The main issue with young pitchers is that their bodies are not fully-grown, so the repetitive motion of pitching takes a toll on their undeveloped elbows and shoulder. In children, the growth plates of these joints are still open, and the surrounding muscles and ligaments are not fully built up for protection. For minors especially, injuries to these undeveloped joints can have lasting affects on function, so it is of paramount importance to follow the rules of prevention throughout the season.

The most basic form of prevention remains conditioning. Staying loose and warming up allows the muscles to stretch out and better absorb the repetitive stresses of pitching. Similarly, having the correct technique can greatly limit improper sprains and strains in a pitcher’s arm, so make sure your child is getting the necessary training he or she needs.

By far, however, the most common cause of injury in little league pitchers is pitching too much. Luckily, Little League Baseball has a set of rules for young pitchers that restrict how often they can pitch, and the types of pitches they can throw, according to their age. There are additional rules that define the required amount of rest between games, as well as assigning a mandatory downtime of 3 months for pitchers in any given year.

Following these rules cannot fully protect pitchers from injury, but they can help limit damage, and allow for a strong recovery. Baseball is meant to be fun, which includes the twists and turns of competition. But competition cannot come at the expense of a long-term injury, especially when it comes down to young pitchers pushed to the edge in the name of winning. Preventing injury now means that your child will be throwing fastballs for a long time—whether for fun or even professionally. All that’s required is some easy conditioning, the proper technique, and adequate rest throughout the season.

PLAY BALL!

Start by checking in with your doctor. Make sure he or she is aware of any nagging aches or pains. If you’ve had a lingering injury this past winter, now might be the time to take a couple of weeks off and monitor how it feels. Let your doctor know if it shows no improvement, or even better, come in and let one of our specialists check it out and come up with a plan to get you active.

The next step is to update your equipment, beginning with your sneakers. The first question we ask our patients is whether they have the right shoes. Worn down sneakers have an outsize effect on our joints and muscles, and many aches and pains simply disappear when our patients buy a pair of new shoes, no matter the season.

We have found that one of the easiest ways to ensure a proper pair of shoes year round is to write the date in them the day you buy them. That way there will be no doubt as to their age, and it’ll be an easy reminder for when you should get the next pair. As a rule, the average runner should get new shoes every 300 miles, so if you run about 10 miles a week it makes sense to get a new pair after about seven or eight months.

It may seem obvious, but it’s always smart to transition from long sleeves to short sleeves. As it warms up, dehydration becomes more of an issue, so even if you haven’t changed your routine, your hydration will be affected by these warm afternoons.

When you start back up after a winter lull, you’re bound to be a little sore. That’s what we call “good pain” from the normal breakdown and buildup of tissue as your muscles and tendons begin to renew. This discomfort usually resolves itself with further activity, but tell your doctor if the pain persists and make sure you note exactly what the issue is.

We all want to enjoy these wonderful spring days, so remember to start slow and steady as your ramp up your activities. Having a plan is the first step of preparation in this new year, and if you follow it while keeping your body relaxed and healthy, you can look forward to a long season of fun in the sun ahead.

Manhattan Orthopedic & Sports Medicine is proud to announce ROBOTIC ASSISTED PARTIAL KNEE REPLACEMENT (MAKOplasty®). Through the use of a Robotic Arm our surgeons now perform more precise partial knee replacements using a MINIMALLY INVASIVE technique. This cutting edge technology helps restore a patient’s more natural knee motion.

Unlike Total Knee Replacement, ROBOTIC ASSISTED PARTIAL KNEE REPLACEMENT (MAKOplasty®) is a resurfacing of the joint with much less bone being removed. Our surgeons use a smaller incision than required for traditional total knee replacement surgery. During the procedure, the diseased portion of the knee is resurfaced and an implant is then secured in the joint to allow the knee to move smoothly again.

Arthritis is the breakdown of cartilage in a joint allowing the bones to rub together. MAKOplasty® partial knee replacement is an innovative treatment option for adults living with early to mid-stage osteoarthritis in one compartment of the knee. As patients living with arthritis know, this is exciting news!

ROBOTIC ASSISTED PARTIAL KNEE REPLACEMENT is an outpatient procedure, therefore patients will have surgery in the morning and go home later in the afternoon.

Other patient benefits include:

• Minimal surgical incision.
• Reduced post-surgical pain.
• Accelerated recovery and improved outcomes.
• A more rapid return to daily lifestyle and activities.
• A more natural feeling knee following surgery

Since the earliest days of surgery, doctors have been working to hone the existing tools and techniques of the operating room in order to allow patients to heal faster and limit the discomfort inherent to such procedures. Now, as we move steadily into the 21st century, new technologies are allowing orthopedic surgeons to achieve a level of surgical precision that goes beyond what we have ever seen before. ROBOTIC ASSISTED PARTIAL KNEE REPLACEMENT gets our patients back to work and resuming their active lifestyles faster than ever.

And that’s something worth jumping for joy over—literally.

Today, a total hip replacement is one of the most successful orthopedic reconstructive procedures. 85- 90% continue to function well at 20 years, allowing most individuals to remain active for decades. So where then do the problems arise?

This becomes a story of distinction. The majority of hip implants used today are not the metal-on-metal variety, but rather metal-on-polyethylene (plastic) or ceramic on polyethylene. Metal-on-polyethylene implants are the most commonly used replacements, as well as the oldest. Surface wear and loosening is what causes failure after years of use. Doctors have spent years looking to reduce the amount of wear and instability in these devices. Ceramic on ceramic implants wore well, but a small percentage squeaked and recent use has decreased. Metal-on-metal implants were proposed as a way to introduce an implant that not only reduced the wear but more closely matched the size of the normal hip; allowing a greater range of motion. It soon became clear, however, there were a host of major issues associated with metal-on-metal implants: severe inflammatory responses, the detection of metal ions in the blood stream, and a greater rate of wear and loosening, which can lead to the formation of cysts around the prostheses.

The New York Times and others have spotlighted the toll that the widespread use of metal-on-metal hip implants has had on individuals, physicians, and yes, even insurers. They point out the need for unforgiving precision when inserting these prostheses. Metal-on-metal implants may still be required but care must be taken in order to minimize the chance of complications.

To recap, there is great concern about metal-on-metal prostheses, and they should not be used unless it is necessary, and even then, only by the most accomplished hip surgeons. That is not to say that anyone currently with a metal-on-metal prostheses should replace it with polyethylene or ceramic, but rather, anyone with a hip replacement should be evaluated if there is increased pain, grinding and any changes in how the hip feels.

BE AWARE AND INFORMED. If you’re a patient of Manhattan Orthopedic and Sports Medicine Group, you can be confident knowing that we have never used metal-on-metal implants and only use the most proven tools and techniques for all of our procedures.

When a bone breaks, the broken ends may stay in contact with each other or may move considerably. If there is bony contact after a break, we call this a non-displaced fracture.  As long as the alignment of the bone and the stability of the joint are preserved, these types of fractures can often be treated without an operation. Alternatively, if there is major shifting of bones, loss of alignment, and instability at the joint after a fracture, we term this a displaced fracture. Displaced fractures will not heal on their own and will often require surgery as a result.

Lastly, there is the stress fracture. Stress fractures result from continual, repeated loading of bone. These types of fractures occur almost exclusively in the bones of the legs and feet. Stress fractures were first recognized in new recruits to the army, who were forced to complete long marches in training. Today, we often diagnose stress fractures in distance runners.

Non-displaced and displaced fractures are often the result of a specific injury and there’s little we can do to prevent the fluke stumbles and slips that cause them. Stress fractures, however, are a little more particular as to who is affected and why. Individuals who suffer from anorexia have a higher incidence of stress fractures due to a lack of necessary nutrients for proper bone strength. Sometimes, however, it is the healthiest and hardiest of us who succumb to stress fractures as we push ourselves beyond our limits while training for our first marathon or entering the new season after a few months off.

The good news is that stress fractures can be avoided by staying healthy and smart. That means knowing your limits when it comes to repetitive exercises like jogging, and eating right. As always, speak to your primary care physician about any questions or concerns you may have, and find out if there are any risk factors that could increase your risk of a stress fracture. Exercise should keep you healthy, not harm you, so don’t let a stress fracture get in your way of staying active and well.

Let’s start with the quotidian. Nor’easters can come out of nowhere, and no matter how much canned soup you’ve stocked up, the deluge often means a ton of shoveling on short notice. That means doctors’ offices are soon filled with sufferers of pulled back muscles and slipped discs. The problem is that many people slow down their activities during the winter months, so a normal chore quickly becomes a painful lesson in the benefits of daily stretching and regular exercise.

Stretching, as always, is one of the most important activities you can do to prevent common back injuries from snow shoveling and the like. There are a number of great back stretches out there, but if you require some assistance or if you have a history of back issues, you should definitely speak to a physical therapist or personal trainer for some tips and techniques. Try adding a few exercises that isolate your core muscles so they’re fortified against the additional strains of winter chores.

Winter chores are just one way that the seasonal weather can wreak havoc on our fitness. Slipping on ice may seem cartoonish, but as anyone who’s spent a cold December night in the emergency room can attest, a broken wrist or fractured tailbone is an easy way to lose that holiday cheer.

Preventing such an injury is usually only evident through hindsight, so it’s important to remember that if you’ve hurt yourself by falling you should immediately see an orthopedic surgeon for a thorough assessment of your injury. Thinking your injury will heal itself can lead to further injury or worse, so don’t take any chances and schedule a consultation as soon as possible. As beautiful as winter can be, it has a knack for laying us out, so be careful and remember to stay active and be aware of these common winter injuries in the coming months.

It seems obvious, but simple endurance exercises are important to staying safe this winter. Did you know that most skiing and snowboarding injuries occur after lunch because we’re tired? Any good cardio exercise will keep your legs from turning into jelly and reduce the risk of falling. Conditioning your hamstrings and quadriceps is a good place to start, so if you haven’t focused on your lower body as much this summer, you should try to incorporate lower extremity strengthening exercises into your weekly workouts.

Before you’re on the mountain, it’s important to know that skiers and snowboarders are prone to different types of injuries. Wrist injuries are more common in snowboarders, while skiers are more prone to knee injuries, especially their ACL’s and collateral ligaments. Skiers’ poles also make them vulnerable to the dreaded “skiers thumb,” a type of injury to the interior ligament of the thumb that can quickly put an end to any more skiing for the season.

Consider this startling fact: Beginners make up more than half of all injuries in any given year, something to keep in mind when you find out your kids want to take up snowboarding for the first time this year. The most effective guard against injuring your wrist while snowboarding is a wrist guard. The problem used to be that snowboarding safety equipment was about as comfortable as being wrapped in Styrofoam. But today there’s an entire industry based around gloves with protective guards built into the lining, lightweight helmets that are comfortable and aerodynamic, and goggles that don’t get completely fogged by the first run.

Wrist guards have been shown to reduce the risk of hand, wrist and forearm injuries by 85%. The physicians here at Manhattan Orthopedics, rarely, if ever, come across a patient who has fractured their wrist while wearing a wrist guard. In fact, the most common response we hear is usually, “I should have worn a wrist guard!”

Skiing and Snowboarding can be fun, but it’s easy to forget how physically demanding each of these sports are as well. Preparing yourself over the coming weeks will ensure that you have a safe and fulfilling season of winter activities ahead of you.

Question: How will patients get the best care when they need the help of several specialists?

Answer: By creating communities where healthcare professionals from different concentrations can collaborate.

On the surface, repairing an injury like a torn rotator tendon seems straightforward: the patient has arthroscopic surgery and soon is back to playing tennis. But in truth, the journey from diagnosis to recovery may involve more disciplines than just your primary physician.

Let’s call this patient John. Initially, he will see his primary doctor for diagnosis and surgical repair. After recovering from surgery, John will require the expertise of a physical therapist for several months to regain use of the shoulder and reduce any pain. The transition from physician to physical therapist is critical to the success of treatment, but once therapy is complete,

John may require the ongoing care provided by Pilates instructors massage therapists, athletic trainers, and acupuncturists. But how will he know what’s best?

Start Talking

Historically, there has been limited communication or coordination of care amongst these groups; healthcare professionals have existed in separate silos, each specialty with its own experiences, culture and scientific literature. Patients require the skill and care of multiple disciplines to get well, but in addition, those professionals need to agree on one course of treatment. Success requires a continuity of care and collaboration, and that requires communication. Physicians and therapists need to be on the same page. A physical therapist needs to understand the principles of fixing a rotator tendon and how these may impact what they can do with the patient in their clinic. Likewise, the surgeon needs to understand what the therapist is able to do and how it may benefit their patient, as well as which therapy treatments should be implemented for each specific case.

The Prognosis

Caring for a patient is a team effort. Through the creation of cross discipline communities, healthcare professionals from several specialties learn from each other and collaborate on research, education and treatments. By encouraging PTs to spend time in MD offices and operating rooms, and encouraging MDs to learn more about alternate treatments, professionals will understand, and begin to develop, the best possible treatment for every patient.

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Our minds need time off from physical activity as much as our bodies, so let the change in seasons be your cue to ease up and focus on simple, easy exercises and stretches. A month of rest can help remedy a number of built up aches and pains, so use this time to rejuvenate your spirit, when sunlight is at a premium and the weather may force us indoors.

Transitioning to indoor workout routines in the fall and winter shifts the focus on a different set of muscles and tendons, so make sure your body is ready for the slight changes that can have a big effect on musculoskeletal health. As always, consult your doctor for professional advice on any nagging injuries from your adventures this summer.

Getting a fresh start for each season means fresh equipment, and new shorts and shirts go a long way in prepping for a new workout routine. Additionally, the crisp treads of new sneakers can help limit the danger of slipping on wet fallen leaves or unseen ice slicks, further protecting you from injury. Winter’s early sunsets make for dark afternoon jogs, so consider investing in a lightweight reflective vest and check your bicycle lights for brightness. No matter your age or experience, getting the most out of your workouts in the coming months means preparing against factors outside of your control.

The best thing anyone can do at this point, however, is take up to a month-long break and start looking towards your accomplishments from this summer with an eye towards the next.

Keeping your knees healthy begins with maintaining motion and strength through regular exercise. The catch-22, however, is that the more we exercise, the more wear and tear builds up, leading to arthritis.

Stiffness and soreness begin to show up in the knees just about the time your children begin to outplay you on the tennis court. But take heart! This is an opportunity to a) congratulate your children on their fine achievement, and b) talk to your orthopedist about maintaining knee health for the long-term.  In fact, building a relationship with your orthopedist can slow the arthritic process and delay the need for surgery.   Seek professional attention and care.

Physical therapy and sensible amounts of anti-inflammatory medicine are the start of any regimen to ensure strong knees through continued sports and exercise. Your orthopedist may recommend occasional injections of steroids to  decrease inflammation and maintain movement. The arsenal to protect your knees also includes lubrication injections, non-invasive arthroscopic surgery, or partial knee replacement, leaving total knee replacement as the last resort for repairing damaged knees.

Seeing your orthopedist regularly can keep you one step ahead of meniscal tears, ligament damage and the development of arthritis. The vast majority of individuals who undergo knee surgery return to most sports other than running, but who needs running when you’ve got tennis, golf, skiing or even badminton?

Any long-term regimen for maintaining healthy knees requires an awareness of boundaries. Don’t push yourself too hard.  Know that your active lifestyle has only just begun.

As Tennyson so resolutely stated: “to strive, to seek, to find, and not to yield,” so too should we approach our active lifestyles—and most surely the health of our knees.

Advice is one thing, but results speak for themselves. Manhattan Orthopedic understands that any long-term plan to keep your knees healthy must be personalized and comprehensive. We not only guide you through the available medical options, we also administer and supervise the process to make sure that you receive the best care possible.

One of the modes of failure has been wear of the articular or moving surfaces, namely the ball within the cup.  The original implants used in the United States consisted of a metal ball articulating within a high density polyethylene (plastic) socket.  With time the plastic tends to wear and needs replacement.  This usually occurs within 15 – 25 years.  The newer highly cross-linked polyethylene may last longer.

There have been attempts to use surfaces that are more durable, namely ceramic on ceramic, or metal on metal.  Ceramic seemed ideal, but for some still undiscovered reason about 10% of the hips produce a loud squeak and their use has decreased.

Metal on metal replacements have been around for many years and there has always been some concern about high levels of cobalt and chromium ions in the blood.  Studies for this condition have not demonstrated any long term problems.  The use of metal on metal increased as surface replacement, rather than total replacement became more popular in the younger (? Under 65) population.

Now a new problem has presented.  Particles of cobalt and chromium in the tissues around the hip have caused an inflammatory response that loosens the prosthesis and causes very early failure.  A revision is required and is never as successful as the primary procedure.  Therefore, surgeons must be very cautious in using metal on metal prosthesis and must not be in a rush to operate on younger and younger patients.

We must never forget the old adage, “Be not the first to try the new or the last to give up the old”

Marvin S. Gilbert, M.D.
Clinical Professor of Orthopedic Surgery
Mount Sinai School of Medicine

The two most common shoulder injuries for tennis players are tendinitis and bursitis. Bursitis affects the tiny fluid-filled bursa that provides a cushion between the bones and tendons around a joint. Tendinitis is a result of inflammation and damage to the tendons.

If you feel the wear of your stroke in your shoulder, then start by asking a tennis pro to evaluate your form and equipment so that you have the right grip and a proper racket. Similarly, never play with dead balls, which can needlessly tax the mechanics of your arm. And while it’s not ideal, replacing your overhead shots with ground strokes can greatly alleviate the strain on your shoulder. Your serve may have to take a backseat for a few games, but altering your technique in this way can greatly divert the strains on your shoulder that are the root cause of inflammation.

And what about in the gym—how often do you focus on building strength and endurance in your shoulder’s rotator cuff or scapula muscles? Because these tissues are involved in many overuse injuries, a physical therapist or personal trainer should be able to suggest some workouts that strengthen this muscle region that is often an afterthought of most workout routines.

The rest is quite easy: stay hydrated, remember to ice your shoulder when done playing, and, if your physician recommends it, take an anti-inflammatory medication to help relieve discomfort. These tips may seem straightforward, but the simplest preventative steps are sometimes the easiest to overlook, no matter your age or skill set.

Off the court, try not to sleep on the shoulder that’s bothering you. You might want to even consider taking a break for a few weeks—overuse injuries can oftentimes heal with rest, allowing the inflammation to go down while the tissue heals. If the pain persists, consult an orthopedic surgeon about further options.

There are a number of ways to get the best out of your tennis game, but prevention and knowing your limits will keep you swinging for plenty of hot summers to come.

The physiological factors most responsible for our bodies deterioration are: decreased blood supply to cells (example: high blood pressure), higher blood sugar levels (example: diabetes), and cumulative free radical damage (example: cell damage due to smoking). The amazing fact is that exercise affects all of these factors in a positive way.  It increases blood supply to all body parts by strengthening the heart to pump blood more effectively. As you build muscle, your body creates more blood vessels to carry nourishment to your cells. Muscles also store glucose more effectively with exercise, which reduces your body’s reliance on insulin so you’re better able to control your blood sugar levels. Regular workouts also activate enzymes that help reduce or block cancer-causing free radicals.

More specifically, the benefits of exercise to your health include:

INCREASED LONGEVITY
Several large-scale studies have directly linked physical activity to increased longevity. In 1989, the Journal of American Medical Association (JAMA) published the results of a study conducted at the Institute for Aerobics Research and the Cooper Clinic. Researchers there found that simply walking a half hour a day reduced death rates from both heart disease and cancer. The Harvard Alumni Health study, published in JAMA in 1995, supported these findings and also revealed that the benefits of exercise are cumulative throughout the day. In other words, you can do two or three 15-minute bouts if you don’t have time to do one 30- to 45-minute session and still reap similar benefits. The pedestrian lifestyle of New Yorkers benefits us also, as the New York Public Health statistics featured in the August, 2007 New York magazine cover article, featured: New Yorkers now live longer than other Americans, attributed to their frequent walking, stair climbing, and independence from automobiles.

IMPROVED HEART FUNCTION
Exercise makes muscles stronger. The heart is a muscle, so it makes sense that working out strengthens the heart. It stimulates the heart to contract more efficiently with stronger force and at a lower rate. The exercised heart develops a better blood supply, very protective in the instance of a heart attack due to blocked arteries, because blood can be redirected to the heart through other avenues. Exercise has been associated with a 40 percent reduction in heart attacks in women and a 60 percent reduction in men. Those who do not exercise are three times more likely to die of a heart attack.

IMPROVED CHOLESTEROL LEVELS
A concerning measure for risk of heart disease and stroke is cholesterol levels. Cholesterol is measured as HDL (high density lipoprotein; the only measure that is favorable if higher) total cholesterol, LDL (low density lipoprotein) and triglycerides; these three measures are favorable the lower they are. Exercise has been found to improve all cholesterol levels and also change the size of the cholesterol particles in the blood to make them less adherent to blood vessel walls and less likely to cause artery-blocking clots.

LOWERED BLOOD PRESSURE
This is a well-known fact. There are many patients who are able to manage their blood pressure with exercise and avoid medications entirely. Lower blood pressure results in better blood flow to organs, helping them to function more efficiently throughout your lifetime.

REDUCED RISK OF STROKE
Most preventable strokes, similar to heart attacks, are caused by a blockage of the blood supply to the brain due to a clot or cholesterol plaques. The positive effects of exercise cumulatively lower risk of stroke significantly: 30 minutes of brisk walking five days a week lowers risk of stroke by 24 per cent; 60 minute walks lower the risk 46 per cent.

IMPROVED LUNG EFFICIENCY
Exercise increases the number of blood vessels supplying the lungs, so they get better at absorbing oxygen and clearing carbon dioxide from the body. Lung volume (size) and air flow rate (expandability) increase with training as the lungs respond to the muscles’ demand for oxygen.

REDUCED INCIDENCE OF DIABETES
Diabetes, the disease of either insensitivity to insulin, or underproduction of insulin, leads to high circulating blood glucose. This increases the risk for virtually every disease, and is known to decrease lifespan. Exercise makes cells more sensitive to insulin, which can make it easier to control blood sugar. In the case of Type II diabetes, exercise can help patients manage the disease without medications and is known to prevent diabetes in susceptible patients.

REDUCED SYMPTOMS OF DEPRESSION
In addition to enhancing the effectiveness of antidepressant medication and therapy, exercise also lowers anxiety, decreases irritability and stress, and reduces levels of anger, self-doubt and hopelessness. Exercisers also experience increased confidence and motivation, are better able to cope with daily problems, and benefit from the social interaction that physical activity often involves.

CANCER PREVENTION
Studies have found that people who exercise regularly have a lower risk of developing colon, lung, breast, ovarian and uterine cancer, and melanoma. Regular exercise also decreases the risk of dying from prostate cancer in men over age of 65. A study published in JAMA in 2003 found that five brisk, 30-minute walks a week reduced the risk of breast cancer by 20 percent. And while this isn’t an excuse to start or continue smoking, smokers who lead an athletic lifestyle have a 28 percent reduced risk of developing lung cancer.

IMPROVED STRESS MANAGEMENT
Regular exercise decreases the amount of cortisol, a hormone released when your body or mind are stressed, while releasing endorphins, the feel-good hormone. It provides a break in the day that allows you to focus on yourself and dispel any negative energy that accumulates during your day.

PREVENTS MUSCLE LOSS
The only way to build and maintain muscle is to challenge muscle by exercising it through strength training or repetition and exertion. An unused muscle deteriorates in size, strength and reaction time. Exercise results in bigger muscle bulk and prevents the predicted muscle loss otherwise associated with aging.

IMPROVED JOINT MOBILITY
Joints are lined by cartilage bathed in fluid to keep them moving smoothly. Exercise maintains joint function by stimulating the synovium, or joint lining, to continue producing fluid. Ligaments and tendons, which help move your joints and muscles, also become stiff and weak when they’re not adequately used.

LESS BACK PAIN
The spine is supported by muscles and ligaments that are designed to protect the spinal cord and surrounding skeletal framework from damage every time you move. Exercise helps strengthen these muscles and ligaments and make them better able to respond protectively during unexpected movements.

LESS FATIGUE
Anyone who’s gone to a workout after a long day at the office can tell you how quickly they felt revived and energized. Exercise increases blood and oxygen flow to your brain and muscles, and boosts your body temperature, which perks you up.

WEIGHT MANAGEMENT
Exercise boosts resting metabolism, allowing you to burn more calories and store less fat.

ENHANCED MEMORY PRESERVATION
Exercise stimulates and even leads to the development of new brain cells, improving both long and short-term memory.

IMPROVED QUALITY OF SLEEP
Sleep experts agree that the more active you are during the day, the better your quality of rest and the easier it is to fall asleep.

IMPROVED SEX LIFE
Being fit increases flexibility, strength and endurance along with improved body confidence and awareness; all these factors are directly related to sexual enjoyment and fulfillment.

IMPROVED IMMUNITY
Exercise has been proven to trigger immune factors that fight viruses and infections, repair and heal cells, and oppose inflammation and destruction.

OSTEOPOROSIS PREVENTION
Osteoporosis, the disease in which your bones become brittle and more likely to fracture, is a concern for all post-menopausal women. Exercisers have significantly lower rates of osteoporosis.

FALL (AND HOSPITALIZATION)PREVENTION
People who are active are naturally more balanced and less likely to fall on their wrist, hip, or head. This reduces risk of fractures, hospitalization and surgery.

HEALTHIER PREGNANCY
Exercise prevents back pain, manages weight gain, relieves stress, and protects the fetus as the body becomes more adapt at responding to physical stress.

Finally, in addition to exercise, other health-promoting activities, such as following a healthy diet, quitting smoking, getting regular checkups, and nurturing positive interpersonal relationships has been shown to increase longevity. It’s similar to how an athlete’s body adapts to a sport and how a healthy mind quickly learns new tasks. If you train your body to function like a younger person’s through exercise, social activity, mental challenges, and a healthy diet, it will adapt and reward you by performing well for years to come.

Hip injuries, then, can slow us down to the point of frustration. Let’s go through a quick rundown of common hip injuries in order to understand and demystify some of the strains and sprains before they turn into chronic conditions.

To start, the most common hip problem is Hip Bursitis. Its technical name is trochanteric bursitis, and it refers to an injury at the bursa located on the outside, or lateral, region of the hip. Bursae are small packets of fluid that allow for the smooth movement of muscles on tendons and are present in all of our major joints. Hip Bursitis can be caused by overuse or trauma and is indicated by pain on the outside of the hip.

If we move from the outside to the rear of the hip, we encounter an injury sometimes referred to as Runner’s Hip. Runner’s Hip is another term for gluteus medius tendonitis. The gluteus medius sits close to the hip, a location that makes it comparable to the hip’s version of a rotator cuff. This muscle acts as a stabilizer for the hip and pelvis when we stand, walk, or run, thus its tendency to bother joggers.

Next, the hip’s inside, or medial region is the site of what is sometimes termed Dancer’s Hip. The technical term for this injury is the tongue twisting iliopsoas tendonitis, and in addition to pain, is associated by a light snapping or clicking sensation. Again, rest and awareness can help this strain to heal.

Finally, there is hip arthritis. A grinding hip pain that runs towards the groin can sometimes be caused by hip arthritis. This condition is common in middle age and older individuals, and results from degeneration and inflammation of the joints.

The bright side is that most sprains and strains of the hip will improve with a simple, time-tested regimen. This regimen is commonly referred to as RICE and stands for: Rest-Ice-Compression-Elevation. An even more effective (and accurate) acronym for the hip might be RICA, where the final “A” stands for anti-inflammatory medicine such as ibuprofen.

Now that we understand the anatomy of the hip, it’s easier to see how important it can be to thoroughly stretch and exercise to protect these muscles and tendons from injury. If you’ve been slowed down by troubling hip pain, and feel that you need an evaluation, do not hesitate to see one of our hip specialists today.

Acute trauma that causes a muscle to tear can occur during activities like sprinting. That is not always the inciting agent. For those of you who like to do repetitive activities like running, overuse strains of the hamstrings also occur. Repetitive loading to a muscle can over time cause tissue to fail and cause the feeling of muscle tightness, pain and disability even with activities like sitting in the chair. Some people even think that it might feel like so called sciatic pain because it can radiate down the leg.

Most tears occur at the weak link of the muscle attachment site often referred to the musculo-tendinous junction. This is the transition spot where very rubbery muscle tissue becomes the stronger tendon tissue that attaches to the bone. Here the tissue can be torn/stretched or what we called strained. Tears do occur in the muscle itself as well as at the tendon attachment site to the bone. For the most part all hamstring injuries are treated the same. Only in the event of a large complete tear of the tendon off the bone do we consider performing surgery.

The acute care of these injuries follow the same basic principle of any acute injury. First, recognize there is a problem. Easy for the guy who blows it out on the football field; Much more difficult for the individual who is a runner who feels a twinge in the back of the thigh and thinks they can run through it. Those are the tough ones because if we don’t catch those in the butt, no pun intended, they will become a source of continued disability.

RICE is the acronym that describes initial management of these injuries. Rest or avoidance of activity implies that we take away the offending agent to allow our body to begin the process of healing. Those can be very variable depending on the extent of injury. Some individuals can’t walk and need to rest. Sometimes ambulatory assistance with crutches until normal activities can be resumed may be helpful. Some on the other hand, might feel that another activity like riding a stationary bike or using a rowing machine might be totally fine and cause no discomfort. In those cases I recommend that as long as there is no pain or discomfort with the activity or an exacerbation of discomfort after the activity that it is ok to do and can be of some assistance during the healing phase. Be careful with that suggestion. Go slow and do not push the envelope.

Ice is an invaluable tool in the early phases of healing. When muscle tissue is torn or strained, even at the microscopic level, bleeding occurs. Ice causes vasoconstriction or a shutting off of the blood vessels which helps reduce the amount of bleeding and subsequent swelling. The first 36-72 hours is critical for using ice. There is no statistical evidence that using a treatment plan of alternating heat and cold during this period is better. I will say that after the first 72 hours that ice helps reduce pain and heat helps loosen the thigh.

During the next phase of rehabilitation, restoration of Range of Motion (ROM) becomes essential. Hamstrings become tight which leads to lower back stiffness and calf tightness. Gentle stretching can be started as you start to feel better, walking seems easier and possibly you can spin easy on a bike. Easy stretches such as a standing hamstring stretch, hurdler’s stretch, single knee to chest, and runner’s calf stretches can be done. Overstretching your hamstring can reignite the fire and cause more pain. I actually prefer to do only minimal stretching, as with my own hamstring, it would often make it feel worse. If you are going to stretch only a gentle pull should be felt and the stretch should be help for a minimum of 15 to 20 seconds. If you have a large shower, take a nice warm one and do the stretching in there. Guaranteed to make you feel good. A thigh sleeve like a knee sleeve can be worn to ease discomfort and keep it warm.

Although no scientific evidence to support it, my feeling is that strength training is potentially the most important step in rehabilitation. Like stretching there should be minimal discomfort while you are doing these exercises. The concept of “no pain no gain” is not acceptable in a rehabilitation program. Isometric exercises, those that are performed with little or no joint motion can be performed with minimal risk if reinjury. As you feel better more aggressive strength training can be added. Squats and lunges can be performed as they involve multi-joint motion, which help the return of functional strength. Core strengthening which is the buzzword of the new generation of health professionals is now being seen as the missing link to injury prevention. Our ability to maintain a stable spine while our lower body and upper body move, which requires an intricate coordination of muscle actions, is a significant factor in injury prevention. There are also many studies that show that plyometric exercises, high intensity jumping, can be an effective means to rehabilitate from these injuries. Great care must be taken when doing these exercises. Consult with a health or fitness professional to guide you with these exercises.

Return to sports can sometimes take as much as 6-8 weeks of persistent attention to rehabilitation. Sitting on the couch will not make you better. Take the time to get better. Your hamstring will thank you and be stronger for it. Good luck!

The good news is that protecting your back doesn’t require an extensive knowledge of yoga or Pilates. Prevention takes strong core muscles and simple back stretches that incorporate more than just bending and twisting.

The abs, pelvis, and leg muscles depend on the back for support; but our backs depend on these muscles in just the same way. Exercising your core is a great way to strengthen this support network to prevent future back injuries. If you’ve been noticing any extra strains or soreness in your back, stretch frequently, but think also about aligning your workout to focus a bit more on your core.

A strong core, however, can’t always prevent an injury due to spring-cleaning. How often do we stretch before cleaning the garage (hint: never is not enough)? Regular stretching can contribute to prevention, but backstretches are not limited to the obvious bending and twisting. Our hamstrings play an important role in supporting the back; therefore, think of it as a back muscle in its own right. An even better idea? Try to incorporate your hamstrings into your normal back stretch routine.

The interconnected network of our back and leg muscles also shows itself in a range of back injuries. 90-95% of all “thrown” backs are stresses and strains that will heal with rest and stretches. Occasionally, individuals with back injuries will feel numbness or a sharp pain radiating down their leg. Often, this is a sign of a pinched nerve that may require more attention.  As with any injury—and especially with injuries to the back—be sure to see a physician or physical therapist if symptoms persist.

Back injuries can seem to come out of nowhere, but by treating your back like any other muscle and making sure it gets the stretches and exercises it needs you won’t be the one hobbling around the coffee machine on a Monday morning.

Tennis elbow is the result of micro-tears to the tendon that originates from the bony prominence on the outside of the elbow, known as the lateral epicondyle.  Tennis elbow, or lateral epicondylitis, affects 1% to 3% of the population as a whole, but gets its name from the fact that it affects almost half of all tennis players at some point in time.

Golfer’s elbow is similar, but its discomfort is due to microtears affecting the tendon located at the inside of the elbow. Golfer’s elbow, also known as medial epicondylitis, affects mostly golfers, but weight lifting, gardening, or other activities that strain this part of the elbow can cause this condition in non-golfers alike.

As always, the best form of treatment is prevention. Whether you feel the onset of soreness or simply want to maintain a pain-free routine, these three short tips are focused on preventing both conditions from slowing you down, and keeping you in the swing of things, literally.

1) First and foremost, proper conditioning, through a regimen particular to the forearm, is necessary to keep your forearm muscles limber, strengthened and stretched. It is these muscles that absorb most of the strain when you swing the racket or club. Additionally, working on your core muscles allows for your body to absorb extra shock from the repetitive movements of these sports.

Take some practice swings before you start a game. If you haven’t played in a while, make sure that you start slowly before trying to burn a hole through your opponent’s racket, or blasting that golf ball over 300 yards.

2) The right equipment will significantly reduce the strain on your tendons and muscles. For tennis, be sure to take your racket in to be restrung if its been sitting in the closet all winter, and talk to a pro about the right measurements. If the racket’s grip is too big or too small or if it is too heavy or too light, the extra force required of your forearm leads to increased strain in those muscles. Similarly, if the strings are loose or improperly tensioned, then these small amounts of force can quickly add up and cause additional stress and strain.

Before going out on the golf course, talk to a professional about what works best for your physique and skill level. The proper length of the club helps keep a smooth swing and reduces muscle strain, while the correct weight limits the power required for a good shot.

3) Finally, have a professional assess your technique to ensure that you’re not placing undue stress at any point in your game. In tennis, most of the strain for tennis elbow occurs from the backhand; by following the proper movements, it is possible to spread out the force evenly, while sparing your elbow’s outer tendon. Similarly, while golfing, you may have the proper equipment, but that doesn’t always mean that your grip is correct, or that your stance is conducive to pain-free movements. If you haven’t played throughout the winter, have a pro take a quick look to make sure that you’re executing the proper movements.

Then go out there and have some pain-free fun! But if you still have an ache, please see our list of services to learn how we can help. Our expertise ranges from sports medicine, arthroscopic and minimally invasive surgery to physical medicine and rehabilitation among others.

Are you confused about whether or not to snack during your busy day? Have you tried to eat “3 square” (meals) and no snacks in order to drop a few unwanted pounds, only to find you are ravenous come dinnertime and eat more than you had planned? Are you looking for fun, easy, snack ideas you can take with you on the go? If so, you are certainly not alone.

Healthy snacking can really be the key to keeping your energy level even throughout the day, having enough energy to complete your workouts, prepare a healthy dinner and stick to your healthy eating/healthy lifestyle resolve…as long as you know HOW to snack!

Below are 10 of my most popular (and easy) snack ideas. Try 1-2 snacks daily between meals over the next two weeks and see if you notice a more even energy throughout your day, less nighttime eating, and maybe even a dip on the scale.

Lauren’s Healthy Snacks

1. 8oz (1 cup) low-fat or non-fat yogurt with 1 tsp of all fruit jam and 2 Tbs nuts
2. 1 frozen, cooked whole grain waffle with ½ cup of fruit and powdered sugar
3. 1 cup low-fat milk and ½ cup sliced fruit, 4 oz juice blended into a shake
4. 1 cup unsweetened cereal and ½ cup non-fat or low-fat milk
5. 3 graham cracker squares with 1 Tbs natural peanut butter
6. 3-5 cups air popped popcorn with cinnamon an nutmeg on top
7. 1/2 sandwich ( 1 slice whole grain bread, 2 tsp natural peanut butter, 1 tsp jelly)
8. 1 cup tomato or vegetable soup
9. ½ whole wheat English muffin with 1 oz low-fat cheese and ¼ cup tomato sauce
10. 5-8 whole grain crackers and 2 Tbs of low-fat cottage cheese & 1 tsp jam

Give yourself permission to snack daily and remember to make your snacks fun and enjoyable. If you can make your new healthy eating habits fun, then chances are you will stick with them for years to come!

For more healthy and realistic nutrition tips, or to find out more about scheduling a nutrition evaluation for yourself, please visit www.nutritionenergy.com or contact Lauren Antonucci, MS, RD, CSSD, CDE, CDN directly by email at lauren@Nutritionenergy.com or at (646) 361-6803. Insurance accepted at Nutrition Energy.

By Lauren Antonucci, MS, RD, CSSD, CDE, CDN
Registered Dietitian, Board Certified Specialist in Sports Dietetics
Marathoner, Ironman triathlete and Founding Director of Nutrition Energy, NYC

Just think about the varied terrain and urban obstacles of jogging outdoors versus the treadmill’s regularity; now apply that same comparison to every gym exercise and the variables of its outdoor equivalent, from biking in the park to soccer on the grass.

The following are three important steps you should take to ensure that getting back into shape leaves you free from injury while offering the most beneficial takeaway of getting back into shape for spring.

1. To start, take a moment to set a goal. Setting a goal helps propel yourself towards a specific aim, a simple enough idea which cannot be understated in its power to focus yourself on a reasonable achievement.
2. Renew one of your new year’s resolutions or challenge yourself to meet or beat a pace that you haven’t quite kept up with over the past few years.
3. More importantly, set up a log book to keep track of your times and achievements. Having a physical record of where you started with a means to your ends is paramount to meeting your goal.

Speaking of physical reminders, the change in season is the perfect opportunity to change your sneakers! Most dedicated running stores offer in-depth analyses of your feet and gait to make sure that you get the proper equipment. Think about marking your shoes with the date of purchase so you can keep tabs on when you got them so that you don’t keep using them after their time is up.

You should also set up an appointment with your physician to go over all the requisites, making sure to get the OK for the goals you’ve set for yourself before the start of new routines.

Again, the simple act of updating your equipment and evaluating your physiology are powerful motivators for getting back in shape and keeping you injury free.

Finally, it is important that you start out easy. In the early stages of getting back into shape, you want to feel energized rather than worn out. Too many people start a new exercise and quickly become demotivated by the stiffness and pain associated with Delayed Onset Muscle Soreness (DOMS), a condition in which the damage done to your muscles is felt 24 to 72 hours after the exercise. Your body will be adapting to new stresses, and the healing of microscopic tears to your muscles, ligaments and tendons should be treated with proper rest and gradual escalation of your activities. It can take anywhere from six to twelve weeks for adaptation to your new exercises, a period of time in which your mitochondrial aerobic engine will ramp up in reaction to your body’s new routine, a change which takes time but allows for an overall increase in the effectiveness and well-being provided by your activities.

Following these recommendations for getting back into shape or transitioning from the gym to outdoors will allow for a safe and satisfying spring filled with new challenges. Prevention is key to keeping you healthy and happy while enjoying the new season, and that’s definitely worth following such simple advice.

“Skier’s thumb” represents an injury to the ulnar collateral ligament of the metacarpophalangeal (MCP) joint of the thumb. As the eponym implies, it can be secondary to a fall while skiing, when the thumb is forcibly radial deviated when the hand is caught in a ski pole. These injuries can also occur secondary to any injury, such as a fall, which stresses the ulnar collateral ligament of the thumb MCP joint.

Diagnosis

These injuries can usually be diagnosed on physical exam alone. Patients present with pain and swelling along the ulnar aspect of the MCP joint of the thumb. The MCP joint should be manually stressed, to determine if the injury has resulted in instability, usually necessitating surgery.

Radiographs should be evaluated in all patients, to rule-out an associated ligamentous avulsion fracture. Stress radiographs may be helpful in determining potential instability. If there is any question as to the diagnosis, or to the extent of the ligamentous injury, an MRI should be obtained.

Treatment

If the ligamentous injury is found to be stable on stress testing, it can be treated with either a removable thumb spica splint or cast for approximately four weeks. Unstable injuries, or those with displaced avulsion fractures, usually require surgical repair. This is most often performed by reattaching the ruptured ligament employing a suture anchor. The thumb is then immobilized for approximately four weeks postoperatively. If the injury is diagnosed late, after about three to four weeks, the ligament usually requires reconstruction with a tendon graft.

Prevention

The incidence of these injuries can be decreased by newer ski pole designs, and proper technique and wrist/hand guards.

Because there are several potential causes, it is important to have heel pain properly diagnosed. A foot and ankle surgeon is able to distinguish between all the possibilities and determine the underlying source of your heel pain.

What Is Plantar Fasciitis?
Plantar fasciitis is an inflammation of the band of tissue (the plantar fascia) that extends from the heel to the toes. In this condition, the fascia first becomes irritated and then inflamed, resulting in heel pain.

Causes
The most common cause of plantar fasciitis relates to faulty structure of the foot. For example, people who have problems with their arches, either overly flat feet or high-arched feet, are more prone to developing plantar fasciitis.

Wearing non-supportive footwear on hard, flat surfaces puts abnormal strain on the plantar fascia and can also lead to plantar fasciitis. This is particularly evident when one’s job requires long hours on the feet. Obesity may also contribute to plantar fasciitis.

Symptoms
The symptoms of plantar fasciitis are:

• Pain on the bottom of the heel
• Pain that is usually worse upon arising
• Pain that increases over a period of months

People with plantar fasciitis often describe the pain as worse when they get up in the morning or after they’ve been sitting for long periods of time. After a few minutes of walking the pain decreases, because walking stretches the fascia. For some people the pain subsides but returns after spending long periods of time on their feet.

Diagnosis
To arrive at a diagnosis, the foot and ankle surgeon will obtain your medical history and examine your foot. Throughout this process the surgeon rules out all the possible causes for your heel pain other than plantar fasciitis.

In addition, diagnostic imaging studies such as x-rays or other imaging modalities may be used to distinguish the different types of heel pain. Sometimes heel spurs are found in patients with plantar fasciitis, but these are rarely a source of pain. When they are present, the condition may be diagnosed as plantar fasciitis/heel spur syndrome.

Non-Surgical Treatment
Treatment of plantar fasciitis begins with first-line strategies, which you can begin at home:

• Stretching exercises. Exercises that stretch out the calf muscles help ease pain and assist with recovery.
• Avoid going barefoot. When you walk without shoes, you put undue strain and stress on your plantar fascia.
• Ice. Putting an ice pack on your heel for 20 minutes several times a day helps reduce inflammation. Place a thin towel between the ice and your heel; do not apply ice directly to the skin.
• Limit activities. Cut down on extended physical activities to give your heel a rest.
• Shoe modifications. Wearing supportive shoes that have good arch support and a slightly raised heel reduces stress on the plantar fascia.
• Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation.

If you still have pain after several weeks, see your foot and ankle surgeon, who may add one or more of these treatment approaches:

• Padding and strapping. Placing pads in the shoe softens the impact of walking. Strapping helps support the foot and reduce strain on the fascia.
• Orthotic devices. Custom orthotic devices that fit into your shoe help correct the underlying structural abnormalities causing the plantar fasciitis.
• Injection therapy. In some cases, corticosteroid injections are used to help reduce the inflammation and relieve pain.
• Removable walking cast. A removable walking cast may be used to keep your foot immobile for a few weeks to allow it to rest and heal.
• Night splint. Wearing a night splint allows you to maintain an extended stretch of the plantar fascia while sleeping. This may help reduce the morning pain experienced by some patients.
• Physical therapy. Exercises and other physical therapy measures may be used to help provide relief.

When Is Surgery Needed?
Although most patients with plantar fasciitis respond to non-surgical treatment, a small percentage of patients may require surgery. If, after several months of non-surgical treatment, you continue to have heel pain, surgery will be considered. Your foot and ankle surgeon will discuss the surgical options with you and determine which approach would be most beneficial for you.

Long-term Care
No matter what kind of treatment you undergo for plantar fasciitis, the underlying causes that led to this condition may remain. Therefore, you will need to continue with preventive measures. Wearing supportive shoes, stretching, and using custom orthotic devices are the mainstay of long-term treatment for plantar fasciitis.

Our very own Spine Specialist, Dr. Vikas Varma and Aaron Huppert, PT, CertMDT will speak at the 92St Y on February 8th, 2011 at 6:30 pm.

New technology, improved therapies and surgical techniques, and unprecedented collaborations between orthopedics and neurosciences have created a new era for treating back pain that was previously prolonged and sometimes only marginally effective. Discover how these advances can help provide permanent pain relief and the questions to ask medical specialists when contemplating these new treatment options.

Click here to learn more.

To purchase tickets, click here or call 212.415.5500.

In Unicondylar Knee replacement, only one compartment of the knee is replaced. The two other compartments remain untouched. This often leads to less pain and shorter recovery periods for patients. Because the native ACL is also preserved, overall knee function is often excellent.

Good candidates for Unicondylar Knee Replacement will have only minimal deformity of the knee joint, a functioning ACL, and a body weight under 200 pounds. Most importantly, their radiographic arthritis and painful symptoms will be confined to only one knee compartment. Current orthopedic research estimates that approximately 5% to15% of knee arthritis patients will satisfy these criteria.  For those that do, Unicondylar Knee Replacement offers an excellent treatment option.

With a steady push from surgeons, and a growing demand for minimally invasive surgery from patients, industry has responded with the development of improved lighting and retractor technology, to allow for the development of this new technique.  Extreme Lateral Interbody Fusion (XLIF) is an exciting new technique that has been developed by an international team of spinal surgeons. Although technically demanding, studies have shown this to be a very effective operation. Although very few spinal surgeons have been trained in this new technique, Dr. Varma has performed research on, and has extensive experience with, this surgical procedure.   He has experience performing this procedure in both simple and complex cases, such as revision surgery, spinal infections, and scoliosis.

For more information, or to find out if you are a candidate for an XLIF procedure, please call our office and make an appointment with Dr. Varma.

Etiology (Causes) of Frozen Shoulder

• We do not know why frozen shoulder occurs in 95% of the cases.
• In the other 5%, patients develop stiffness as a result of trauma, calcium deposits, arthritis, or following surgery if scar tissue forms.
• Diabetic patients, women and people in their 40s and 50s have a higher risk for developing (being afflicted with) frozen shoulder.
• It appears that 3% of the population can suffer from frozen shoulder but this number jumps to 10% in diabetic patients.

Pathology

So what’s making the shoulder stiff? Every joint has a capsule that encloses the joint and is lined with a layer of cells called synovium. The synovium and capsule become very inflamed which is very painful and limits motion. Then the capsule itself, which is usually paper-thin, starts thickening and that also restricts range of motion in the shoulder. The medical term for frozen shoulder is idiopathic adhesive capsulitis: idiopathic (unknown cause) adhesive (stiff) capsulitis (inflamed capsule).

Non-operative Management

Most patients can be successfully treated without surgery but it can take 9 – 12 months to resolve.

• To start with the inflammation needs to be controlled and that can be with anti-inflammatory medications (NSAIDS) or steroid injection. Some patients may not be able to take these medications and should check with their physician.
• Next the capsule needs to be stretched and that is best performed with the help and guidance of a physical therapist. A home stretching program is also essential.
• Using a heating pad before stretching or doing the stretches in a warm shower can help.
• For diabetic patients keeping their blood sugars controlled is also important.

Operative Management / Minimally Invasive / Shoulder Arthroscopy

Some patients don’t get better. They reach a plateau and their shoulder range of motion remains limited, affecting their basic activities of daily living. These patients can benefit tremendously from an arthroscopic (minimally invasive) procedure that releases/removes the thickened capsule. Following surgery patients are able to return to physical therapy and regain most of their motion.

Mechanisms of Labrum Injury

• Trauma: Such as a violent twisting or pivoting maneuver or a hip dislocation.
• Repetitive overuse: Repetitive twisting or pivoting maneuvers such as golf, dancing, or hockey without a specific injury event.
• Ligamentous laxity: Some people have very loose ligaments and this can lead to increased stresses and tears of the labrum.
• Developmental Dysplasia of the Hip (DDH): The hip joint is a ball & socket joint. Some people have a shallow socket that doesn’t cover enough of the ball. This puts excessive stresses on the labrum and leads to tears.
• Femoro-Acetabular Impingement (FAI): In some people the femoral head neck junction (the ball) or the hip socket develop in such a way that they impinge on each other in an abnormal fashion which leads to labrum tears.

(A) Normal hip. (B) CAM impingement. (C) Pincer impingement. (D) CAM + Pincer impingement.

Symptoms:

• Groin pain
• Clicking or snapping sensation in the hip
• Pain with pivoting, twisting, squatting
• Pain with sitting for extended periods of time

Evaluation by the Physician

• Review of the patient’s symptoms and activities.
• Physical examination: There are several specific maneuvers the physician will perform to the hip to help determine if a labrum tear is the cause of the patient’s hip pain.
• Diagnostic injection: Occasionally the physician will send the patient to get an injection (anesthetic and sometimes with steroid) into the hip joint under ultrasound or fluoroscopic imaging. If the pain resolves even for a few hours this indicates that the pain is emanating from the joint (i.e. labrum tear).

Imaging

• X-rays are helpful in evaluating Femoro-Acetabular Impingement (FAI), DDH and ruling out arthritis.
• MRI is useful in identifying labrum tears, cartilage defects, Femoro-Acetabular Impingement (FAI) and ruling out arthritis. Often a dye is injected (arthrogram) to the hip joint at the time of the MRI.  This improves the accuracy of the MRI identifying labrum tears.

This is an MRI showing a patient with a labrum tear and impingement problem. The arrow is pointing to the labrum tear. The white line represents the tear, the labrum is to the left of the line and the acetabulum is to the right of the line. In a normal hip, without a tear, there would be no white line. The arrowheads are pointing to the bony protuberance (CAM defect) on the femoral head which is causing impingement.

Non-operative Treatment

• Activity modification: Patients are advised to avoid activities requiring pivoting, twisting, and squatting. Patients can be educated by a physical therapist how to perform activities without aggravating the hip.
• Physical therapy: Although therapeutic exercises will not heal a labrum tear they can improve the overall mechanics of the hip. This can lead to improved function and decreased pain.
• Medication: Antiinflammatory medications (NSAIDS) can help relieve pain and inflammation. Patients with GI or cardiac disease need to consult a physician prior to taking these types of medications.

Surgery

There is a limited ability for the hip labrum to heal without surgical intervention. Recent advances in arthroscopic surgical techniques now allow specially trained orthopedic surgeons (Dr. Edmond Cleeman & Dr. Mark Klion) to repair labrum tears through 2 or 3 small portals around the hip. These procedures are performed in an ambulatory setting (patient goes home the same day).

• Repairing the labrum: The torn labrum is reattached to the acetabular rim (socket).  Sutures are arthroscopically placed around the torn labrum and fixed to the acetabular rim with implants called anchors. These anchors are non-metallic.
• Addressing Impingement: Bony impingement issues (FAI) can also be corrected arthroscopically.  The bony protuberances are reshaped using high-speed arthroscopic burrs.

Post Surgery Care:

• Partial weight bearing with crutches for 2-4 weeks
• Occasionally a brace is used for 2 weeks
• Ice is applied to the surgical area.
• Pain medication
• Physical therapy
• Recovery can take 3-4 months before patients are ready to return to sports

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The wrist arthroscope contains a pencil-sized camera and a lighting system. The surgeon makes a series of tiny incisions, called portals, enabling the surgeon to look directly into the joint. Through these portals, specialized miniature arthroscopic instruments (probes, knives, shavers, and forceps) are used to diagnose and treat the condition.

Because the incisions used in wrist arthroscopy are smaller and disrupt less soft tissue than more conventional open surgery, pain, swelling, stiffness, and complications are usually minimized, and recovery is oftentimes faster.

Common conditions treated with wrist arthroscopy include:

• TFCC injuries (triangular fibrocartilage complex or “the meniscus of the wrist”)
• Ligament and cartilage injuries and degenerative conditions
• Distal radius fractures (wrist fractures)
• Scaphoid fractures
• Ganglion cysts
• Arthritis
• Chronic wrist pain

If your wrist condition requires surgery, please ask our hand surgeon, Dr. Richard Gilbert, if your particular diagnosis is amenable to arthroscopic or other minimally invasive forms of treatment.

Mechanisms of Rotator Cuff Injury:

• Trauma
• Overuse: Some patients just wake up one day with symptoms but most are active and participate in overhead sports or activities and develop symptoms as a result of repetitive overuse.
• Impingement: Some patients may have a bone spur that protrudes down from another bone called the acromion.  In time the bone spur can irritate the bursa, leading to bursitis and eventually wear into the rotator cuff and lead to a rotator cuff tendon tear.

Symptoms

• Patients are typically over 40 years of age
• Weakness
• Pain: Patients may develop pain with basic activities of daily living such as lifting a carton of milk, fastening a bra, tucking in a shirt, combing their hair and others. Patients may have pain with sport activities like throwing, serving tennis balls, and swimming. The pain can also interrupt sleep.
• snapping/crackling with motion
• stiffness.

Evaluation by the Physician

• Review of the patient’s symptoms and activities.
• Physical examination: There are several specific maneuvers the physician will perform to the shoulder to help determine if a rotator cuff tendon tear is the cause of the patient’s pain.

Imaging

• X-rays are helpful when looking for bone spurs, calcium deposits and ruling out arthritis.
• MRIs are designed to evaluate soft tissue such as the rotator cuff tendons, ligaments and cartilage.
• Ultrasound devices are being used more frequently in the office to evaluate the rotator cuff tendons. Some advantages are that it can be done immediately, takes less time, and no issues of claustrophobia.

X-ray Black arrows pointing to large bone spur emanating from the acromion and impinging on the bursa and rotator cuff tendons

MRI: Showing  of a shoulder revealing a torn and retracted rotator cuff tendon.  Red arrow pointing to torn free edge of the rotator cuff tendon. Green arrow pointing to normal insertion site where the tendon should be attached.

Non-Operative Treatment

• Activity modification: Patients are advised to avoid overhead activities.
• Physical therapy: Although therapeutic exercises will not heal a torn rotator cuff tendon they can improve the overall mechanics of the shoulder. Most commonly only one of the rotator cuff tendons is torn (supraspinatus), therefore strengthening the remaining rotator cuff tendons will help compensate for the torn tendon. This can lead to improved function and decreased pain.
• Medication: Antiinflammatory medications (NSAIDS) can help relieve pain and inflammation. Patients with GI or cardiac disease need to consult a physician prior to taking these types of medications.
• Steroid injection: An injection to the bursa is commonly performed to decrease pain. Limited use of steroid injections is recommended to avoid further damage to the tissues.

Can rotator cuff tendon tears be treated non-surgically?

Before we can answer this question, we need to review some of the science:

• Rotator cuff tendon tears do not heal on their own.
• 50% of rotator cuff tendon tears expand with time if not repaired.
• The muscle attached to the torn tendon atrophies and contracts with time. These changes eventually become irreversible.
• Rotator cuff tendon tears that have a delayed repair have poorer mechanical properties then those repaired early.

Minimally Invasive Surgery / Shoulder Arthroscopy

Recent advances in arthroscopic surgical techniques now allow specially trained orthopedic surgeons (Dr. Edmond Cleeman & Dr. Mark Klion) to repair torn rotator cuff tendons through minimally invasive techniques (usually 4 small portals around the shoulder). These procedures are usually performed with a regional anesthetic (the arm is numbed) and the patient goes home the same day.  Success rates are high in small tears but success diminishes with increasing tear size.

• Repairing the tendon: The torn rotator cuff is reattached to the bone.  Sutures are arthroscopically placed through the torn rotator cuff tendon and fixed to the bone with implants called anchors. These anchors are non-metallic.
• Addressing Impingement: Bony impingement issues (bone spurs) are also corrected arthroscopically.  The bony spurs are removed using high-speed arthroscopic burrs.

Post Surgery Care:

• Sling for 6 weeks
• Ice or compression ice machine is applied to the surgical area.
• Pain medication
• Physical therapy
• Recovery can take 4-6 months before patients are ready to return to sports

Shoulder Anatomy

Fig 1. Bony anatomy of the shoulder

Fig 2. Soft tissue anatomy of the shoulder

Fig. 3 Inflammed bursa and rotator cuff tendon tear

Arthroscopic Rotator cuff Tendon Repair.

Fig 4. Bursa is surgically debrided.

Fig 5. Suture anchor placed into bone

Fig 6. Rotator cuff tendon sewn back to bony insertion site.

PRP involves injecting concentrated portions of a patient’s own blood directly into an injured or affected area, thereby stimulating the body’s own healing mechanism. This is performed in the office, and involves drawing a small amount of the patient’s own blood, concentrating the platelets by spinning down the blood in a centrifuge, and then injecting the affected area.  The whole process takes less than 15 minutes.

PRP can shorten healing time, possibly obviate surgery, and may be used in conjunction with surgery to accelerate rehabilitation.

Possible Indicated Conditions

Tennis Elbow (Lateral Epicondylitis)
Achilles Tendinitis
Runner’s Knee (Patella Tendinitis)
Rotator Cuff Strains and Bursitis
Partial Ligament Tears
Muscle Strains
Arthritis

Dupuytren’s disease is a condition that affects the hands in certain individuals. In Dupuytren’s disease, the tissue underneath the skin in the palm thickens, and becomes similar to scar tissue. As the condition progresses, a rope-like cord develops beneath the skin, pulling the affected digit(s) into the palm, resulting in a contracture. With a significant contracture, Dupuytren’s disease can interfere with everyday activities, such as getting dressed, shaking hands, and using a computer.

The typical appearance of Dupuytren’s disease, resulting in a digital flexion contracture.

Before Xiaflex ™, the traditional treatment for symptomatic Dupuytren’s contractures was surgery. Surgery for Dupuytren’s disease is quite complex, requires anesthesia, and has been associated with a number of complications. After surgery, extensive post-operative hand therapy is usually required, and full recovery can take up to six months. Recurrence of the contracture is also not uncommon.

Xiaflex ™ involves giving one or two injections, in the doctor’s office, and then manipulating the affected digit the day after the injection. No anesthesia or incisions are required. The reported results are as good or better than surgery, with a minimal risk for minor complications. There is no prolonged recovery, and there is usually no need for postoperative hand therapy.

If you suffer from Dupuytren’s disease, ask Dr. Gilbert if you are a candidate for this exciting new treatment.