Professional Orthopaedic Associates

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Shin splints or medial tibial stress syndrome is a term used by athletes to describe anterior shin pain involving the anterior proximal or distal medial aspects of the leg.

Posterior shin splints involve the posterior tibia muscle and tendon and occur one to six inches above and slightly posterior to the medial malleolus or medial ankle bone. In the younger runners it usually represents either micro-tears of the muscle or tears involving the origin of the muscle fibers on the bone, which is described as periostitis. It is frequently painful and tender both along the medial and posterior aspects of the distal tibia involving the posterior tibial tendon, and in more severe cases, the flexor digitorum longus and flexor hallucis longus tendons. The pain is more severe when rising up on the toes or everting the foot, thereby stretching the tendon myofascia muscle complex.

The first risk factor to consider is overtraining or normal training involving a younger or beginner runner. Evaluation of the runner’s schedule is important. This includes both the training and racing schedule shoe wear. Hyperpronation may also contribute to the problem, therefore, shoe evaluation is important. Shoes that are highly rated for control of pronation may be helpful. The running surface should be supportive such as all weather artificial tracks or packed dirt. Avoid excessive hard and soft surfaces. General posterior stretching exercises and ice baths following running may offer some relief. They are not curative. Excessive pronation is a contributor to this problem, therefore, orthotics to control excessive pronation or heel lifts may offer some relief. Avoid running on a canted surface because the uphill foot has excessive pronation during the full weightbearing force on the foot.

Decrease training immediately and find the distance that you can run without reproducing excessive pain. Cross-training may be an alternative to include swimming, biking and pool running. Also, physical therapy may help to include stretching, strengthening, electric stimulation and ultrasound. Appropriate anti-inflammatory medication may also be used.

Anterior shin splints involve the anterior tibial muscle and tendon and occur along the proximal anterior lateral tibia for a distance of about four to five inches. There is a higher instance of either stress fractures or compartment syndrome problems as the differential diagnosis of this overuse problem. Again, this is a soft tissue injury involving the muscular origin of the tibialis anterior muscle on both bone and periosteum.

There is usually a mechanical imbalance between the posterior and anterior muscle groups. The posterior muscle groups are usually too tight and relatively too strong. At heel strike, (initial foot contact with the ground), the anterior muscles must function to slow the forward or downward plantarflexion of the foot. This is a deceleration function. If the posterior muscle groups are too tight and strong, they will force the anterior muscles to work harder and longer to control the foot. The second imbalance occurs during toe off when again, the anterior muscles are overused to lift up or dorsiflex the foot so it will clear the ground as the leg is brought forward. As the anterior muscle grip fatigues, it becomes dysfunctional producing over trauma or muscle micro tears/strains.

This imbalance is accentuating by running downhill, which only exacerbates the overuse on the anterior leg muscles. Running on harder surfaces is also a more frequent problem with anterior shin splints.

Overtraining and improper shoes also can accelerate this problem. Shoes must have appropriate shock absorption and again, overtraining only makes the situation worse. The muscles naturally become more fatigued and dysfunctional, causing more injury.

The treatment is similar to that for posteromedial shin splints. It should also include stretching the posterior muscles of the leg and calf to include the hamstrings, changing shoes to a more shock absorbing or soft shoe as compared to a shoe that controls pronation, and avoidance of downhill running and running on hard concrete-like surfaces.

If symptoms persist, running should be decreased or stopped. Also, appropriate medical evaluation to rule out stress fracture and anterior compartment syndrome should be considered. Anti-inflammatory medication also may be used along with physical therapy.

These conditions are common in high school runners and early recognition and treatment is essential in maintaining the athlete’s ability to compete.

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Turf toe injuries have become increasingly frequent in football. This is partly because of the popularity of more flexible shoes that allow increased toe motion. Turf toe injuries are caused by hyperextension of the great toe, where the toe is forced upwards, as in a football pile-up or tackle. These injuries are more common in linemen and receivers. The severity of injury depends on the degree of soft tissue tearing at the joint. The joint at the base of the great toe (the 1 st metatarsophalangeal joint) becomes swollen, bruised, and painful with standing. Pushing off with the great toe while walking or running is especially painful. X-rays are obtained to look for a dislocation or fracture. Treatment begins with rest, ice, compression, and elevation (RICE). A walking boot is worn to prevent motion at the joint. Most athletes with mild to moderate turf toe injuries return to sports in 4 weeks. Severe injuries may keep an athlete out for 6 weeks. Rarely, a turf toe may need surgery to repair the soft tissue tears. When the athlete returns to sports the toe is protected with taping, a stiff sole shoe, or a stiff orthotic to prevent re-injury to the joint.

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A high ankle sprain involves tearing the ligaments connecting the tibia and fibula bones of the ankle. These ligaments are called the syndesmotic ligaments. A high ankle sprain occurs when the foot is twisted outward. This often happens when a football player is tackled from behind as the athlete’s foot is planted on the ground and is turning towards the opposite side. Swelling and pain develop at the front and outer side of the ankle. It is painful to stand on the affected leg. The pain and swelling in a high ankle sprain occur higher up on the leg than the more common lateral ankle sprain. Lateral ankle sprains occur when the foot rolls over and the ankle is twisted inward. High ankle sprains take a longer time to heal than lateral ankle sprains. X-rays are obtained to look for fractures or widening of the space between the tibia and fibula. The space between the bones may be wide with a severe high ankle sprain if the syndesmotic ligaments are completely torn. Sometimes surgery is required to repair the syndesmotic ligaments. Usually there is no widening of the space so the ligaments will heal in a boot or cast. Most athletes can return to sports in 6 to 8 weeks.

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Burner’s syndrome “stingers” is an acute peripheral nerve injury involving the upper trunk of the brachial plexus nerves, which is formed by the C5 and C6 nerve roots exiting from the cervical spine. It is characterized by immediate and severe burning pain along with the sensation of prickly paresthesias and numbness that radiates from the upper shoulder or supraclavicular area extending circumferentially to the shoulder, lateral arm and at times, to the forearm, wrist, hand and fingers. It follows no specific nerve root innervations of the skin or dermatomes. This is an injury to the pain fibers of the peripheral nerve root. There are also motor fibers within the peripheral nerve root, which causes a concomitant weakness of the involved extremity. This weakness involves mainly the muscles that rotate and flex the shoulder but also the biceps muscle, which flexes the elbow and twists the forearm into a palm-up position. The pain is usually transient, lasting seconds or greater than five or maybe ten minutes. The motor weakness is longer lasting and needs an initial evaluation followed by follow-up evaluations to correctly estimate the extent of nerve injury. In the majority of cases motor power returns to normal again within several minutes. Occasionally, motor power will not return for days or even weeks, or may become more severe with an increased loss of strength and rarely may become permanent with the severest of injuries. This injury is commonly seen in collision or contact sports such as football, ice hockey, wrestling, and rugby. The incidence is rather high involving between 50 and 65% of collegiate football players. It is probably higher because there is also a high incidence of non-reporting by these same collegiate football players. In football it occurs most commonly in the linebackers and smaller defensive backs while tackling. It may also occur with running backs or linemen while blocking or being tackled. There is also a very high incidence of recurrence, which must be addressed by the medical staff to minimize this problem.

The mechanism of injury is usually traction occurring with a substantial direct blow to the lateral shoulder pad, depressing the lateral shoulder at the same time the neck or cervical spine is pushed or tilted in the opposite direction. A second type of injury occurs from a direct contusion to the brachial plexus or supraclavicular fossa. This occurs from a direct blow, which may cause the edge of the shoulder pads to come in contact with the brachial plexus. The final mechanism is a compression-flexion combination that occurs with a combination of the shoulder being flexed and the neck being hyperextended and rotated toward the injured shoulder.

The injuries are graded as I, II or III. Grade I injuries are transient loss of nerve function or motor power, lasting from hours to at most two weeks. With this, there is both edema and demyelination of the nerve axon which repairs itself within two to three weeks. Grade II injuries exhibit motor weakness that lasts for longer than two weeks with usually 80 to 90% recovery by six weeks and full strength returning at six months. Grade III injuries are continued motor weakness after one year or permanent motor weakness.

Electrodiagnostic testing to include EMG studies are done after three weeks. They will likely be positive in a Grade II injury or multiple Grade I injuries. Repeat EMG studies can monitor the recovery or healing of the nerve and muscles.

Treatment is best left to skilled medical personnel to include athletic trainers, emergency medical staff and sports medicine physicians. It is important to document the history and physical examination of the initial and all recurrent stingers. An athlete may return to his sport when he is pain-free, muscle strength is vastly improved and adequate to protect him (4+/5), the recovery has occurred over a short period of time (ten to fifteen minutes) and additional protection is afforded the athlete, which is initially the application of at least a neck roll.

To avoid recurrent injuries, which occur in at least 50 to 60% of the athletes, it should begin with an immediate reevaluation of the athlete’s equipment, i.e. shoulder pads and helmet. The helmet must fit properly and an extension of the face mask can protect cervical motion. The addition of a cowboy collar has been found to be better than a neck roll to limit cervical motion. In recurrent conditions, both the cowboy collar and neck roll should be considered. Proper blocking and tackling technique should be addressed by the coaching staff. Maintenance of proper strength involving the cervical and scapular rotator muscles is necessary and should be continued in the off season. A strengthening program for the deltoid, biceps, supraspinatus and infraspinatus rotator cuff muscles should be initiated immediately. Shoulder pads can also be lifted upwards with additional padding beneath the shoulder pads, which are termed either lifters or spider pads.

More severe injuries necessitate appropriate medical evaluation and referral to appropriate medical experts. This includes emergency personnel, sports medicine specialists, orthopaedic surgeons or even neurologists. The burner syndrome is from the shoulder down and does not involve the cervical spine. Cervical spine pain with stiffness may possibly be a more serious injury and should be treated appropriately. A player should not return to action if he has continued cervical pain. Symptoms into both arms or radiation into both legs is also a more significant injury probably of the cervical spine. Weakness lasting several days or progressive weakness is also more serious, or a history of recurrent burners with each becoming symptomatic for longer periods of time. Congenital spinal stenosis, herniated intervertebral discs, fracture, cervical sprain or strain, if considered, must be appropriately protected and ruled out by standard medical evaluation.

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Some of the most frequently asked questions from young patient’s are directed at weight lifting.

Parents are often concerned about their preadolescent children who may be “lifting weights too early”. Concern for muscle injuries, growth stunting and loss of flexibility are the most frequent fears young athletes mention as they consider whether or not to initiate a strength training program.

In actuality, strength training is really a conditioning technique that focuses on repetitive exertion of muscle force against resisting objects such as barbells, dumbbells and the use of machines or body weight. Weightlifting is actually a sport geared towards lifting a maximum weight using specific techniques.

Several studies have indicated that strength training is safe for young athletes as long as proper training techniques and supervision are provided.

Safety precautions are an important consideration in weight training and observation of these precautions will limit potential injuries?

Supervision by a knowledgeable adult with proper training with credentials in conditioning and strength training is advisable.
Workouts should focus on large muscle groups first and then smaller groups.
If free weights are being utilized then a spotter is mandatory.
The athlete should work on a variety of muscles, i.e. upper extremities, lower extremities, chest and back.
Specific workouts should focus on exercising opposing muscle groups in pairs (triceps and biceps or quadriceps and hamstrings).
Fifteen to twenty minute cool down comprised of stretching and light calisthenics is strongly recommended to conclude a strength-training program

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DON’T FORGET TO STRETCH
By Brian M. Torpey, M.D.

Exercise training that focuses on maintaining good muscle tone and flexibility can help an athlete perform sports activities at the most optimal level. Stretching and preloading of muscles and joints allows athletes to condition themselves and thereby prevent overload injury when they perform competitive and training exercise. Several interesting facts concerning flexibility include:

Females, especially children, are typically more flexible than males.
Flexibility decreases with age.
Strength training does not limit flexibility.

Athletes who do strength training and flexibility training can maintain good flexibility. The enhancement of flexibility is perhaps best attained by performing a regular stretching routine. This will allow the athlete to reduce muscle tension and make the body feel relaxed. Coordination will also be enhanced by an athlete’s ability to obtain freer range of motion. Injuries such as muscle strain and shin splints are examples of sports associated problems that respond well to the use of good flexibility and stretching techniques.

The following guidelines for stretching are strongly recommended. Typically three stretching repetitions should be performed for the specific muscle grouping targeted. When stretching, hold the stretch for at least six seconds (although some experts recommend up to 30 seconds). Stretching should be performed both before and after sporting activities. “Slow” stretching when the muscle is slowly stretched out has a much less associated injury rate than active, jerky stretching motions, such as jumping jacks. When performing stretching activities, a good rule of thumb is to try not to force any motion. Do not bounce up and down or stretch to the point of pain. Finally, remember that stretching becomes more important as the athletes’ sport season progresses. Athletes with persistently fatigued muscles that are repeatedly exposed to strenuous activities are more apt to experience a muscle strain injury it they have not maintained their flexibility.

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HEEL PAIN
Brian M. Torpey, M.D.

One of the more disabling injuries that athletes have always encountered is heel pain. Heel pain is commonly secondary to a stretch injury to a band of thick fibrous tissue located at the instep of the foot. This band of tissue, called the plantar fascia, is connected to the heel bone, which becomes inflamed by the tugging and pulling, which occurs during the sporting activity. Chronic inflammation of this band of tissue can even result in the formation of a heel spur, which is confirmed by an x-ray. Patients with heel pain typically complain of pain that starts at the heel and radiates to the instep of the foot. The pain becomes worse with running and jumping activities and it resolves with the cessation of the activity.

Specific treatment for inflammation and pain of the heel that radiated to the instep of the foot should include rest until the athlete can walk or run without discomfort, anti-inflammatory medicines as needed and an icing program to the areas of pain and inflammation and a stretching program geared to relieve tension in the instep region and surrounding soft tissues. A heel cushion, easily inserted into an athletic shoe, also helps relieve discomfort in the majority of cases.

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BASKETBALL BUMPS & BRUISES
Brian M. Torpey, M.D.

Now that basketball season is in full swing, it is important to review some of the common injuries sustained by both male and female basketball players during the course of any given season. Injuries, in their order of increasing frequency include trauma to the ankle, knee, hand, wrist, forearm, head and neck, back, thigh, shoulder and elbow. Ankle injuries account for approximately 50% of all reported basketball associated injuries. The most common ankle injury that occurs during basketball activities are lateral ankle sprains, which typically respond to early aggressive physical therapy. Jumpers knee (pain and swelling in the front of the knee), is another frequently noted basketball injury. This injury typically responds to a stretching and strengthening program.

Other disabling basketball injuries include heel pain which can result from fasciitis, tendonitis and bursitis, quadriceps or thigh contusions, eye and nose injuries and knee ligament injuries. Females have a six-fold incidence of ACL related injuries as a result of basketball participation. These injuries are thought to occur as a result of frequent, sudden acceleration and decelerations, cutting, pivoting and jumping that occurs in close quarters without the benefit of protective padding to exposed body areas. The use of and implementation of a plyometric-conditioning program, prior to the onset of basketball season may work to protect basketball players, especially female basketball players from the onset of associated knee injuries.

In light of these considerations, it is no surprise that basketball is classified as a contact sport!

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SKIER’S THUMB
By David R. Gentile, M.D.

The thumb is commonly injured during contact sports, such as wrestling, when it becomes entrapped in an opponent’s uniform or during a fall on the outstretched hand causing the thumb to be pulled away from the hand, as in skiing. The thumb plays a critical role in hand function especially pinch and grip activities. Injuries of the thumb treated improperly can be a source of significant pain and disability.

The metacarpo-phalangeal (MCP) joint is located at the base of the thumb where it joins the hand and is the most common site for injuries of the thumb. A capsule surrounds the joint with thickenings along each side known as the radial and ulnar collateral ligaments (UCL).

These injuries may be classified as mild, moderate or severe (grade I, II or III). Any injury to the ulnar collateral ligament may be accompanied by a fracture, especially in immature athletes who are still growing. Initially, the injured athlete should be checked for obvious deformity. If he/she is comfortable the athlete may be allowed to complete competition with the MCP joint taped and the thumb taped to the hand. All athletes with suspected UCL injuries should be evaluated with x-rays following competition to rule out any associated fractures.

Treatment for partial tears of the UCL consists of immobilization in a thumb splint for 3-4 weeks. Rehabilitation is started after this period and includes range of motion exercise with splinting between exercise sessions. The splint is discontinued between 4-8 weeks depending on the severity of the injury except for sports participation. A brace is used for 3 months following the injury during sports to allow the ligament to heal and prevent re-injury.

Surgical repair of UCL injuries is recommended for most complete tears. Severe bruising and laxity of the joint without an endpoint on stress examination usually help to identify complete tears. Fractures that involve more than one third of the joint surface or those which are displaced should be stabilized surgically. Immobilization after surgery is the same as for conservative management.

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Mennace Elbow
By Brain M. Torpey M.D.

Tennis elbow is a frustrating type of tendonitis that may affect recreational as well as high caliber athletes. Athletes typically complain of pain when performing activities that involve the wrist as commonly seen during the backhand motion of the tennis volley, swinging a heavy bat or certain weight lifting motions. This type of strain or tendonitis usually occurs in the beginning of the sports season when the wrist and forearm muscles are de-conditioned and “out of shape”.

In the case of tennis elbow, the site of the inflammation includes the muscles and attachments on the outside of the athletes elbow. These muscles and tendons are aggravated with actions that cause the wrist to extend (as in the motion of traffic police officer when he holds his arm out straight to stop the flow of traffic). This motion causes a sensation of burning or pulling that is noted on the outside of the elbow. Although this form of tendonitis initially starts off as an irritating nuisance it can eventually handicap the athlete and adversely affect their performance in sports activities. Treatment of tennis elbow includes a three-prong approach, rest from the offending activity, ice-massage to the elbow area at least twice a day for approximately twenty minutes, and a short course of anti-inflammatory medications.

In order to prevent the recurrence of tennis elbow, a stretching program should be initiated after the athlete has controlled the inflammation associated with acute tennis elbow. They should then proceed with an exercise program that focuses on strengthening of the wrists and forearm muscles.

A sports medicine physician should evaluate recurrent tennis elbow that does not respond well to a stretching program in order to help prevent the buildup of inflammatory scar tissue.

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Wrestlemania
By Brian M. Torpey, M.D.

Most competitive wrestlers, unlike their “Saturday Morning wrestling” counterparts (depending on your age: The Rock, Hulk Hogan or George the Animal Steel), have injury levels that are similar as those seen in football and soccer.

Instead of being thrown from the ring, most competitive wrestlers actually sustain their injuries during the course of practice activities. It is also important to note the occurrence of wrestling associated injuries increases with the wrestler’s level of expertise and increase in age.

Perhaps the most common category of injury associated with wrestling includes skin lesions, specifically abrasions and infections of the skin. Most abrasions occur during the takedown when the wrestler being taken down is relatively out of control. Specific infections that occur in wrestlers include ringworm, herpes and impetigo. These skin diseases are passed from wrestler to wrestler during practice and/or competition. The appearance of skin rashes and weeping skin lesions should prompt all wrestlers to be evaluated by their certified athletic trainer or sports medicine physician, so that an appropriate evaluation and treatment may be administered.

“Cauliflower ear” or friction trauma to the outer ear is also an injury commonly associated with wrestling. The injury declares itself as a swollen outer ear that is tender and filled with blood. Properly fitting headgear is the best preventative treatment when cauliflower ear does occur. Treatment may include proper drainage of the blood collection as well as compression with cotton packing.

Nosebleeds, another common injury seen during wrestling competition, also respond well to cotton packing. Wrestlers with a nosebleed should forcefully blow the blood and the blood clot into a paper towel and then pinch their nose tightly until the cotton packing can be placed into the affected nostril. This technique should allow the wrestler to promptly and safely return to his wrestling match.

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Scoliosis…Treatable if Caught Early

By Jason D. Cohen, M.D.
Professional Orthopaedic Associates
Professional Spine and Scoliosis Center

Does your child have an excessive curvature of the spine? If so, they may have scoliosis. Scoliosis is an appreciable lateral curvature of the spine and rotation of the vertebrae around the long axis of the spine. It is a deformity, which can be very minimal or severe. As the degree of scoliosis increases, it can

Become more cosmetically worrisome.
Begin to effect lung function
Can cause further problems in adulthood

How is scoliosis detected?

The easiest way to detect scoliosis is to see the curvature of the back. At that time, your child should be referred to an orthopaedic physician. The physician will perform a general inspection, looking at the shoulders and waistline for symmetry, noting any differences. The next portion of the exam is called the “bending” test. The patient places their palms together and bends forward. The spine is then viewed from the front and back. Additionally, the spine is palpated to feel for a curve. During this test, the ribs will become more prominent on one side. Another method to measure scoliosis is to use a scoliometer (spinal level) to measure rotation of the spine during the bending test. This can be recorded and repeated at a later date to compare and look for any progression.

What are the appropriate treatments?

Treatments for scoliosis will vary based on the patients’ age, location of the curve and the underlying cause of deformity. X-rays should be taken so that the magnitude, location and type of scoliosis can be determined. The x-ray is also important in determining the skeletal age of the patient and how much growth remains. It may be necessary to take a series of x-rays ranging anywhere between three months to one year.

Generally, small curves within 10-20 degrees are observed over time for any increase in size. Bracing is used for curves greater than 20 degrees or curves that have documented progression of greater than 5 degrees. Curves greater than 45 degrees are treated with spinal fusion surgery. Children with scoliosis can lead normal active lifestyles during any phase of treatment and after the surgical treatment as well.