New option for ACL reconstruction

Anterior cruciate ligament, or ACL, tears can have a devastating impact on an athlete's ability to return to play.  Its important role in stabilizing the knee almost universally requires surgery to restore its function, and fortunately most patients will return to play after recovery.  I wanted to briefly discuss the use of a new graft option available for ACL reconstruction and why I feel it can be a great option for getting you back on the field.

ACL reconstruction surgery entails replacing the torn ACL with a graft.  One option is to obtain a sterile graft from a cadaver, or an allograft.  This can be a great option as it entails much smaller incisions, less initial pain and a quicker earlier rehabilitation.  The graft does take longer to heal, and there is an elevated risk of rerupture mainly in the young athlete.  The second source of graft material is from the patient's own body, or an autograft.  Benefits of this option include faster graft healing, no chance of disease transmission, and lower rerupture rates in young athletes.  Some downfalls include larger incisions and injury or weakness in the structures from where the graft is harvested from, primarily the hamstrings and patella tendon.

Recent research has identified a new source of graft, the quadriceps tendon.  This stout tendon connects the thigh muscles to the kneecap.  In obtaining this graft the surgeon only has to take a small piece of the quadriceps tendon, leaving a significant portion behind which likely lessens the chance for weakness in this area after surgery.  The very thick tendon is also much stronger than the traditional gold standard of the patella tendon, and does not typically require sawing the kneecap which can lead to pain after surgery and possibly fractures.   It is my belief that this graft option can provide a great alternative to patients worried about anterior knee pain after ACL reconstruction but who would like to use their own tissue, especially in young athletes.   Utilizing the newest technology and research here at Floyd Memorial, I believe this technique can offer yet another tool for getting our patients back in the game!

The Crossfit craze. How to train safely and avoid injury

Crossfit gyms seem to spring up almost on a weekly basis as this workout craze continues to gain popularity.  The combination of varying workouts, its potential for dramatic improvements in physical and mental fitness, and the sense of community has afforded it a growing place in the nation's fitness scene.  Televised competitions are now broadcast showcasing elite athletes performing at the highest levels further spreading the appeal of Crossfit.  As a sports medicine physician, I've witnessed the ups and downs of this rising sports firsthand.  Many of its movements and training regimens are being adopted by the sports teams I cover and recreational athletes I see every day tout its benefits but also suffer a variety of ailments in the course of training.  Hopefully this post will help answer some common questions such as is Crossfit right for me?  How do I get started?  How can I prevent injury?  And what should I do if something hurts or I'm injured during Crossfit.

Is crossfit right for me?

Finding the right workout regimen for me is one of the most effective injury prevention techniqes I can recommend.  Going from a sedentary lifestlyle to the rigors of crossfit is a recipe for injury almost every time.  My personal recommendation is that crossfit probably isn't the ideal program to get in shape, but is phenomonal for getting in top shape.  As in every physical activity, periodization, or gradually increasing the intensity and duration of workouts should be an integral aspect of all injury prevention strategies.   Many crossfit coaches are aware of this and incorporate it into their programs and in those cases crossfit may be a safe way to begin a fitness program.  However sometimes the athlete or the coach can be so motivated to keep up with their online and box community that this is ignored, leading to stress injuries and other ailments.  Overall, one should be comfortable in a moderate exercise program from a cardiovascular standpoint and free from significant joint pain with mild to moderate resistance activities before embarking on the rigors of crossfit.   If that's not the case then working up to that level is the first step I would recommend before enrolling in a crossfit program.

How do I get started?

Touching on the above items, being in an active exercise program and pain free with moderate exercise is for me the first step in considering a crossfit program.  Next is selecting the proper box, coach, and or community.  If you're a novice ensure that they have experience in acclimating new members in the proper techniques and basic movements first before proceeding with more complex tasks.  Ensure you can master basic kettle bell and air squats with good form before attempting clean and jerk type activities.   Several programs will even completely remove these olympic type activities from their regimens to lessen the wear and tear on the lumbar spine that these movements can put one at risk for.  Lastly ensure that as you begin the program you are getting adequate rest.  1-2 days a week, possibly more in the early weeks of training, of rest appears to be a good rule of thumb to allow your body to rest and recover.

How do I prevent injury?

Once you have ensured that crossfit is the proper level of training for you, found a good environment with people at similar fitness levels, and become acclimated to the program, how does one go about preventing injury during the rigorous training of crossfit to maximize the benefits it can provide?   Paramount is ensuring the proper supervision and training to ensure your technique is sound.  Experienced coaches are key in preventing injury.  Focusing on technique and repetition as opposed to speed and the amount of weight you're lifting should be to goal, especially as you acclimate to training.    Having done that, as one progresses to new skills and increasing levels of activity, constantly be aware of your limits.  One of crossfit's biggest benefits is when one pushes their body to its limits and achieves levels of strength and endurance you may not have thought possible for yourself.  Balancing this benefit with a realistic knowledge of your body's limits based on your age, fitness level, and pre-existing limitations is key to progressing without injury.  

No pain no gain

Crossfit is a strenuous workout and will inevitably lead to soreness and fatigue.  However severe pain that affects other activities of daily living, especially sleep, can be a warning sign of a more significant problem.  Resting, ice, over the counter pain medication, and modifying your workouts shoulder get you back in short time.  If not seeking professional evaluation is a recommended step to make sure it is safe to resume training or if further action is needed. 

Joint Preservation Options at Floyd Memorial Hospital

Joint pain and swelling can have a significant impact on one's activities and quality of life.  Traditional options for managing a frequent cause of this, osteoarthritis, or degenerative joint disease, have ranged from medication to injections to surgery, frequently replacing the joint with an arthroplasty.  While very successful, many patients are hesitant to undertake this step and are looking for other options to treat their pain.  Today's post will discuss a range of joint preservation options, some nonoperative and others that involve surgery, but which thankfully can be done in a minimally invasive fashion while preserving one's native joint.

One of the most successful options for mild to moderate arthritis is low impact exercise and weight loss.  Even minimal weight loss can result in dramatically less stress on the joints of the hip and knee.  Low impact exercise like cycling, swimming, and walking can strenghten the muscles and supporting structures of our joints as well.  

Oral medications commonly used in treating this condition range from traditional NSAIDs, or non-steroidal anti-inflammatories, to acetaminophen.  These can be used in an over the counter fashion, or be prescribed by your physician to provide easier once daily dosing.  Other medications such as glucosamine and chondroitin sulfate have flourished in health food and supplement stores.   Evidence for their benefit is quite mixed in large studies but there do appear to be patients who obtain pain relief from these medications.  It can be useful to perform a trial of these medications to see if they really do work, as taking them provides no benefit toward commonly marketed goals of cartilage restoration and preservation.  

Another category of medications is what I call injectables.  Steroid injections have been a mainstay for decades. They can be quite effective for acute flairs of joint pain that can occur.  It is prudent to space out these injections as their overuse can lead to further joint and soft tissue breakdown.  A newer class of medication, viscosupplementation, involves injecting the joint with a gel.  This gel is hyaluronic acid, a natural protein found in human joint fluid.  Multiple brand names exist, and treatments can range from one to five injections.  These injections can provide some with longer term relief than cortisone and may have fewer side effects in the long term.  The newest injection utilized is PRP, or platelet rich plasma.  This involves processing blood drawn in similar fashion to a blood test one may have performed to monitor things like cholesterol levels.  It is then processed to form a concentrated fluid of platelets and growth factors.  This is then injected in to the joint.  Studies have shown this treatment to be at least as, and for some, more effective than viscosupplementation.   At Floyd Memorial Orthopdic Group we can perform this as an office procedure to help minimize the costs until insurance companies agree to reimburse for its use.

If these options are not working, minimally invasive surgical management can then be discussed as an option.  For the shoulder, some patients with arthritis can benefit from procedures to address bone spurs and painful soft tissue conditions such as biceps tendon tears.  In the hip, early surgery to address bone spurs can slow down the progression of arthritis that appears to stem from these spurs.  And in the knee, a new procedure called subchondroplasty can be done in conjuction with a standard knee arthroscopy can offer some patients relief of their knee pain in an outpatient setting.  These surgeries aren't for everyone though.  Many patients will still be best served by traditional joint replacement options so a consultation in our office is still the best way to find what will work for you!  

Summer Injury Prevention and Training

As we head into Memorial Day weekend, the summer season brings warmer weather and an explosion of outdoor sporting and recreational activities.  The trend for year round scholastic sports has also taken what was traditionally a time of rest and made it just another season for games and training.  With that in mind today we'll discuss some things to keep in mind whether the summer is a time for further competition, recovery, or just enjoying the outdoors

For the scholastic athlete, ideally summer would be a time away from competition, especially if you're a spring athlete who will resume sports like soccer and football in the fall.  Giving your body periods of rest is one of the best injury prevention techniques available.  Even if it's a month, time away from vigorous training can minimize the chance of suffering overuse injuries such as stress fractures and tendinitis.  Rest should not mean becoming a couch potato however.  Athletes should continue to maintain a healthy diet and get regular exercise, but cross training and participating in activities other than organized sports such as hiking, cycling, and swimming can allow recovery while maintaining conditioning and muscle mass.   If mandatory training is scheduled over the summer, be aware that warmer weather will increase your fluid requirements, so hydrate before training and throughout practice to minimize the chance of dehydration.  Don't wait until you're thirsty, otherwise it's sometimes too late. Lastly, training during cooler times of the day before ten and after four can be beneficial in reducing heat related illnesses.

For the outdoor enthusiast, summer affords a range of fresh opportunities from water sports to climbing and hiking and golf.  Each of these activities can provide hours of beneficial physical activity and enjoyment but also exposure to injury.  

Water sports especially require diligence to prevent what can unfortunately be catastrophic accidents.  Learning to swim and appropriate utilization of flotation devices are paramount for anyone participating in these events.  Utilizing resources such as community pools and the YMCA in the winter and spring months can get you a head start on acclimating to the water and increasing your endurance.  Recognize that river and lake currents can fatigue one quicker than the backyard pool so take appropriate precautions to avoid cramping and fatigue while on the water.  Swim with a friend always, as unfortunately drowning is the second leading killer of children ages 1-14.  Adequate supervision and lessons can minimize harm for this age group.  

Activities in wooded areas such as hiking and climbing require their own preparation and precautions to ensure safety.  Checking safety equipment that has been stored all winter is the first step.  For remote destinations having adequate provisions for first aid, nutrition, water, and communications is mandatory.  Just as competitive athletics requires training, so do recreational activities such as these.  Being in appropriate shape and fitness and setting realistic goals for the level of difficulty one is ready for can go along way towards preventing injury.  Similar to watersports, don't travel alone.  Lastly many illnesses can be transmitted from insects such as ticks and mosquitoes so utilize appropriate clothing and sprays to minimize these pests.

With these and other guidelines, summer can be a great time for the weekend warrior to enjoy new activities and the scholastic athlete to optimize their recovery and conditioning.  If you are injured, we at Floyd Memorial Orthopedic Group are here to get you back and healthy.  Stay safe and enjoy the warm weather!

Free joint pain seminar for anyone with hip, knee or shoulder pain. More information at Floyd Memorial Events

Free shoulder pain seminar

Join me for a free shoulder pain seminar discussing a range of topics affecting the shoulder such as rotator cuff tears, shoulder instability, bursitis, and arthritis. Topics will also include minimally invasive surgery, joint replacement, and rehabilitation. The seminar will be held tomorrow at 6 pm at Floyd Memorial Hospital. For details http://floydmemorial.com/events/event-details/2679/

Updated ACL prevention

I've previously written on this space about ACL prevention. I wanted to update any readers that a new web site, sort of the next generation of the PEP program, has been unveiled. The FIFA 11+ program combines all the research of the PEP program and other ACL prevention strategies into a compact program meant to prevent a wide range of injuries, not just ACL tears. Check out more details and some great information at

FIFA 11+

Shoulder replacement, is it right for me?

Shoulder pain can be a debilitating condition. A range of issues can be the cause of this pain, from tendon and ligament tears that are more common in younger patients, to arthritis which more commonly affects middle-aged and older patients. Options for treating shoulder arthritis have increased dramatically in the last decade due to new technologies and research that has helped surgeons better understand the best approach to treating the various causes of shoulder pain in the older patient. Today I’d like to focus on that research, which predominantly involves shoulder arthroplasty, or replacement.

As in other joints in the body, the shoulder joint relies on smooth articular cartilage that lines the bones which form the joint. This smooth surface allows the shoulder to glide through a remarkable range of motion. If however the cartilage starts to thin out, those surfaces are no longer smooth. The human body will often react by forming bone spurs, or osteophytes, in an attempt to limit motion at this no longer smooth surface. This can result in further pain and loss of motion in the shoulder. At the same time, the muscles that stabilize the shoulder, the rotator cuff, can also be tearing. This can lead to further problems such as weakness in the shoulder, damage to the biceps tendon, and a special type of arthritis called rotator cuff arthropathy.

When this occurs, you will often notice pain, especially at night, in the shoulder. Motion will be lost, especially in attempting to reach overhead or behind your back. The shoulder may like it is grinding as well. If these symptoms are occurring the next step is to be seen in the office and evaluated by your surgeon. This will involve a physical exam and likely x-rays of the shoulder. In most cases of shoulder arthritis this is often enough testing to provide an accurate diagnosis and treatment plan. Sometimes an MRI or CT scan can be helpful for a more detailed assessment of the soft tissue and bony structure of the shoulder. Depending on the amount of cartilage loss and other damage to the shoulder, multiple treatment options exist. This can range from oral medications, ice, and physical therapy, to cortisone injections, to surgery.



The most predictable option to relieve arthritis of the shoulder joint is total joint replacement, or arthroplasty. This involves surgery to implant a combination and metal and plastic components that restore a smooth surface to the joint, improving motion and relieving pain. Standard arthroplasty is the most common option, with the newer reverse arthroplasty that I have displayed below an option for situations where there is a deficient rotator cuff. The surgery involves being placed under general anesthesia and several days stay in the hospital. After the replacement you can expect to wear a sling for 4-6 weeks and participate in physical therapy to focus on regaining motion and strength in the shoulder. Full recovery can take 3-4 months. Shoulder replacement surgery is highly successful. Risks of the surgery can involve infection, nerve injury, fracture, prosthesis related problems, and stiffness. Talk to your surgeon to discuss your specific condition and see if this surgery is an option for you.

Expanding Team Coverage

I wanted to write today and thank the new schools that have offered to have me as part of their already excellent medical teams. I'll be working with a stellar group of doctors and trainers to provide orthopedic and sports medicine coverage at Jeffersonville, Clarksville, Providence, Charlestown, and North Harrison High Schools for the upcoming scholastic season. This is in addition to continuing my work with Indiana University Southeast, the University of Louisville, and Waggener High School. Providing care for scholastic athletes is one of the highlights of my career and I look forward to a successful and healthy season for all the competitors. Thanks to everyone at these institutions for having me as part of the team.

I tore my ACL

The words above are amongst the most dreaded that can be spoken by any patient, be it a scholastic athlete, weekend warrior, or a work injury. Although the widespread attention this injury and its treatment have garnered from the coverage of college and professional athletes who have suffered it, there is often a significant amount of fear and uncertainty when dealing with the diagnosis, management, and recovery from this injury. The following post will go over this and hopefully provide a primer for patients and their families’ as they begin the road to recovery.


What is your ACL?

The ACL, or anterior cruciate ligament, is one of four stabilizing ligaments of the knee. It is located within the knee joint and when torn, can leave the patient with the inability to perform activities that require cutting, pivoting, and a change of direction. Heavy lifting, climbing, and other job activities can be difficult as well. Walking, swimming, and other straight ahead and low impact activities are less often affected by this injury. ACL tears primarily occur via noncontact mechanisms. That is, an athlete will often be changing direction or landing when the injury occurs. These moments can be quite painful and patients will often feel or hear a pop, followed by rapid swelling of the knee and the inability to bear weight on the leg.




How do I know if I tore it?

Most ACL tears will have the typical history above. I recommend anyone with that history to be evaluated by a physician in short time. That evaluation will focus on several things. First the stability of the knee will be tested on physical examination. This can also diagnose other ligament tears that can be associated with ACL tears. X-rays are helpful to rule out other injuries as well. Commonly this evaluation will result in an MRI, or magnetic resonance image, being ordered. This test, which does not involve radiation, will evaluate the soft tissue, cartilage, and bone of the knee with higher detail than an x-ray. When this information is available, your physician will be able to provide a complete diagnosis and treatment plan.

What’s Next?

At this point the treatment plan becomes very individualized. Every ACL tear is different in the amount of pain and instability a patient will suffer from. Different physical demands also go into determining the best way to treat a tear. In general, the younger and higher demand that a patient’s sport, job, or daily activities require, the more likely a surgical option is to be recommended. Associated injuries like meniscus and cartilage tears occur in about half of these injuries and can play a role in determining the recommended treatment.

Nonsurgical Treatment

This treatment plan will progress from an initial focus on pain and swelling control through progressive physical therapy and rehabilitation. This may be supplemented with knee bracing. Many patients in this group will see a significant gain in function over the course of six to eight weeks, but full recovery can take several months. Some patients initially treated with nonsurgical means will find their knee to be too unstable and go on to have surgical treatment.

Surgical Treatment

The consensus on treating ACL tears surgically at this point is to reconstruct, rather than repair, the ACL. This means using a substitute graft made of tendon to replace the ACL. This graft can either come from another area of your own body, called an autograft, or from donated tissue, called an allograft. The choice of graft is often individualized based on associated injuries and surgeon and patient preference. Each option has its own pluses and minuses, but overall large studies show most grafts provide similar results in the long term.

The surgery will typically be performed with the assistance of small cameras, or arthroscopes, than can minimize the size of the incisions and aid in visualizing the joint. Most patients will go home the same day of their surgery. A brace may be used along with crutches to protect the repair in the early postoperative period. ACL surgery is very safe. Complications are rare but can include infection, bleeding, blood clots, stiffness, recurrent instability, and complications from harvesting tissue to replace your ACL.

Rehabilitation

While the surgery can often be the focus for many when dealing with an ACL tear, an equally important part is the rehabilitation. A combination of home exercises, formal physical therapy, and a return to full activity will take place over four to six months after ACL reconstruction. Crutches and bracing will be used in the first couple of weeks, and a period of restricted activity that may affect driving and certain job activities can be the norm. Long term, most patients will be able to return to their desired sport or other activity after going through this rehabilitation. If you or a family member is going through this injury, I hope everyone can use this information as a starting point to ask the right questions and feel comfortable starting down the road to getting back on the field!

Suiting up with a new team: Dr. Abeln joins Floyd Memorial Hospital

When I began this blog I had hoped to post on a regular basis, and through the previous sports season was happy with the direction it was taking. Many posts discussed injuries affecting athletes, where changing teams comes with the territory. This scenario is increasingly becoming the norm in the medical field as well. As we head into the upcoming scholastic sports season I’m happy to announce I’ve been welcomed with open arms into the Floyd Memorial Medical Group, a team poised to lead the way in orthopedic care in the region. I will be joining Floyd Memorial Orthopedic Group in the upcoming weeks and couldn’t be more excited. Jumping across the river has opened numerous opportunities to service a thriving sports medicine scene in Southern Indiana while continuing to serve the community of Louisville and the rest of Kentuckiana.

Floyd Memorial Hospital in New Albany, Indiana has a stellar reputation in a range of services including orthopedics. I’m excited to join my new partners Drs. Mohammad Majd and Anifiok Uyoe in their New Albany location. This will allow this group to offer a wide range of orthopedic services, including spine, trauma, adult reconstruction, and sports medicine. Being a part of this team was a welcome opportunity that I could not be more excited to call my new home. As the season turns to fall I will be ramping up the number of posts and coverage of topics of interest to the sports medicine community that this blog covers. I hope the information proves useful and look forward to being a part of the team at my new home and interacting through this forum with athletes, patients, and the community at large. I've updated the scheduling link on this site and will officially begin my tenure on September 1st.

Platelet Rich Plasma. Understanding PRP's Role in Sports Medicine

Platelet rich plasma, or PRP, has gained increasing use in treating musculoskeletal injuries in the past decade. Several high profile uses in professional athletes have led to its widespread application in the general public, and an explosion of research into its utility. Today’s entry will hopefully provide an understanding of where we stand with PRP, its function, and the role for its use in treating sports medicine injuries today.

What is PRP?

PRP at its most basic form is any blood product with a concentration of platelets above normal concentration. Platelets are a cellular component of blood that have a role in tissue healing and blood clotting. It’s their role in tissue healing that has spawned its use in a range of therapeutic applications including sports medicine. By increasing the concentration of platelets, PRP systems also increase the concentration of the important growth factors these cells release, providing a product shown to enhance healing of musculoskeletal tissue.

PRP is obtained with a simple blood draw, often in your physician office. It is then processed in a centrifuge to concentrate platelet cells and separate out other cells and fluids. It is then injected in the injured tissue or joint after a local anesthetic is applied. A short period of rest is often recommended to minimize the chances of pain at the injection site and to allow the healing process to begin.

What do we treat with PRP?

A number of clinical studies have been released in recent years looking at PRP’s utility in a range of conditions, from arthritis to acute muscle and ligament injuries to chronic conditions like tendonitis and plantar fasciitis. Further studies have looked into its role in augmenting surgical repair of the structures such as the rotator cuff, achilles tendon, and anterior cruciate ligament. Broadly speaking, these studies would indicate that PRP’s efficacy is best classified as mixed. Many of these studies are relatively small and often conflict with one another. The clearest benefit for the use of PRP has been its use in treating lateral epicondylitis, or tennis elbow, plantar fasciitis, and osteoarthritis of the knee. Its usefulness in treating acute injuries, patellar tendonitis, hip bursitis, and in augmenting surgical repairs is mixed at best, and in the case of rotator cuff repair may even be detrimental to healing.

Should I get a PRP injection?

That is often the question most patients want answered. The clearest answer is to talk to your physician. He or she should be able to discuss PRP’s use in your specific condition. Often other remedies such as physical therapy, rest, or braces can offer a more reliable cure. However, certain conditions do appear to be better candidates for PRP, and I have found it to be very useful for the patient who has tried and failed more traditional approaches such as steroid injections, prolonged physical therapy, and rest. An individualized approach to these conditions is certainly the best medicine.

Meniscus Tear Part Two: Treatment Options

In part one of my post on meniscus tears, I discussed the role of the meniscus in knee function, ways it can be injured, symptoms of a tear, and tests and exams a physician can use to diagnose them. Once that is established, the discussion quickly turns to how best treat these tears.
The most important thing I emphasize with patients is that every meniscus tear is different. There are many things to consider when discussing the best treatment option. The location and type of tear, the patient’s age and activity level, associated symptoms such as if the knee is locking or not, and the presence of other conditions such as osteoarthritis and ligament tears are all important considerations in choosing the best way to proceed

Nonoperative Options

The broadest way to break down treatment options is whether the tear will be treated with or without surgery. With this in mind, there are several instances where most patients will be recommended to not consider nonoperative options. If the knee is locked because of certain meniscus tears, nonoperative treatment is unlikely to lead to successful results. Worst still, the locked fragment can damage the articular surface of the joint if left for too long. Further, meniscus tears associated with significant ligament injuries such as ACL, or anterior cruciate ligament, in athletes or those requiring full stability of their knee will often have their meniscus tear treated surgically at the same time as their ligament tear.

So, for those tears not meeting those criteria, what can be done to hopefully avoid a trip to the operating room? Conservative options abound for many types of meniscus tears, especially smaller degenerative type tears associated with arthritis. Rest, ice, anti-inflammatory medication, and physical therapy can decrease the pain and swelling associated with these tears. Corticosteroid injections have been utilized for years and can be effective if these first line treatments fail to relieve your pain. Newer medications and treatments, such as viscosupplementation and PRP, or platelet rich plasma, are not as well studied but are being increasingly used in the conservative management of certain types of meniscus tears. Each of these can be performed in the physician office with minimal down time. I’ve found nonoperative approaches to be most successful in patients who have few mechanical complaints, that it catching or locking of the knee, or a sensation of popping with activities.

Operative Options

For patients who have failed conservative approaches or have more significant symptoms, surgery can offer relief that can allow you to return to the activities that sports, your job, and life demand. Meniscus tears are now treated almost exclusively via arthroscopic surgery. This surgery utilizes small incisions and instruments the size of a pencil and smaller to assess the tear and manage it.

During surgery, meniscus tears can be addressed one of two ways. The tissue will either be sewed back together, or repaired, or more commonly, trimmed out to remove the damaged tissue that is causing pain. Meniscus repairs are much less common because there are few tears that meet the criteria for this type of treatment. Factors such as your age, the type and location of the tear, the quality of the tissue, and the presence of arthritis are all factors your physician should discuss as before surgery. The final determination of whether the meniscus can be repaired or not will occur during surgery. If it can be repaired, a variety of options exist. Suture can be placed into the meniscus through the same arthroscopic incisions, or through needles placed through the skin. Some tears are better treated by making incisions on the side of the knee to more safely and securely pass the sutures. Meniscus repair requires prolonged rehabilitation, often with crutches, bracing, and periods of nonweightbearing and physical therapy to allow the meniscus to heal.

The more common approach of trimming out the damaged tissue, or partial meniscectomy, does not require the same precautions as a meniscus repair, yet still requires a period of rest and often physical therapy to allow a full recovery. Crutches or a cane can allow the knee to rest for a short period of time after surgery, and limiting how much walking and other activities one does will minimize swelling that can slow down the rehabilitation process

Recognizing that a variety of options exist in treating your meniscus tear is the first step in obtaining a successful outcome. A range of treatments can typically be offered and the first step does not always have to be surgery. If surgery is chosen, most patients will reach a full recovery and have the chance to return to all levels of previous activity. Talk to your physician about your individual case and find what works for you.

Meniscus Tears Part One

The human knee joint can take a tremendous toll in the course of athletic participation, with injury, even everyday activities. A force of three to six times one’s body weight is transmitted through the knee every step one takes. To spread that load and lessen damage to the joint, we rely on a structure called the meniscus, semicircular bands of tissue spanning each side of the joint which service to distribute load and stabilize the knee.

Meniscus tears can occur in a variety of settings. Athletic injury, work accidents, and even minor trauma to the knee can cause acute tears. Age related changes often result in chronic or degenerative tears, of the meniscus which can commonly be seen in the setting of osteoarthritis.

Typical symptoms of a meniscus tear include pain, swelling, and sometimes a sensation of a pop when it occurs. Other associated symptoms can include locking or catching of the knee, a feeling of giving way, and a loss of range of motion

When these symptoms are present, a thorough physical examination is the first step for you and your physician. X-rays can be helpful to evaluate for other conditions such as a fracture, or more commonly osteoarthritis. Magnetic resonance imaging, or an MRI, can fully evaluate the soft tissues of the knee including the meniscus.

Guidelines for healthy marathon running

Marathon running has seen a surge in popularity, with participants nationwide nearly doubling in the last decade. This has brought a new crop of runners into the fold and with it unfortunately exposure to high rates of injury. Running-related injuries, or RRI, can be seen in upwards of three quarters of participants in training cycles for distance running events. One size fits all approaches previously geared to experienced runners have traditionally been the norm in training programs for marathons. While serving as a nice framework, more general guidelines as well as alternative means of training may be more appropriate for novice runners. They can also prove useful for more experienced athletes when injuries do occur during training.

The first consideration is what to do before one starts training. An argument could be made that a thorough physical exam and any indicated testing including an EKG should precede training for a marathon or half marathon. 59 cardiac deaths occurred in the US during the previous decade. Hypertrophic cardiomyopathy, coronary artery disease, and male gender were the overwhelming risk factors. I advise any participant with a family history of these two risk factors, and men over the age of 35 to have thorough history and physical before training begins. Further, I highly encourage runners and their training partners/friend/family to learn CPR. Early administration of CPR resulted in higher survival rates in these athletes. Lastly, seek medical attention for any symptoms of heart disease such as chest pain, shortness of breath, or lightheadedness.

Proper equipment should be a runner’s next step. Several properly fitting shoes, which the experts at local running stores can be of tremendous help, should be a mandatory purchase. Gaining adequate correction of any pronation or arch issues should start there as well. Most guidelines suggest running shoes should be replaced every 350-500 miles. Every runner is different though. Increasing aches and pains, signs of midsole wear, and significant tread wear should prompt a trip to the running store.





Finally it’s time to train. Many marathon and half marathons, running magazines, and other sources now provide day by day training calendars. They’re available on multiple platforms, from traditional print, to web, and now smartphone capability. They can provide structure and help plan the when, how much, and how long for your training runs. I think most of them are done quite well so will delve into what I think are good, general guidelines for athletes in distance events. My general recommendations are to gradually increase mileage until two weeks prior to the race. During that time two long runs a week should gradually build until that run is 18-20 miles. Shorter runs in between should be in the 4-6 mile range. Perform interval training one day a week with short distances or short mixed into an overall shorter run. Run a maximum of six days a week. A day of total rest will allow recovery. Stretching, warming up, cooling down, and icing should be a part of any runner’s routine.

Within that guideline, I think there is tremendous room for modification to prevent injury. Alternating surfaces to dirt and grass is a start. Skipping a light day of running for alternative aerobic activity like swimming, cycling, and elliptical training can ease aches and pains. Pool running can allow you to continue working on your form and cadence, while taking pressure off of joints and providing added resistance training.

Lastly nutrition is critical to successfully training and competing in distance events. Everyday training will require an increase in caloric intake above average intake. Protein intake of a gram per body weight is often recommended. Maintaining an overall well rounded diet rich in fruits and vegetables will prove beneficial. During competition, carbohydrates are your primary fuel source. Thus the ubiquitous carb-loading pre-race pasta meal. Two recent studies looking at participants in the Eau Claire and London Marathons showed better performance amongst participants who had carb-loaded 24-36 hours pre-race. The authors defined carb-loading as greater than 7 grams of carbohydrates for every gram of body weight. The morning of the race, simple carbs like toast, oatmeal, and bagels. Go low on proteins as they can take too long to digest. Many runners like to throw in a banana for its potassium. After that, hydrate, and good luck!

As Louisville welcomes the NCAA Women’s Volleyball Final Four participants, I wanted to highlight the injuries faced by athletes in this booming sport that is so popular here in Louisville. With the explosion of club volleyball, this sport has become a year round completion for many participants. While having many benefits, this has led to a rapid increase in the number of injuries we as physicians see in this sport. While there are many common injuries seen across various sports such as ankle sprains, ACL tears, and stress fractures, the unique demands of volleyball place these athletes at higher risk of several specific injuries

The near constant overhead motion involved in volleyball places the shoulder at the forefront of volleyball injuries. Overuse injuries such as tendonitis, bursitis, and impingement are amongst the most common conditions faced by these athletes. Inadequate rest and recovery, poor mechanics, and muscle imbalances can predispose athletes for these conditions. More advanced conditions such as labral tears, specifically Superior Labrum Anterior Posterior, or SLAP, are also common in this sport. Similar to baseball pitchers, extreme rotation and torque from serving and spiking places strain on this structure’s attachment site. Over time it can become detached, causing pain, loss of power, and often requiring surgery to heal completely. Stretching and scapular strengthening can be very helpful in preventing and even treating these tears.

Lastly, atrophy and injury to a specific rotator cuff muscle, the infraspinatus, has been documented in surprisingly high numbers in elite volleyball players. Stretch on a specific nerve to this muscle is the likely cause. While generally asymptomatic, this condition which can be quite striking visually may warrant attention if it interferes with players’ ability to compete.

Knee injuries are also seen quite frequently in this population. Similar to basketball players, repetitive jumping, crouching, and landing on hard surfaces place these athletes at risk for patellar tendonitis, or “jumpers knee.” This condition will often cause pain in the front of the knee below the knee cap. It is also an overuse injury similar to shoulder tendonitis. Similarly, rest, proper stretching, and strengthening can help prevent this condition. Patellar straps, icing, and anti-inflammatory medication can provide relief when this condition is present.

Lastly, the low back, or lumbar spine, can take a tremendous amount of stress as athletes use their core to generate power in their swing. A condition known as spondylolysis is felt to be related to repetitive extension, or bending backward, of the lumbar spine. This condition affects a portion of the spinal column and can cause low back pain, and occasionally pain can radiate to the buttock or even leg. If present, aggressive treatment is indicated, including rest from sports, physical therapy, anti-inflammatories, and sometimes bracing. Most patients will be successfully treated without surgery but recovery can be prolonged. Very rarely surgery will be required to heal this condition.

These are just a few, but the most commonly seen, conditions faced by all levels of athletes participating in volleyball. Proper rest, mechanics, equipment, and coaching can prevent many of them. If your athlete is experiencing pain in these areas, the best course of action is to notify your coach and training staff they can get the attention they deserve.

Rotator cuff tears are amongst the most common musculoskeletal conditions facing patients today. Despite that their treatment can often bring more questions than answers. This stems mainly from the fact that not all rotator cuff tears are the same, leading to variability in their presentation, diagnosis, and management. This posting will delve into those questions in hopes of bringing some clarity to this all too common condition.

The rotator cuff is a group of four muscles connecting the shoulder blade to the arm bone, the humerus. They function as a group to stabilize the shoulder joint and assist in lifting and rotation of the arm. When injured, patients will often notice pain, weakness, and often mechanical complaints like grinding or catching of the joint, especially with overhead activities.

Rotator cuff injuries can affect patients of any age. Typically in patients younger than 40 years old, the tissue is rarely torn and more often suffers from conditions such as impingement, bursitis, or tendonitis. In these situations, the structure of the rotator cuff is often sound, however weakness in the shoulder blade, inflammation in the surrounding bursa, or early changes in the quality of the rotator cuff tendon are the source of pain.

Because of this, rotator cuff conditions in this age group can often be managed conservatively through combinations of medications, injections, and physical therapy.

In older patients or younger ones suffering from significant injuries sometimes seen in falls and at work, the rotator cuff tissue can begin to tear. When this occurs, pain can become more constant. It will often be felt on the top or front of the shoulder. It can radiate to the upper arm as well. Pain shooting to the hand is less often caused by rotator cuff tears and more so by issues affecting the spine. Pain often manifests worse at night. In these situations, in addition to a thorough physical exam and x-rays, patients will often undergo an MRI. Shoulder injuries are easier to see when there is fluid within the joint, so your physician will often order an arthrogram, whereby a special dye is injected into the joint, just prior to the MRI.

Even if an MRI shows a full thickness tear, there can be some benefit seen with further conservative treatment such as physical therapy, even though the tear will unlikely heal in this situation. However, in patients suffering persistent pain and weakness, or when there is a fear that the tear will enlarge over time, surgery is often recommended. Traditional open and arthroscopic options exist to fix the torn tendon to the bone. The small incisions and lower blood loss of arthroscopic surgery offers the chance to have decreased pain, less stiffness, and a faster recovery. Healing rates are likely similar between the two options.

After surgery most repairs will require the use of a sling for 4-6 weeks. Complete healing of repairs can take three months, and full recover is often anywhere from 4-6 months. Physical therapy and home exercise play a key role in preventing stiffness and regaining strength in the shoulder muscles.

As you can see, rotator cuff tears present multiple options in their treatment. It is important to talk to your physician about which is the best treatment for your situation.

ACL Prevention

Anterior cruciate ligament, or ACL, tears are one of the most common injuries affecting athletes in the United States. Estimates of between 100,000-200,000 of the injuries occur every year, often from non-contact injuries while engaging in cutting and twisting movements. Females have been estimated to suffer these type injuries at rates between four and eight times their male counterparts. As the number of female athletes participating in sporting competition has exploded in recent years, this disparity has created a near epidemic of ACL injuries in the female athlete.

Numerous reasons for this disparity have been expounded. They range from anatomical differences between the sexes, hormonal variations, environmental concerns like playing surfaces and shoes, and likely most important biomechanical factors such as muscular strength and endurance, movement patterns, position, and patterns of neuromuscular control. It is this factor which has seen a significant amount of research and promise in reducing the rates of ACL injury in these athletes. The Santa Monica Orthopaedic and Sports Medicine Research Foundation, and their partners at the University of Southern California, under the direction of Dr. Bert Mandelbaum and Dr. Christopher Powers, have been pioneers in this field. At the completion of my orthopaedic training I spent a year of specialty training with this group, and was exposed to a range of the newest treatments in sports medicine, including ACL prevention strategies

Their research identified several critical factors where female athletes differed from their male counterparts and were felt to contribute to their increased risk of ACL injury. First, women were found to run more erect, with decreased bending at the hips and knees. This is critical because the forces seen by the ACL are significantly less as the knee goes into more flexion, or bending. Second, diminished recruitment and strength of the hamstrings and hip musculature was seen, again placing the limb into a position known to increase the forces the ACL is subjected to. Third, landing patterns in females demonstrated a propensity for absorbing impact through hip and knee rotation instead of bending at the hips and knees, again placing the ACL at higher risk for rupture. In reviewing this and results of other interventions previously espoused to reduce ACL injury, this group created the PEP, or Prevent injury and Enhance Performance, Program. Five key areas are stressed in this program: avoidance of limb positions that place the ACL at risk, improving flexibility, improving strength of deficient muscles, plyometrics to improve landing techniques, and agilities. Athletes participating in this training program, which is done three times a week for a period of 15-20 minutes during their normal warm up period, demonstrated improvements in multiple areas known to affect ACL injury rates including landing patterns and muscle strength. Most importantly, in the first year of enrollment in the PEP program, they demonstrated an 88% reduction in anterior cruciate ligament injury for their athletes. The same authors demonstrated a 100% reduction in non-contact ACL injuries, the most common type, when they enrolled Division I female soccer players in the program.

With this fascinating data in mind, we at Loeb Orthopaedic Group and Frazier Rehabilitation have applied the PEP program to not just ACL prevention, but ACL rehabilitation. After surgery these same principles are applied to get athletes back in the game, to not just participate, but to excel.

Hip pain and arthroscopy

For decades physicians and their patients have had the benefit of a minimally invasive option to treat a wide range of injuries of the shoulder, knee, wrist, and ankle. However options for the treatment of hip and groin disorders were more limited. Conditions often went undiagnosed, untreated, or worse, treated in fashions that made return to sport difficult. Many patients continue to be diagnosed with "pulled muscles" or "pre-arthritis." With the emergence of hip arthroscopy though, there have been dramatic advances in the diagnosis, treatment, and return to play for patients suffering from hip pain. Through the use of xray imaging, surgeons can safely introduce these small instruments into the hip, treat a multitude of issues, and preserve vital muscle and supporting tissue that would otherwise be disrupted through traditionally-used open surgical options. The most common indication for hip arthroscopy is currently a labrum tear. The labrum, similar to in the shoulder, is a ring of soft tissue circling the pelvic side of the hip joint. It serves to deepen the hip socket, provide a tight seal for the joint, and contains nerve endings that sense pain and aid in joint function.

Normal Hip Anatomy

When injured, patients will typically suffer from mechanical symptoms of the hip such as clicking and catching as well as limited range of motion. Other times the symptoms are less obvious, and only manifest with a dull groin pain with certain activities. At the time of arthroscopy, some labrum tears will need to be repaired with suture, and others will need to be trimmed to prevent continued symptoms.

Labrum tear

Coexistent with labrum tears, many surgeons are increasingly recognizing a condition termed femoroacetabular Impingement, or FAI. This condition refers to a mismatch in the shape of the two bones, the femur and acetabulum, which compose the hip joint. Deformity can be present in the femur, the acetabulum, or more commonly both. When on the femur it is termed a cam type impingement and if on the acetabulum, a pincer type impingement.

At a minimum FAI is felt to be the primary causative factor for labrum tears, and there are some who feel this condition is a significant contributor to osteoarthritis of the hip due the articular cartilage damage often seen when this condition exists. Treatment of this condition at the time of hip arthroscopy requires contouring the bone to recreate the natural shape of both bones, to minimize future trauma to the labrum and articular cartilage. In addition to these conditions, hip arthroscopy can successfully treat conditions such as loose bodies, cartilage defects, snapping hip, synovitis, tendon and ligament tears, and in certain cases osteoarthritis. Prior to hip arthroscopy, most patient will require specialized x-rays and MRI where dye is injected into the hip. Most patients will be on crutches approximately two weeks after their arthroscopy, and perform a combination of physical therapy and a home program for their rehabilitation. Return to athletic competition can take anywhere from four to six months.

Welcome

Welcome to a new forum for discussion of all aspects of sports medicine. My aim is to discuss a range of topics, focusing on the treatment of orthopaedic conditions common amongst athletes. I aim to respond to comments and questions as they arise, and provide a resource for those with questions as they pertain to the cause, diagnosis, and treatment of sports medicine injuries. Added focus will be placed on those issues important to the Kentuckiana area as we cheer on the Cards, Cats, and Hoosiers!