The crack of the bat, smell of the leather mitt and running of the bases are a few of the things players love about baseball and softball. More than 33 million Americans play organized baseball and softball each year, with nearly 6 million of these players being children from 5 to 14 years old. According to the U.S. Consumer Product Safety Commission, in 2003 more than 200,000 of these kids were treated in hospitals, doctors’ offices, clinics, ambulatory surgery centers and hospital emergency rooms for baseball-related injuries. That is why the American Academy of Orthopaedic Surgeons recommends that children use caution when partaking in youth baseball, particularly year-round.

“I continue to see increasing numbers of injuries related to youth baseball. I attribute this to the steady progression toward year-round participation and the addition of spring and fall leagues. The drive to compete can lead to overuse and result in minor pain or less commonly to major injuries,” explained Frank Norberg, MD, orthopedic surgeon specializing in the treatment of shoulder and sports medicine injuries. “Children involved in overhead hitting and throwing sports should have a break from these activities for 2-3 months out of the year. It benefits kids to cross-train and change sports throughout the year to avoid overuse injuries and help with balanced physical development. While pitch counts can help avoid overuse, it is more important to make sure players are not throwing with pain.  Persistent pain with throwing is a sign of muscle, ligament or bone injury and should be evaluated by a medical professional.”

The American Academy of Orthopaedic Surgeons offers the following tips to help keep your child off the injured list:

• Always take time to warm up and stretch before and after play. Research studies have shown that cold muscles are more prone to injury.
• If a child is pitching, he should concentrate on stretching his arm and back muscles.
• If a child is catching, the focus should be on the legs and back.
• Children should not be encouraged to play through pain. It is important that they take breaks if tired.
• Limit the number of teams your child is playing on in one season. Kids who play on more than one team are especially at risk for overuse injuries.
• Equipment should fi t each player properly and be worn correctly.
• A batting helmet should be worn at the plate, when waiting a turn at bat and when running bases.
• Facial protection devices that are attached to batting helmets should be worn by children, when available. These devices can help reduce the risk of a serious facial injury if you get hit by a ball.
• Players should wear molded baseball shoes with cleats that fit comfortably.
• Children need to wear the appropriate mitt in each position.
• Catchers should always wear a helmet, face mask, throat guard, long-model chest protector, protective supporter, a catcher’s mitt and shin guards.
• Inspect the playing field for holes, glass and other debris.
• Drink plenty of fluids.
• Supervising adults should be prepared for emergency situations and have a plan to reach medical personnel to treat injuries such as concussions, dislocations, elbow contusions, wrist or finger sprains, and fractures.
• To prevent sliding injuries, install breakaway bases in the playing fields and an extra large first base to avoid the runner stepping on the first baseman’s foot.

While there is no concrete guideline for the number of pitches allowed, reasonable limits are 80 to 100 pitches in a game and 30 to 40 pitches in a single practice session, depending on the child’s skeletal maturity, muscle strength and pitching techniques.

Additional pitching recommendations for young baseball players include:

• 8-10 year olds should only throw from 37 to 67 pitches in approximately 1.4 to 2.6 games per week.
• 11-12 year olds should only throw from 50 to 86 pitches in approximately 1.4 to 2.6 games per week.
• 13-14 year olds should only throw from 60 to 92 pitches in approximately 1.4 to 2.6 games per week.
• 15-16 year olds should only throw from 75 to 107 pitches in approximately 1.4 to 2.6 games per week.
• 17-18 year olds should only throw from 90 to 122 pitches in approximately 1.4 to 2.6 games per week.

Jay S Johnson, MD
For Jay S. Johnson, MD, an orthopedic surgeon in Edina, the call to serve meant traveling to Antigua, Guatemala, once with his wife and a second time with his entire family through the non-profit organization called Common Hope.

Dr. Johnson’s wife, Sue Dittmanson, MD, is an OBGYN physician at United Hospital. During their week-long mission at Hermano Pedro Hospital in Antigua, each operated on approximately 20 people. While in Guatemala, his daughters participated in non-medical social work visiting homes and educating the community.

 “The biggest challenge of the mission is that it is physically very demanding. You are operating all day long. And also you have to manage your time and figure out what you can do well with the equipment,” Johnson said.

In the United States, Dr. Johnson would have his choice between 20 and 30 bone rods when caring for a non-union fracture. In Guatemala, he had only three. When asked what he took away from his trip, Dr. Johnson replied. “We have it really good here.”

One of his highlights for Johnson included performing an ACL reconstruction on one of the Guatemalan World Cup Soccer players.

William Lundberg, MD
Orthopedic Surgeon, William Lundberg’s overseas trip wasn’t a typical medical mission, it was a military one. 

Dr. Lundberg, a member of the Army Reserve, has been deployed three times, twice to Germany and once to Iraq. By day in Iraq, Dr. Lundberg was caring for wounded soldiers in a “pop-up hospital” and by night he was sleeping in a tiny barracks with no windows and walls made of cinderblock with just single light bulb hanging from the ceiling. 

The “pop-up hospitals” had pretty much everything Dr. Lundberg needed to care for wounded soldiers. One of the major differences Lundberg cited while caring for soldiers is that follow-up care was not an option. It was an order, therefore the outcomes were highly successful. “The patients are young and active. They follow orders and tend to get better a lot faster than the average patient in the United States,” Lundberg said. 

When asked what he learned from his time in Iraq, Lundberg said, “It makes you more thankful for the soldiers that protect us. The stuff they do for us is dangerous. How good our troops work and how hard they work and the dangers they are exposed to all the time. They are all young kids; 20-something-year-olds. We should all be proud and thank them.”

Anthony Brown, MD
Through the non-profit group, Surgical Implant Generation Network (SIGN), Dr. Anthony Brown, an orthopedic surgeon in Robbinsdale, Minn., traveled to Vietnam and Indonesia in 2004 and 2005 to assist orthopedic surgeons in caring for patients with traumatic injuries.

While in Vietnam and Indonesia, Dr. Brown said that he was learning almost as much as he was teaching. He described the hospital environments at each location as very collaborative. At first glance that might seem difficult with an obvious language barrier, however according to Dr. Brown, “The good thing about orthopedics is that a picture is worth a thousand words and an x-ray always tells the story.”

According to Brown, the cases he had during each of his two-week long trips were more extreme than those that he typically sees in the United States. Instead of taking care of a fracture that occurred a day ago, he was taking care of ones that happened two months ago.

Additionally, Dr, Brown said he had to learn to do more with less. “In surgery they have much less resources than we have here, therefore you have to be more creative and more technically skilled,” Brown said. “I just think it is fun and interesting.”

Patrick Kraft, MD
Dr. Patrick Kraft, an orthopedic surgeon also practicing in Robbinsdale, Minn., has traveled to Guatemala eleven times. The trips, part of the ministries at Wooddale Church in Eden Prairie, Minn., helped a church in the Lake Atitlan area reach out to the community through providing general health and wellness and other services.

During the first few years of mission work, health education was focused on teaching the Guatemalans how small lifestyle changes could drastically improve their quality of life. Teaching people to cook outside and drink filtered water, vastly decreased the high incidence rate of pulmonary and digestive conditions. 

In later years of his mission work, Dr. Kraft spent his time traveling to more remote villages. “People would hear that we were coming to their village and they would wait in line all day to be seen.” Kraft said.

In treating Guatemalans, Dr. Kraft had to adapt to the local culture. For example, the Guatemalan people believe that in treating fractures the Shaman, an intermediary between the human and spirit worlds that can treat illness, must come in the middle of the night to strike the broken bone before it can heal.

“Patients had a feeling that we had an ability to cure them, but the spirits were just as important in the healing process.” And so over an 11-year period, many Guatemalans were treated by Dr. Kraft and the local Shaman.

UPDATE: Since this article was written, Dr. Brown and Dr. Anderson have traveled to Haiti to care for those injured during the earthquake that ravaged the country on January 12, 2010. Look for their stories and others in an upcoming eNewsletter. Sign-up at www.tcomn.com.

Support the Work
Twin Cities Orthopedics would like to encourage anyone interested in supporting physician mission work to contact the Twin Cities Orthopedics Foundation at www.tcofoundation.org or by phone at (952) 927-2989.

All-American Determination
Last May, Patrick Jager of St. Thomas University had a lot to smile about while standing with his teammates on the podium at the 2009 NCAA Division III Outdoor Track and Field Championships in Marietta, Ohio.

Jager had just finished anchoring the first place teams in both the 4×100 and 4×400 meter relays.  

His journey to the top wasn’t easy. Ankle problems plagued Jager since his freshman year of high school when he suffered an ankle injury that ended his freshmen season and kept him out for his entire sophomore year.

Jager, who also competed in soccer and basketball in high school, returned to track his junior year excelling in his events, but still dealing with persistent ankle pain.  

After high school, Jager decided to continue his track career while studying at St. Thomas University in St. Paul, Minn. He was running well, but the pain just wouldn’t go away.

“Every once in a while I had flashes of me doing really well, and something bad would happen, so I knew I had never really reached my potential,” said Jager.

Most of Jager’s sophomore year at UST he spent confined to wearing a boot. He tried to come back a couple of different times, only to find out that his foot had not fully healed. He decided to see foot and ankle specialist, J.Chris Coetzee, MD at the Minnesota Orthopedic Sports Medicine Institute at Twin Cities Orthopedics.

“Nobody could figure out why it didn’t heal. Dr. Coetzee was actually the one who figured out that I had a bone spur in my ankle that was limiting my motion. I was putting a lot of pressure on the top of my foot and that is why it wouldn’t heal,” said Jager.

“After the consultation, which included a trip to Baltimore for a special test on my ankle, Coetzee did surgery and it got back to where the pain was at least bearable.”

Jager’s last surgery was in 2007. Afterward he was prescribed 12-weeks of physical therapy. “That was the hardest part; keeping up with all of those little exercises. You don’t feel like you are doing much, but you are really helping yourself out.”

After therapy, Jager continued to work hard with his team, steadily improving with each day, each workout and each meet.

“It was all about staying motivated and continuing to work hard,” said Jager.

Winning
All of Jager’s hard work started to pay off when in mid-May, Jager’s 4×100 meter relay team set a school record time of 40.75. “When everything kind of started to come together, it was like ‘whoa, this is really cool.’” said Jager

Just a couple of weeks later his team won the NCAA Division III national championship 4×100 meter relay with a time of 40.76. It was the first time a men’s track and field team from Minnesota had won an NCAA relay championship.

Later on that same day, about three hours later, Jager anchored the NCAA Division III national championship 4×400 meter relay team. That being just the second time a men’s track and field team from Minnesota won a NCAA relay championship.

The Future
Jager is a finance and accounting major at St. Thomas University. He hopes to continue his career in public accounting, but that may be on hold for a little while as he petitions the NCAA for an extra year of competition. No matter what his future holds, we’ll sure he’ll do well.

Though spine surgery can be beneficial for people suffering from radiating leg pain caused by a herniated disc, the standard treatment, a microdiscectomy, often leaves patients with recurrent pain. Now, spine surgeons at Twin Cities Orthopedics (TCO) have introduced a new procedure — the annular disc repair, which is reducing patients’ time in the operating room and the chance of reherniation.

Typically, a microdiscectomy was performed to alleviate radiating leg pain. The surgery involved removing the portion of the disc that was applying pressure to the nerves. This procedure required the surgeon to make an incision in the annulus fibrosus, the outer layer of the disc, to access the nucleus pulposis, the herniated tissue. In other cases, a tear in the annulus allowed surgeons easy access to the herniated tissue. However, previously there has been no easy method to close the anulus following the removal of the tissue. Therefore, surgeons commonly left the anulus to heal on its own, which increased the risk of a recurrent herniation.

Many patients found relief with this procedure, but for others, the disc could reherniate through the annulus opening, resulting in the recurrence of pain and requiring additional surgery. Statistics show approximately 30 percent of patients have pain following a lumbar discectomy, and an estimated 15 percent of patients require a re-operation.

But now, with annular disc repair, the procedure provides a new method for treating the compromised tissue of the anulus fibrosus following a discectomy procedure. This innovative treatment is being performed by TCO spine surgeons, John Sherman, MD; David Holte, MD; and Jeffery Dick, MD. After removing the offending portion of the disc, the surgeons are able to re-approximate the soft tissue to facilitate the healing process of the anulus fibrosus. The device designed to re-approximate the soft tissue is the Xclose Tissue Repair System, developed by Anulex Technologies, Inc. For larger defects, a patch is also available, named Inclose.

“This makes a lot of sense,” Dr. Sherman said. “Previously, we have not had a reliable method of closing the anulus of the disc and when it is not repaired, the material inside may re-extrude, compress the nerve root, and result in recurrent pain and re-operation.”

“This annular disc repair procedure adds minimal time to the overall procedure and is easily completed,” Dr. Holte said. After the discectomy, the spine surgeons use the Xclose Tissue Repair System to re-approximate the soft tissue to facilitate the healing process. The surgery is typically done on an outpatient basis. With successful repair of the annulus, the patients can begin rehabilitation and resume their normal activities sooner.

The TCO spine surgeons were the first surgeons to introduce this procedure in Minnesota, and the procedure now is being performed at Fairview Southdale Hospital, Methodist Hospital, and the Centennial Lakes Surgery Center in Edina. For more information about this procedure, please call the Twin Cites Orthopedics’ Centennial Lakes Center at (952) 832-0076 or visit www.tcomn.com.

One in six Americans has some sort of foot disorder, and more than a third find the problem serious enough to see a doctor. You might be surprised to learn one of the major culprits is improper footwear. Many common aches and pains can be prevented or even corrected with a little extra care when shopping.

It’s no secret that wearing poorly fitting shoes or improper footwear for a particular sport can seriously damage your feet, causing painful bunions, corns, calluses, hammertoes, and other distressing maladies. It’s estimated that the cost of foot surgery to correct problems from tight fitting shoes is $2 billion a year or $3.5 billion, if you include time off from work for the surgery and recovery.

Who is at risk?
A woman’s risk of foot injury is a good deal higher than a man’s — and may increase with the heel height and tightness of her shoes. A study conducted by the American Orthopaedic Foot & Ankle Society found women are nine times more likely to develop a foot problem because of improperly fitting shoes than men. The report notes that nine out of 10 women wear shoes that are too small for their feet, eight out of 10 women say their shoes are painful, and more than seven out of 10 women have developed a bunion, hammertoe, or other painful foot deformity. Nine out of 10 women attribute their foot deformities to tight shoes, according to research.

The American Academy of Orthopaedic Surgeons recommends that women do not wear shoes with heels higher than 2 1/4 inches. They also recommend avoiding high-heeled shoes with pointed, narrow toe boxes that crowd the toes and force them into an unnatural,triangular shape. As heel height increases, the weight on the ball of the foot may double, placing greater pressure on the forefoot as it is forced into the pointed toe box.

Those individuals who participate in sports should keep in mind that proper-fitting sports shoes can enhance performance and prevent injuries. Shin splints — pain in the front of the tibia — is one injury typically caused by excess stress from over training, changing to a hard running surface, or wearing poorly fitting athletic shoes. If not taken care of, this injury can progress into a stress fracture, which is a more painful and debilitating injury.

Shoe Shopping Guidelines

There are many things to consider when choosing the best-suited shoes for fit and the circumstance:

• Have both feet measured every time you purchase shoes. Your foot size increases as you get older.
• Try on new shoes at the end of the day. Your feet normally swell and become larger after standing or sitting during the day.
• Make sure your shoes are fitted to your heel and your toes. Try on both shoes, and make sure there is a half-inch space from the end of your longest toe to the front of each shoe.
• If one of your feet is considerably larger than the other, add an insole to the shoe on the smaller foot.
• When the shoe is on your foot, you should be able to wiggle all toes freely. If the shoes feel too tight, don’t buy them. There is no such thing as a “break-in” period.
• If you participate in a sport three or more times a week, you need a sports- specific shoe.

Follow these fitting suggestions when purchasing athletic shoes:

• Try on athletic shoes after a workout at the end of the day. Your feet will be at their largest.
• Wear the same type of sock you wear for that sport.
• When the shoe is on your foot, you should be able to wiggle all toes freely.
• The shoes should be comfortable as soon as you try them on. Again, there is no break-in period.
• Walk or run a few steps in your shoes. They should be comfortable.
• Always re-lace the shoes you are trying on. Begin at the farthest eyelets and apply even pressure in a crisscross lacing pattern to the top of the shoe.
• If you have foot orthotics, make sure you have them in the shoes you are trying on; they will dramatically alter the fit of your shoe.

Walk the walk
If you’re already experiencing regular foot or ankle pain, your doctor or therapist may recommend any of a variety of effective treatments. Most injuries are initially treated with the RICE method — rest, ice, compression, and elevation. Moderate and severe injuries often require some form of immobilization or protection with either a cast or splint. Strengthening exercises may be recommended in some cases, while other conditions may require surgery.

While there is no sure way to prevent all injuries, risk can significantly be reduced by participating in a conditioning program to build muscle strength (make sure to warm up before taking part in a sport or exercise program), improving agility (exercises that help improve your balance), performing stretching exercises to maintain range of motion specific to your activity, listening to your body (never run if you experience pain in the foot or ankle, for instance), replacing athletic shoes as soon as the tread or heel wears out, and wearing properly fitting athletic, dress, and casual shoes.

In the case of joint replacement surgery, the TCO staff has worked closely with the staff at the Ridgeview Medical Center, Center for Joint Replacement; the Joint Center at North Memorial Medical Hospital; and the Joint Replacement Center at Abbott Northwestern Hospital to develop an educational and therapeutic experience for patients that has proved to improve both patient outcomes and patient satisfaction.

The group experience
The experience begins with a pre-operative educational session filled with as little as four or as many as 20 patients; most of whom will also participate together in group physical therapy sessions following surgery.

While attending the pre-operative educational session, patients are given educational reference guides filled with answers to common questions such as: What does my new joint replacement look like? When will I be able to walk again? When will the pain go away? Sessions are guided by occupational and physical therapists who are also available to help answer additional questions and calm anxieties.

Patients are encouraged to bring a friend or family member to act as a coach. “We encourage the coach to come to all of the hospital visits including the pre-operative educational session, the therapy sessions, and the nursing education sessions,” said Katie Trent, a physical therapist and program coordinator at Ridgeview Medical Center,Center for Joint Replacement. “There is so much going on, it is helpful for the patient to have someone listening and learning with them. It also makes everyone more confident when it’s time to go home.”

Joint Replacement Education Program

In addition to Ridgeview Medical Center, North Memorial Medical Center and Abbott Northwestern Hospital, TCO physicians have also worked with the staff at Fairview Southdale Hospital to develop the Total Joint Replacement Education Program. This comprehensive and popular class prepares patients and their families for surgery, their hospital stay, rehabilitation, and long-range goals that might include returning to an active lifestyle.

“Our patients love the education they receive,” said Deb Smith, RN, a clinical nurse/educator at Fairview Southdale Hospital. “In fact, one total knee replacement patient comes to the class every Monday to tell others who are contemplating joint replacement how valuable the information is and how happy he is with his outcome.”

Pre- and postoperative physical therapy
Patients at Ridgeview Medical Center, North Memorial Medical Center, and Abbott Northwestern Hospital are encouraged to participate in a pre-operative physical therapy session. Exercise participation prior to total joint arthroplasty dramatically reduces the odds of requiring transfer to a swing bed or another inpatient facility, according to research noted in Arthritis & Rheumatism, the official monthly journal of the American College of Rheumatology.

Patients also participate in postoperative group physical therapy sessions prior to being discharged. Group physical therapy sessions give patients extra motivation and allow opportunity for greater support as they begin their road to recovery. Targeted postoperative care has resulted in more patients being discharged directly home after hip or knee arthroplasty, as indicated in research that appears in the Archives of Physical Medicine and Rehabilitation.

The results
Ridgeview Medical Center began offering this group approach to education and therapy when it opened its Center for Joint Replacement in April 2007.

“Prior to opening the Center for Joint Replacement, 65 percent of our patients went home after surgery and 35 percent required nursing home care,” Trent said. “Now, only 20 percent of patients are discharged to a nursing home and 80 percent return home.”

In addition to the improvement of discharge status, the average hospital stay following joint replacement has decreased from 3.8 days to 3.15 days. In 2007, the center achieved a zero percent infection rate for all knee replacement surgeries and a 0.77 percent infection rate on all hip replacement surgeries. At North Memorial Medical Center, the improvements are similar. “The results of our program have been amazing,” said Chuck Lister, program coordinator at the Joint Center at North Memorial Medical Hospital. Since starting the program, the North Memorial Joint Replacement Center has seen a zero percent infection rate and the average hospital stays have decrease from 3.5 days to 3.1 days.

Abbott Northwestern Hospital is just starting their Joint Replacement Center but they are optimistic they will have similar results.

In addition to outcome statistics, patients are also more satisfied with the care they receive. “Today’s patient wants to take an active role in the treatment and recovery process,” Lister said. “Since implementing joint replacement classes, patients have been more satisfied with their ability to be involved and expedite the recovery process.”

Constant improvement

While the results of improvement in patient education and pre- and post-operative physical therapy have helped improve patient recovery and patient satisfaction, TCO and the hospitals it is affiliated with are continuously researching and looking for new ways to improve care.

For more information about TCO physicians, locations, and services offered, visit www.tcomn.com.

With 30 locations in the greater Minneapolis area and more than 79 highly trained physicians, TCO is the largest, most comprehensive and prestigious orthopedic practice in Minnesota and the Midwest, and is one of the largest in the United States. The practice provides conservative, top-quality care and research and uses state-of-the-art technology and procedures to help return each patient to an active, pain-free lifestyle.

TCO was formed between 1996 and 2003 when five orthopedic practices, each of which began nearly 60 years ago, combined. TCO has three goals: 1) To provide worldclass, compassionate care to individuals of all ages with musculoskeletal injuries and conditions; 2) improve the musculoskeletal health of our communities through research and education; and 3) be the orthopedic provider and employer of choice for Twin Cities residents.

New Physicians
Joining the practice in 2008 are Jay Johnson, MD, Christie Heikes, MD, and Erik Wetter, MD. Dr. Wetter specializes in general orthopedics and sports medicine, while Dr. Heikes’ emphasis is in women’s orthopedics and sports medicine. The addition of Dr. Heikes will be of particular benefit to those who prefer to be seen by a female physician. Dr. Johnson, who has been practicing in the Twin Cities for several years, specializes in total joints and general orthopedics.

Additional locations
TCO also is in the midst of an ambitious expansion program in the following locations:

Maple Grove: To meet the demands of a growing market (with a 90-bed hospital that is expected to open its doors in February 2009), TCO has opened a full-service clinic that includes physical therapy, orthotics and prosthetics.

Waconia: TCO is expanding its presence in the Waconia market by providing physical therapy, orthotics, and prosthetics programs and by adding a spine specialist and MedX, a back pain rehabilitation program. The
goal of MedX is to strengthen the back using preventive-type medicine to help the patient avoid undergoing invasive spinal surgery. The new Waconia location has additional space to accommodate the possibility of adding future orthopedic surgeons.

Coon Rapids and Burnsville: Expansions similar to Waconia have already taken place in these two communities. In Coon Rapids, one of TCO’s two offices has moved into a larger building that also houses a clinic, a physical therapy center, magnetic resonance imaging (MRI), and MedX. In Burnsville, the new building houses a surgery center, physical and hand therapy centers, an MRI, and orthotics and prosthetics services.

Edina: With a long-standing presence of four sites in this city, TCO plans to consolidate them into one orthopedic “Center of Excellence” during the next two years, said Troy Simonson, TCO administrator. To enhance the continuity of care for patients it will include every orthopedic specialty and sub-specialty at one convenient location. Plans for the Edina center also include a surgery center, physical therapy, hand therapy, MRI, orthotics, prosthetics, and MedX. Once the center is complete, patients will be able to have all their orthopedic needs met at one central location housing as many as 30 physicians. “We’ve been there (Edina) for many years, but we’ve been fragmented,” Simonson said. “Now, we’re looking to provide improved customer service to our patients and provide those services more efficiently.”

The common goal driving much of the expansion is improving patient satisfaction. “For example, to improve the convenience and continuity of care we are striving to provide the full spectrum of orthopedic care patients desire at one convenient location,” Simonson said.

Patient satisfaction
To better gauge patient service, TCO has begun a patient satisfaction campaign. Patients were asked to complete questionnaires and, to date, more than 1,600 responses have been obtained. Survey feedback indicates that 96 percent of patients either agreed or strongly agreed that “I would rate my overall care at TCO as excellent.” On a second question — “Was staff helpful, courteous and did staff treat me respectfully?” — 97 percent either agreed or strongly agreed. “We are looking to gather this data continually,” Simonson said. “We are constantly going to measure and maintain that high level of service.”

What begins as a gradual onset of dull, achy pain in one knee, can also feel like the knee is giving way. Patients have also said that knee pain increases with prolonged sitting or when climbing the stairs, kneeling, squatting, or running up an incline.

Causes and precautions
Many doctors suspect that changes to the surface of the patella – the kneecap or bone at the front of the knee – cause the pain. Pain may also result from irritation to the tissue around the knee. While the precise mechanism of injury and pain remains unknown, several factors contribute to development of the condition. Overuse of the joint often leads to runner’s knee. In addition, the kneecap may be out of alignment; thigh muscles may be tight, out of balance, or weak; or the patient may have flat feet. Sometimes an injury will precipitate the pain.

To avoid runner’s knee, individuals should maintain a healthy weight. They should also warm up, and stretch before running or engaging in other physical activity. Runners should wear shoes with good shock absorption and train at a gradually increasing pace. They should also lean forward, keeping their knees bent as they run. Jogging on a smooth, resilient surface, such as a cushioned track rather than the road, is also a good idea, as is walking down steep hills or running downhill in a zigzag pattern to put less stress on the knee joint.

Diagnosis
When assessing runner’s knee, physicians inquire about the onset of symptoms, type of activities, and the types of running and playing surfaces. They perform a physical exam and watch how the patient walks, squats, sits, and moves. Often, individuals with runner’s knee favor the injured leg. Doctors also examine the knee and note any fluid or swelling; check joint alignment; evaluate muscle tone, strength, and flexibility; and assessfor tenderness when they touch or move the knee.

X-rays may be ordered to rule out other conditions such as arthritis. Doctors might also ask for a computed tomography (CT) or magnetic resonance imaging(MRI) scan to check for abnormalities.

Treatment
Treatment of runner’s knee aims to decrease pain and improve function. Initial therapy may involve elevating the knee, wrapping it in an elastic bandage, and applying cold packs several times a day to help decrease the pain and swelling. Physicians may have the patient tape the knee or wear a brace to support the joint. After the initial swelling goes down, doctors may suggest heat to relax muscles and increase blood flow. Alternating heat and cold can increase flexibility in a stiff joint. In addition, physicians may recommend a nonsteroidal anti-inflammatory medication. Once the pain and swelling decrease, doctors may also suggest a rehabilitation program to stretch and strengthen the supporting muscles and improve range of motion, agility, and coordination.

To aid in recovery, patients should avoid any activity that increases the pain until the action can be completed without discomfort. Patients may swim or try another low-impact activity instead of running or jumping until the problem resolves. Patients can participate in sports again once the injury heals and the doctor gives the go-ahead, but they should resume athletic pursuits gradually. It’s also important for runners to wear proper shoes to reduce or prevent knee pain. They can also place custom orthotics – or sometimes an off -the-shelf arch support – in their shoes to help relieve knee discomfort.

While most patients respond to conservative treatment with time, some cases may require surgery to remove debris from the knee or return the kneecap to proper alignment. Runner’s knee usually responds well to treatment and an active rehabilitation program. If athletes stick to sensible training schedules, wear supportive shoes, and use proper running technique, they can help alleviate the condition – and may even prevent its onset.

The relative risk for glenohumeral instability is explained by the joint’s anatomy. The humeral head is round and articulates with the flat glenoid fossa of the scapula (shoulder blade). Therefore, maintaining normal joint stability requires the interplay of both static restraints (the glenohumeral capsule ligaments, or capsulolabral complex) and dynamic forces (the musculature surrounding the shoulder, including the rotator cuff).

Initial Treatment
Initial management of shoulder dislocations requires recognition of the injury. Medical professionals (certifi ed athletic trainers, emergency medical personnel, or physicians) who are familiar with the injury may be able to perform an initial reduction of the injury with gentle, nonforced maneuvers. When early attempts are unsuccessful, prompt referral to an emergency room is appropriate. In this setting, a reduction can be performed either with conscious sedation or the use of an intra-articular anesthetic agent, such as lidocaine.² Radiographs should be obtained both before and after the reduction maneuver to confirm anatomic position of the joint, and to rule out associated bone injury, such as a fracture.

Problem Management
Once the joint is reduced, secondary management is initiated. First, the patient should be educated about the natural history and potential complications that might result from the injury. The secondary eff ects are generally age-dependent. In patients younger than 30 years, the primary concern is the development of recurrent joint instability. Recurrent instability may manifest itself as a spectrum of disability, from frank dislocation requiring repeated reduction, to painful “apprehension” or a sense of instability that interferes with daily or athletic activities.³

In patients older than 35, the concern is for associated injuries that occur at the time of dislocation, such as bone fracture, nerve injury, or rotator cuff tears.⁴ Evaluating for associated injuries and initiating prompt treatment often require secondary imaging studies, including magnetic resonance imaging (MRI) or occasionally computed tomography (CT) scanning. A variety of treatment options might exist. Orthopedic consultation after an initial glenohumeral dislocation is appropriate to help determine the optimal treatment plan, thereby improving recovery and functional outcome.

Surgery or not?
Historically, surgical treatment has been reserved for patients who have developed recurring shoulder dislocation. Advancements with arthroscopic shoulder surgery in the past fi ve to 10 years have led to increased interest in early surgical treatment to correct
the anatomic lesion (tear of the labrum, or Bankart-Perthes lesion) that occurs with shoulder dislocations. For cadets at the United States Military Academy, such treatment has provided improved shoulder stability when compared to rehabilitation alone.⁵

When managing young inseason athletes, treatment with brief immobilization and early rehabilitation remains a good option. Surgery can be delayed until the off season for those athletes with persistent instability despite appropriate rehabilitation, or those who desire to minimize risk of recurrent instability over time.

References
1. Matsen FA III, Titelman RM, Lippitt SB, Rockwood CA Jr., Wirth MA. In: Rockwood CA Jr., Matsen FA III, Wirth MA, Lippitt SB, eds., The Shoulder, 3rd ed., 2004.
2. Miller SL, Cleeman E, Auerbach J, Flatow EL. Comparison of intra-articular lidocaine and intravenous sedation for reduction of shoulder dislocations: a randomized, prospective study. J Bone Joint Surg Am. 2002;84A:2135-9.
3. Hovelius L, Augustini BG, Fredin H, Johansson O, Norlin R, Thorling J. Primary anterior dislocation of the shoulder in young patients. A ten-year prospective study. J Bone Joint Surg Am. 1996;78(11):1677-84.
4. Neviaser RJ, Neviaser TJ, Neviaser JS. Anterior dislocation of the shoulder and rotator cuff rupture. Clin Orth Rel Res. 1993;291:103-6.
5. Bottoni CR, Wilckens JH, DeBerardino TM, D’Alleyrand JC, Rooeny RC, Harpstrite JK, Arciero RA. A prospective, randomized evaluation of arthroscopic stabilization versus nonoperative treatment in patients with acute, traumatic, fi rst-time shoulder dislocations. Am J Sports Med. 2002;30(4):576-80.

Although some occupations requiring repetitive hand use and/or exposure to vibration seem to increase the risk of carpal tunnel syndrome, the majority of individuals in such jobs do not get carpal tunnel syndrome, unless they are anatomically predisposed to it.

Diagnosing Carpal Tunnel
Physical exam findings in the patient who has carpal tunnel consist primarily of median nerve irritability, which is identified by sensitivity to tapping at the wrist level. An examiner can test for sensitivity to pressure by holding the wrist in a flexed position or placing direct pressure on it for a short period of time. Examination of the neck and proximal forearm to rule out other causes of nerve compression are also done as part of the examination.

In most cases, the patient’s history and a physical exam are enough for a diagnosis, but in some cases, it may be necessary to provide additional objective confirmation of nerve dysfunction. This can be done by doing an electromyogram (EMG), which is a nerve test to evaluate the electrical conductivity of the nerve. The EMG is not infallible and fails to diagnose about 10 percent of confirmed carpal tunnel syndrome cases. It may also produce a false positive.

Another way of obtaining objective information is to inject adrenal corticosteroids into the carpal canal to shrink swelling, thus diminishing pressure. A steroid injection will decrease pressure and invariably improve true carpal tunnel syndrome symptoms, unless permanent median nerve damage has occurred. The benefit is usually temporary, but temporary improvement confirms the carpal canal as the source of the symptoms.

Other tests such as X-rays and magnetic resonance imaging (MRI) scans might be useful to rule out other causes of wrist pain, but these tests cannot confirm a diagnosis.

Exploring treatments for Carpal Tunnel
Treatments to decrease swelling in the carpal canal include activity modification, stabilizing the wrist, physical therapy, use of antiinflammatory medication, and occasional injections of corticosteroids. These measures are effective in mild cases; but once symptoms begin occurring on a frequent or continuous basis, these treatments are rarely effective in providing any significant longterm or permanent relief.

For those patients with significant symptoms, the only permanent solution is carpal tunnel release, a surgery that will increase the size of the carpal tunnel. This procedure is performed frequently with a high success rate and a relatively low rate of repeat surgery.

Transverse carpal ligament surgery, a traditional method of relieving carpal tunnel syndrome, consisted of an open incision along the transverse carpal ligament and distal forearm fascia. Historically, this operation required a 2- to 3-inch incision beginning at the narrowest part of the wrist in the midline continuing out into the palm of the hand; and it was recommended to dissect around the tendons and nerves to remove inflammatory tissue and scarring. However, various studies have identified that in most cases dissection of the nerve and removal of synovial tissue is not necessary and is perhaps detrimental to recovery from carpal tunnel syndrome, because it may cause the formation of additional scar tissue.

After this type of surgery, “pillar pain” has been recognized as the most likely side effect. This pain is an ongoing tenderness in the palm of the hand usually associated with grasping, which is present in all patients for the first four to six weeks. In a few individuals individuals, however, it lasts for several months and even permanently. Unfortunately most of those at risk cannot be identified preoperatively; but it usually can be treated successfully with physical therapy.

Trying an alternative
The problems recognized above led to the development of the endoscopic technique, which has been widely practiced for at least 10 years. Endoscopic carpal tunnel surgery makes up about 20 percent of the carpal tunnel releases done today. The technique is demanding, and may increase the risk of nerve injury. Published studies offer conflicting results with respect to this issue. Risk of nerve injury is dependent on the surgeon’s experience with the technique. There are few contraindications to endoscopic carpal surgery, except perhaps previous carpal tunnel surgery.

On the positive side, although studies are conflicting, the consensus seems to be that individuals who undergo endoscopic carpal tunnel surgery are able to recover more rapidly and return to activities sooner than those undergoing traditional open carpal tunnel surgery. In most cases individuals undergoing endoscopic carpal tunnel surgery recovered two to three weeks faster than their counterparts who had traditional carpal tunnel surgery. Long-term results between the two techniques have not been shown to be any different.