D1 Sports Medicine is “going pink” for October, which is Breast Cancer Awareness Month, which might cause one to wonder why an orthopedic sports medicine facility would be involved in this issue. Well, not only do we as physicians and staff have friends and family members who have suffered from this disease, but there are also many important links between breast cancer and bone health that are extremely important to the orthopedic patient and doctor.

First, there is a significant incidence of osteoporosis (and its inherent problems of fractures) in breast cancer survivors. This has a number of causes: osteoclast stimulation by the cancer, a drop in estrogen production caused by chemotherapy (aromatase inhibitors) or surgery, and early menopause caused by the disease.  Thankfully, there are a number of treatments and strategies that a breast cancer patient can undertake with the assistance of their orthopedist.  These include nutritional assistance (with calcium and vitamin D maintenance), exercise programs to support bone health, smoking cessation, bone density test monitoring, and, if necessary, bisphosphonate medications.  Furthermore, there are now some medications that can directly counteract the bone damaging affects of chemotherapy while one is in treatment.  There are countless excellent resources for patient education on this issue, but my usual “go to” source on this is the National Institutes of Health:

http://www.niams.nih.gov/health_info/bone/Osteoporosis/Conditions_Behaviors/osteoporosis_breast_cancer.asp

Another big reason that breast cancer awareness is important to the orthopedic patient and physician is the fact that metastatic disease and recurrence most commonly occurs in the bone.  One must pay very close attention to bone or extremity pain in a cancer survivor. Among patients who experience a recurrence of breast cancer, the occurrence is in the bones 70% of the time.  Bony metastasis can unfortunately result in acute need for consultation with an orthopedist either as a result of a fracture or impending fracture. These often require surgical intervention with open reduction and internal fixation.  Luckily, there are a number of diagnostic tests that can be run to assess for bony involvement in the survivor.  There are also hormonal and chemotherapy adjuncts that are thought to reduce the risk of bony metastasis in the breast cancer patient.  Another of my favorite sites for addition information is:

http://www.breastcancer.org

So, there are clearly many reasons for D1 Sports Medicine to “join the fight” against breast cancer, and we are proud to do so by “going pink” on our website, facebook page and twitter feeds for the month of October. So stay pink. Stay Well.

I’ve heard this a couple of times when encountering patients that have torn their Achilles tendons while playing football, basketball, or soccer.  The fact is, as we continue to be very active into our 30’s, 40’s, and 50’s we place ourselves at significant risk for bigger injuries as we play cutting sports, and no, pilgrim, nobody likely kicked you in the ankle. It is however likely that you spontaneously ruptured your Achilles tendon and are now in need of surgical repair. Patients invariably report that someone shot them or kicked them in the ankle. I even had one patient threatening to sue the opponent and the league for injuring him.

Watch the accompanying video of NFL star Jon Beason tearing his Achilles last year while pursuing a wideout on a breakout, uncovered touchdown….he looks like he’s been shot like JFK prior to falling to the ground…but of course, he hasn’t, his “heel-cord” has simply snapped in two and he falls dramatically face first to the turf.

http://www.youtube.com/watch?v=8Go8xk7hofw&feature=BFa&list=ULVkp5F3xtm1w

Now, it is important to note on this topic that indeed, non-surgical treatment of this injury can and does work.  BUT, it takes longer and is more likely to result in recurrent, repetitive problems than surgical repair. So, if this happens to you, and you intend to return to cutting and jumping sports, you should consider surgical repair.

Once again, I’d like to insert a disclaimer (or qualifier perhaps), my 70+ year old uncle, who once played for the Cleveland Indians, recently tore his Achilles.  I did not recommend surgical repair. Why not? Because of his age and his lack of interest in returning to cutting sports.  He was placed in a boot that forced his foot to point downward for 4 weeks.  His son-in-law, on the other hand, who was in his 30’s and enjoyed playing flag football, he got surgical repair.

So, the take home?  If you feel something “Pop” in your heel while playing sports, no, your competitor, didn’t do it, and yes, you need to see an orthopaedist. You may need an 11 blade, you may not.

(Warning- there are a few medical pictures in this one…if you have a weak stomach DO NOT scroll down)

Well, we got a little off topic last month with the stretching video for Alabama Power (which was a lot of fun, and thanks for the great feedback everybody).  Now, I’d like to return to our previous theme – Does it need surgery?  The perfect topic came to my mind today because it can be very confusing to people.  That is, what do we do for a biceps tear?  I can’t tell you how many patients I have had come in saying something like (in my best North-Central Alabama accent), “Doc, I heard a pop and now I’ve got this big a’ risin on my arm.  Some of my friends say you have to get surgery, others tell me, naw the doc’s going to tell you to ice it up and get back to work. What’s the deal?”

The deal is this.  The biceps tendon can tear at the shoulder or at the elbow.  The treatment for the two injuries couldn’t be more different.  That is why there is confusion. When the tendon tears at the shoulder it is almost always handled with rest, ice, and anti-inflammatories (conservative care).  When the tendon tears at the elbow, it almost always needs surgery.

The biceps can tear at the shoulder or elbow

With biceps tears at the shoulder one usually feels a pop, gets swelling and bruising, and can even have a bit of a “popeye” deformity at the upper arm (see picture below). The biceps tendon starts in two places at the shoulder (thus the name “bi”) – the place that usually tears is called “the long head” and comes from the portion of wing-bone within the shoulder called the glenoid.  When torn the tendon slides down into the muscle and fascia of the upper arm. Since it scars there and there is very little power lost in the arm as the result of this tear (most of the actual strength of flexion of the elbow comes from another muscle called the brachialis.  The biceps may make a body-builders arm look ripped, but it actually isn’t nearly as powerful a flexor as the brachialis). So, when the tendon tears at this point it is generally felt that surgical repair is not worth the risk. Interestingly, I have had body-builder patients and entertainment wrestlers tear a biceps on one side and then requestthat I do it to their opposite side. They seem to like the popeye look and want to have a matching pair.

A typical "Popeye" deformity from a biceps rupture at the shoulder

When the biceps tears at the elbow it is an entirely different story.  Usually this injury presents as a pop or tearing sensation at the elbow in a person doing a fairly heavy-duty activity (like moving a TV or trying to lift an air-conditioner unit).  There is painful swelling and bruising at the elbow. Often, the person can continue to function at a fairly high level.  The biceps at the elbow provides a great deal of the power of supination strength.  That is to say, it is what powerfully rotates the hand and wrist.  Think of using a screwdriver and how hard one must occasionally turn the tool in order to get in the last few rotations.  The biceps tendon insertion onto the radial bone is what is largely responsible for this power.  If a working man or athlete is to lose that power in their dominant arm it can be a big problem.  In these cases, surgery is the answer and doing it fairly quickly (within a week or so) is critical. If the tendon retracts up into the arm it can begin to shorten and scar, thus losing the opportunity to fix it without ill-effect.

So, the take home points are: if you feel a pop in your shoulder or elbow you should probably have it looked at by a professional, if you tear your biceps at the shoulder you are likely to have conservative care, and if you tear you biceps at the elbow you are likely to need surgery.  I hope this has been helpful.  If you have any questions or concerns about this or any other orthopedic issue please don’t hesitate to contact us at the office. Stay Well.

Surgical View of Ruptured Biceps Tendon at Elbow

 

Biceps tendon being repaired to Radius bone using suture

But, probably not in the way we once thought it did – and the timing and type of stretches that athletes once did religiously have been mostly dropped in favor of more effective maneuvers.  Primarily, the preponderance of refereed literature does not seem to support that stretching, in and of itself does much to prevent acute injuries.  It is likely, however, that improved balance and coordination can prevent injury and this may be a secondary benefit of stretching.  Also, improved posture that can be a result of the consistent practice of stretching is likely to result in decreased incidence of degenerative change to the axial skeleton (meaning primarily to the lower back).

My opinion, in brief, is that static stretching, prior to activity is essentially useless (for either flexibility or injury prevention).  A combination of dynamic stretching during exercise and static stretching at the close of exercise or an active day is the best combination for maximal flexibility (note the key word flexibility, not necessarily injury prevention).  Static stretching during exercise can result in diminished performance due to ATP loss.  Static or dynamic stretching prior to warm-up can actually cause an injury (due to strain of muscle prior to adequate blood flow).  Balance postures, core strengthening, and the stretching prescription above are likely the best bet to maintain maximum performance, flexibility, and injury prevention.

The following is a video on stretching in the work place that we shot in association with Alabama Power.  I welcome your thoughts and feedback on yet another hot-button issue in the Sports Medicine field.

http://youtu.be/6db1CL_fDc8

There is, in my mind, but one rare exception to this rule: shoulder arthritis caused by a long-standing rotator cuff tear.  The medical term for this problem is rotator cuff arthropathy. This type of shoulder arthritis creates a particular set of deformities in the joint that render it very difficult to use…even if repaired surgically by conventional methods! You see, in these cases, even if we restore the joint, in a fashion similar to knee and hip replacement, the muscles around the joint still don’t work, because they need a rotator cuff to do part of the job of moving the shoulder around.  Well, that muscle and tendon unit has been gone for a long time and the end result is a painful, stiff shoulder….not the desired result from a major surgery, to be sure.

So, what to do? There is severe arthritis causing pain and disability and the muscle-tendon unit necessary to get good function – even with surgery- is missing. The answer – Reverse Shoulder Arthroplasty.  This procedure is similar to conventional joint replacement in that it removes the painful cartilage surfaces and replaces them with metal and plastic, it is very different in that it changes the very nature of the joint.  Another little thing I say to patients in this circumstance is, “We are going to take your shoulder’s ice cream and cone and turn it into a cone and ice cream.” That is to say, we flip the joint.  We take the ball joint of the arm and turn it into a socket.  We take the socket of the wing bone and turn it into a ball.

Why? Well, in the face of my maxim above, this is the rare case where the natural anatomy of the human body is no longer able to get the job done. By reversing the orientation of the shoulder joint, we are able to move the center of rotation of the shoulder out laterally, allowing the intact deltoid muscle to do the job that the rotator cuff is no longer able to do. In layman’s terms, we are taking the slack out of the line so the muscles have something to pull on.  Again, this situation is thankfully somewhat rare, but if you’ve been told that there is nothing that can be done about your painful, arthritic shoulder, give me a call, it is quite possible that all is not lost, Reverse Shoulder Replacement may be the answer.

Surgeons aren't usually this angry

“Avoid Surgery at all Cost” or “The Surgeon is the Enemy”

This picture is from an ad run locally by chiropractors who clearly want to convince you that a man with a knife is always a dangerous thing.  As one of my favorite authors, John Eldredge, says, you want the knife in the hands of a person with the skill to use it.  Is it dangerous? Possibly.  Is it good? Yes.

On this topic I am clearly biased.  My life’s work is reconstructing broken biological parts; Surgically. That said, I tell patients every day, I promise you that I will only do for and to you that which I would recommend for my own family. With that in mind, I’m going to talk about some things this month that require surgery – unequivocally.   I will inform you about some websites that try to convince you that infrared lights or magnets or witch-hazel or manipulations can fix certain problems and then show you why, in certain circumstances, they just can’t.  Don’t get me wrong, those things may have certain, focused, indications.  But, please stay tuned, to the coming weeks where I’ll be giving you some examples where the knife may well be the only thing that can lead to a meaningful or permanent improvement in one’s physical condition.  Sadly, in these particular cases, you need a skilled person….sometimes with an 11 blade.

Surgical view of freshly torn ACL

“Your ACL can heal. You don’t “kneed” an operation.”

I saw this comment on another website not so long ago.

Sadly, this is almost universally and unequivocally wrong – at least the part about the ACL “healing.”  Whether or not one needs an operation is something to be carefully considered with your physician, but once your Anterior Cruciate Ligament (also known as the ACL) is torn it is unable to heal.  There are circumstances when it is still connected by a bony avulsion (piece) that healing is possible, but even when it is healing is unlikely unless the piece of bone is in close contact with the bone from whence it came.  Here again, not to sound as the omnipotent, arrogant, god-complexed surgeon, I’m not saying that every ACL tear needs surgery, I’m just saying that they don’t heal.  For example, my mother, a 60-something doubles only tennis player, tore her ACL some years ago.  With some rehab and quad strengthening she was able to prevent knee instability in most of the circumstances in which she wanted to participate.  Now, that said, her ACL isn’t healed.  You get her playing singles, where she has to do a lot of lateral movement, and her knee gives way and she is face-down on the court before you know it.  On exam, she has a positive Lachman test (the tibia bone moves forward freely on the femur) and a positive pivot-shift (her tibia “pops” back into place when flexed against the femure under pressure).  She doesn’t need an operation though, because her age and activity level do not warrant it, not because her ACL has “healed.”  I don’t want to get all scientific on you, but basically every person can be divided into one of four levels of activity and demand levels on their knees. If you aren’t in the first two levels, you don’t need ACL reconstruction after a tear. If you are, you do.  It is that simple.

Why doesn’t your ACL heal?  Well, the ACL has an artery running right down the middle of it. It is a branch of the larger artery called the geniculate(Latin for knee).  When your ACL tears, this artery tears. That is why when you have an ACL rupture you can expect a large amount of internal swelling or effusion. Not to be too gross, but your knee has filled up with blood for the most part.  This is also, for some part, the reason your ACL won’t heal when ruptured. It just doesn’t have any mechanical stability or any consistent exposure to nutrients for repair.  Think of it this way: If you had a broken bone where one end stuck out of the skin and flopped around, would you expect it to heal to the other end of bone? No. No chance. The same is true of the two ends of ACL “rope” that aren’t in contact with one another and have no common access to nutrients.  Bottom line, if you participate in cutting sports (football, soccer, basketball, skiing) and want to continue to do it after a complete rupture of the ACL it is likely that you will the help of an orthopaedist and perhaps his 11 blade.

Newly reconstructed ACL

Sugar pill or cartilage builder?

Well, at this point, again, based on the fact that this is a naturally occurring substance, I hope you can guess how I feel about it.  Let’s review the known facts (if not the broad ranging, difficult to understand research data): these are naturally occurring substances that one will take in to their diet at some point or another with or without trying, the substances pass through the body and get utilized or eliminated based on need without creating side effects (much like most vitamins when taken in relatively normal doses), the substances are relatively inexpensive (certainly  because they are not patent protected and in the hands of major Pharma), and they are widely commercially available.

The meta-analyses are all over the board, but certainly not overwhelmingly negative. So. Here is what I tell my patients, “Let’s try this for a month, if it doesn’t have any appreciable affect we can stop it.”  The reason for this is, insurers don’t pay for this stuff, and manufacturers are often very proud of it – so it can be a pretty heavy blow to your wallet.  There are very few situations in which the supplement is worth a heavy expense on a sustained basis (as in cases of specific dietary deficiency or conditions which prevent absorption or processing of a nutrient). In this case, we hedge our bets, no harm, no foul. If it doesn’t work or help we move on to the next modality.

Here’s my two cents: in all of the litany/catologue of the “natural” solutions you might want to try it is unlikely that more than one or two are truly appropriate.  In those cases the dosage needs to be monitored and your physician needs to be aware that you are on it.  A great example of a good supplement gone bad is Ginkgo biloba…it has been shown to improve memory, but it can also cause easy bleeding…so if you take it your doctor needs to be aware of it (what if you were at risk for stroke and she also has you taking aspirin?  You could be in big trouble).

If you think I’m just a naysaying western trained physician here is my advice: Do some research on a well trained MD or nutritionist that has studied these supplements in detail and then approach them about what you should and shouldn’t take.  If they recommend that you take all of them…find another practitioner. If they recommend that you take only the ones they sell….find another practitioner.  A reasonable, competent provider should be able to help you decide what exotic supplements might help and which might hurt based on your other medications and conditions.