Posts Tagged ‘orthopedic surgery’

Shoulder Injuries, Part II

Friday, July 3rd, 2009

There are three factors which predispose you to rotator cuff tendonitis:  a weakness or imbalance of the muscles around the shoulder; a lack of endurance in the muscles of the rotator cuff to perform the given task; lack of flexibility which decreases the rotator cuff’s ability to sustain forces exerted upon it.

The first cause is typically seen in football players or body builders who bulk up the large muscles around the shoulder (deltoid, biceps and pectoralis) but neglect the rotator cuff muscles. The pull of these large muscles overcome the ability of the rotator cuff to keep the humeral head located in the glenoid and it subluxes or slides out of the glenoid causing added stretch and injury to the tendons.  When this is repeated numerous times it causes micro-tears in the tendon. If ignored, this can lead to a damaged rotator cuff.

The second cause is usually seen in the golfers or tennis players who go out and play more than they are accustomed, an extra nine holes or that extra set.  Pitchers and quarterbacks are prone to this when they are at the end of a game and have thrown more than usual.  Typically, as you continue past the point of endurance the arm becomes heavy and numb.  Pitchers refer to this as “throwing their arm out”.

The third cause is prevalent in throwing athletes in their dominant arm. So much force is generated when throwing a ball to the plate or throwing to the end zone that the fibers of the tendon separate.  As the tendon heals, it contracts and tightens.  As this is repeated over the course of a season, the player actually loses range of motion in their shoulder.

In Part III, we will discuss ways in which the likelihood of shoulder injuries can be reduced.

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Shoulder Injuries, Part I

Tuesday, June 30th, 2009

Shoulder injuries are far too prevalent in many sports.  These injuries tend to fall into two groups.  The least common are those injuries caused by a sudden traumatic force, as seen with the football player being tackled and landing oddly, causing a dislocation or separation of the shoulder.

The more common injury type is the overuse injury that occurs in athletes who are involved in weightlifting, throwing, swimming, swinging clubs or racquets.  The majority of these injuries are preventable with a program of specific shoulder exercises and an understanding of the workings of the shoulder joint.

The shoulder is the most mobile joint in the body.  The shoulder joint looks like a golf ball sitting on a tee.  The humeral head (ball) sits in the glenoid (socket) which is shaped like a shallow dish.  A circular structure of soft tissue, the labrum, deepens the dish.  The stability of the shoulder joint is provided by the labrum and the tendons of the rotator cuff.  The rotator cuff is comprised of four small but very powerful muscles.  They wrap around the humeral head to keep it located in the glenoid.  The rotator cuff also internally and externally rotates the upper arm (humerus).  Above the rotator cuff tendons is a water-filled sac or bursa that reduces friction and cushions the rotator cuff tendons as they slide under the cowl of bone on top of the shoulder, the acromion.

The shoulder works in a balancing act, a force couple, between the deltoid and the rotator cuff. As you raise your arm the deltoid contracts to bring your arm up.  The rotator cuff muscles contract in synchrony to depress the humeral head ointo the glenoid. If your rotator cuff muscles are weak or your deltoid overpowers them, then the shoulder subluxes (partially dislocates) and rides up against the acromion.  This in turn pinches the tendons and bursa between the two.  This is called impingement.  Repeated often enough and the tendons and bursa become irritated and swell.  This leads to tendonitis, bursitis or even a small tear in the rotator cuff tendons.

Part II will discuss factors which predispose you to rotator cuff pathology, ways to reduce the likelihood of injury, and treatment options.

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Knee Pain, Part I.

Thursday, June 4th, 2009

Many of you have friends or have heard it said that they have “torn cartilage” in their knees.  They are probably not talking about the cartilage that covers the end of the bone – the articular cartilage – but rather  a tear of one of the two bushings in the knee, a meniscal tear.  These are rather common injuries in athletes and in the general population and tend to increase in frequency with increasing age of the individual.

Each knee has two of these fibrocartilaginous bushings, the medial meniscus (inside) and the lateral meniscus (outside).  These menisci act as shock absorbers in the knee and help to conform the shape of the two bones of the knee, femur (thigh bone) and tibia (shin bone) to one another.  The menisci also act in concert with the ligaments and muscles to provide stability to the knee.  The medial meniscus is attached securely to the ligaments on the back and on the inner side of the knee and because of this attachment is the more frequently torn of the two.

The menisci can be torn when there is a sudden, unexpected twisting motion to the knee.  This motion traps the meniscus between the ends of the two bones and causes a shearing action on the tissue.  This frequently happens in conjunction with ligament injuries, especially ACL tears.  As you get older your menisci becomes softer and the blood supple decreases.  This can lead to tears with little or no trauma; sometimes just a misstep will cause a tear.

When your meniscus tears you will usually feel a sharp pain on that side of the knee at the joint line.  Generally, the knee will then start to swell within a few hours.  You may find your knee locks up on you and you are unable to straighten it all the way.  This occurs because the meniscus flips into the joint and forms a mechanical block to motion.  The swelling will eventually decrease and the pain will subside with time and you may feel your knee is back to “normal”.  It might not even bother you too much when walking straight ahead; however, when trying a sharp cut or turn you may experience a return of the sharp pain.

To determine whether you have a meniscal tear, your doctor will ask you questions about how the injury occurred and then will examine your knee.  This usually involves moving the knee around if it is not too inflamed and pressing over your joint line on either side.  Sometimes as your knee is moved from bent to straight a pop can be felt as the torn meniscus moves out of the way.  X-rays are usually taken just to assure there are no broken bones or loose bodies floating around the knee.  The X-ray will not show the torn meniscus as X-rays only show bone detail and not soft tissue.  Sometimes, if there is question remaining after examination, your doctor may order an MRI to confirm the diagnosis or determine if the meniscal tear may be repaired.

In Part II we will discuss treatment options for this common knee condition….

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Ankle Sprains, Part III

Wednesday, April 15th, 2009

Prevention of ankle sprains
It is estimated that 30 to 40% of all ankle inversion sprains end in re-injury. To avoid being one of the 30 to 40% it is important not to stop the rehabilitation process but continue with it until full fitness is regained. It is a common complaint that once an athlete goes over on the ankle they become prone to doing the same thing again. If the original sprain is a bad one and joint laxity has resulted, then it may be for certain sports where fast changes of direction are required that strapping of the ankle or wearing a brace is necessary to prevent re-injury.

If the sprain does not result in joint laxity then a recurrence may be avoided by the following:
1. Re-establish proprioception. This involves lots of balancing exercises on one leg which is essential to avoid re-injury. If you start to turn the ankle over then you will find you automatically right it without even thinking about it. If the proprioception is damaged then you lose this ability.
2. You need to strengthen the ankle in order to provide a far more stable joint. Then, if the ankle does start to turn and the proprioceptors work as they should, the ankle muscles should contract quickly to hold the joint stable
3. For a severe sprain (one you can not put weight on), you may need a visit a physician to make sure you don’t have a fracture, ligament tendon damage or another serious ankle injury.

In general, you should avoid putting weight on the joint as long as you have swelling. When possible, you should keep your foot elevated. Within a couple of days, your pain should decrease enough to allow moderate weight bearing without pain. As you are able to tolerate more weight, you can begin a walking and gentle stretching program to increase your flexibility.

Proprioception exercises or balance exercise can help you recover more quickly and should actually be preformed as part of a prevention program. Poor balance is a good predictor of future ankle sprains. After an ankle injury, balance training is essential to recovery. In addition to our eyes and inner ears, there are special receptors in our joints (proprioceptors) that provide information about our position in space.

By balancing on one leg, you can reinforce and strengthen those receptors in the ankle. Balance on the affected leg and hold steady for 15 seconds. Continue to challenge your ankle by balancing with your eyes closed, or with your head turning from side to side. If you play soccer, balance on your sprained ankle and kick a soccer ball against a wall. If you play basketball, balance and shoot or practice bounce passes. Get creative with your exercise to match your sport.

Ankle sprains can be prevented by using appropriate equipment for your sport. However, sport-specific shoes and protective gear are just the start. To avoid ankle sprains, you need to strengthen your ankle joint and develop a highly refined balance system. Don’t forget to keep your first aid kit nearby.
• Range of Motion Exercises
Some simple exercises can help maintain ankle motion, and stretch the injured ligaments in the ankle joint.
• Achilles stretches
Achilles tendon stretching can easily be started soon after sustaining an ankle sprain. While seated or lying down, take a towel and loop it around your toes. Pull the ends of the towel, pulling your toes upwards, and feel the stretch in the back of the ankle. Perform this 3-4 times a day for several minutes.
• Alphabet writing
While seated or lying down, write the alphabet in the air with your toes. Make the letters as big as possible. Get creative by trying all uppercase, then lower case, then cursive, etc…
• Strength Exercises
The next step in recovery from ankle sprains is strengthening the muscles that surround the ankle joint. By strengthening these muscles, you can help support the ankle joint and help prevent further injury. Some exercises to perform after an ankle sprain include:
• Toe raises
Stand on a stair or ledge with your heel over the edge. Stand up on your tip toes, then in a controlled manner, let the heel rest down. Repeat 10-20 times (each foot), 4 times a day.
• Heel and Toe Walking
Walk on your toes for one minute, then on your heels for one minute. Alternate walking on your heel and toes, and work up in time to a total of 10 minutes, repeating 4 times each day.
• Activity-Specific Training
Activity specific exercises may include simply walking or jogging, or may be more intense for athletes who participate in basketball, soccer, or other sports. The key, no matter what level (recreational or competitive) athlete you may be, is to progress slowly. Begin at very low intensity, and very low duration of activity, and slowly work up–never suddenly increase either the intensity or duration of your activity.
Here is a sample progression for a soccer player
• Jogging
Begin at 50% intensity. Jog 100 yards, walk 100 yards. Repeat 4 times. Increase intensity and duration over 2-3 weeks
• Figure of Eights
Jog in a figure-of-8 pattern around cones. Begin with the cones near each other. Each day, spread out the cones and increase the speed.
• Box Runs
Make a box of cones. Jog forward the first side, side shuffle to the right, run backwards, then side shuffle to the left. Again, increase the size of the box and the speed of the running each day.

Once these activities can be done at full speed with no pain, patients can resume their sport. More sport specific exercises can be given to you by a coach or trainer if needed.

What if the pain continues?
The most common cause of persistent pain following an ankle sprain is known as incomplete rehabilitation. This means that patients either don’t complete the right type of rehabilitation, or they don’t progress properly (i.e. too fast or too slow). If you feel that your progress is not going along properly, make sure you seek advice such as speaking to your doctor or working with a physical therapist or athletic trainer. Most causes of chronic ankle pain are due to a lack of full rehabilitation and returning to play before all healing has occurred.

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The Athletic Knee, Part II

Friday, March 27th, 2009

PREVENTION
Unfortunately, ACL injuries have become a major part of athletics. In particular, female soccer players have a reported 4-6 times greater risk of ACL injury than the male athlete and over 30,000 ACL injuries are reported every year with an estimated healthcare cost of over 720 million dollars. In response, over the past several years, many programs have been developed, designed and promoted to reduce the risk of ACL Injury. Results from this focus on proper athletic development have returned a reduced rate of injury in as much as 75% for athletes in a specifically designed program. (Boone 2007)

A properly designed training program should consist of nine basic components: evaluation, movement preparation, plyometrics, core strengthening, weak point training, integrated strength training, multi-directional speed training, footwork, and proper recovery drills.

1. Evaluation/Testing

Just as a coach evaluates the tactical and technical skill of the player, it is vital to asses the overall functional movement skills of the athlete. Can the player move correctly? Do they react quickly? Do they have the ability to stop or change direction?
Again, there are many programs that have been marketed to do this, including Cook’s Functional Movement Screen, Sportsmetrics, Jumpmetrics, and the ACL Hop & Stop Test. No matter the program, it is important to asses 6 areas of basic athletic movement.
• Posture
• Single Leg Stance & Movement
• Jumping
• Landing
• Posterior Chain (hamstring and glute development)
• Deceleration & Directional Change

2. Performance Preparation

Prior to performing any athletic activity, the body must be prepared to move in all directions, speeds, and methods that will be required during that activity. The days of taking two laps and playing are over. If the body is not properly prepared and the neuromuscular system is not fully engaged, there will be a greater risk of injury to the athlete. In particular, both the mobility and flexibility of the athlete must be addressed. The purpose is NOT to just “warm-up”, this is PART of the workout!

– Increase core temp, mobility, flexibility, stability and strength; “activate muscles”; use muscles in stretched position; establish and maintain ability to reproduce movements
– Mobility: range of motion with stability & control – correct motion at correct joint at correct plane at correct time (Gray, 2000)
– Flexibility: range of motion (ROM) around a joint (Gambetta, 2007)
• Static Flexibility – static flexibility is a limiting factor to athletic mobility
• Dynamic Flexibility – just like balance and posture flexibility is dynamic, not just static in nature

3. Plyometrics

Plyometrics are not a new training program and have been employed as far back as the late 1950’s. Plyometrics are simply a method of training that develops explosive power and have often been referred to as “jump training”. There are several forms of plyometric training that need to be employed in any athletic training program in order to maximize the power of the athlete.
• Rapid Fire Plyo – quick, short burst of jumps and landings with minimal time spent on the ground
• Max effort Plyo – focus on exploding off the ground with as much force as possible and allowing a full, complete landing
• Lateral v. Linear – Jumping both front-back and side to side
• SL v. DL – Jumping and landing on both a single leg and a double leg
• Landing/Tech – The correct biomechanics of landing in order to properly control the body and reduce stress on ankle, knee and hip. The most common problem with female athletes is the inability to bend the knees to assist in force dispersal as well as a “knock-knee” when landing creating an increased stress in the medial knee and ACL.

4. Torso Training

The term “CORE Training” is so over used and misused that we have gone away from that term and have begun to utilize the term “torso training”. This training is the focus on any body part with the exception of the arms and legs. It is more than just abs! It includes low back, hips, glutes, mid back & scapula stabilizing muscles. A proper program will focus on the ability to prevent rotation as well as the ability to produce rotation from the torso. Without the ability to stabilize the body, you can not mobilize its segments, namely the arms and legs. In order to produce and reduce force properly, it is vital to have a strong and efficient torso.

5. Weak Point Training

Another overused and misapplied word is prehabilitation or injury prevention exercises. It is impossible to prevent all injury. At best our goal is to reduce the likelihood of injury while promoting an increase in sport performance. In order to do so, each athlete must work on particular areas of the body that were addressed in the evaluation & testing component that have been viewed as a limiting factor. These areas that affect the lower extremity and the ACL often include:

• Foot
• Ankle
• Knee
• Hip
• Low Back

6. Integrated Strength Training

Strength is the basic building block of any athletic development program. Without strength it is impossible to produce and, more importantly, reduce force. Therefore, a properly designed program will address both the knee dominant exercises (lower body pushing exercises such as squat, lunge and step-ups) as well as hip dominant exercises (both closed chain – foot on the ground exercise such as deadlifts, glute hams & open chain – foot moving exercises such as stability ball curls, band kickbacks, etc)

• Knee Dom – squat, lunge, step-up
• Hip Dom – posterior chain development (both open chain and closed chain)

7. MDST

MDST is multi-directional speed training. Soccer athletes must develop foot speed in all directions not just straight ahead; too many athlete focus on getting quicker for the 30m or 40 yard dash. Athletes need to develop translatable speed in all directions. Most importantly, athletes need to focus on proper mechanics of decelerating. The ability to stop is one of the least trained yet most often causes of injury.
• Form/Tech – proper mechanics of running to increase efficiency or form
• Resisted – training designed to resist the athlete from running at highest speed and tax the muscular system developing an increase in stride length
• Assisted – training designed to assist the athlete to run at highest speed and develop a greater stride rate.

8. Footwork & Quickness

Lateral Speed, agility and foot quickness are just as important as linear speed to the soccer athlete. The athlete must not only posses great directional speed but also the ability to react and change direction with the appropriate body control in order to avoid injury.
• Directional
• Reactional

9. Recovery & Regeneration

Finally, the athlete must reduce stress on the muscular system and avoid adhesions and flexibility-limiting problems through a planned regeneration and recovery program utilizing massage, stretching and rest periods.

TREATMENT
The treatment for ACL injuries can be either non-operative or operative. Non-operative treatment consists of supervised physical therapy, activity (sport) modification and bracing. However, many initial non-operative treatments end up requiring surgery due to continued instability and/or further injury. The operative treatment of ACL injuries has progressed significantly over the past 20 years. Due to new arthroscopic techniques, better graft selection and improved postoperative rehabilitation, an increased number of athletes have been able to return to their chosen sport more quickly and safely than ever before. If surgery is chosen it is usually performed in an outpatient setting. Recovery times to return to sport depend on many factors and can vary from 3 – 8 months with aggressive rehabilitation.

SUMMARY
ACL injuries are increasing due to increased sport participation and continued year round training. Prevention programs are available and have proven to reduce risks of injury by up to 75%. If necessary, surgery has a high rate of success if performed by an experienced Orthopedic Surgeon and followed with an aggressive rehabilitation plan supervised by an experienced physical therapist and/or certified athletic trainer.

Gary A. Levengood, M.D., is the Founder and President of Sports Medicine South, LLC. Board certified in Orthopaedic Surgery and Sports Medicine by the American Board of Orthopedic Surgeons, Dr. Levengood completed a Sports Medicine fellowship at The Hughston Clinic in Columbus, Georgia, where he specialized in Arthroscopic Surgery and Sports Medicine. He also holds membership in the American Academy of Orthopedic Surgeons. He was the former Team Physician of the Georgia Force Arena Football Team and the Atlanta Silverbacks Soccer team; serves as the Medical Director for the Georgia State Soccer Association’s Olympic Development program and served recently as the Chief of Orthopedics at Gwinnett Medical Center.

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The Athletic Knee, Part I.

Wednesday, March 25th, 2009

You’re out playing a soccer game, a tennis match, or maybe even down hill skiing when all of a sudden you lose your balance and feel a “pop” in your knee. For a moment, the pain is excruciating, but then it becomes more tolerable. However, your knee starts to swell and it is painful to walk on. So, you are helped off the field, court, or get a sled ride down the mountain. Unfortunately, you have just joined the nearly 200,000 others who will tear their Anterior Cruciate Ligament (ACL) this year.

With a general increase in organized sports and year round training, games and tournaments, it is not surprising that the exposures and risks for ACL injuries has increased as well. If you are female athlete (especially those participating in soccer, basketball or gymnastics) your risk of injuring your ACL is 2 – 10 times greater than your male counterparts, and the numbers are growing! With the advent of Title IX legislation and the rise in opportunities for female athletic participation, a whole new number of athletes have become at risk of injury.

ANATOMY
The ACL is one of the four principle ligaments which help to stabilize the knee. The ACL is anterior or in front of the Posterior Cruciate Ligament (PCL) and crosses it from inside to outside. The other two major ligaments are the Medial Collateral Ligament (MCL) on the inside part of the knee, and the Lateral Collateral Ligament (LCL) on the outside part of the knee. The ACL functions to prevent the Tibia (shin bone) from being pulled off the Femur (thigh bone). The quadriceps (thigh) muscles in front help to extend the knee and the Hamstring muscles in back help to flex or bend the knee. The hamstrings are vital as they actively help to prevent the quads from pulling the tibia off the femur.

RISKS
The probability of tearing your ACL is increased if you are involved in a contact or collision sport that includes cutting, twisting and jumping. However, it is important to note that non-contact ACL injuries (where no one hits you) are responsible for 70% of these injuries, where direct contact accounts for only 30%. Again, female athletes have an increased incidence of non-contact ACL injuries than do male athletes (up to 10%).

GENDER DIFFERENCES
Some of the factors increasing the risk of injury to the female athlete include:

• Anatomical Structure: women tend to have wider pelvises than men and tend to be more “knock-kneed”, putting increased stresses across the knee joint.
• Muscular Activation: female athletes do not contract the hamstrings as quickly as male athletes and are unable to protect the ACL from shearing forces.
• Ligament Structure: the female ACL is smaller in diameter than the corresponding male ACL.
• Hormonal Differences: Some have even suggested a hormonal reason, however this remains relatively inconclusive.

Coming in The Athletic Knee, Part II, we will discuss the methods used to reduce the liklihood of non-contact ACL injuries to the knee….

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Sports Medicine South Kicks Off Their New Blog

Monday, March 23rd, 2009

The staff of Sports Medicine South and I would like to extend our warmest welcome to you. Our desire is to present to you a comfortable and professional atmosphere for all your orthopaedic and sports medicine needs. Our mission remains to exceed the expectations of the patient by providing the highest quality of orthopaedic and sports medicine care available. Our core values of respect, professionalism, trust, caring for others, and education, drive us daily to meet that mission. Our goal is to not only care for the patient when the need arises but to become a stimulus that leads to decisions that promote a healthier and happier life. It is with that thought that we have started this blog. We honestly desire that Sports Medicine South becomes a place that leads you Beyond Better!

Our recent location and name change reflect our desire to remain Atlanta’s Orthopaedic & Sports Medicine Specialists. In order to continue to provide the best service available, we have moved into a state-of-the-art medical center located at 1900 Riverside Parkway, Lawrenceville, Georgia 30043. Our new center is in the heart of Gwinnett County, only minutes from the Gwinnett Medical Center, SR 316, and I-85! With improved parking, easy access, a large lobby, eight patient treatment rooms, cast and brace room, procedural room, digital imaging, on-site physical therapy and rehabilitation, and a patient education area, our new center is designed to exceed all patient expectations.

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