Total Knee Replacement from a familar patient's perspective

NBC Nightly News Anchorman, Brian Williams, just underwent his first total knee replacement at the age of 54. His story is not unlike many of the "Baby Boomers" I see in the office: played sports at a young age, had a few injuries over the years, now experiencing the price of pain. Although there are some temporary non-surgical things we can do to lessen the symptoms of joint pain, the knee replacement has long been a reliable option to treat severe arthritis. <http://dailynightly.nbcnews.com/_news/2013/08/16/20055492-brian-williams-on-knee-replacement-and-why-he-has-disappeared-from-tv-for-a-while>

"Will I be able to play golf after surgery?"

NBA Hall of Famer Charles Barkley is recovering from a torn biceps tendon that was injured while weightlifting.

The biceps muscle is in the front of your upper arm. It helps you bend your elbow and rotate your forearm. It also helps keep your shoulder stable. If you tear the biceps tendon at the elbow, you will lose strength in your arm and be unable to forcefully flex and turn your arm from palm down to palm up (eg, opening a doorknob, unscrewing a cap, turning a wrench). This is called supination. Significant, permanent weakness during supination will occur if this tendon is not surgically repaired.

There is often a "pop" at the elbow when the biceps tendon ruptures. Pain is severe at first, but it may subside after a week. Other signs include: swelling and bruising in the front of the elbow, weakness in bending and twisting the forearm (supination), a bulge in the upper arm (created by the recoiled biceps muscle) and a gap in the front of the elbow (created by the detached tendon).

Surgery should be performed to repair the torn biceps tendon unless you are elderly, inactive, or have medical problems that are too risky for moderate surgery. Surgical results are excellent in returning strength and range-of-motion after a few months of postoperative therapy. Maybe it will help Charles' golf swing!

A biceps tendon repaired back to bone with the assistance of a button and calcium screw.
(From the files of Dr. Jerome Enad, Orthopedic Surgeon)

Is your Smartphone or Computer causing you injury?

Upper extremity overuse syndromes are making a comeback with modern day technology. For example, one used to suffer from “DeQuervain’s Tendonitis” with gripping activities during manual labor or when first-time mothers would repeatedly carry their newborn. Pain and swelling of the tendons at the bottom of the thumb would occur as the wrist would be overused and become inflamed. Now, we see DeQuervain’s in many people as an overuse syndrome from using smartphones and texting - same tendons, same inflammation, different activity that caused it. Similarly, too much texting can aggravate any pre-existing arthritis at the base of the thumb (i.e., “basal joint arthritis”), also. Surprisingly, we are not seeing an increased incidence of carpal tunnel syndrome related to smartphones and texting, probably because the main nerve is not being compressed with this type of finger motion.

However, other common computer use habits are bringing back old conditions. Touch screens can cause tendonitis at the tip of the finger if striking the screen too hard, or can also cause finger sprains (i.e., “Mallet Finger”) at the fingertip. Further, frequent use of the computer mouse has resulted in a condition recently coined “Mouse Elbow,” which is an overuse tendonitis at the outer part of the elbow that was previously referred to as “Tennis Elbow.” The muscles of the wrist and forearm that help you grab, click, and maneuver the mouse attach to the lateral elbow and can frequently become inflamed with overuse. We also use these muscles for driving, eating, reaching, etc. so it is difficult to give them the proper rest they need.

Fortunately, all of these “modern day technology” conditions can usually be treated by decreasing the amount of time spent on the activity that caused them, using ice and oral or topical anti-inflammatory medication, sometimes a brace helps in properly positioning your hand or wrist to cause the least amount of irritation, or possibly a cortisone injection. Surgery may be recommended for severe cases that do not go away.

See your local orthopedic surgeon if you believe you need treatment for any of these conditions.

"It felt like someone kicked me!" - The Achilles Tendon Rupture

Kobe Bryant is now 3 months postop from his Achilles tendon repair after he ruptured it toward the end of the NBA season. Surgery was done by my mentors (Doctors Neal ElAttrache and Stephen Lombardo) at the Kerlan-Jobe Orthopedic Clinic in Los Angeles.

The Achilles tendon connects your calf muscle to the heel and helps you point your foot downward and push off as you walk. If stretched too far, the tendon can tear (ie, rupture), causing severe pain in the ankle and lower leg that can make it difficult or even impossible to walk. An Achilles tendon rupture might occur after repeated stress on the tendon and may be partial or complete, depending on the severity of the injury.

Injuries to the Achilles tendon are common and are usually caused by several different factors, including:

• Overuse
• Poor stretching habits
• Tight or weak calf muscles
• Flat feet
• Wearing shoes that do not fit properly
• Engaging in physical activity after a long break

After an Achilles tendon rupture, people often experience severe pain and swelling, and are unable to walk normally or bend their foot. You may hear a pop or snap with the rupture, or you may feel like someone kicked you in the calf. However, these symptoms are similar to other conditions, such as bursitis and tendonitis, so it is important to seek prompt medical attention in order to determine the correct diagnosis of your condition.

Treatment for an Achilles tendon rupture depends on the severity of the condition, but often requires surgery to repair the tendon and restore function to the foot. Less severe cases may only require a cast or walking boot for several weeks, although the risk of a recurring rupture is higher. Patients can help prevent an Achilles tendon injury by stretching the tendon and nearby muscles before participating in physical activity.

Hoffa Syndrome: Impingement of the Fat Pad of the Knee

Here is a great illustration of the amount of pressure tennis pro Rafael Nadal places on his knee during play.  Impingement of the fatpad behind the kneecap is known as Hoffa Syndrome.

Symptoms & findings include:

• Pain and/or swelling behind or below the kneecap
• Possible history of knee hyper-extension (called genu recurvatum)
• Positive finding on "Hoffa’s test" physical exam manuever by a sports medicine physician

Treatment should start with non-surgical:

• Rest and avoiding aggravating activities
• Ice or cryotherapy
• Anti-inflammatory (pills or injection)
• Physiotherapy modalities such as ultrasound or TENS.
• Muscle strengthening
• Kinesio-Taping

If conservative treatment does not work then surgery may be advised. This may involve the complete or partial removal of the fat pad itself.  See a sports medicine specialist if you think you have Hoffa Syndrome.

You Don't Have to be a Golfer to get Golfer's Elbow

I was recently asked to comment on Cincinnati Reds middle reliever Jonathan Broxton being placed on the Disabled List due to a flexor mass strain in his elbow. This ailment is a type of "Golfer's Elbow" (a.k.a. medial epicondylitis) that occurs in recreational athletes or people who participate in work that requires repetitive and vigorous use of the forearm muscles (for example: painters, plumbers, carpenters, auto workers, cooks, and even butchers). It is thought that the repetition and power grip required in these occupations leads to injury.

Most people who get medial epicondylitis are between the ages of 30 and 50, although anyone can get it if they have the risk factors. In sports like golf, improper stroke technique, poor flexibility, and improper equipment may be risk factors.

Almost always the condition gets better without surgery, but treatment is necessary. Treatment programs include a temporary rest from the offending activity (for example, lay off sports or light duty at work), anti-inflammatories (preferably pills but possibly an injection), checking the equipment you're using for proper size and weight, physical therapy for stretching and pain-relieving modalities, and possible use of a special brace that takes pressure off of the medial epicondyle muscles.

Images from the American Academy of Orthopaedic Surgeons


The condition will usually wax and wane before it goes away with treatment.

Have you ever had Golfer's Elbow? What caused it and what did it take for you to get better?

Why all the Hamstring Injuries in Major League Baseball?

It looks like Los Angeles Dodgers All-Star outfielder Matt Kemp is headed back to the Disable List with a right hamstring injury this year (last year he injured his left hamstring and missed 51 days). Of the 189 players currently on the MLB DL, 19 are for hamstring injuries, greater than 10%.  A study published in the American Journal of Sports Medicine in 2011 noted that hamstring injuries comprised 13.5% of injuries for position players and 8% overall.
So why all the hamstring injuries in baseball? Traditional thinking had blamed tightness, poor warm-up and poor conditioning of the posterior chain of the body (i.e., hamstrings, gluteals, piriformis). However current thinking takes it a step further. Tightness and poor warm-up cannot be overcome with static stretching (like reach-and-hold type of stretching). Only dynamic stretching (flexibility through movement) will condition the muscles to handle the sudden start and stop movements of baseball. Also, single line strengthening, such as hamstring curls and squats, do not adequately prepare the muscles for the twisting/turning/cutting/pivoting movements that frequently cause injury during sports. Therefore, diagonal and multi-directional strengthening is needed to condition the muscles to handle these complex movements. These contemporary approaches are already being incorporated into MLB conditioning programs, and we hope they will result in a decrease in hamstring injuries.

Have you ever had a hamstring injury? What did it take for you to get better?