Category Archives: Sports

Weight Lifting Injuries

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Statistically, more and more people are working out using weights and weight bearing exercise than ever before.  Whether it’s to achieve those major biceps for men or to tone and stave off the ravages of osteoporosis for women,  fitness with weights is at all an all time high.  So, unfortunately, are serious shoulder injuries, most of which occur with upper arm strengthening.

One common problem  is an injury to the A-C joint  The A-C Joint is the small accessory joint at the top of the shoulder. You can feel it — it is the small bump at the end of your collarbone. A-C stands for Acromio-Clavicular. The acromion is a flat bone at the top end of the shoulder blade. It is nature’s shoulder-pad — a square shaped bone that you can feel at the top of your shoulder.  The clavicle is the collarbone. Between the end of the clavicle and the acromion is the A-C joint which plays a major supporting role in the function of the shoulder.”

Both those who work out and their fitness trainers can stress the A-C joint when they do bench-presses and overheads because any exercise that uses a substantial amount weight to move the arm also involves stress to the shoulder.  Both of these lifts strengthen the powerful deltoid muscle which lies along the acromion and the clavicle and thus, the stress of heavy lifting can be transmitted to the small A-C joint. People who lift weights for years may injure the A-C joint and develop arthritic degeneration in the area. My patients frequently complain of pain and popping  at this joint.   I can even hear the pop on examination before x-ray or MRI confirms the injury or arthritic condition.”

The bad news on A-C  joint degeneration is that  once the damage occurs, it cannot be reversed. There is no cure for arthritis. One solution might be to curtail or give up overhead lifting, but this is usually not an option for dedicated weight lifters.  They may abstain from or limit weight lifting, but usually only for short periods of time and rarely long enough to stabilize a serious joint condition. Anti-inflammatory medicines like Aleve, Celebrex and Advil  may relieve pain but their effects may only be temporary.  A cortisone injection into the A-C  joint may also help, albeit temporarily. And neither will relieve the ‘popping’ of the joint.  That said, both therapies  should be tried prior to surgical intervention.

When A-C joint surgery is indicated, both the pain of the injury and the ‘popping’ sound can be cured with comparatively minor surgery. Quite simply, the end of the collarbone is removed. The painful arthritis and the pressure at the joint are relieved. This often ends both the pain and the popping.  The surgery can be done either arthroscopically or through a very small incision at the top of the shoulder. Recuperation is relatively quick – usually two to three weeksto return to normal activity .  The good news for the gym set is that there is usually little or no postoperative impairment to the shoulder and patients can happily resume weight lifting and other sports. Some lifters may note slight loss of maximum bench press strength, but this will be offset by relief of painful popping.

Weight lifters can also develop muscular injuries from overuse or overdoing it! One common condition is bicepital tendinitis.  “The biceps muscle bends the elbow and it’s long tendon lies in a groove in the front of the shoulder. Tendinitis or inflammation of the tendon can occur with bench presses and ‘dips’.  Treatment consists of pain and/or anti-inflammatory medication ; Physical therapy can be useful.  Sometimes, a cortisone injection. is necessary. 

Older lifters may even rupture the tendon. Sharp pain and a popping sensation may be felt in the front of the shoulder. The pain will eventually subside and usually there will be little or no lasting disability so surgery is rarely necessary.

Another muscle that can tear with excessive stress during bench presses is a tear to the so-called “pecs” – the pectoralis major muscles. A partial tear can be treated with rest and therapy and should heal on it’s own. A complete tear may require surgical repair.

Working out with weights is an important part of many people’s lifestyles. It is, for the most part, an excellent way to help stay fit and an anti-aging boost.  That  said, it must be approached with care in order for people to gain the maximum benefit from work-outs.”  In short, take care of your arms and shoulders and they will help take care of you.  If not, your upper body fitness is at serious and potentially permanent risk due to injury.

 Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

Ankle/Achilles Injuries

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I have treated many people ,who, after twisting their ankle, were told by either a family doctor or emergency room person, that it ” is only a sprain.”

The ankle is wrapped in an Ace bandage and the patient is advised to see a specialist if no better in a week or two. The implication is that this injury is no big deal.

This attitude always upsets me because ankle sprains are commonly potentially serious injuries. In my opinion, if not aggressively treated early on, they may not sufficiently heal and could cause ongoing and chronic trouble in the future.

A sprain is a stretch injury or tear of a ligament. A ligament is a tight, fibrous cord that holds joints together and provides stability. A force that stretches a ligament can cause merely a stretch injury ( Grade 1 ), a partial tear of the ligament ( Grade 2 ) , or a complete rear or rupture ( Grade 3 ).

There are two groups of ankle ligaments. On the inner or medial side of the ankle is the broad and thick Deltoid ligament. On the outer or lateral side are two lateral ligaments. The lateral ligaments are injured more often-probably because the foot has a greater tendency to twist inward.

A mild sprain causes some discomfort and localized swelling, but the patient can usually walk. A more severe sprain –in which the lateral ligaments are either partially or completely torn is much more serious. There is greater swelling and the patient can barely walk. It is because of these injuries, that I believe ankle sprains require urgent attention by an orthopedist. A delay of several weeks in addressing a Grade 2 or Grade 3 ligament tear could result in a permanently lax ankle–prone to re-injury.

First, an x-ray needs to be performed to rule-out the possibly of a fracture. And, sometimes a stress x-ray–performed while pressure is placed against the ankle—is required. A positive stress x-ray will indicate ankle joint tilting or instability. In extreme cases, I may order an MRI to deteremine if a ligament is torn and to what extent.

We all have out different ways of treating a sprain and, with the exception of pure neglect, there may be no right or wrong way. The practice of medicine, after all, is an art.

I prefer to treat simple sprains by wrapping the ankle with 2 inch white sports tape which I leave on for a week. This is in effect,a soft cast, and it gives support and controls swelling. My patients usually feel much better and have less pain once the tape is applied. Many can suddenly walk again. If the sprain is worse, say, Grade 2, I may supplement the tape with a brace like an aircast.

I recommend anti-inflammatory medication for a week or so and later, I may order physiotherapy.

I personally rarely use an ace bandage to treat an ankle sprain.

Most people with Grade 1 sprains recover within three weeks but some can take longer.

I also may treat people with Grade 2 sprains in a similar manner, but if there is ankle looseness and laxity, I very well may recommend a solid cast for three weeks to allow the ligament to heal. This may be somewhat inconvenient for the patient, but allowing the ligament to heal in its normal length and tension may save that patient future injuries and aggravation.

A Grade 3 complete tear –confirmed by an MRI – should either be treated in a cast or with surgical repair. The latter would be my preference in many cases, but this decision is ultimately tailored to an individual patient’s requirements.

Recently a saw a man in his late thirties who complained of recurrent ankle sprains. A stress x-ray in my office indicated severe laxity. I told him that unless he wanted to live with this, reconstructive surgery would be the only feasible treatment to stabilize the ankle. He initially injured his ankle years before while playing college football, and it was my impression– from speaking to him–that he never received adequate treatment early on after he sprained his ankle. Thus, the outcome did not surprise me. The torn ligament probably never healed.

The deltoid ligament on the inner side of the ankle is basically treated the same, but because it is a broader ligament and is an important stabilizer of the ankle, I am more inclined to treat deltoid injuries in a cast or surgically, if they are completely torn.

ACHILLES TEARS

There are three muscles in the calf. All converge into a large broad tendon above the back of the ankle—the Achilles Tendon.

I refer to these muscles –the Gastronemius, the Soleus, and the Plantaris as the three bears.

The planteris—the baby bear – is a long thin muscle / tendon and it is of little significance. It is famous because many people tear it –frequently in a tennis or basketball game. People with an acute planteris tear develop stabbing calf pain. Some describe a feeling that they were struck in the calf by a tennis ball. They limp and may have pain for several weeks.

There is no treatment except RICE – rest, ice, compression, elevation. To this I would add anti-inflammatory medication and possibly physiotherapy. Since people complain of calf pain, an ultrasound to rule out a blood clot may be considered depending on the patient’s history.

These usually heal completely in a few weeks with no residual problems or lasting impairment. Surgery is never necessary.

A rupture of the Achilles tendon is a different story.

Frequently, this is a sports injury as the heel forcibly extends. Severe stress and tension is placed on the stretched Achilles tendon. A rip, pop, or tear is felt or even heard. The victim can walk but limps noticeably as the foot drags. The diagnosis is easily made on the field, court, or in the office. A gap can be felt in the tendon and ankle motion is compromised. X-rays and an MRI are not really necessary. But, an MRI could be ordered –if for no other reason but to satisfy the patient that surgery is necessary.

These injuries can certainly be treated in a cast with the foot fully tipped down like a ballet dancer en pointe. The tendon should come together and it should heal.

But today, most orthopedists—myself included – recommend surgery. The procedure is fairly routine and the incision does not need to be very large. No, it cannot be performed arthroscopically. With surgery, the tear is brought together and stitched under direct visualization. And the success rate for healing is high.

A post operative cast for a few weeks is still necessary, but I have lately been replacing the cast with a brace–sooner– after a few weeks, and this helps the patient regain motion earlier. The overall recovery is not quick, but the results are usually excellent.

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

Meniscus Tears

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Since we can all laugh at ourselves, I will share an old crack about Orthopedists—strong as an Ox and twice as smart.

Well, maybe there was a time when many muscular medical students in the lower half of their class went into orthopedic surgery, but that certainly has changed. The orthopedists that I have known throughout my career have been plenty smart.

To prove this, two of the major medical advances of the past hundred years have been in our field: total joint replacements and arthroscopic surgery.

Presently, other surgeons do arthroscopic type surgery –general surgeons now remove the gall bladder and the appendix with a laproscope, thus avoiding the large abdominal incisions of the past. Yet, orthopedic knee and shoulder arthroscopic (arthro meaning joint) surgery was routinely performed decades before general surgeons started doing similar surgery on the belly.

When I trained in the 70’s, a patient with a torn meniscus(torn cartilage) would have the knee cut open with a two-three inch incision at surgery and the entire meniscus would be removed. The patient would eventually go home two to five days later on crutches and require a month or two to recover.

Now the meniscus tear is treated in an outpatient surgical center requiring only several hours stay. The tear is removed with micro instruments through three tiny ¼ inch cuts (one stitch each) and most of my patients are walking without crutches, or a limp, for that matter, within a week of the surgery.

What a great medical advance in the past thirty years!

Nor, do we remove the entire meniscus as we used to. This is bad and can eventually cause degenerative arthritis as the result of bone on bone contact. Now, we only remove the portion of the meniscus that is torn and we preserve the uninvolved remainder. This works out just fine, and most people do very well and recover quickly. Sometimes, rarely, the meniscus tear can be repaired.

The knee has two meniscui –medial and lateral. They are half-moon shaped. They have various functions, but they are basically shock absorbers to prevent bone on bone contact in the knee joint. They are rubbery in quality and with stress, torque, or a twisting mechanism, they can be torn. A torn meniscus can cause pain, clicking, or interfere with motion(locking –as the knee can get stuck and unable to fully extend).

The perimeter of the meniscus does have blood supply (red zone) and tears in this outer rim and be repaired and can heal. More commonly, the tears are through the inner, avascular 2/3’s of the meniscus and are not repairable. These tears are simply removed.

My patients go home on crutches and pain killers after the surgery and most can walk without crutches within 4-5 days. Almost all walk normally and bend their knee fully two weeks later when the stitches are removed. Some require physical therapy; many do not. But knee exercises hasten the recovery. I have had patients return to sedentary work within days of the surgery, but full return to sports can require weeks or even months.

Younger people do great. Older individuals with arthritis in their knee may not fare as well as due to the arthritic pain, but many improve enough to be satisfied.

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

Rotator Cuff Injuries

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The Rotator Cuff – not rotary cuff, as some people call it – is a broad tendon that covers the humeral head –or ball of the shoulder joint. The shoulder is a ball and socket joint. Both are very shallow and the joint would be unstable were it not for multiple muscles and ligaments which hold the ball and socket together. The fact that the joint is shallow allows for better and circular motion of the shoulder.

The rotator cuff is actually a broad tendon which, to me, looks like a bathing cap-covering the ball of the shoulder like a cap covers one’s head. Four muscles converge into the cuff –the subscapularis, the supraspinatus, the infraspinatus, and the teres minor. The tendon attachments of the middle two muscles (the supraspinatus and the infraspinatus) are more commonly torn.

These muscles allow internal and external rotation of the shoulder and assist the larger muscle that covers the shoulder-the deltoid – with abduction(raising the arm sideways and upwards). The deltoid abducts the arm, but cannot do so without the assistance of the rotator cuff muscles. This is why patients with a strong, normal deltoid but with a large rotator cuff tear frequently cannot lift their arm.

I mainly see three rotator cuff conditions:

1. TENDONITIS or TENDONOSIS.

Tendonitis means that the cuff tendon is inflamed and clinically there is tenderness and pain on movement. Overhead elevation produces pain –a positive Impingement Sign. Under arthroscopic visualization, the cuff looks scarred and irregular. Calcium deposits may occur.

Depending on the severity of this condition, I try to initially treat this problem with rest, therapy, and anti-inflammatory medications. Frequently, I give a cortisone injection ,which commonly works.

If these conservative measures, fail, the last resort could be arthroscopic surgery to smooth and clean out the scar tissue. This is usually successful and the recovery time is short –most of my patients regain full motion within a week or two.

2. PARTIAL ROTATOR CUFF TEAR

This is commonly associated with tendonitis ( above) and the treatment is the same. I first recommend conservative treatment. If surgery is later performed, I usually smooth and clean out the scar tissue adjacent to the partial tear and it probably heals without surgical repair or opening up the shoulder.

3. COMPLETE ROTATOR CUFF TEAR

This is a full thickness tear – a complete tear: the size of the tear is commonly the size of a dime but frequently larger. Usually, although, not always, the patient cannot raise his or her arm, or if they can, they do so with pain. The tear could be caused by chronic use and wear in an older person. In younger people or in workers who do heavy labor, it can be caused by an acute wrenching injury. Falling directly on the shoulder can tear the rotator cuff. Throwing hard can do it. Or some injury that jams the arm — thus transmitting force towards the shoulder– can tear it.

These are serious injuries. The treatment is frequently surgical –commonly with a skin incision. The tear is stitched together. Sometimes, it can be repaired arthroscopically, but usually a small mini incision is necessary. Post operatively, a sling to rest the arm and to allow the repair to heal is needed for 3-4 weeks. And then, physical therapy to rehab the shoulder –for 2-3 months – or longer. No picnic!

But, the results are frequently good, although there are no guarantees. Much of the success of this surgery depends on the patient. Patients must adhere to their doctor’s orders, lest they re-tear the repair in the vital post-operative period. And, if they do not follow-through with their rehab program, they may develop stiffness, a frozen shoulder, or weakness. And in older patients with poor circulation, the repair may not heal ;  also,  in patients who smoke or have diabetes.

Some people with large tears, paradoxically, have surprisingly decent shoulder motion. If these patients have relatively little pain, they theoretically could avoid surgery if they can live with this condition. But, most people with rotator cuff tears have trouble and require surgery.

Is there treatment besides surgery ?  Probably not.  Physical therapy could be offered for the patient in the paragraph above, but therapy will not heal the tear. Large tears most probably will not heal, so surgery is usually indicated for these.

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

Shine Splints

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The term “shin splints” is commonly used to describe leg pain or aches, but it specifically refers to pain along the inner border of the tibia—the large bone of the leg.  It usually occurs in novice or poorly-conditioned runners, and the main treatment is rest.  The exact cause of shin splints is somewhat controversial because there are several different reasons for the pain to occur:

OVERUSE SYNDROME 

Overuse of a muscle refers to stress or sprain of a muscle from too much exercise.  The overuse syndrome can also be caused by wearing inadequate shoes or by running on hard or sloped surfaces.  The basic postural problem producing this is pronation of the foot.  Pronation is a medical term which means outward tilting of the foot.  People with flat feet or dropped arches have pronated feet.  Stretching the foot outward places increased pull on the muscles that run along the inner border of the ankle and under the arch.  These muscles originate along the inner side of the tibia.  The major muscle–the posterior tibial muscle–helps hold up the arch.  As a result of pounding on the arch and, thus, constant tugging on the muscle, the muscle belly is stretched and even torn away from the bone.  Pain and inflammation result.

The pain may initially occur after running.  Persistent running with the injury will only aggravate it and produce pain during activity and later with normal walking.

Treatment consists of rest and application of ice to the leg.  Telling a serious runner to rest is about as undesirable as suggesting that he purchase a bicycle, but, like it or not, rest is most important for healing to occur.  The period of rest may vary, but usually two to three weeks are required.

Once a runner has recovered, attempts are made to prevent future injuries.  Firm, well-constructed shoes with arch supports are recommended.  The arch support helps tilt the foot inward and corrects the pronation.  If the standard supports in the shoes are not sufficient—and they may not be for excessively pronated feet—custom-made inserts or orthotics should be obtained. I usually recommend first trying less expensive standard inserts which can be purchased in any running store. Changes in running environment from hard to softer surfaces, such as a track, and away from uneven ground, will also help.

Also, I see many patients who have one leg that is around a ½ inch shorter than the other. It is a minor discrepancy and frequently, we do not know why this occurred. However, it can cause problems with the back, knees, or ankles. And it can also cause shin splints. The treatment is simple—a shoe lift or insert for the shorter leg.

TIBIAL STRESS FRACTURE

Another cause of leg pain is a stress fracture of the tibia.  This is a small crack or hairline fracture of the bone.  It occurs from the pressure of constant pounding.  Localized pain results.  The fracture may not become evident on x-rays for several weeks and sometimes a bone scan is necessary to make the diagnosis.  The treatment is absolute rest from running until the fracture heals.  A cast is sometimes required, but in some instances, protection with crutches is sufficient.

 COMPARTMENT SYNDROME

A third –and rare reason — for shin splints is a “compartment syndrome.”  Muscles are covered under the skin by a tissue called fascia.  An analogy is the encasement of a sausage.  Muscles enlarge when they are exercised, and in the leg, muscle expansion produces increased pressure in the compartment.  The muscles become too tight under the skin and swelling results.  The nerves and blood vessels adjacent to the muscles also become crowded and pinched, producing discomfort.  Treatment consists of rest and ankle exercises, but in severe cases, surgery may be necessary to slit the fascial covering of the compartment and relieve pressure on the muscles.  The surgery is fairly simple and usually effective.

To conclude, proper conditioning is important because shin splints frequently occur during training or in individuals who are unfit.  Thus, increases in exercise and activities should be gradual.  Proper shoes and orthotics may prevent overuse syndromes, but they will have little effect on stress fractures or compartment syndrome.  And, finally, the importance of rest cannot be overemphasized.

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.

Ski Injuries

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Preventing Common Ski Injuries

Once again, many are heading north to the slopes and most will return invigorated, tanned, and happy.  Some, unfortunately, will return with slings or crutches, pale and unhappy.  Here are some common ski injuries and how to avoid.

Well over half of the ski injuries involve the lower extremities, and most of these favor the knee and leg.

Knee Injuries

Knee sprains are by far the most common injuries.  The ligaments along the inside of the knee are injured when a skier catches the inner edge of a ski in the snow and the foot rotates outward as the body continues forward.  Stress is then placed on the inner side of the knee, which is forced into a “knock-knee” position as the skier falls.  The ligament will be stretched (sprained) if the force is minimal and if the bindings release.  Otherwise, the ligament can be completely torn.  Another potentially dangerous position is the “snow plow”—where both knees are knocked and the body weight is placed on the inner edge of the ski.  A fall will place direct force against the inside of the knee.

Catching the outer edge of the ski may injure the ligament that lies along the outside of the knee.  This can occur if the tips of the skis accidentally cross and the skier falls sideways.  The leg on the side of the fall will twist inward and will remain straight.  Stress is placed on the outer ligaments.

The new shorter, shaped skis place more stress on the knees than the former, longer skis.

Especially stress on the medial collateral ligiment(MCL).

Prevention of these injuries mainly centers around adequate bindings.  It has been reported that a high percentage of lower extremity injuries result from a failure of bindings to release.  Quality bindings properly mounted and maintained will prevent many knee injuries.  Various knee braces can also be worn and, to some extent, can provide protection.  A brace with metal sidings and hinges can comfortably be worn under ski pants and allow an acceptable degree of knee mobility.

Fractures

Another common injury is the tibial fracture—or broken leg.  This occurs when the leg is forced against the hard boot top during a fall.  The leg can also break when the bindings fail to release and the leg is twisted.  This torque can snap the bone.  Again, proper bindings are the best insurance against this unfortunate and incapacitating injury.

Shoulder Dislocations

If inadequate bindings are a cause of knee and leg injuries, faulty pole technique can contribute to upper extremity injuries—specifically the shoulder or thumb.

Shoulder dislocations are very commonly treated at base clinics.  The shoulder can dislocate when a backwards force is applied to the outstretched arm and the shoulder is levered forward.  Thus, a skier who falls on his outstretched (abducted) arm may sustain this injury.  Frequently, however, the arm is levered by a planted pole; as the body continues forward, the arm is forcibly stretched and rotated outward, aggravating the injury and making a dislocation more likely.  Slalom racers who grasp too long on their planted poles are especially susceptible to this type of injury.

A shoulder dislocation is very painful and requires immediate setting to relocate the joint.  Multiple dislocations can eventually produce a damaged, unstable shoulder, and surgery will frequently be required to repair it.  One way to avoid this injury is to be aware of the mechanism and try to eliminate excessive pole planting.  Poles with strapless hand grips, which release better from the skier’s hand, may also prevent this injury.  If a skier has a dislocated shoulder, he or she might consider a brace to check excessive shoulder stretching.  These braces are custom made, but they are light, comfortable, and usually don’t interfere with normal skiing.  They can be worn inconspicuously under the ski jacket. ( I have personal experience on this matter, as I dislocated my shoulder twice while skiing—once on a bunny trail at Stratton-when I first learned to ski—but again, and less embarrassingly, on a real black diamond trail—Nosedive—at Stowe, a few years later. I successfully skied down Nosedive without falling and ,of course, at the bottom on level terrain, slipped and fell. I had a custom made brace made which I wore thereafter and never again dislocated my shoulder.) 

Thumb Injuries 

The other notorious injury caused by ski poles is damage to the ligament on the inside of the thumb.  Since the pole is grasped between the thumb and the index finger, sudden force along the pole can jam the handle of the pole into the base of the thumb and injure the ligament.  This is a serious injury which is treated with a cast and perhaps surgery.   Pole straps incorrectly positioned can result in greater risk of this accident.  A strap held around the palm just below the base of the thumb can be stretched.  The strap should properly lie around the wrist, well away from the thumb.  The risk of thumb injuries may also be decreased—although not eliminated—by using poles with a strapless type of hand grip.

Finally, here are five useful tips for prevention of ski injuries:

  1. Service your bindings at the start of each ski season.
  2. Stay fit prior to the ski vacation.
  3. Do warm-up exercises before you go out.
  4. Quit whenever you feel tired.
  5. Don’t be a daredevil.

Please note: these articles are for general information. They are not intended to serve as medical advice or treatment for a specific problem. Diagnosis and treatment of a problem can only be accomplished in person by a qualified physician.