Skiing ACL Injuries and Recovery

 

The anterior cruciate ligament, frequently known as the ACL, is the most commonly injured ligament in the knee. Approximately 1 in 3,000 people injure their ACL every year. Several of these injuries occur while skiing in the winter months. Skiers are more susceptible to ACL injuries because they are constantly flying over bumps, landing a jump on the tails of their skis, recovering from a skid, or finding themselves temporarily off-balance. Most skiing injuries occur when a skier “catches an edge” as a result of these actions and their ski is pushed sideways and to the outside, resulting in a twisting motion of the knee. Advancements in surgical techniques and rehabilitation over the years have allowed patients with ACL injuries to participate in early pre and postoperative rehabilitation to return the patient to a preinjury performance level.

Before surgery, patients should focus on reducing knee swelling and establishing a normal walking pattern and active range of motion between 0° and 90°. Elevating the leg with a cold compress or using compression sleeves are two techniques that can be used to reduce knee swelling after the initial injury. If a patient is stable with a normal walking pattern, they may keep the brace unlocked and bear weight while performing daily activities. Otherwise, the brace should remain locked to provide support to the unstable knee. Patients should establish a good range of motion after the initial injury because preoperative range of motion is an important predictor of postoperative range of motion.  

To re-establish range of motion, please try some of these techniques:

1.    Prone hangs: Lie on stomach and slide down to the end of the table so that the thigh is supported and the lower leg hangs off. Hold this position for 30 to 60 seconds and repeat 5 to 10 times.

https://www.youtube.com/watch?v=nBjoOQ3D0cs

2.    Heel slides: Lying on your back, slide your heel towards your butt

https://www.youtube.com/watch?v=_jvUnWbBPXc

3.    Prone flexion: Lying on your stomach, flex your knee and bring your foot towards your butt

https://www.youtube.com/watch?v=lFz0wn_ssxs

               During the early postoperative phase (0-4 weeks after surgery), patients must strive to minimize pain and swelling, form a normal walking pattern with a goal to discontinue crutch use, achieve 90° flexion and full extension, and establish quadriceps function and control. Always ensure that the incisions are clean and dry and the knee is iced and elevated until the acute inflammation is controlled. After this inflammation is controlled, ice and elevate the leg 3 times a day for 15 minutes. Weight bearing with a brace and both crutches should also begin the day of surgery. Crutch use should be discontinued when the patient establishes a normal walk pattern without a limp and can walk up and down stairs without pain or instability. This phase is also important to establish range of motion and quadriceps function. We recommend attending physical therapy 2 to 3 times a week to extend range of motion to 120° and demonstrate straight leg raises without lag by week 4.

               During the strengthening phase (4 weeks-6 months after surgery), the brace should be shortened and unlocked. There should not be an increase in swelling or pain and the patient should focus on proper technique and achieving full range of motion as soon as possible. The following exercises should be performed during this phase of recovery: mini-squats, mini-lunges, leg press, hamstring curls, step-downs, wall sits, one-legged dead lifts, and 4-way hip exercises. Weights should gradually increase as strength improves. The patient can also start walking for exercise and use balance cushions to improve endurance and balance.

               The return to activity phase begins 3 months after surgery and ends when the patient returns to his or her sport. The patient must continue improving muscle strength with activities such as squats, lunges, plyometrics, and agility drills. At the beginning of this phase, the patient should perform low-impact activities on softer surfaces, eventually introducing walk/jog intervals and agility ladder drills, and finally cutting and pivoting with advanced plyometrics and team participation without contact. Each patient is unique and his or her return to sport should be individualized instead of follow a strict time line. Once the patient can jump without pain or instability, has full range of motion, regained muscle strength and balance, and can perform sport specific activities without pain, swelling, or instability, the patient is ready to return to the sport. 

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If you suspect you have an injured ACL, it is important to see an orthopedic surgeon. To schedule an appointment with board certified orthopedic surgeon, John Vitolo, MD, call 973-300-1553.

Bankhart Repair – Arthroscopic Stabilization of the Shoulder

Bankhart repair, also known as arthroscopic labrum repair of the shoulder, is performed to fix a detached labrum. The labrum is a circumferential structure that is surrounds the glenoid, which is the boney socket of the shoulder. There are also ligaments that surround the shoulder that attach to the labrum. Together the labrum and the attached ligaments act as a stabilizer for the joint.

A Bankhart tear occurs when the labrum is torn away from the bone. These tears are often a result of a shoulder dislocation which also tears the anterior inferior glenohumeral ligament. Because the ligaments and labrum are no longer attached to the bone, the shoulder becomes unstable and requires appropriate treatment.

Acute Bankart tears are more common in young individuals, usually under the age of 35. Initially, conservative treatment may be implemented, but if repeat shoulder dislocations occur, surgical repair of the labrum and ligaments is recommended. When surgery is indicated, arthroscopic stabilization of the shoulder or a Bankart repair is performed. 

How is the Bankart Repair Performed?

The Bankhart repair is performed by making a few small incisions in the front and back of the shoulder. A video camera (arthroscope) is inserted to view the inside of the shoulder joint. Small instruments are then inserted to perform the repair. 

The first step of the Bankhart repair is to prepare the area around the detached labrum. Any loose particles are removed and rough edges are made smooth. The orthopedic surgeon then drills a small hole in the bone by the detached labrum. An anchor and suture are then placed in the hole, and the suture from the anchor are sewn into the labrum and pulled tightly to reattach it to the glenoid. The steps are repeated for each anchor, and the amount of anchors used depends on the size of the labrum and ligament tear. The small incisions are then sutured closed. 

After the procedure, the patient is asked to remain in a sling for about 4 weeks to allow the labrum to heal to the bone. Physical therapy is then typically prescribed 3x a week for 12 to 16 weeks. Patients can normally return to desk work after 2-4 weeks and physical labor and sports within 4 months. 

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If you suspect you have a labral tear it is important to see an orthopedic surgeon. To schedule an appointment with board certified orthopedic surgeon, John Vitolo, MD, call 973-300-1553.

Looking At the Whole Picture

Medical tests have evolved dramatically over the past 50 years. MRIs are revealing details of the anatomy that we could not see historically. The advances are incredible and valuable, but as physicians, we must remember the importance of looking at the full picture.

In my experience, each tool we use fits a piece of a puzzle that reveals the most appropriate treatment protocol. We cannot and should not depend solely on imaging to determine if surgery is needed. The imaging tools today are advanced and may show an injury that is not necessarily the root of the pain. In order to determine the most appropriate treatment we must also rely on the physical exam and medical history of the patient.

Exams

Traditional physical exams are vital to identifying the appropriate course of action when treating patients. For example, a patient complaining of shoulder pain may have an MRI showing multiple injuries. However, it is possible that one injury was pre-existing and not the root of the pain. By utilizing physical exams, such as the Hawkins-Kennedy Impingement Test or the Neer’s Test, we can identify the injury causing pain and then use the MRI to gather more information. 

History

It is vital to talk to patients and gather information about their personal medical history. By understanding the type of work they do and the lifestyle they lead, we can determine the treatments that will be most effective. For example, certain surgical procedures may be more appropriate for athletes, while a more conservative approach may be the better option for someone who works a desk job. 

Imaging

Imaging provides physicians with the ability to see inside the body and identify the scope of the injury or condition. X-rays give us a way to see bones and diagnose fractures and arthritis, while MRIs allow us to see the soft tissues. CT scans provide images of internal organs, bones, soft tissue and blood vessels and are able to provide greater detail than traditional x-rays, particularly of soft tissues and blood vessels.

In this technologically advanced world we live in, it is important to remember that all the diagnostic tools tie together to create the most appropriate treatment plan for each patient. If we as physicians solely relied on one piece (i.e. imaging) we may be doing a disservice to the patient and miss a detail that could be vital to that person’s recovery. In an upcoming series, we will review tests that are used during orthopedic physical exams and describe what each test is used to diagnose.

Injury Prevention: Little League Pitch Counts and Rest

© sherrie smith | Dreamstime Stock Photos

We have discussed pitch counts and injury prevention for our young athletes in the past, but with baseball season upon us, it is important to remind parents and athletes of the guidelines. Young athletes feel invincible and feel injury "won't happen to them". As a physician with over 20 years of experience in sports medicine, I can assure you that injuries can and do happen. Luckily, some simple precautions can help minimize injury risk.

It is important to mention that while the old adage “practice makes perfect” is true, our youth need guidance in order to prevent injury. Overuse injuries in school aged athletes are on the rise. The incidence of shoulder and elbow injuries among youth baseball and softball players is five times greater than it was in the year 2000.[i]

Many of these baseball injuries are preventable. In recent years, Little League Baseball has released guidelines and enforced regulations to help prevent injury in young athletes (see charts below). The league has put limits on pitch counts during games and also enforced required rest periods. All the guidelines are based on the age of the athlete.

While the guidelines from Little League Baseball are important, there are additional steps that can be taken at practices and off the field.

Here are some tips:
1. Always warm up – stretch, jog and begin with some easy, gradual throwing
2. Try different positions – different positions require the use of various muscle groups
3. REST – don’t play year round and allow rest between games
4. Focus on your form, accuracy and control
5. If you have shoulder or elbow pain, do not pitch
6. Talk to your parents and coaches about any pain – do not play through the pain!

Getting kids involved in sports at an early age is a great idea, but it is important to remember an injury can end their baseball career too soon. By following the suggestions outlined here, injury can be avoided and a lifelong love of baseball and activity can be built!

Lateral Patellar Instability and the Medial Patellofemoral Ligament (MPFL)

Lateral patellar instability occurs when the kneecap dislocates out of place. The kneecap or patella is a small bone in the front of the knee. It glides along the femoral groove (a groove in the femur bone) as the knee bends and straightens. If the patella comes out of the groove completely, it is referred to as patellar dislocation. If the patella comes out of the groove partially, it is referred to as patellar subluxation.

Symptoms of dislocations of the kneecap are as follows:

-          Pain at the knee joint
-          Swelling
-          Obvious displacement of the kneecap (kneecap can often briefly dislocate and return, but pain and swelling will still be present)

When the kneecap dislocates, it often tears the medial patellofemoral ligament on the inside of the knee. The MPFL is a thin band of tissue that attaches the kneecap to the inner part of the knee. The medial patellofemoral ligament or MPFL is important for stability in the knee.

There are surgical and non-surgical treatments for patellar instability. Rest, ice and bracing have been known to heal the injury and prevent recurrent dislocations. However, surgical intervention is sometimes needed to correct recurrent dislocations.

If the MPFL is torn, the patient can potentially benefit from a surgical procedure known as MPFL reconstruction. Reconstruction of the MPFL is a surgical procedure that restores patellofemoral stability. The most successful and widely accepted approach to this procedure is to use an approach that restores the MPFL to its anatomically correct position. This procedure, along with other options, such as tibial tubercle osteotomy, and/or a trochleoplasty can be used to correct the problem. The exact treatment protocol varies by individual.

 

Prominent Orthopedic Surgeon to Open Office in Chester, NJ

Advocare Orthopedic and Sports Medicine Center, the office of NJ Top Doc orthopedic surgeon, John Vitolo, MD announced the opening of a satellite office in Chester, NJ on January 27^th 2015. The office will be located at 530 East Main Street in Chester, Suite 4A, with Advocare Aygen Pediatrics and Adult Care. This office location is being established to better suit the needs of patients from Morris County.

The new office is Advocare Orthopedic and Sports Medicine Center’s second location. “Opening the office in Chester is an important step toward expanding our practice into Morris County,” said Vitolo, “When we were presented with the opportunity to open an office in Chester, we looked at the area and noticed a need for orthopedic care. We are very excited to have this opportunity to offer quality orthopedic care in the area.”

The new office will focus on the treatment of orthopedic injuries and conditions of the shoulder and knee. Dr. Vitolo has over 20 years of experience treating sports and workplace injuries. Dr. Vitolo is committed to providing the highest quality, individualized care to his patients.

John Vitolo, M.D. is board certified in Orthopedic Surgery and holds a Subspecialty Certification in Sports Medicine.  Dr. Vitolo specializes in arthroscopic surgery of the shoulder and knee and was a former team physician for the Boston Red Sox.  He received his undergraduate degree from Brown University, then attended Columbia University and the University of Medicine and Dentistry of New Jersey.  Dr. Vitolo’s main office is located at 540 Lafayette Rd in Sparta, NJ.  Dr. Vitolo is currently accepting new patients and is also available for IME’s and second opinions. Please call (973) 300-1553 or visit advocareorthosportsmed.com for more information. 

ACL SURGICAL NEWS: ALLOGRAFT VS. AUTOGRAFT

When the ACL is torn, is can rarely be repaired. Surgery is often required to reconstruct the ACL. If reconstruction is not performed, the knee is at increased risk of cartilage damage, meniscal tear and osteoarthritis. Especially in younger patients, surgical repair is recommended following an ACL tear.

Surgery is performed arthroscopically and the ACL is either repaired or replaced. If the torn ligament cannot be repaired, the ACL is replaced with a tissue graft. The surgeon and patient have the option to use autograft tissue or allograft tissue.

Autograft tissue is a tendon from another location on the patient’s body. Most commonly a surgeon would use a hamstring tendon or patellar bone tendon bone. With the patellar bone tendon bone, the middle third of the tendon is removed and used as the new ACL.

Allograft tissue is a cadaver tendon that is taken from another person. In this case, the surgeon would use the achilles tendon, patellar bone tendon bone or a hamstring tendon.

Autograft is recommended for patients 30 years old or younger. The failure rate of allograft tendons is much higher in those under the age of 30 and the risk of infection is very low. The downside of using the patient’s tissue is that the operation is more involved and painful. The surgeon must surgically remove the autograft tendon and then also repair the ACL. The patient is undergoing two procedures as opposed to one. 

Allograft tendons are preferred in patients over the age of 30. The advantage of allograft is that it involves less surgical time and is less painful. The disadvantage of allograft is increased risk of infection and rejection. It is important to mention that the advances in allograft testing and sterilization have improved significantly in recent years. Risk of infection and disease is extremely low. Another advantage with allograft is that there are now numerous options to choose from, which allows the surgeon some flexibility in deciding which option is best for each individual patient.

In summary, if you are having surgery on your ACL, it is best to talk to your orthopedic surgeon about which option is best for you. Each case is unique and should be evaluated thoroughly before making a final decision.  

ACL Injury and Prevention

ACL injuries are common and on the rise. These injuries can cause young athletes to sit on the sidelines for months, lose out on valuable scholarship money and lead to long term osteoarthritis. It is estimated that over 50,000 high school and college age female athletes suffer from ACL injuries each year.[1] While some of these incidents cannot be prevented, there are steps that can be taken to reduce the number of injuries. 

One common misconception about ACL tears is that they are a result of player-to-player contact and little can be done to prevent occurrence. While ACLs are injured/torn in this manner, most occur as a result of the following: 

• Sudden change in direction
• Cutting maneuvers coupled with a sudden stop
• Awkward landing following a jump
• Pivoting with knee fully extended while foot is planted on the ground

Unfortunately, female athletes are more susceptible to ACL injury. Anatomical differences, such as a greater Q-angle, are primarily to blame. Other factors include weak muscle groups, bad habits, improper form and decreased range of motion. The good news is that while we cannot change the anatomy, we can identify risk factors and help reduce the chance of injury. 

A few suggestions for prevention would include: 

• Strength training – especially the smaller muscles around the knee and the hamstring 
•  Jump routine exercises emphasizing proper form and landing
• Pivoting exercises – also focusing on proper form

These tools are most successful when implemented in early adolescence. By utilizing prevention tools early in life, we can ensure that kids are learning proper form and technique from the beginning. This alleviates the need to undo risky habits in the future. 

Many organizations are implementing pre-season screening programs where professionals can assess athletes and determine if they are high risk for ACL injury. If you have access to one of these programs, take advantage of it and use the prevention tools provided. In future posts, we will also highlight exercises and routines that could be helpful.

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[1] Stopsportsinjuriesnow.org

To Cut or Not to Cut: Biceps Tenodesis vs Biceps Tenotomy

Recently, we discussed injuries and anatomy of the biceps muscle and tendons. If surgery is needed when an injury occurs to the biceps tendon, two procedures are commonly performed: biceps tenodesis and biceps tenotomy. In this post, we will review each and discuss the positives and negatives to each.

Biceps Tenodesis

With biceps tenodesis, the biceps is first released and then re-attached to the bone in a minimally invasive arthroscopic procedure. To do this, anchors or biotenodesis screws are drilled into the bone and the tendon is reattached. 

This procedure can also be used for labral injuries. The labrum is attached to the biceps tendon and can pull the labrum off and place the labrum under constant tension. Here, the tension is released by cutting the biceps tendon and allowing the labrum to return to its normal position, relieving the pain. The biceps tendon is then reattached to another anatomic position, where it will function properly and not cause pain. Patients that benefit most from tenodesis are younger and more active.

Biceps Tenotomy

In a biceps tenotomy, the biceps muscle is cut from the shoulder. By doing this, the pain is relieved. A tenotomy is performed arthroscopically and is a relatively simple procedure. A tenotomy is normally performed in less active individuals who lead a more sedentary life. Side effects with a tenotomy are weakness in the biceps muscle and a deformity referred to as ‘popeye arm’ sometimes occurs. 

To cut or repair?

The decision to perform a tenodesis or tenotomy is based on many factors. Each individual must be evaluated by a qualified orthopedic surgeon. Factors such as age, activity level, overall health, other injuries and occupation are considered. In younger and more active patients, a tenodesis is preferred. Also, people returning to physical labor often do better with a tenodesis.

Tenodesis restores the arm to a more anatomic state, therefore allowing the arm to heal and continue to function the way nature intended. Tenotomy is often the best option for older patients who lead more sedentary lives. The main goal with a tenotomy is to relieve pain and discomfort. Each option has advantages and disadvantages. If you feel you have a biceps injury, John Vitolo, MD is available to help. Contact our office, Advocare Orthopedic and Sports Medicine Center at 973-300-1553 or find us on facebook.com/johnvitolomd.