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Drillbits

Thoughts from an orthopedic surgeon specializing in sports medicine and fracture care, including insight into the practice of medicine.



The Athlete's Pain

Sports Medicine is exploding and with that comes new opportunities and treatments, unfortunately some of them fad...at least for now. Came across an interesting article (part of a series) in the NY Times that discusses how some treatments are being rendered even without scientific evidence supporting its success - PRP and stem cell injections - as a couple examples. It seems that many patients are asking for these treatments because high profile athletes are touting their success, even though we don't really know whether the treatment works.

 

Injecting PRP (platelet rich plasma) into areas of injury, including rotator cuff tears and tennis elbow, have been tried, but no data seems to be conclusive regarding the benefit. But testimonials from doctors and their high-profile athletes seems to go a long way, regardless of lack of science, a tried and true way to popularize an unproven treatment. Dr John Bergfeld of the Cleveland Clinic calls this the "Orthopedic Triad: famous athlete, famous doctor, untested treatment."

 

I have some patients who request a treatment simply because they have heard a high profile athlete has reveived it. I always tell them that just because an athlete says it worked, doesn't mean it really worked. I encourage all patients to review the science with their physican before any treatment. 

 

To check out the whole article: http://goo.gl/8kzWU

 
Vitamin D levels linked to muscle injury

At the recent American Orthopedic Society for Sports Medicine (AOSSM) meeting in San Diego, a study was presented linking vitamin D levels to muscle injury.

 

Specifically, the study identified lack of vitamin D being related to an increased chance of muscle injury in NFL football players. 89 players from a single team were identified as being players that sustained muscle injuries, lost playing time, and had low vitamin D levels. Interestingly, the mean vitamin D level in African American players (20.4 ng/mL) was lower than that for white players (30.3 ng/mL). Values within normal limits were those >32ng/mL.

 

Screening and treatment of vitamin D insufficiency in professional athletes may be a simple way to help prevent injuries, according to Dr Scott Rodeo.This study may prompt me to obtain vitamin D levels in patients who have recurrent muscle injuries.

 
Platelet Rich Plasma (PRP) & Sports Medicine

Platelet Rich Plasma, or PRP, has become more popular as a treatment for certain types of Sports Medicine problems ever since Hines Ward of the Pittsburgh Steelers had an injection of this before the Super Bowl in 2006. Ward had injured his medial collateral ligament (MCL), which typically heals without surgery less than 2 weeks before the big game, and his ability to play in the super bowl was in doubt. The Steelers team physician gave him PRP injections, which they say allowed the MCL to heal quicker and Ward played in the game.

 

So what exactly is PRP? Basically your own blood is drawn and then spun in a centrifuge-type machine, leaving a super high concentration of platelets (above baseline values), without the red blood cells. Platelets play a crucial role in normal healing by releasing growth factors and recruiting reparative cells. This concentrate is then injected into an area of injury – muscle, tendon, or ligament.

 

Does it work? Overall the jury is still out on this. In the orthopedic surgery literature, there has not been any conclusive evidence to support that it helps injuries heal quicker, let alone do anything. However in the non-orthopedic literature, there has been data to suggest that PRP has some promise / benefit. Perhaps this is due to the fact that the orthopedic research has been conducted in the OR setting, say injecting PRP into / on the rotator cuff or ACL during surgery when the surgery itself causes bleeding, and therefore release of platelets into the area. Maybe adding more platelets into the region doesn’t provide any added benefit.

 

But in the office setting it may be reasonable to think that in certain chronic conditions, like lateral epicondylitis (tennis elbow), Achilles tendinitis, or even slow to heal MCL sprains, PRP may help. After all there is no continued bleeding in these areas after the initial injury and therefore unlike in surgical settings, no increased platelet concentration would be found.

 

Even Kobe Bryant recently had PRP injections done. As reported by LakerNation on twitter, Kobe had PRP injections done in Germany for his knee arthritis (http://bit.ly/lEC9GB). Not entirely sure why he wouldn’t have just had the injections done in Los Angeles.

 

Acceleration of muscle, tendon, and ligament healing with PRP seems promising, but there is currently little evidence to support its use. To this effect, insurance companies (for the most part) recognize PRP treatment as experimental and thus don’t cover it. So patients have to pay cash out of pocket to get it. I don’t think there is a downside to the treatment – after all it’s your own blood. I am just not sure yet whether it works.

 

I have given PRP injections for a few different conditions, most notably tennis elbow and MCL injuries that don’t seem to heal with conventional forms of treatment. I’ve seen mixed results, but no side effects or worsening of problems. I still think this is an area where the marketing is ahead of the science and more research needs to be done.

 

I bet if Kobe’s knee holds up in the next season, the popularity of PRP will make another jump – whether it truly works or not.

 
Are my hamstring tendons big enough for ACL Reconstruction?

I prefer to use hamstring tendon grafts for Anterior Cruciate Ligament (ACL) Reconstructions, but often wonder (and get asked all the time): “Will the graft be big enough?”

 

Came across a recent study in the American Journal of Orthopedics (June 2011) that looked at the relationship between sex, age, height, and body mass index (BMI) to hamstring graft diameter. In general males had adequate hamstring graft size / diameter and women typically had smaller hamstring tendons than men.

 

Age and BMI did not correlate with hamstring graft diameter in women. Height correlated to graft diameter in women; women shorter than 65 inches had significantly smaller hamstring graft diameters than those women 65 inches and taller.

 

In men, age and height did not have any correlation. BMI greater than 25 correlated with larger graft diameter, but BMI less than 18 did not predict graft sizes that were too small.

 

Study concluded that alternative graft options (patellar tendon and cadaver) should be considered in women less than 65 inches tall.

 
Patellofemoral Pain Syndrome

I’ve been seeing a lot of people with pain in the front of the knee, worse with stairs and hills, mostly women, all classic findings of patellofemoral pain syndrome. Easy to diagnose, hard to treat. So what exactly is it and what causes it? No one knows for sure, though there are a bunch of theories.

 

The most common theories include overuse & overload (runners), biomechanical problems (flatfoot or high arch), and muscle imbalance (seen more in women). Treatment almost always involves physical therapy for quadriceps strengthening, especially the inner quad. The misconception is that the kneecap only moves up and down, when in fact it also moves “side-to-side.” Thus, strengthening the inner quad helps to provide a more “neutral” alignment of the kneecap.

 

Other forms of treatment include rest, ice, & anti-inflammatories, all of which may help relieve pain, but not alter the actual condition. In rare instances, surgery may be warranted to help align the kneecap a bit better, but this should be reserved for extreme situations when nonoperative management has failed.

 

I have recently started treating these with visco-supplementation injections (rooster comb shots like Synvisc) followed by a long course of therapy. I also recently learned of a brace that seems to help stabilize the kneecap better than the traditional knee sleeves. A colleague of mine has been using this for quite some time and most of his patients really think it helps. The downside is that it is a custom brace and is definitely bigger than a typical knee sleeve. But if it helps get rid of your pain and allow you to do the things you want to do….check out some more info on this brace at http://bledsoebrace.com/products/2050.asp

 

 

I would always recommend as much PT as possible, in conjunction with injections and the brace before considering any of the surgeries now. I have seen too many people not respond too favorably with surgery

 
Clavicle Fractures - Do I need surgery?

 

claviclefx

The other day I saw and fixed one of the worst clavicle fractures I have ever seen – in another physician no less - biking accident, 5 pieces, about 1 ½ hrs of surgery time to put the jigsaw puzzle back together. In the end, I was pleased with how it came together; I think the fracture will heal and he will do well. 

But it made me wonder about what the latest research shows regarding clavicle fractures – should they all be fixed? If not, which ones should and why? Historically all clavicle fractures were treated without surgery and the great majority went on to heal. 

But recent literature suggests that some of these patients did not fare so well when it comes to regaining all their motion, strength, and function.

claviclesxA recent prospective, randomized study of more than 100 displaced clavicle fractures found that it took an average of 28 weeks to heal without surgery and an average of 16 weeks to heal with surgery. Most people would probably like to return to their activities, usually sports, sooner rather than later.

That said, it should be noted again that the majority of clavicle fractures heal on their own. So when do you fix a clavicle?

Indications for fixing a clavicle include open fractures (bone sticks out of skin), tenting fractures (bone going to stick out of skin if nothing is done), displaced fracture with 2cm or more of shortening, multi-extremity involvement, floating shoulder (scapula fracture with clavicle fracture), seizure disorders, and cosmesis. Other variables to consider include how comminuted the fracture is (how many pieces), age of patient, and how healthy the patient is.

According to some studies, ORIF (fixing the fracture) enables athletes with displaced clavicle fractures to return to sport sooner than without surgery.

Like anything else, there are drawbacks to surgery – hardware irritation, need for plate removal, numbness around incision, infection, and the scar itself. 

I tend to decide whether to fix a clavicle fracture based on individual patient needs – if the fracture is displaced and in an athlete, I recommend surgery. If not an athlete (or patient with lots of medical problems), I recommend no surgery – risk of surgery not worth it.

 
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