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What We Know: ACL Injury Prevention Programs

Over 200,000 injuries to the ACL (anterior cruciate ligament) occur in the U.S. each year. A tear to the ACL puts most people out of commission for quite some time. In fact, recovery from an ACL injury often requires surgical intervention and approximately one year of rehabilitation.

Can You Prevent an ACL Injury?

We cannot control our anatomy, but we can control our movements. ACL prevention programs work to improve how we move in order to help prevent injury. ACL programs typically focus in three area: plyometrics, neuromuscular training and strength training. Many ACL injuries happen when someone jumps and lands. As the person lands, one knee caves in towards the other knee ( an increased valgus knee position)

Prevention programs focus on plyometric training to teach you how to avoid this positioning. A good program helps you understand how you land from a jump by using feedback. You may watch your body positioning in a mirror or you may have a trained person verbally tell you. With practice, proper landing movement can be achieved.

Neuromuscular and Strength Training

Plyometric training teaches you to avoid vulnerable positioning. Neuromuscular and strength training must be included in order to ensure proper movement. When you move, your nerves communicate with your muscles in order to perform movement. With neuromuscular injury prevention training, you focus on correct muscle firing patterns when performing movements. (For example: One exercise might have you work to make sure your quads and hamstrings co-contract).

When we move, we need muscles to fire equally to control our dynamic movements. We need to ensure the muscles have the proper strength to do so. Often, a person’s quads are much stronger than hamstrings. When they contract at the same time, the quads always win the tug of war. A dominant muscle creates an imbalance that makes us more susceptible to injury. A good prevention program will focus on strength training from the core all the way to the feet.

How Long is the Program?

Research shows that the most effective ACL prevention programs are performed at least 3 times per week for 6 weeks. Start the program in pre-season. Continue some of the components during your sport’s season. Plan to spend 20-30 minutes in order for each session. Don’t rush it.  

Devote enough time to each piece of training. Blowing through the program, just to say you’ve completed it, will be ineffective.

Prevention programs are great for people of any age, but research has seen the best results with kids who start at a younger age, usually around 12. They should then continue the program yearly until they are skeletally and muscularly mature. There are several ACL prevention programs out there. We recommend two programs scientifically proven to reduce the risk of ACL injury – Sportsmetrics and Prevent Injury and Enhance Performance (PEP).

How to Diagnose and Treat a Rotator Cuff Tear without Surgery

To first, diagnose whether or not your rotator cuff has been torn, a targeted examination takes place. This exam works to determine what part of the shoulder is hurt.  Often when a diagnosis becomes clear the exam will be stopped in order not to aggravate the shoulder, and typically proceed with diagnostic ultrasound.

In some cases, one or more of the following imaging tests may be recommended:

Ultrasound

Diagnostic ultrasound uses sound waves to produce images.  It is particularly good at seeing details within soft tissues such as the rotator cuff.  Often, this is the only study necessary in order to get an informed diagnosis. During an exam, the joint can be moved to see how the structures within the joint moves.  This is an advantage over MRI.

X-rays

This is usually only needed in the setting of trauma or suspected arthritis.

Magnetic Resonance Imaging (MRI)

An expensive test but sometimes required during certain diagnoses such as a labral tear.

 

Rotator Cuff Treatment Options without Surgery

 

Injections

We may recommend a steroid injection into your shoulder joint.  These can temporarily reduce pain. However, at the same time, they may shut down all healing and make the tendons weaker.  We reserve these treatments for true rescues – such as times when the person cannot sleep for multiple days in a row or is elderly and has little chance of healing a shoulder problem.  We consider steroid injections generally harmful and to be used only in desperation to relieve pain.

Growing evidence shows that regenerative medicine can help tendons heal and improve their connection to the bone.  A powerful article in the Feb. 2019 issue in Medicine Science Sports & Exercise shows that PRP therapy heals certain partial rotator cuff tears that ordinarily never heal.

Therapy

We recommend physical therapy. A mainstay of rotator cuff treatment in any scenario, physical therapy restores natural movements and encourages healing through movement. This type of intentional activation of muscle-tendon groups works well to move the healing process along.

Nutrition for Concussion Recovery

A concussion (also known as a mild traumatic brain injury) is caused by a hit to the head or body that causes the brain to move rapidly inside the skull. Following a hit like this, blood flow slows down on its way to the brain forcing the brain into an “energy crisis”. During this “crisis” the brain demands an increase in energy supply. The neurons (nerve cells) are also at their most vulnerable during this period.

How to treat concussions with proper nutrition

The purpose of this article is to address the role that nutrition plays in concussion recovery. When determining how to care for a concussion initially, consult our Concussion Care page. Oftentimes, nutrition gets overlooked as a key piece in recovery. Like any other injured body part, the brain needs calories in order to heal. So following a concussion, follow these simple steps:

  1. Continue your normal caloric intake. This is not the time to diet.
  2. Maintain, if not increase, your protein intake. Protein serves a vital role in cell and tissue production and repair. Your brain needs repairing so give it the right tools to repair itself.

The chart to the right, by the National Athletic Trainers’ Association (2016), shows how many grams of protein you should consume per day during recovery. The chart also offers examples of good sources of protein.

Don’t forget the other concussion repair tools

Following a concussion, levels of magnesium and zinc in the brain immediately drop – two crucial repair tools that the body utilizes. Magnesium lowers inflammation and helps rebuild/repair neurons. Zinc has been shown to help improve mood and cognition. In addition to protein, eat magnesium and zinc rich foods which include:

Magnesium-Rich Foods:

  • Nuts/Seeds

  • Avocados

  • Legumes

  • Whole Grains

  • Tofu

  • Leafy Greens

Zinc-Rich Foods:

  • Meat

  • Shellfish

  • Nuts/Seeds

  • Whole Grains

  • Dairy Products

  • Eggs

We recommend you restore these nutrients to their pre-concussion levels in order to shorten recovery time.

Do vitamins and supplements help during concussion recovery?

Several studies are also investigating the effects of additional vitamins and supplements for concussion recovery. It is widely accepted that increasing omega 3 fatty acids helps in recovery.  Eicosapentaenoic acid (EPA) and Docosahexaenoic acid (DHA), two key omegas can be found in fish oils. These fatty acids reduce inflammation and promote healthy cell structure. Creatine, another widely accepted supplement during concussion recovery can be found in red meat, poultry, pork and fish. Creatine increases brain cell energy production as well as preserving the mitochondria (the power plant of each cell).

Antioxidant vitamins such as vitamin C, D and E are also being studied for their effectiveness in concussion recovery. Antioxidants reduce or delay cell destruction which may prove useful as the body repairs itself. Good sources of vitamin C include fruits and vegetables, particularly citrus/tropical fruits, berries and bell peppers. Good sources of vitamin D are fortified milk products and fortified plant-based beverages. Lastly, good sources of vitamin E include nuts/seeds, dark green leafy vegetables, avocado, wheat germ, fish and eggs.

Three other supplements also under investigation include resveratrol, melatonin and turmeric. Resveratrol is found in nuts, grapes, blueberries, cranberries and dark chocolate and is known to be neuroprotective (helping to preserve neuron structure and function). Melatonin is a hormone naturally released by the body and is also considered neuroprotective. It is currently being researched in humans because of promising studies in animals. Lastly, turmeric, or its component curcumin, is a spice known to increase neuron communication and decrease inflammation in animals. It has yet to be studied in humans in relationship to concussion repair.

Although these vitamins and supplements naturally occur in foods and our bodies and are therefore safe to include in your diet, consult the healthcare provider managing your head injury for recommended dosages and advice on what to eat during your concussion recovery.

Please remember, nutrition, although a key to recovery, is just one piece of a concussion management strategy. It is essential to give your body its best chance at healing by providing it with healthy sources of nutrients, but don’t neglect rest and other important instructions provided by your healthcare provider.

Leone. (2017, November 15). Concussion nutrition. Retrieved from

https://gazellenutrition.com/concussion-nutrition

Silverman (2016, December 30). The five best ways to feed your concussion. Retrieved from

http://www.drrobertsilverman.com/the-five-best-ways-to-feed-your-concussion

University of Pittsburgh Medical Center. (2018, March 16). Concussion care: do supplements and over

the-counter relievers help-or hurt?. Retrieved from

http://rethinkconcussions.upmc.com/2018/03/supplements-pain-relievers

Weidman, C., Knappenberger, K., & Vance, C. (2016). Nutrition for concussion recovery. Retrieved from

https://www.nata.org/sites/default/files/nutrition-for-concussion-recovery.pdf

Platelet-Rich Plasma Therapy for Rotator Cuff Partial Tears

Platelet-Rich Plasma works for rotator cuff partial tears.

At Integrative Sports Medicine, we know from experience treating carefully-selected patients that PRP can work well in getting the rotator cuff to heal, and now we have a really strong piece of literature to further back that up.  This paper was released in the most recent issue of Medicine & Science in Sports & Exercise, The Official Journal of the American College of Sports Medicine. The study was performed as a double-blind, randomized controlled trial showing the superiority of both PRP and PRP+hyaluronic acid (Hyalgan, Synvisc, Euflexxa etc. commonly used for osteoarthritis) in treating partial-thickness rotator cuff tears vs. sham (saline) and steroid.

The summary is that this study demonstrated “the following outcomes: 1) PRP enhanced the recovery of small to medium bursal-sided partial thickness rotator cuff tears by alleviating pain and improving the Constant and ASES scores, and 2) Sodium Hyaluronate in combination with PRP had a better effect compared with PRP injection alone.”

To learn more about this groundbreaking study, click here.

 

Citation:

Cai, Yu, et al. “Sodium Hyaluronate and Platelet-Rich Plasma for Partial-Thickness Rotator Cuff Tears.” Medicine & Science in Sports & Exercise, Sept. 2018, p. 1., doi:10.1249/mss.0000000000001781.

Skiing in Colorado – How to Prevent Ski Injuries

Many say that Colorado is home to some of the world’s best skiing and snowboarding, which also means our state sees a tremendous amount of ski injuries. Heavy snowfall and a vast variety of mountain terrain make Colorado ski resorts a terrific choice for skiers and snowboarders of all levels. Colorado also offers unparalleled ski schools, sunshine, and historic ski towns.

Being active in sports has many positive health effects. It can help prevent cardiovascular disease, diabetes, cancer, hypertension, obesity, depression, and osteoporosis. Besides the beneficial health effects of being active, sports participation is of course also associated with a risk of injuries. Being aware of the risk of injuries while skiing and snowboarding is important, as well as making sure that you are protecting yourself, whether it is a knee brace while skiing or wearing a helmet on the slopes.

Do you have knee pain while skiing? Should you use knee support?

A lot of people ask whether they should use a brace when they ski, much like some football players are urged to use a knee brace to prevent injury. After conducting further research on knee pain while skiing, we were surprised with our findings

For skiers with prior ACL injuries, there was a significant reduction in re-injury rate when using a functional, hinged knee brace. So, if you have ever hurt your ACL, stop by and we will evaluate your degree of laxity and what specific braces would be the best for you.

At Integrative Sports Medicine, we stock but do not sell knee braces, and we have no financial interest in bracing, so our advice is objective. From personal experience, I have chosen to use a knee brace while skiing after a football injury and have seen improvements in my ability to maneuver on the slopes. In addition to that, it drastically reduces the risk of re-injuring my knee due to the stability that knee braces can provide.

Human joints need stability. If you are concerned about the impact skiing or snowboarding may have on your knees, or other joints, come visits us. At Integrative Sports Medicine, we will be able to evaluate your joints and help you make the best decision to enjoy your time on the slopes.

Potential of Concussions from Skiing

In snow sports, helmets really do matter. As a fairly late adopter of helmet use while skiing, I was lucky enough to leave the slopes without any severe injuries. After seeing my navigate down Big Chute at Crested Butte, my wife mandated I purchase a helmet. As we’ve seen, many skiers and snowboarders choose not to wear a helmet, for various reasons. At Integrative Sports Medicine, we recommend all skiers and snowboarders wear helmets on the slopes, regardless of your skill level.

We tend to see the majority of concussions stemming from two groups, males and snowboarders. This statistic can be explained easily by their behaviors, and their lack of desire to change them. Over the past four decades on the ski slopes, we have noticed a slight improvement in the amount of males and snowboarders adopting helmets. An injury on the ski hill is capable of causing a traumatic injury to your brain, including concussions or even worse.

Interesting Ski and Snowboard Injury Facts

• In the terrain park, the number of turns or spins made correlates with injury more so than the distance traveled.
• Landing on a flat surface or the knuckle of the pipe increases the rate of falls.
• Staying within your ability level will reduce the risk of injury while skiing/snowboarding.
• Collisions are a major cause of ski and snowboard injuries. Find runs that are not as crowded, and are less likely to have multiple riding styles can reduce that risk.
• New ACL-Preventing bindings compliment your body’s biomechanics and can be a potential way to reduce ski injuries.

Overall, when skiing or snowboarding, it is important to be aware that a major injury can always happen. Be mindful of various risks on the slopes.

So, have a great and safe day on the slopes! Brad Abrahamson, MD

Brad Abrahamson, MD is the designated Northern Colorado Affiliate of Stop Sports Injuries. Here are some additional tips from them.

Is Bursitis a Real Diagnosis? A Functional and Integrative Medicine Approach

Diagnosis is the first step in getting better treatment plans. A Functional approach assesses the whole patient, considering underlying causes in a serious way. Functional medical thinking refuses to accept the presenting symptom as the entire picture. It leads to a diagnosis that is more holistic and more specific. The integrative approach then utilizes several treatment approaches to get a much more comprehensive set of treatment options. Integrative sports medicine asserts a true team approach, where the team synergistically employs the available skills, techniques and treatments, utilizing any or all parts of my skill-set, and most importantly any and all of the therapeutic community.

Bursitis

A bursa is a friction-reducing structure between two things in the body that move. It is a “potential space,” like a water balloon with just a tiny amount of lubrication inside so that whatever is attached to one side can freely glide against whatever is attached to the other side. I’ll give two examples. First, the subacromial bursa. This sits between the rotator cuff and the acromion bone at the top of the inside of the shoulder. It allows the rotator cuff, which moves a great deal, to glide by overlying structures such as the acromion bone, the end of the collarbone (clavicle) and the deltoid muscle, do not move much compared with the rotator cuff tendons.

Figure 1: Subacromial bursa of shoulder, Courtesy AAOS (see above)

A good second example would be any of the bursae around the greater trochanter, which collectively are called the “trochanteric bursa.” These bursae allow movement of the muscles overlying the greater trochanter against themselves and against the bone. The tensor fascia lata, has to glide against the iliotibial band, and both of these structures are muscles with a big, wide band of tendon. All the muscle-tendon units have to be able to glide over the greater trochanter. The trochanteric bursa allows this by greatly reducing the friction.

All bursae are subject to becoming inflamed, and typical medical advice includes icing, taking NSAIDs, and sometimes progression to corticosteroid injection and even surgical bursectomy.

My take is that all these therapies miss the point. They miss it because they assume that bursitis is the entity. To the contrary, bursitis is a side-effect. To get a diagnosis that can lead to a cure rather than a band-aid approach, integrative and functional medicine need to be employed.

Functional Medicine as the Basis of Diagnosis and Integrative Medicine as a System of Treatment

If you are reading this, I am guessing that you have a sense that there is something terribly wrong with how traditional medicine is being presented to you. You are right. It is not just the money machine, not just “Big Pharma” and not just the unreasonable time pressure your doctor faces. Traditional medicine is at times fundamentally flawed by cognitive errors which are sometimes intertwined with the system errors within medical bureaucracy. There are many cognitive errors in medicine (see https://www.jround.co.uk/error/reading/crosskerry1.pdf). Functional medicine is a step towards correcting some of these cognitive errors that lead to superficial or spurious diagnoses.

Functional medicine looks for underlying causes in a serious way. It’s not just “you contracted bursitis from overuse.” It is more like, “you contracted bursitis because the adjacent tendon/muscle use is under chronic strain due to an adverse biomechanical pattern, under-recovery, sub-optimal nutrition and other specific factors.” This gets to why bursitis should not just be squelched by a steroid injection, but the underlying reasons it happened in the first place should be addressed. Here is an example of how Functional thinking might occur in a certain patient with a subacromial bursitis.

  1.     The patient has gotten “out of shape,” leaving the tendons adjacent to the bursa unhealthy.
  2.     The person got “out of shape” because of work and life stressors that reached a breaking point, leading to the patient taking less time to rest, sleep and exercise;
  3.     Because of time pressure and a shift of priorities from good health to making deadlines, good nutrition such as an exuberant intake of vegetables and a control on calorie intake went by the wayside.
  4.     Because of the inadequate intake of micronutrients (vitamins in food) and rest, tendons are not able to heal from day to day.
  5.     Because the tendons are under stress, the patient takes NSAIDs (non-steroidal anti-inflammatory medications) to deal with the pain. The NSAIDs compound the problem by blocking an “inflammatory” biological pathway in connective tissue healing. This compounds the underlying tendon healing problem.
  6.     Because the patient realizes they are “out of shape” they start exercising, but not with good form and beyond their current ability level, thinking about an earlier era in their life when certain effort and repetitions did not lead to problems. They do military overhead presses which stress the rotator cuff tendons in the shoulder and mechanically damage them by impinging on the acromion bone.
  7.     Because of the impingement, under-nutrition and under-recovery, the rotator cuff tendons begin to develop micro-tearing.
  8.     Because of the micro-tearing, the rotator cuff tendons develop micro-tearing of their collagen sub-units, the collagen fibrils. If I am lucky enough to see the patient at that point, I can see these small injuries on in-office diagnostic ultrasound and address the problem before it progresses to a rotator cuff tear.
  9.     Because tendon micro-tears don’t hurt badly at first, all the above processes continue unabated.
  10. Because the patient is un-aware of an impending problem, they continue to do military overhead presses, and the impingement problem is ever-worsening due to the progressively bad biomechanics that results from a sub-optimal rotator cuff.
  11. Eventually micro-tears of the rotator cuff release enough inflammatory mediators that the sub-acromial bursa becomes inflamed.  In addition, by this point, there is likely a partial tear of the rotator cuff.
  12. The point of this is that the “bursitis” is not an isolated inflammation of the bursa that came out of no-where. It is a result of the adjacent tendons trying to heal from chronic micro-tearing.

At this point, most clinicians are trained and time-pressured to identify and “treat” the bursitis. They are using System 1 thinking, the immediate, emotional response of what seems right (see https://bigthink.com/errors-we-live-by/kahnemans-mind-clarifying-biases for a quick look at that).  Then the doctor might jump right to “inject the bursa with steroid” (unintentionally by often harmful) and move on with the day. In contrast, the Functional approach is to consider all 11 (and more) of the above factors causing the bursitis and deal with each one. This is System 2 thinking.

As you can see, bursitis is not a self-explaining entity and is not a satisfying diagnosis that can be treated with corticosteroids or surgery. Corticosteroids mask the underlying problems and shut down healing processes.  Surgery removes an essential structure. This is where functional and integrative sports medicine comes in. Now, we can think about biomechanical causes while we watch the patient walk, thrown or run. We can find out if they need nutritional help, and we can find out what type of physical therapy will help solve the underlying problems. Sometimes, as in my last published case of the youth pitcher, all we needed to do was link the existing coaching information for the patient into a single pitch, and the stress on the painful joint is relieved. Occasionally biologic and cutting-edge therapies may have a role. Integrative medicine takes a multi-disciplinary approach, for a more permanent and natural solution.

To summarize, a functional approach assesses the patient, adds up the underlying causes, and refuses to accept the presenting symptom as the entire picture. It leads to a diagnosis that is more holistic and more specific. The integrative approach then utilizes several treatment approaches to get a much more comprehensive set of treatment options. Integrative sports medicine asserts a true team approach, where the team synergistically employs the available skills, techniques, and treatments, utilizing any or all parts of my skill-set, and most importantly all the therapeutic community.

Did my 9-year-old throw his shoulder out playing baseball?

Did my 9-year-old throw his shoulder out playing baseball?

A baseball parent recently came into our clinic with his son. The 9 yr-old pitcher was experiencing shoulder pain in the top and back of his dominant throwing arm, but only when he was throwing a ball. Because he played on an active club team,  his arm had few days off from throwing and catching.

While playing the battery makes you an effective baseball player, it can be hard on the body. That’s because this position combines both pitching and catching, resulting in the most throws per week of any position combination in baseball.

To figure out what was going on, we brought the young ball player into the Integrative Sports Medicine office for a throwing and pitching analysis using his own baseball equipment. Our analysis led us to some very interesting observations.

Throwing and pitching analysis

We asked the young boy to bring his baseball gear and demonstrate an authentic throw and catch that he may do during a game or practice session. During the assessment we asked him tons of questions so we could understand the full context to his situation.

What was uncovered:

  1. Muscle overcompensation
    Lackluster power generation in the thigh, butt and back muscles led to an overcompensation in the shoulder. He also tended to drop his elbow and throw with more displacement of the elbow when tired or unfocused. This was creating increased stress on the shoulder and elbow. An imbalance of arm velocity is developmentally normal for a 9/10-year-old and is fixable in a gifted and coachable student-athlete.
  2. Chronic shoulder pain and problems
    Physical exam findings consistent with mild, chronic and repetitive shoulder impingement, likely as result of sloppy arm control during follow through set up by imperfect mechanics from cocking phase through delivery. He also has congenital shoulder laxity (multidirectional instability or MDI). This is consistent with his mother being a hitter in volleyball and also consistent with his ability to put his shoulder through a large range of motion, which in part correlates with arm and ball velocity.
  3. Regular ultrasound results
    A basically normal ultrasound showed mild fluid in the joint but nothing severe. There were no torn structures.
  4. Back to baseball basics
    By asking lots of questions about his past training, we could tell that he knew the basics of how to throw a ball. Due to his age-appropriate brain development, he did not actually realize that he had already gotten pitching coaching but had not consciously linked the throwing elements into a sequence during his pitching motion. He didn’t realize that the purpose of his coach’s drills were for which is completely normal for a 9/10-year-old kid. In fact, when he followed the fundamentals that his coaches had already taught him and put them all together, he had a very good to excellent motion and no pain at all.

The most interesting part of the throwing analysis was that the patient was able to correct his throwing “errors” simply by getting him to remember his deliberate coaching. His coaches have come up with cleverly worded drills to get players to use other muscle groups that activate supportive muscle groups, such as the gluteals, to throw from the lower extremity and back.  For example, when the player incorporated “fart and flush” and “towel drill” together within the same pitch, there was less force on the shoulder and elbow and yet the pitch came in with excellent pace and accuracy. Another observation is that the patient reported a history of throwing for a radar gun, which is common, but in modern Sports Medicine is recommended for all student-athletes at all times.

Raising student athletes

This is a student-athlete who is lucky enough to play in a very sophisticated system of baseball. By dissecting his coaching tips, linking them into a single throw and correcting a tendency to drop his elbow when fatigued or not paying attention, his throw was completely fixed (for now) and he threw better and with less shoulder pain.

It is difficult for a coach to have time to spend large amounts of time with every individual thrower on the team to assess where the player is cognitively in understanding what he is being taught and how to use it.  There are literally not enough hours in the week when dealing with schedules, rosters, parents, and leagues, not to mention the other jobs and family responsibilities coaches have.  However, it is possible for a 9/10-year-old to understand and correct a throw when the coaching base is there and a thorough examination and analysis are turned into a conversation with the student-athlete coupled with actual throwing in real time.

Our success this time had everything to do with having a well-coached student-athlete with very supportive parents with great communication skills and not excessive pressure on the child.  All that made my job a lot easier. It’s important to keep the long-term in mind and not this year’s radar ratings and winning percentage/ERA and championships at the forefront.  I struggle with this myself as a parent.  These are children, not professional athletes and it can be hard to remember (just not in this case) how young they are at times.

From our research-filled and parent and coach friendly website, https://www.stopsportsinjuries.org/ with which I am the official affiliate for Northern Colorado, the max pitches you are allowed to throw per day at this age is 75 pitches, with outings being 4 or more days apart.  This is based on a lot of guesswork and common sense about what we are seeing, admittedly, and not particularly rigorous, hard data.  Despite our shortcomings as scientists, it is fair to agree with the book The Arm by Jeff Passan.  We are in an epidemic of shoulder and elbow injuries occurring at younger and younger ages.  Jeff Passan’s book mainly deals with the epidemic related to Tommy John surgery, so it can be more featured in a future article about the ulnar collateral ligament, but the epidemiology of injury also applies to shoulder overuse injuries in throwers.

Further commentary: there is no role for corticosteroid injections.  These student-athletes need healing time and activity modification, not a drug that shuts down healing, weakens connective tissue of the body and masks injury.  For an older player, regenerative medicine could be appropriate.  A 10-year-old has plenty of growth factors and stem cells in the area of any injury, so changing the biomechanics of the throw and allowing time for healing should be completely sufficient and no medical procedures should be needed.

This player was returned to play on a limited but increasing schedule to be supervised by parents and coaches, including the use of pitch counts and frequent check-ins with the player as to whether he is experiencing discomfort.  If we have learned nothing else over the past 100 years of baseball in this country, it is that injuries can start with minor discomfort, which if ignored can become major injuries with just a few more pitches.  Communication between players and coaches needs to be nurtured into an environment of comfort, honesty, and complete transparency.  We all know that is a major feat when dealing with pre-teens and teens, but it might be the best thing we have to prevent minor injuries from becoming life-changing injuries.

Check out:

https://www.stopsportsinjuries.org/STOP/Prevent_Injuries/Baseball_Injury_Prevention.aspx?WebsiteKey=22144c04-3260-4510-b318-8b5768345a42

Diagnostic Ultrasound – Saving Money

“I think I need an MRI for my shoulder”

A female in her mid-twenties recently visited my office, presenting with right shoulder pain.  She works as a painter and fabricator, a pretty physical job, and she is right hand dominant.  She began having shoulder pain 2 months prior after working a double shit. Since then, she has tried stretching and relative rest, naproxen, and has had no improvement in her pain, except notable improvement every time she gets 2 or more days off work in a row.  After working, she states that she experiences extreme pain in her shoulder, as if “it is going to fall off.” Due to the pain, she has not been getting an adequate amount of sleep. 

The patients primary care physician thought she might have a rotator cuff tear and referred her for a second opinion. She stated that she wanted MRI to “see what is going on,” which is not a rare request.

On physical examination, the patient had:

  • a positive Watsons
  • a negative drop-arm with pain
  • negative dynamic labral shear test
  • irritation of her rotator cuff
  • no significant alteration in her scapulothoracic rhythm

After her exam, my initial impression somewhat aligned with her desire for further diagnostic imaging. Instead of going through the hassle of scheduling an MRI, we were able to achieve clarity through imaging in my office, that day, with ultrasound imaging. Faced with the ability to avoid an MRI, the patient agreed to undergo a diagnostic ultrasound of her shoulder.

The images were as follows:

Figure 1: Axial view of biceps -normal

Figure 2: Long axis view of long head of biceps, normal

Figure 3: Coronal view of subscapularis, normal

Figure 4: Supraspinatus coronal view.  This is normal. The hypoechoic signal on the right is artifact.  Note how collagen fibrils can be seen as intact and linear as they course over the humeral head.  Multiple views are obtained to see the whole tendon.

Figure 5: Infraspinatus, normal.  The hypoechogenicity on the left is the red-white junction.

Figure 6: Teres minor coming off humerus to left, normal.

Figure 7: Normal glenohumeral joint and posterior labrum

Diagnosis  

This is an irritating but benign overuse injury.  There is no macroscopic, anatomic damage to the rotator cuff.  Importantly, she does not need surgery. Since she does not need surgery, she does not need MRI since MRI is a pre-operative study and she did not have labral findings.

Plan of Care

In this case, I advised the patient that the most effective plan would be to rest the shoulder and do physical therapy. Since she will still have to work, she was advised to do more with her left hand to avoid over-using her right shoulder. 

I did not recommend for her to have corticosteroid injections, as they can weaken the rotator cuff and slow certain biochemical healing pathways.  I also advised avoiding NSAIDs (non-steroidal anti-inflammatories such as naproxen and ibuprofen).

If several weeks pass and she has not seen any improvement, I would suspect that she is developing tendinopathy. In order to diagnose, we would use the ultrasound. If that is in fact the case, I would recommend the patient considers PRP (platelet-rich plasma, a way to introduce high concentrations of 7 key growth factors to the injured structure).

Conclusion

Diagnostic ultrasound can provide immediate answers and save the patient a lot of money and time.  Physical Therapy and relative rest and avoiding steroids and NSAIDs are the treatments of choice. If this plan of care did not work and she developed worsening tendinopathy down the line, the Physical Therapist could consider sending her to get consider platelet-rich plasma (PRP) injection for a boost to the tendon healing, which is offered at Integrative Sports Medicine.  

Tendinitis, tendinosis, tendinopathy, tenosynovitis… Which is it?

Tendinitis, tendinosis, tendinopathy, tenosynovitis… Which is it?

Tendons are specialized tissues that connect muscle to bone.  They transmit the forces generated by muscle to bone as they cross a joint, resulting in joint movement.  Basically, skeletal muscle in the body can not cause movement without tendons, so it is important that they are healthy and strong enough to carry the load.  There can be various problems.  Most people starting at age 9 to end of life have pain in a tendon from time to time.   Tendinopathies are one of the most prevalent sports/musculoskeletal pr For patients and parents, a basic understanding can help you know when to get help from a Sports Medicine professional.  For medical practitioners, it is important to be able to distinguish between different types of tendon problems. Future articles will address specific structures such as Achilles and rotator cuff; this article addresses tendon injuries in a broad, introductory fashion.

Not all Sports Medicine professionals use exactly the same terminology for exactly the same problem.  My terminology is modern and generally accepted. Furthermore, tendon injuries and problems morph from one state to another over time, often, and getting a specific diagnosis requires an expert in tendons.

Tendinopathy

I use this term as a blanket term to describe each of the tendon pathologies, just like “tendonitis” was used (incorrectly in my opinion) for all tendon problems a decade or two ago.  There are some useful specific facts about tendinopathy:

  • Tendinopathy generally relates to micro-tearing in the collagen fibrils that traverse the length of a tendon like the parallel fibers along the length of a boat rope.
  • Tendinopathy is a result of insufficient healing of a tendon from day to day.  It is often related to overuse or under-recovery.
  • Tendinopathy may not hurt, which makes it dangerous, because a person can go from a pain free but diseased tendon to a tendon rupture without warning.
  • When there is robust active healing in a tendon, there is usually discomfort.
  • Biologic factors affect the rate of healing of tendinopathy, which is why PRP (platelet rich plasma) and other growth factor sources work.  Things like nicotine, certain pharmaceuticals such as statins and fluoroquinolones, poor nutrition and a poor metabolism are detrimental to tendon healing and can lead to tendinopathy.
  • Biomechanical factors can cause tendinopathy.  Anything that can increase the “dose” of load to the tendon enthesis – including increased activity, weight, advancing age, and genetic factors can cause tendinopathy.  For athletes, the usual culprit is large repetitive loading and lack of adequate rest in between challenges to the tendon.

Fundamentals of the treatment of tendinopathy include relative rest, time, physiotherapy, avoiding NSAIDs in most cases, and encouraging good blood supply and nutrition.  It is usually a good idea to avoid corticosteroid injections, which can weaken the tendon and predispose it to rupture, particularly in repeated injections. In refractory cases of tendinopathy, I’ll do a debridement of non-viable tendon tissue with a Tenex procedure, leaving healthy tenocytes (tendon cells) intact.  This can be followed up with a regenerative medicine procedures. In all cases, chronic or long-lasting tendon injuries need a heavy dose of patience. Tendons generally hurt while they are actively healing.

Tendinosis

Tendinosis is a bad actor.  It is a disorder of impaired inflammation.  In tendinosis, the collagen fibrils do not heal in an organized fashion but become disorganized clumps of abnormal tissue, often forming a lump.  The way I think of this clinically is that a focal part of a tendon has forgotten how to heal, stays chronically unhealthy, and eventually seems to “give up.”  This is a major risk factor for complete rupture of the tendon and for chronicity of the problem. Fortunately, we now have techniques in regenerative medicine that can debride the unhealthy part of the tendon if necessary and / or to “jump start” the natural healing process.  Along with many types of tendinopathy, tendinosis is a particularly good indication for PRP. If there is too much unhealthy inert tissue, I may also need to do a Tenex debridement to clean the area up before PRP.

Tendinitis

Inflammation of a tendon can help heal tendon injury.  There are different kinds of inflammation and they are not all bad.  However, sometimes there is too much inflammation or the wrong kind.  Acute pain and tenderness can be this excessive or pathologic inflammation, and this is the kind of tendinopathy that can be called tendinitis.  This should be initially treated with relative rest and often is self-limited. Occasionally immobilization, injection, physiotherapy or a combination of treatments is needed for a tendinitis that is severe or just won’t go away.

Tenosynovitis

Many tendons are encased in a sheath that completely encircles the tendon and allows the tendon to glide within the sheath.  (A notable exception to that is the Achilles tendon, which has a direct covering of the tendon called a peritenon). When the tendon or tendon sheath develops certain types of inflammation, fluid can be secreted in the space between the tendon and the tendon sheath.  This swelling can cause pain and make it difficult for a tendon to move through anatomic pulleys. This may be self limited with rest, but also sometimes requires immobilization, and injection is sometimes required.

Summary

Tendon injuries come in various forms.  In general they need rest, nutrition, time, Physical Therapy, massage, and sometimes help from a regenerative sports medicine physician like me.  Steroid injections should generally be avoided except in “rescue” situations.