ladder should overlap to provide stability.

Recommended Height of a Ladder:

Before using a stepladder, make sure it is fully open and the spreaders or braces between the two sections are fully extended and locked.

Whether inside or outside the house, do not place stepladders or utility ladders on boxes, countertops or unstable surfaces to gain additional height.

The highest standing level on a stepladder should be two steps down from the top.

Using the Ladder:

Before climbing a ladder, make sure the locks are secured and the bottom and top of the ladder rails are on firm surfaces. The soles of your shoes should be clean so they do not slip off the ladder rungs. Do not wear leather-soled shoes, because they can be slippery. Your shoelaces should be securely tied. Make sure your shoelaces and pant legs are not so long that they extend under your shoes and cause you to slip.

• Face the ladder while climbing and stay in the center of the rails. Grip both rails securely while climbing.
• Do not lean over the side of the ladder. Your belt buckle should not be further than the side rail.
• On single or extension ladders, never stand above the third rung from the top and never climb above the point where the ladder touches the wall or vertical support.
• On stepladders, never stand on the paint shelf, spreaders or back section.
• Never stand on the top rung of any ladder.
• Do not overreach. It is safer to move the ladder to a new location when needed. Do not try to "jog" or "walk" the ladder to a new location while standing on it. Climb down and reposition the ladder.
• Do not overload a ladder. It is meant to be used by only one person at a time.
• Never use a ladder in high winds.
• Do not use any ladder if you tire easily, are subject to fainting spells or are using medications or alcohol that make you dizzy or drowsy.

What to Do If You Fall From a Ladder:

• Calmly assess the situation and determine if you are hurt.
• Get up slowly.
• If you feel that an injury has occurred which prevents standing or walking, do not panic. Call for assistance. If the injury is serious, call 911.
• If you are not injured, rest for awhile and regain your composure before climbing again.
• Ladders are useful tools, but they must be used properly to avoid turning a household chore into a trip to the emergency room or a physician's office.

Source: American Academy of Orthopaedic Surgeons: http://orthoinfo.aaos.org/topic.cfm?topic=A00235

It’s that time of the year! Students are officially returning back to the classroom and hitting the books as the new school year kicks off. Along with a student’s busy schedule, a backpack filled with books, binders, lunches, laptops, iPods and gym clothes can easily pack on the pounds and lead to improper fit, causing back strain and pain to a child’s back.

According to the U.S. Consumer Product Safety Commission, in 2010, nearly 28,000 people were treated in hospitals, doctors’ offices and emergency rooms for backpack-related injuries including strains, sprains, dislocations and fractures.

To avoid pain and discomfort caused from heavy backpacks, the American Academy of Orthopaedic Surgeons recommends the following safety tips:

·         Always use both shoulder straps to keep the weight of the backpack better distributed.

·         Tighten the straps and use waist strap if the bag has one.

·         Remove or organize items if too heavy and place biggest items closest to the back.

·         Lift properly and bend at the knees to pick up a backpack.

·         Carry only those items that are required for the day.

·         Encourage you child or teenager to tell you about pain or discomfort that may be caused by a heavy backpack, like numbness or tingling in the arms or legs.

·         Purchase a backpack appropriate for the size of your child and look for any changes in your child’s posture when they wear the backpack.

·         Watch your child put on or take off the backpack to see if your child or teenager expresses discomfort.

                                         ·         Talk to the school about lightening the load. Keep the load at 10-15 percent or less
                              of the child’s bodyweight.

                                         ·         Be sure the school allows students to stop at their lockers throughout the day.

For more information about backpack safety, please visit AAOS at: http://www6.aaos.org/news/pemr/releases/release.cfm?releasenum=1014

Photo and Image Credits:

Freedigitalphotos.net- Photostock

Tennis elbow, formally known as lateral epicondylitis, is a very common and painful musculoskeletal condition affecting the elbow due to overuse. Tennis elbow is caused by an inflammation of the tendons that join the forearm muscle on the outside of the elbow. The forearm muscles and tendons become damaged from repetitive motions, resulting in pain and tenderness on the outside of the elbow.

Typically, the most frequent causes of tennis elbow are from participating in activities, such as golf and racquet sports in which the forearm is involved in repetitive motions. Also, certain occupations including painters, mechanics and carpenters are at a higher risk for developing tennis elbow.

The elbow joint is made up of three bones, which include the upper arm bone (humerus) and two bones in the forearm (radius and ulna). At the bottom of the humerus, are bony bumps called epicondyles. More specifically, the bony bump on the lateral side of the elbow (outside) is called the lateral epicondyle.

The elbow joint is held together by a network of muscles, ligaments and tendons. Tennis elbow involves the muscles and tendons of the forearm, which straighten the wrist and fingers. The tendons in the forearm attach muscles to bone, including attaching to the lateral epicondyle. The tendon typically involved in tennis elbow is called the Extensor Carpi Radialis Brevis (ECRB).

According to the American Academy of Orthopaedic Surgeons (AAOS), recent studies show that tennis elbow is often due to damage to a specific forearm muscle, typically the ECRB. When the ECRB is weakened from extensive overuse, microscopic tears develop in the tendon where it attaches to the lateral epicondyle, and most commonly results in pain and inflammation.

The Orthopaedic Institute’s Rodger D. Powell, M.D., a board certified orthopaedic surgeon, specializes in hand and upper extremity musculoskeletal injuries, and sees up to 12-15 patients a week who suffer from tennis elbow.

“Patients range in age from the 20’s to even the 80’s as boomers strive to remain fit and active,” Dr. Powell said.

Symptoms of tennis elbow gradually develop, initially beginning as a mild pain that worsens over an extended period of time. Symptoms of tennis elbow include, but are not limited to:

• Pain or burning on the outer part of the elbow
• Weak grip strength (such as having difficulty picking up a jug of milk or holding a cup of coffee)
• Pain radiating into the shoulder or down into the forearm

 Tennis elbow treatments include both non-surgical and surgical approaches, depending on the severity. Non-surgical treatments are the first step in an effort to correct tennis elbow. Approximately 80 to 95 percent of patients have success with non-surgical treatments including:

• Rest
• Non-steroidal anti-inflammatory medicines (aspirin or ibuprofen to reduce pain and swelling)
• Equipment checks (having equipment examined to ensure proper fit)
• Physical therapy (including stretching, massage or muscle-stimulating techniques to improve muscle healing)
• Wearing a brace
• Injections (including cortisone and prolotherapy)

 Patients whose condition is unresponsive to six or more months of non-surgical treatment are candidates for surgery. Most procedures include removing the diseased muscle and reattaching healthy muscle back to the bone. Your physician will determine if surgical treatment is the best option for relief after exhausting all other non-surgical options.

One surgical option known as the Nirschl approach, is a simple surgical procedure that Dr. Powell typically recommends to patients.

“It’s a simple operation where you find the origin of the ECRB and cut the tendon from the bone,” Dr. Powell said.

The damaged portion of the ECRB is removed and any damage to the surrounding tendons is then repaired, allowing immediate use of the arm for light activity. After the surgery, in an effort to avoid reoccurring episodes of tennis elbow, patients are frequently placed on a recommended home exercise program.

Preventative actions that patients can take in order to avoid developing tennis elbow include maintaining upper extremity strength and flexibility, Dr. Powell said.

Below are a few tips from the Mayo Clinic on how to prevent overuse injuries, such as tennis elbow:

• Address medical conditions
• Use proper form and gear
• Pace yourself
• Gradually increase your activity level
• Mix up your routine

Written by Edward M. Jaffe, M.D.

The Anterior Cruciate Ligament (ACL) is one of the most important structures that provide stability to the knee. When the knee is forced into positions that stretch the ACL beyond its normal length, this important ligament can tear. These injuries may occur during sports, typically while changing directions with the planted foot not rotating or during a collision with the force on the outer (lateral) or front (anterior) part of the knee. Often times the tear is accompanied by an audible “pop”.

The most common symptoms after an ACL tear include pain, swelling of the knee, and an inability to bear weight. Once the initial swelling and pain resolve, typically after a few weeks, there is often a sense of instability or “giving way” of the knee.

Once the initial pain and swelling have resolved and knee motion has improved, your orthopedic surgeon can help you decide on the treatment option that is best suited for you. As the technique of surgical reconstruction for torn ACLs has improved, along with refined post-operative physical therapy methods, more and more people opt for surgical reconstruction. The primary indications for surgery are a desire to return to an active lifestyle or continuing knee instability with normal daily activities.

Since a torn ACL will not heal on its own, surgical treatment requires replacement of the torn ligament with another structure. My surgical technique for reconstructing knees with torn ACLs has evolved over the years. Early on I would use a portion of the patients own patellar tendon with attached bone fragments. Over the last couple of years I have treated about one hundred patients with a technique that uses a strand of cadaver tendon that is twice as strong as the previously used patellar tendon. These tendons are obtained from organ donors and are provided in sterile conditions from companies that are accredited by a national organization of tissue banks. Surgical techniques provide secure fixation of the tendon graft which allows early weight bearing. The incisions with the new procedure are cosmetically desirable (less than one inch in length), and the patient goes home the same day as surgery. Patients that had the older technique on one knee and the newer technique on the opposite knee greatly appreciate the decreased pain and quicker recovery period. The newer techniques have greatly improved the surgical and recovery process for patients with ACL injuries.

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