Overuse Injuries: Recovery Time (Part II)

Elbow_Pain_WebRemember last week’s post? Dr.Cohen’s knowledge of “overuse injuries” does not stop at what causes the condition; she has valuable insight on the treatment and prevention as well.

The Mystery is in the History
Careful history taking and examination helps the sports medicine physician diagnose the condition. It is helpful to know what maneuver produces the pain; or when the pain occurs. Many times with an overuse the injury the symptoms will first occur after the activity; then earlier and earlier into the activity until you become symptomatic at rest. It is important to seek medical attention long before that occurs. It is not normal to have pain with the activity. It is important to consult a physician regarding your symptoms, and to find the cause of the injury so that re-injury does not occur once the present injury is treated.

What are the treatment principles for Overuse Injuries?
Management of the condition depends on the severity. Relative rest, which is stopping the aggravating activity while maintaining cardiovascular activity with another activity is one aspect of the treatment program. For example, use of a stationary bicycle or elliptical, or swimming, which are nonimpact activities, might be an alternate activity for a runner while the injury is healing. One needs to individualize the modified activity for the patient and their injury. Other aspects of the treatment plan are pain management with nonsteroidal anti-inflammatory medication as indicated if no contraindication; physical therapy to include instruction in stretching and strengthening exercises; use of an appropriate brace or support for the injured body part; correction of predisposing factors; and modification of biomechanics.

Are there some injury prevention guidelines?
We would all like to prevent an injury from occurring and to maximize our athletic endeavors. Some key points to remember to help get you there are: appropriate training and conditioning for the sport; check your biomechanics for the sport; allow for adequate recovery and do not engage in your sport when you are tired or in pain. Engage in a variety of sports and activities so that you are not always using the same muscles in the same way. Many elite level athletes complement their specialized sport training with another sport. For example, a cyclist might skate or play hockey in the off season to maintain muscle balance of the quadriceps and hamstring muscles of the thigh. It is best to be proactive and prevent the injury from happening.

Dr.Cohen will be discussing Stress Fractures and Biomechanical assessment in future blogs.

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Ready for Spring Sports?

Golfer

Foot and ankle, hand and wrist injury prevention tips by orthopedics specialists

When: February 25, 2015 at 6:30 p.m.
Where: Noble Auditorium, Greenwich Hospital
SpeakersSean Peden, MDMark Vitale, MD, and Paddle and Tennis Professional Patrick Hirscht

If golf or racket sports are in your plans for the spring you will want to hear tips from fellowship trained orthopedic foot and ankle specialist Sean Peden, MD and fellowship trained hand/wrist/elbow specialist Mark Vitale, MD, MPH who will discuss common injuries seen in golf and racket sports. Special guest and local tennis pro Patrick Hirscht will also speak. Learn about common injuries, and how to choose footwear, braces and exercises to prevent injury and play your best; whether it’s the foot, hand, wrist or elbow, they’re all at risk for injury when you’re active. Dr.Peden and Dr.Vitale will discuss nonsurgical and surgical treatments, along with ailments particular to racquet sports. You will have the opportunity to ask questions at the conclusion of the talk. The program is free and open to the public. Registration Requested. Call (203) 863-4277 or register online at www.greenhosp.org.

Posted in Community Outreach, Foot and Ankle, Greenwich Community, Greenwich Hospital, Hand and Wrist, Health Seminar, Medical, Medical Expertise, News and Announcements, ONS Surgical Team, Orthopaedic Conditions, Orthopedics, Physical Medicine, Sports Injury, Sports Medicine | Tagged , , , , , , , , | Leave a comment

ONS Success Story: William McHale

William McHale TestimonialWilliam McHale started off as many other athletes did, full of energy and feeling invincible. As we all know, that feeling of invincibility is only a feeling. In the 7th grade, young William broke his ankle playing football; fortunately he was then referred to Dr. Paul Sethi.

Dr. Sethi considers all of the athlete’s needs which helps set the stage for a successful and timely recovery period and translates into an ideal patient-doctor experience.  When McHale got older, Will started as a linebacker in 30 consecutive games between his sophomore and senior years at  Yale University. During his senior year though, the labrums in both of his shoulders tore. Time was of the essence if he wanted to recover in time for his Pro Day in front of NFL Scouts. Who did he contact? None other than our very own Dr. Sethi.

The MRIs originally taken of the injury did not reveal the full extent of the damage but Dr. Sethi corrected all issues encountered during the surgery . After the procedure William was scheduled to go to physical therapy multiple times a week and overall it took about six to seven months for a full recovery. Since then William has not had any other issues regarding his shoulders.

Where is William McHale now? He played to his full potential on Pro Day, was invited to Minicamp with the New Orleans Saints, and just returned from playing football in France; congratulations!

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Overuse Injuries: Cause and Effect (Part I)

Cohen headshot for letterGloria Cohen, MD is a specialist in non-operative sports medicine who believes in taking an integrative approach to medical management by considering a patients’ bio-mechanics, cardio-vascular and pulmonary function as it relates to athletic performance. Aside from her impressive medical career, Dr. Cohen is a successful competitive runner who has qualified twice for the New York Marathon and is also an off-road and road cyclist. Her academic insights are a combination of both research and real-world experience, the following article is her most recent commentary on the topic of “overuse injuries”:

What is an “overuse injury”?
An “overuse injury” is an injury that results when excessive stress is applied over a period of time to bones, muscles, tendons, and other supporting soft tissue structures of a particular body part.  This differs from an acute injury which happens quickly and is traumatic in nature. Too much stress to a body part will cause the tissues to break down faster than healing can occur, thereby resulting in an injury. A good analogy would be to consider what happens to a credit card or a piece of metal when you bend it back and forth repetitively – first you see the stress reaction, and then with continued stress the item breaks in two.  As you can appreciate, we want to avoid the latter situation when it comes to the body.

What are some common examples of “overuse injuries”?
Every body part can be affected by an overuse injury.  Some common examples you might be familiar with are: rotator cuff injuries of the shoulder; epicondylitis or tennis elbow; patellofemoral pain syndrome of the knee; and tibial stress syndrome or “shin splints” for the lower leg.  Here are a few case examples of classic overuse syndromes:

Jogging injury.

  1. A 40 year old male has recently increased the intensity and frequency of his swimming activity over the summer months. He now complains of pain in the front of his shoulder with overhead and rotation motion. Diagnosis: Rotator cuff tendinitis
  2. A 30 year old female has been playing tennis daily, now competing in matches at a more difficult level. She complains of increasing soreness in the outside aspect of her elbow. She had tried to play through the pain, but had to stop. She says that she can barely lift a coffee cup now because of the elbow pain. Diagnosis: Tennis Elbow /Lateral epicondylitis
  3. A 20 year college student takes up running during her summer break from school. When she returns to school, she decides to train for a half marathon. As she increases her mileage, and adds speed work to her training program, she develops pain in the inside aspect of one shin. She now complains of pain with just walking. Diagnosis: Shin splints/Medial Tibial Stress Syndrome

What are some of the specific causes of these “overuse injuries”?
As a primary care sports medicine physician I recognize that there are sport specific issues which may contribute to the resulting injury; but there are common “intrinsic” and “extrinsic” factors which play a major role in the development of these types of injuries. “Intrinsic” factors refer to the elements that we cannot control but that we can modify.  These include biomechanical alignment, such as knock knees, bowl legs, flat feet or high arched feet; leg length difference; muscle imbalance; muscle weakness; and lack of flexibility.  These factors can be modified to maximize the individual’s performance, and thereby treat or prevent injury.  An example would be a conditioning program and sport specific training. The “extrinsic factors” include training errors, such as doing “too much too soon”; training surfaces – running on too hard a surface, or playing on an uneven surface; shoes – it is important to wear the appropriate type of shoe for your foot mechanics and the sport; equipment; and environmental conditions. Paying attention to the “extrinsic factors” will help you modify the “intrinsic” ones.

… to be continued in the next segment, Overuse Injuries: Recovery (Part II)

Posted in Injury Prevention, Medical Expertise, Orthopaedic Conditions, Orthopedics, Prevention, Running, Sports Injury, Throwing Injuries | Tagged , , , , | Leave a comment

Maximizing Your Child’s Athletic Potential: Expert Advice on Training Smarter and Preventing Injuries

Demetris Delos, MD

Demetris Delos, MD

When: Thursday, January 22, 2015, 7 -9 p.m.
Where: Greenwich Library, Cole Auditorium
Speakers: Demetris Delos, MD, Andy Barr and Mubarak Malik, moderator Allan Houston

Join the Junior League of Greenwich and the Greenwich Library for a discussion moderated by two-time NBA all-star Allan Houston and featuring a panel of experts from the NBA and NFL on the prevention of adolescent sports injuries. Former Knicks star and Greenwich resident Allan Houston is one of the NBA’s all-time greatest long range shooters, an Olympic gold medalist, current Assistant General Manager of the NY Knicks and spokesperson for the National Fatherhood Initiative.

Panelists include Andy Barr – Director of Performance and Rehab for the New York Knicks, Mubarak Malik – Head of Strength and Conditioning for the New York Knicks and Dr. Demetris Delos – orthopedic surgeon at ONS (Greenwich Hospital) and formerly of the NY Giants.

The Junior League of Greenwich and the Greenwich Library aim to educate parents about helping their kids reach their full physical and athletic potential. Admission is free but seats must be reserved online at www.greenwichlibrary.org.

Read Press Release

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ONS SPONSORS: Waveny LifeCare Network Mixed Paddle Tournament

men playing paddle tennisWaveny LifeCare Network Mixed Paddle Tournament

When: February 28, 2015 from 5:30 – 9:30 p.m.
Where: Four Paddle Courts – Country Club of New Canaan, Field Club of new Canaan, Waveny Paddle Courts and The Lake Club

Sign-up to play: Call Joanne Boyer at 203.594.5416 or email jboyer@waveny.org

ONS sponsors Waveny LifeCare Network, a not-for-profit comprehensive continuum of care that has served the needs of New Canaan and the greater community since 1975. Waveny LifeCare Network offers a progression of therapeutic programs, services and living options to enhance the quality of life of those they serve.

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Getting Ready for the Slopes: Ski Conditioning

chalonChalon Lefebvre is the Clinical Manager and Coordinator for Education at ONS Physical Therapy. Chalon is from Vermont where she was a ski racer and continues to lecture on ski injury prevention, the following is her expert advice for the season:

Certain exercises come to mind when I think about growing up as a ski racer in Vermont. Wall sits, crunches, push-ups, lateral bounds and lots and lots of box jumps got me into shape but were they really the best exercises for ski conditioning? Not necessarily, but they were on the right track. As a physical therapist, I now understand skiing and the biomechanics that go along with the sport. I understand the appropriate exercises that help to prevent injury while conditioning people so they are ready to enjoy the season.

Skiing can be broken down into concentric (muscles shorten/lifting portion of the movement against gravity) and eccentric (lowering portion while lengthening) movements. Skiing starts at the top of the mountain, as you ski down, you perform eccentric movements the entire way, resisting gravity’s pull by controlling your body’s movements. EMG studies have shown that throughout the ski turn, the prime movers and stabilizers change at different points in the turn and therefore it is important to work your muscles in functional patterns consistent with the sport.

1) Lunges are an amazing exercise for skiers. Lunges work the quadriceps, glutes and hamstrings. Both your legs are working independently of one another in concentric and eccentric motions. To perform a good lunch, stand with both feet positioned shoulder width apart and step forward with one foot making sure to step far enough so that your knee does not extend past your toes and your shin is nearly vertical, and then step back into the start position. This exercise can progress to walking lunges or by lunging while holding dumbbells in your hands. Once you are proficient, you can make these a plyometric exercise by jumping in between each lunge.

2) Squats, whether one footed and two footed, work your quadriceps and glutes. Start with your feet shoulder width apart with your back slightly arched. Initiate the squat by sitting back and down keeping your weight through your heels. Lower yourself so that your thighs are parallel to the floor (or as low as you can) being careful not to let your knees fall in front of your toes. This exercise should be done at high repetitions for endurance.

Ski_Web_II

3) The Romanian deadlift is one of the best and most functional hamstring exercises. ACL tears often occur because people have a strength imbalance between their quadriceps and hamstrings. Stand holding a barbell or a dumbbell in each hand with your feet shoulder width apart. Maintain the lordosis in your lower back and keep a slight bend in your knees, lower the weight towards the floor until you feel a slight stretch in your hamstrings. Reverse the movement by contracting your hamstrings and glutes and push your hips forward as you return to the starting position. This exercise can also be done on one.

4) Planks and side planks work your abdominals, erector spinae, and glutes. Both of these exercises will provide you with the core strength that you need to be able to hold yourself upright while skiing. Lie on your stomach; place your hands at either side of your chest and tuck your elbows in at your sides. Keep your back flat, and push up onto your toes and elbows so that your body is off the floor. Pull your abdominals into your spine and try to maintain this position for 10 seconds to two minutes. If this is too challenging, this can also be down on your knees. A side plank is done using one arm and on one side at a time.

5) Lateral bounds work on agility and reaction time and when done consecutively will carry over to your ski turns. They can be done one footed or two footed. Create a line on the floor and jump sideways across the line, when your feet land, immediately jump back to the other side. This can be done for time as well as number of repetitions.

Although this is just a taste of what I would include in a ski conditioning program but are some of my favorite exercises for keeping my clients injury free and having fun on the mountain.

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The Fragile Feet: A Gymnast Story (Part II)

Gymnast

Gymnast on balance beam.

Remember last week’s post? Surprisingly enough, gymnasts share a lot in common with ballerinas, especially in terms of injuries of the feet.

Both gymnasts and dancers place a tremendous amount of stress on their feet for a significant amount of time per week – often greater than 10 hours a day. Because of this combination of stress and time, stress fractures are common. Stress fractures can occur almost anywhere in the foot or ankle, but the most common locations are the metatarsals, navicular, tibia, calcaneus, and fibula. A key to avoiding stress fractures is proper nutrition, avoiding disturbances in the menstrual cycle, and proper technique and amount of training. A gymnast who trains 4 hours a week that increases the workload to 10 hours a week in preparation for a performance without any ramp up is a setup for stress fractures. A better way to ramp up training would be to increase the workload by approximately 25% per week, or going from 4 hours a week to 5 hours a week and so forth. The treatment of stress fractures varies depending on the location and character of the fractures. It also depends on the patients demands and expectations. In most situations a period of immobilization and rest is all that is necessary.

Young gymnasts often complain of various painful lumps and bumps on the feet. Some of these are calluses, which are the bodies response to repetitive force on areas of weight bearing. Another extra bone in the foot – the accessory navicular, also thought to exist in about 10% of all people – can be a troublemaker for gymnasts in particular. It is a tender prominence on the inside of the ankle. Flatfooted patients will sprain or strain the ligaments that attach to the accessory navicular. Continued activity worsens the symptoms and the first line treatment is a period of immobilization to allow it to heal. When that fails, the extra bone is excised, and the damaged tendons and ligaments on the inside of the ankle are repaired or reconstructed.

Many of the problems in both ballet and gymnastics results from the nature of the sports – long hours and repetition in little to no footwear. These patients are predisposed to develop certain problems based on the alignment or posture of the feet. Feet come in two general shapes – flat and high arched. In reality it is a spectrum. So many problems can be treated simply by accommodating or adjusting a patient’s flat or high arch with a specific type of shoe or insert (orthotic). Unfortunately, the competitive gymnast and dancer cannot wear athletic shoes or orthotics. Some may be able to train in orthotics or custom shoes and that is important to keep in mind.

Want to learn even more? Dr. Peden will be giving a seminar on “Solutions for Foot and Ankle Pain: Beyond a Foot Massage.”  The program is free and open to the public. Registration Requested. Call (203) 863-4277 or register online at www.greenhosp.org.

Posted in Foot and Ankle, Health Seminar, Medical, Medical Expertise, Orthopaedic Conditions, Orthopedics, Physical Medicine, Seminars, Sports Medicine | Leave a comment

The Fragile Feet: A Ballerina Story (Part I)

Ballerina

Ballerina in en pointe position

Dr. Peden of ONS and Greenwich Hospital is an orthopedic surgeon specializing in foot and ankle surgery and treatments for adult foot conditions as well as youth sports injuries in field athletes, gymnasts and ballet dancers. He shares a two-part blog about conditions to be aware of for ballet dancers and gymnasts.

Ballet dancers feet are much like a musician’s handsthey earn a living with them. In addition to putting an amazing amount of stress on their feet, they also are often well below an ideal body weight – either because of the stress of an enormous amount of training or because of unrealistic expectations placed on them by the ballet community. This leads to several different and often unique foot and ankle conditions.

One fairly unique foot and ankle condition in ballet is caused by the en pointe position. In this position an enormous amount of strain is put on the dancer’s great toe, as it is essentially holding up the entire body weight through a small joint. The main flexor tendon of the toe, called the flexor hallicus longus – normally quite small, takes over the job of the largest tendon in the body, the Achilles. The flexor hallicus longus hypertrophies well in compensation for its new job, but unfortunately this tendon is forced through a tight tunnel in the back of the ankle. When it gets too large it will get pinched in the posterior ankle joint. Patients develop painful irritation of the bones and soft tissues in the posterior ankle. An extra bone in the posterior ankle called the os trigonum, which present in about 10% of all people, can be become very painful and irritated in many ballerinas. This constellation of problems is called posterior impingement of the ankle, and it is noticed by the patient as a vague deep pain in the posterior part of the ankle, in front of the Achilles, that is felt with plantarflexion, the position of pointing the foot and toes downward.

Ballet dancers suffer from numerous other problems of the foot & ankle, many of which are not unique. One of the less glamorous problems they deal with are corns, calluses, and blisters. These are necessary adaptations to allow a high level dancer to compete.

Similar to posterior impingement, which arises from dancers spending an inordinate amount of time and stress in an extreme position at the ankle, ballet dancers will develop anterior impingement at the ankle. This comes from repetitive forceful dorsiflexion – pulling the foot and toes upward, toward the shin. Landing from jumps and deep knee bends exacerbate this problem. Pain is felt in the anterior ankle.

Treatment for the above condition is customized to the patient. Often a minor activity modification, or period of rest, can dramatically improve the symptoms. Unfortunately, rest is not easy to come by in the competitive living of a gymnast. Many dancers will treat the symptoms with a combination of anti-inflammatory medications and occasional steroid injections in the region of maximal tenderness. Surgery is a last resort option for any ballerina – when symptoms persist for many months and are limiting, despite all other efforts. Surgery is typically very successful in these patients and can be done with arthroscopic or minimally invasive techniques.

The most common orthopaedic injury of all is also very common amongst ballet dancers: the lateral (traditional) ankle sprain. The mainstay of treatment for ankle sprains is rest, ice, compression, and elevation – mnemonic RICE. A short period of rest and immobilization (1-2 weeks) is followed by aggressive physical therapy, with strengthening of the muscles that stabilize the ankle. Recent research has pointed to improved short and long-term outcomes when early motion and weight bearing is initiated. There is promising early research on the role of stem cell injections – harvested from the patient’s own blood or bone marrow – in the setting of an acute ankle sprain. This is a technique we will offer for the highest level athletes and dancers in certain situations, understanding that the research data on this intervention is still in development.

… to be continued in the next segment, The Fragile Feet: A Gymnast Story (Part II)

Want to learn even more? Dr. Peden will be giving a seminar on “Solutions for Foot and Ankle Pain: Beyond a Foot Massage.”  The program is free and open to the public. Registration Requested. Call (203) 863-4277 or register online at www.greenhosp.org.

Posted in Foot and Ankle, Health Seminar, Medical Expertise, Orthopedics, Physical Medicine, Prevention, Sports Medicine, Treatment, Uncategorized, Women's Sports Medicine | Tagged , , , , , , , , , , | Leave a comment

What do you do when you are diagnosed with an old (chronic) Achilles tendon rupture?

Sean C. Peden, MD

Sean C. Peden, MD

Sean Peden, MD is an orthopedic surgeon who specializes in foot and ankle surgery. Dr. Peden has expertise in treating a variety of foot pain and deformity related conditions including Achilles tendonitis, ankle instability, cartilage injuries, bunions and hammer toes.  His practice will also focus on youth athlete sports injuries and the types of injuries seen in field athletes, gymnasts and ballet dancers.

Achilles tendon ruptures will often not be discovered for months after the injury. In the months between injury and showing up at the doctor’s office, the torn tendon develops scar tissue which decreased the quality and elasticity of the tissue. Because of this, directly repairing the torn tendon, as is done in an acute injury, becomes is less than ideal. In this situation, we will supplement the tendon repair with a tendon transfer. Essentially, we borrow a tendon that bends the big toe (there is another tendon that compensates when it is borrowed), reroute it, and reattach it to the heel bone. This does two very important things:

 

1. It supplements the strength of the torn Achilles, allowing a quicker and better recovery.

2.It provides improved blood supply to the Achilles repair, providing healing factors to the area of diseased tendon.

In summary, ruptures of the Achilles Foot_AnklePictendon are increasingly common in our aging yet increasingly active population. In cases where an Achilles rupture is missed or the rupture cannot be repaired directly under normal tension, adding the flexor hallicus longus tendon transfer allows for significantly improved results with a shorter recovery.

If you suffer from foot and ankle pain and would like to attend a free seminar, Dr. Peden of ONS and Greenwich Hospital will present Solutions for Foot & Ankle Pain: Beyond Foot Massage is an orthopedic surgeon specializing in foot and ankle surgery. He will present treatments and surgical techniques for bunions and other foot deformities. Learn more and register online here.

Posted in Community Outreach, Foot and Ankle, Greenwich Community, Greenwich Hospital, Health Seminar, Management, Medical, Medical Expertise, News and Announcements, ONS Surgical Team, Orthopaedic Conditions, Seminars, Treatment | Tagged , , , , , , , , , | Comments Off