Given that we’ve had a number of requests for a discussion on summer and/or heat sports safety, I had an ironic thing happen to me this week while on vacation in South Carolina. It was a beautiful sunny day and I had been pretty slack in my workout regimine while off work, so I decided to do my workout outside. I was invigorated by finally getting my heart rate up and I threw myself into sets of pull-ups, push-ups, abs and jump rope. About halfway into a workout that I have done many times without too much difficulty I began to feel nauseated. I noticed that I was sweating much more than usual and a quick check of my heart rate came back at 170 (much higher than I would expect 20 minutes in to this workout).

I sat down under a shade tree to take a break, hoping the feeling would pass and I could resume my workout, but instead I noticed I felt a bit dizzy and was cramping in my calf muscles. I decided to call it quits, laid down on a bench in the shade and started downing electrolyte fluid (my preference and recommendation on this, by the way, is Advocare Rehydrate).

Interestingly, I had not really paid much attention to the fact that the ambient temperature was 90 degrees Fahrenheit and the humidity was 85% – a heat index of 117. Furthermore, I was in full sunshine, which is thought by some to increase the index by as much as 15 degrees.  I had done some other numbskull things too: I had 3 cups of coffee that morning and I have been on a high protein, low carbohydrate diet (which demands a little better than usual hydration). In short, because I wasn’t thinking about the summer heat conditions I had dialed up a perfect recipe for heat exhaustion, or worse, heat stroke.  Luckily, I noticed the symptoms relatively early and had some good electrolyte replenishment on hand. I was reminded of an important lesson though – good intentions and even good understanding are useless in sports safety without appropriate actions. Don’t do what I did and plan ahead for safety in the summer heat. Below are both the signs and symptoms of heat related illness and some tips on how to avoid them both.

Heat Cramps

Occur in the setting of excessive sweating and muscle spasm. They can involve virtually any muscle group, but are most common in the calves, quads, glutes, and hamstrings.

Treat with small, but frequent amounts of water/electrolyte intake and gentle extensile stretching of the muscle group.

Heat Exhaustion

This is generally characterized by heavy perspiration, weakness, elevated pulse, nausea, vomiting, dizziness, and and/or syncope (fainting). Interestingly, skin may be cool and/or clammy, cramps may or may not be present, and body temperature can be normal.

Treatment is likewise small, frequent doses of water/electrolytes for rehydration. One also needs to quickly move to a cooler, shaded environment. Apply cool, moist towels to skin. Remove or loosen any constrictive clothing.

Heat Stroke

Some counter-intuitive things begin to occur in heat stroke. Sweating may cease. Altered mental status (like confusion) may set in. Skin temperature may be elevated (eg 106 degrees).  Other symptoms are rapid pulse, shallow breathing, headache, and even loss of consciousness.

Heat stroke is a significant, potentially life-threatening medical emergency. If it is suspected, fluids shouldNOT be administered, but rather emergency medical assistance (dial 911) should be sought. In the meantime, the individual should be moved to a cool, air-conditioned or shady environment and cold, moist towels or a water mister applied while awaiting assistance.

Some additional heat safety tips:

–     Schedule vigorous participation or activities for the coolest times of day or evening.

–     Make sure that there is plenty of adequate hydration on hand and that participants have adequately hydrated prior to starting.

–     Make sure that gear which may increase heat levels is kept to a minimum (i.e. headgear only for football).

–     If the heat index is above 80 be sure to take frequent water breaks (at least every 20 minutes) and have ice and towels ready.

–     If participating in the sun, be sure to wear appropriate sun-block.

–     Significantly limit or eliminate intake of caffeine and alcohol in the days leading up to sporting in the heat and sun.

–     Do not take salt tablets unless prescribed by a physician.

–     Be sure to wear cool, loose fitting clothing if possible.

Finally, and to reiterate, none of these tips is remotely useful if not accompanied by action. Until next time, Stay Well.

With the NBA Finals in full swing I thought we’d take on a basketball topic for this week’s version of The 11 Blade.  The orthopedic injuries basketball players encounter are many, but they are certainly not as frequent as in other contact sports.  At D1 Birmingham we treat largely knee ligament injuries (such as those to the ACL), achilles ruptures, and shoulder instability in the hoops population.  You can see our recommendations for sports safety in basketball here.  Today, however, I will specifically discuss not a particular injury, but rather, my take on the recent controversy regarding the decision not to play Chicago Bulls guard Derrick Rose despite a playoff push (and the fact that, at the end of the day, for professional athletes, return to play is, indeed, return to work). That said, as an orthopedic sports specialist, the decision of when an athlete should return to play following recovery from an injury is one which my patients and I face every day – so it warrants some discussion.

Rose, undeniably one of the stars of the NBA, underwent anterior cruciate ligament reconstruction last year, and, as fate would have it, seemed to be closing in on completing his rehab and returning to the court just in time for the Bulls to make a playoff run. There ensued various conflicting reports as to what “percent” ready his knee was, a number of parties with various motivations became involved, and it was readily apparent that this had become far more complicated that a simple question of medical readiness. This was, rather, a soap opera drama, with the young man’s knee as the plot line.

Now, the circumstances, injury, and sport were quite different, but the question was largely the same last year when a similar issue arose in Major League Baseball. The Washington Nationals, who like the Bulls had their sites set on post-season glory, had their ace, Stephen Strasburg, hold out from participation after a specific number of innings thrown. Strasburg had previously overcome surgery and rehab from ulnar collateral ligament reconstruction (or UCL, more commonly known as the Tommy John procedure). In this circumstance, the athlete and his caregivers had the objective of preventing re-injury by limiting the patient from overuse.  It is my judgement that they were absolutely right in doing this. However, they would also be absolutely right to tell him not to throw at all. Ever.  Indeed the athlete’s risk of re-injury is limited with limited participation, but the patient population is too small and the data too limited to say with any certainty when the risk/benefit scales are tipped in the direction of continuing on or stopping play.

So, how do we really determine, from a medical standpoint, when a patient can return to play?  I try to keep it as simple as possible. For my patients, I recommend that they may return to play when their risk for injury has returned to the baseline risk for their sport. That doesn’t always mean they can play – medical readiness and competition readiness don’t always align. It also doesn’t mean that medical concerns are the only factors to consider, as is clearly demonstrated in the cases of Strasburg and Rose – family concerns, professional club investments in the player, team dynamics and chemistry, and current team success or projected success can all play a role in this decision. So, as tough as it was for the Bulls to endure, I really side with Rose sitting out. I am reminded of a very young man I was treating for a tibia fracture sustained while playing quarterback (not too dissimilar from the famous Joe Theisman injury).  After months of rehab and healing the Mom said tearfully, “Dr. Connor please tell him he can’t play football again.” I replied, “Well, his leg is healed. The sport has inherent risks. I can only say that he may play from a medical standpoint. Weather or not he can is up to you and him.”

Until next time, Stay Well.

The Champions Tour is fantastic on so many levels. It allows us, the fans, to see some of our favorite golfers, perhaps well past their prime, but no less talented, up close and personal. It allows those past “champions” to continue to exercise their skills and earn a handsome living doing so.  It provides opportunities for cities, many of which do not host a big tour event, to showcase themselves while reaping economic impact rewards.  Last, and probably least, it gives me, a sports surgeon to talk a little bit about a sport I enjoy and the injuries to which its (aging) participants are prone.

Perhaps one of my fondest memories of my grandfather was rolling out onto the golf course with him. He was over 70 years old and was tethered to an oxygen tank, but out he would go, every day – and I never, ever beat him.  One of the great things about golf is that it is an athletic activity that one can do, even with significant disability well into the sunset years of life.  That said, it WILL result in any number of chronic, repetitive, and/or stress injuries the more it is played. It can, occasionally, if not rarely, result in traumatic injuries (such as labral tears, wrist ligament injuries or rotator cuff tears) but overwhelmingly overuse injuries are the concern.

There are a number of resources both locally and nationally that promote fitness for golf, but my favorite is the Titleist Performance Institute. The local entity in Birminingham, Alabama of which I am aware that has trainers certified by the TPI is Personal Trainers of Mountain Brook. Further, we are very pleased to announce the development at D1 Birmingham of the Golf Performance Institute which will provide not only traditional swing analyses, but also a revolutionary technology involving force plates to include weight distribution timing in the data.  Along the lines of injury prevention, we have compiled a set of recommendations for injury prevention which focus on basic fitness, flexibility, and form which are designed to prevent injury and keep one swinging away. Until next time, stay well.

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