• New Ways to Treat Carpal Tunnel Syndrome

      Sir James Paget

      Sir James Paget | Pathologist
      Image: MaterialScientist

      Sir James Paget and James Putnam

      Although we may think that carpal tunnel syndrome is a relatively new disorder, which came about during the computer age, it was actually originally described by Sir James Paget in 1854. James Putnam, a Boston neurologist, published the first clinical study of 37 patients with carpal tunnel syndrome in 1880 and Learmonth performed the first carpal tunnel release surgery at Mayo in 1933.

      Open Carpal Tunnel Release Surgery Or Open Release

      However, up until the 1960s, when carpal tunnel syndrome and its treatment options became fairly well defined, there was still no clear consensus on how to treat the condition. In fact, up until the late 1940s, resection of the first rib was a common treatment for this diagnosis! Once medical opinion coalesced about the cause of the disorder, a standard surgical treatment quickly developed, known as “open carpal tunnel release surgery,” or “open release.”

      Open Release Surgery

      During open release surgery, the transverse carpal ligament is cut, which releases pressure on the median nerve and subsequently relieves the symptoms of carpal tunnel syndrome. A 1 – 1 ½ inch incision is made at the base of the palm of the hand, allowing the surgeon to see the transverse carpal ligament. After the ligament is cut, the skin is closed with stitches. The ligament is left open, and this decreases the pressure on the median nerve in the carpal tunnel. This sectioning of the ligament does not result in any loss of function.

      With the traditional open release surgery, the hand can remain swollen and tender for a couple of months. Full use of the hand, especially during gripping and grasping activities, can sometimes take up to 6 to 8 weeks, or possibly longer.

      Endoscopic Release

      Endoscopic release is a relatively new technique, which uses a thin tube with a camera attached (endoscope). The endoscope is guided through a small incision in the wrist, allowing the surgeon to see the transverse carpal ligament without opening the entire area with a large incision. A miniature blade, inserted through the tube, is used to cut the transverse tunnel ligament.

      SmartRelease Full Assembly

      MicroAire® SmartRelease® Endoscopic Carpal Tunnel Release System Image: microaire.com

      Smart Release Procedure Illustration

      MicroAire® SmartRelease® Endoscopic Carpal Tunnel Release System Image: microaire.com

      Here is a quick video of the endoscopic release procedure.

      Relief Of Symptoms Of Endoscopic Release

      The relief of symptoms of endoscopic release are similar to the traditional open technique. However, you can expect a less post-operative pain and a shorter recovery period after endoscopic carpal tunnel release, because the procedure does not require cutting the palm open and disturbing a large area of the hand. As a result, you can return to work or practicing sports earlier, especially sports that require gripping, such as golf and tennis. Endoscopic release also produces a smaller scar with less swelling and scar-related pain.

      Call Us!

      If you suspect that you have carpal tunnel syndrome, please give us a call and let one of our physician’s determine the cause of your pain, and know that should you need surgery, we will offer you the most innovative and safe treatment available.

      Lessons from the Doctor 

      A couple of weeks ago, our very own Dr. Klion competed in a mountain bike race. As he had increased his training mileage for the event, he had noticed that his wrist was sore, but didn’t find this unusual as almost all cyclists often experience pain in the hand, wrist, and finger region due to excessive pressure placed on the handle bars. It was only after the event that he learned he had broken a bone in his wrist.

      Other symptoms that can occur from pressure and overuse include numbness and tingling. Common cycling syndromes are described below.

      Ulnar neuropathy – known to cyclists as “handlebar palsy” – results from compression of the ulnar nerve, which controls sensation in your ring and little finger, as well as hand strength with gripping. Holding the lower section of drop-down handlebars can compress the ulnar nerve.

      The constant pressure on the hand’s median nerve that comes when resting one’s hands on the top of the handlebars can lead to carpal tunnel syndrome. In this case, typical symptoms are numbness or tingling in the thumb, index, middle and ring fingers, as well as a general weakness in the hand.

      As with handlebar palsy, the most immediate and effective action is to change your hand position, use well-padded gloves and lessen the pressure by loosening your grip.

      It may take months for the symptoms to resolve; rest, stretching exercises, and anti-inflammatories usually help to relieve the symptoms.

      More importantly, you must adjust your equipment and habits! Proper bike fit is essential; adjusting the handlebars, seat, and pedals to your fit is the key to preventing most cycling overuse injuries, a third of which happen to the hands and wrist.

      By sitting in a more upright position, you will take weight and pressure off your hands and wrists.  During long rides, take rest stops, and change your hand position often. As often as possible, shift your weight from the center of your palms to the outside edge. Padded gloves and good shock-absorbent handlebar grip/tape will help protect your hands from injury.

      Like any other part of your body, your hands and wrists will benefit from a short session of hand and wrist stretches before you hit the road.

      In order to prevent injury, listen to the moral of Dr. Klion’s story; pay attention to any signs of physical discomfort and seek medical advice if the symptoms do not abate.

      Heading (Gently) Into Fall

      For runners, the arrival of fall means more than just shorter days and longer sleeves. Fall foliage signals a critical time of the year, when our bodies deserve special attention. Especially for those anticipating marathon or other demanding competitive events, there is a tendency to increase mileage on training runs, which can be a recipe for disaster. In these first weeks of autumn, we should take a lesson from the trees – cut back, slow down. As the trees drop their leaves, you can afford to drop a few miles from your weekly mileage, as a safeguard against injury.

      We often see an increase in injuries at this season, and you should be vigilant in heeding any early warning signs – swelling, mild discomfort, tenderness – that suggest you are exceeding your body’s limits. Resist the temptation to push through when pain arises; it is always better to adjust your training schedule modestly now, rather than lose your momentum altogether due to an injury. Early recognition is a key to maintaining health.

      Not all warnings come in the form of pain. Irritability, insomnia, or a change in appetite can be signs of impending injury or illness. A simple rule-of-thumb is to measure your resting heart rate in the morning, then gear your workout in relationship to this. Autumn is a good time to assess your equipment, after a full summer season. How are your shoes? 300 to 500 miles, or 3 to 6 months, is the normal duration before replacing your running shoes.

      At any season, Achilles tendonitis and plantar fasciitis represent particularly painful challenges to the runner. A patient recently reported that a fellow runner recommended a Castor oil compress to facilitate heeling of a sore Achilles. A much more effective remedy is a night splint, which, by holding the foot in a dorsiflexed position, provides a passive stretch through 8 hours of sleep. Other treatment approaches might include supportive footwear, arch taping, and physical therapy.

      dorsiflexed position

      dorsiflexed position

      Remember though, if you have persistent pain, we are here to help you. Just give us a ring!

      When Leg Pain Really Isn’t Leg Pain

      Leg pain isn’t always leg pain. If it’s running down the back of your thighs and calves, then the problem may be located somewhere else entirely. And anyone who’s experienced the slow, dull pain that arises from the sciatic nerve, will know that leg pain might not actually arise from the leg.

      Why? Because of the unique role of the sciatic nerve.sciaticNerve

      As the nerves exit your spine, they form a bundle as it extends into your legs and continues all the way to your feet. This is called the sciatic nerve. Through this nerve back problems can be transmitted to your lower extremities and often feel like a pulled hamstring. Man holding hamstring

      Many people who experience this radiating pain don’t realize that it’s a sciatic problem, so it takes an experienced orthopedist to correctly identify the issue and work with the patient to remedy the problem.

      There are a number of solutions to deal with leg pain coming from the sciatic nerve. Proper stretching and exercise is always the foremost prevention. Often a simple injection can clear up most of the pain within a couple weeks.

      Additionally, physical therapy can help you find a routine that corrects your posture and alignment to make sure the sciatic nerve isn’t impeded for future activities.

      The quickest way to get on the road to recovery is through an accurate diagnosis. At Manhattan Orthopedic our spine specialists and sports medicine practitioners collaborate regularly and through a team-based approach work to get our patients feeling better as quickly as possible.

      If you’re experiencing similar issues, then go ahead and make an appointment to see one of our specialists today. Taking care of the problem now will help ensure a quick recovery and get you back into the action just as summer starts to really ramp up!

      The Well-Tuned Tendon

      Our tendons are the great connectors of our bodies: transferring the forces from bone to muscle and back again, they ensure our movements while bearing the brunt of our exertions. It may come as no surprise then that the sudden shift from indoor to outdoor activities often results in overuse injuries that are entirely preventable.

      Injury prevention involves stretching, having the proper equipment, and easing into any new routine. man stretchingTendons that aren’t prepared for a sudden change in activity can act a lot like a bundle of cold rubber bands pulled beyond their limit.

      The bundle may remain intact, but some of the individual bands may break or fray. This is roughly what happens when our tendons are subjected to new or aggressive forces. The result? Tendinopathy, a condition characterized by degenerative changes in the tendon that cause pain and decreased mobility.

      If left untreated, tendinopathy contributes to a cyclical process of worsening pain and inflammation. Initially, the pain can be discomforting yet bearable; many athletes will even continue their normal routines thinking they’ll work through it. But as the tendon weakens it overcompensates, further straining the tendon’s tiny cables and aggravating the condition.

      So how does one break the cycle? Modify your activity and adopt a regimen that puts fewer stresses on the problem area. Additionally, one should ice the problem area after exercise and take anti- inflammatory to reduce swelling and pain.

      This is also a good place to point out that our incredible team of Triarq physical therapists can help tailor a routine specifically for you, no matter where your tendon problem may be.

      Some of the more interesting developments in treating tendinopathy are new creams that combine multiple medicines as part of a multi-pronged attack against the problem area. In addition to topical pain creams such as Lidocaine or Voltaren gel, we now have access to creams that combine a few medications that may be able to relieve pain while also reducing inflammation. The combination helps our patients experience faster relief while healing faster.

      runner on pathBut our best advice is to stay healthy by preparing for the transition from treadmill to jogging trail. We know you might feel like jogging an extra five or ten miles on one of these bright and sunny days, but you’ve got all summer to do that! For everything else, we’re just a phone call away.

      Spring & Sensibility: Staying Injury-Free in a New Outdoor Routine

      With fresh leaves on the trees and perfectly mild weather, spring may just be the best time for outdoor exercises. Every year it seems, we devote at least one article to getting ready for spring, yet we continue to treat injuries that could have either been prevented or lessened by following a few simple rules.

      First, always start out slowly. The main injuries we see this time of year are overuse injuries such as runner’s knee. Even if you’ve been exercising in the gym this winter, switching to outdoor activities will engage your muscles and joints in ways that they may not be ready for. In order to acclimate your body to new conditions, start by doing a lighter workout and ramp up incrementally.

      Second, always have the right equipment. When changing from indoor exercises to outdoor activities, make sure you throw out your worn out running shoes and replace them with a fresh pair. For those in-the-know, one of the best ways to pick out a new running shoe is to see a professional fitter at a shoe store or sports retailer. Some stores also offer treadmill analyses to give you a comprehensive overview as to the best shoe for your stride.

      Proper clothing also plays a role in staying injury free. When you’re jogging outside and perspiring heavily, wearing clothes that draw away sweat and reduce friction will help reduce overall bodily stress and maximize the effectiveness of your workout. Also, most runners are probably aware of the importance of lubricants during long jogs. If you feel any irritation in sensitive areas, then you should consult with a professional trainer or physician about a lubricant that will keep you moving with ease.

      Finally, going on a strength training routine can help prevent injuries of all kinds by building up muscles and firming up the connective tissue in your joints. Strength training reduces the risk of injury by reinforcing those connections—something that cardiovascular training can’t do on its own. If you have any questions, ask a professional trainer or physical therapist as to what might be the best strength training routine for you.

      So what are some of the red flags that indicate you might have an overuse injury? Persistent pain and swelling point to injuries that may be more than just a minor sprain. If swelling doesn’t go away after a thorough icing of the problem area, that may indicate an overuse injury. Similarly, if that tweak in your knee persists even when you’re not working out, then it’s time to go see a professional.

      It’s always best to seek out a like-minded soul when it comes to finding out more about your springtime injury. If you’re a runner, then try to see an orthopedist who’s also a runner. If you’re a cyclist, seek a physician that knows about cycling. The reason is one of relatedness: seeing a doctor that knows your sport will help inform the diagnosis and allow for a better response to your injury.

      Spring is not inherently hazardous, but there is something to say about overzealous individuals who end up as patients in our practice. Know your limits and stick to the basics: new shoes, new shirts, and, especially, a new attitude for a new season.

      Have a wonderful spring and stay safe!

      A Home Run for A-Rod’s Hip

      Baseball star Alex Rodriguez, known to New York Yankee fans as A-Rod, is in the news again. This time around it s not because of his exploits on or off the field, but because of his experiences in the operating room. Just last month, the sports pages reported that A-Rod is planning to undergo arthroscopic surgery at the hip to address a torn labrum. This will be his second surgery.

      What’s amazing is that despite surgery, he’s expected to be back in full action by mid-summer of next year. How is that even possible for an athlete pushing 40? The answer lies in the non-invasive surgical technique known as arthroscopic surgery.

      Readers of this space may know that arthroscopic surgery involves a camera and a couple of small incisions. Knee arthroscopy has been around for decades, but only recently has hip arthroscopy become more widespread. The benefit is that the technique is minimally invasive and allows for faster recovery times than traditional methods.

      Hip arthroscopy is the method of choice for repairing labrum tears. The labrum is the soft tissue bumper that encircles the socket of the ball-in-socket hip joint. Labrum tears can cause reduced athletic performance and lead to varying levels of discomfort. If you’ve ever experience a torn labrum, you know something’s wrong but you may not know what, exactly, is the problem.

      In fact, A-Rod had the same issue when doctors were initially trying to diagnose what was sapping his performance near the end of the recent season. An MRI of his hip revealed the labrum injury.

      There are two ways the labrum can become injured: it can either fray or tear. A frayed labrum occurs from repeated strains and the normal wear of physical activity. Torn labrums are usually the result of some sort of trauma, be it a hyperextension of the hip joint or a bad fall. The sensitive imaging techniques of MRIs allow doctors to diagnose these slight injuries and then recommend a course of treatment.

      The first-line treatment for labrum tear is physical therapy, which can help strengthen the surrounding muscles and tissue to allow the body to compensate for small tears. If there’s still pain, however, arthroscopic surgery may be recommended. The good news is that arthroscopic surgery is a same-day procedure, meaning you’re in and out of the hospital on the same day. Recovery can take some time, but using A-Rod as an example, you can get back to high-level activity within about 6 months—and that’s a timeline for a professional athlete. The weekend warrior could get back to normal workouts in about half that.

      If you have a nagging hip injury that hasn’t gotten better for some time, then it’s a good idea to come on down and let us check it out. Even if you’re not A-Rod, we can still make sure you’re back to peak condition and rounding the bases for the company baseball team.

      That’s something to cheer about.

      A Pain in the Post-Partem Wrist

      We sacrifice many things for our children—sleep and a small slice of sanity are just two examples that come to mind. But for many new mothers, the constant lifting and toting of a young child can lead to a condition much more agonizing and confusing than a few sleepless nights.

      If you’ve never heard of it before, “New Mom’s Syndrome” may sound like a good description of overprotective mothers. In reality, it is a painful form of tendonitis that affects the tendons on the outside of the thumb and wrist. This occurs when the repetitive stresses of carrying a child results in inflammation of the tendons in this region.

      Most of the people who are affected by “New Mom’s Syndrome”—known clinically as De Quervain’s Tendonitis—have often never experienced this type of pain or discomfort in their hands or wrists. Some of the blame can be placed on the natural swelling associated with the later part of pregnancy and after delivery, which intensifies the natural strains on one’s ligaments and tendons.

      Indeed, some pregnant women develop carpal tunnel in the last trimester, due to the increased swelling of the wrist tendon’s that sit next to the nerve within the carpal tunnel. And if that weren’t enough, just as a new mother’s carpal tunnel syndrome is receding, De Quervain’s Tendonitis starts kicking in after delivery.

      It’s true, however, that “New Mom’s Syndrome” is not exclusive to new moms. De Quarvain’s tendonitis can affect both genders, both the young and the old, but rarely do men’s bodies swell after their wives pregnancy—unless they’ve been sneaking in a few too many candy bars.

      Luckily for everyone, “New Mom’s Syndrome” can be easily treated.  In some cases, pain can improve by modifying the way one hold’s the child and by wearing a splint to relieve some of the strains on the wrist tendons.  Physical or occupational therapy can be helpful as well.  The most common and effective treatment, however, is usually a simple cortisone shot, which permanently solves the issue in most patients.  If that doesn’t work, well, you might want to get your child a scooter to cruise around on. We’re totally kidding, but at least then you wouldn’t have to carry them as much!

      Running the Town: Training for the NYC Marathon

      The diaspora and excitement of New York City’s marathon has turned the first Sunday in November into an annual 5-borough tribute to the sport of running. Runners need not be reminded about properly training for a marathon, yet every year we see hundreds of runner-related issues, and would you believe that 90% of these injuries are due to the increased volume in training in advance of the marathon?

      What we commonly find are overuse injuries arising from the microscopic strains and tears on soft tissue and bone. A classic overuse injury is the runner’s knee, often caused by too much pressure on the kneecap. As runners ramp up the distance or speed of their training runs, the tissue surrounding the kneecap undergoes a considerable amount of stress because of its central role in anchoring the large muscles of the quadriceps.

      Runner’s knee can be a road bump in a training regime, but that’s all it ever should be. Icing your knee and taking anti-inflammatory medicine should be enough to get you back to light exercise, but if the pain persists your orthopedist may recommend some form of physical therapy.

      But what about the 10% of runners whose injuries aren’t caused by overuse? Overuse injuries are often aches that go away after about 15 minutes into a jog. If, however, the pain increases throughout one’s run, then it is likely a more serious injury to the underlying tissue. These injuries can creep into one’s daily life. Climbing stairs is painful; sitting and standing becomes an achy chore. These injuries can range from torn ligaments or tendons to stress fractures and should be addressed by your orthopedist at once, especially before any more marathon training.

      That brings us to the question of whether you can continue to work out while experiencing one of the above symptoms. The answer ought to be self-explanatory, but if there is ever any doubt it’s best to take a break no matter what and do the proper stretching and icing regime.

      What about shoes? We’ve said it before, but the quality of one’s shoes plays an outsized role in keeping your legs in top shape because fresh shoes with the right fit go a long way in preventing overuse injuries.

      While training for a marathon, give yourself a minimum of four months in which to prepare, and try not to increase your mileage more than 10% per week. A few smart steps, both physically and mentally, can go a long way to having an injury-free New York City marathon.

      But even the best preparation can’t always prevent a few small aches here and there—Manhattan Orthopedic and Sports Medical Group wants to help you in the long run, whether it’s a marathon or a quick lap around the park, we’re here to make sure you keep running.

      And running.

      And running.

      Injuries of a Certain Age: Labrum Tears vs. Rotator Cuffs

      For those of us with a few gray hairs, it’s about now in the middle of the summer that all those pickup games from May and June are starting to show their wear. An ache in the knee or a pulled bicep; these are pretty normal for an older sportsman on the weekend pitch. As frustrating as these injuries are, the real rub is how your kids can go full speed all summer long without some nagging pain to remind them of their age.

      The tortoise did beat the hare, however, so a little insight into what type of injuries we get at different ages will hopefully lead to a longer and stronger summer season. The most important place to start is with conditioning. Gentle stretching goes along with any type of cardiovascular as a good base, but with games like softball or tennis, resting and icing your favored arm will help you recover faster and guard against the chance of future strains.

      Once you start to hit middle age, those strains become measurable. The effects of age on the body are such that older athletes tend to experience bursitis and rotator cuff injuries at a much higher rate than their younger counterparts. Comparatively, younger athletes are affected by injuries such as labrum tears and other such trauma; in other words, there’s usually no doubt about the injury.

      The good news is that as long as we stay fit at any age, we can usually sweat the small stuff out with some rest and ice. But as we get older, the small stuff should still be watched. Amazingly, it’s been found that 10% of patients 50 years and older have rotator tears—and most don’t’ even realize it. At 60 years old, that percentage goes up 20%. And at 70 years old, the percentage of people with rotator cuff injuries rises to an astounding 40%.

      When a pain persists, it’s always best to see your doctor. If it’s a rotator cuff injury, a quick cortisone shot will sometimes be prescribed for the short term, while some form of physical therapy can provide for a lasting recovery. And while it’s never good to be out of the game, the recovery from a rotator cuff strain or inflamed bursa takes about as long as the recovery of a labrum tear, which often requires MRI’s, therapy, and sometimes surgery. The recovery from a full rotator cuff tear that requires surgery will put you out of the whole season.

      Staying fit and watching those aches goes a long way to staying in the game, so know your limits. Lamenting the young for their youth is as old as the hills, but that doesn’t mean you can’t compete.