Wednesday, August 29, 2012

MY PAINFUL ACHING ACHILLES



The Achilles tendon is the largest tendon in the body.  It connects the calf muscle to the heel and is commonly injured with an explosive-type injury, such as a running start; it can also be an injury that happens over time where you have chronic heel pain, which eventually will result in acute pain and then loss of ability to push off with the foot.  This is loss of what we call plantar flexion.  This is a very common problem. It can be treated nonoperatively with heel lifts and boots, as well as judicious use of injection and physical therapy.  Normal symptoms the patient will complain about will be tenderness and swelling along the Achilles tendon.  This can be found both in the midsubstance of the tendon in the back of the heel or it can be actually where it inserts on the heel bone or the calcaneus.  These are both treated in a different fashion.  The non-insertional Achilles tendonitis is what we find in the middle of the tendon and tends to affect younger and active people.  This is normally the area that we see in a rupture of an Achilles tendon.

Insertional Achilles tendonitis is more of a chronic condition with tenderness where the tendon attaches to the heel.  There can be associated both tendonitis as well as with bone spur formation in this area that may need to be addressed by removing that bone spur.  There can be calcification of the tendon insertion, as well.  I refer you to the radiograph that shows the calcaneus, which shows evidence of a large spur where the Achilles attaches, as well as a very sharp, bony prominence on the heel bone itself that can irritate the Achilles and may need to be removed.  

Tight calf muscles can also aggravate the Achilles tendon, and stretching of the calf muscles is important; this, as well as warming up before doing a run or performing any aggressive physical activities.

Symptoms:  Common symptoms are pain after exercising, a thick tendon, pain and stiffness along the Achilles tendon while running, and swelling in the foot.

Tests:  Commonly utilized tests will be radiographs as well as magnetic resonance imaging, both of which are noninvasive and will help evaluate the bony insertion as well as the tendon and the health of the tendon.

Treatment of the Achilles Tendonitis:  In most cases, nonsurgical.  We are aggressive on treating this with calf stretches, what we call heel drop stretches, as well as single-leg heel drop.  See photos.  Other treatments that have been done are cortisone injections, shoes and orthotics, and extracorporeal shockwave therapy.  This is not normally performed at this day because the results have been inconsistent.

Written by Paul Spezia, DO

Monday, August 27, 2012

Two Common Answers to “Why do I have hip pain?” Hip Arthritis and Bursitis and How They Differ


Hip pain is extremely common and has multiple sources.  It can be complicated and frustrating.  However, let’s narrow down two of the most common sources and talk about their typical presentation and options for treatment. 

First, bursitis is inflammation of a small sack on the outer aspect of the hip over the bony prominence called the trochanter.  Typically the bursa helps tissues glide past each other, however, when the bursa becomes inflamed it can quite painful and limit function and activity.  Many patients complain of pain over the outer aspect of the hip and thigh that’s worse with increased activity and other activities like sitting in a car a long time, sleeping on the affected side, and going up and down stairs.  Most patients don’t recall a specific injury.  Often the symptoms start without a specific incident.  The good news is that hip bursitis is typically treated without surgery and responds well to other treatments.

In many cases bursitis is self-limiting and may respond to moderation of activity.  However, when symptoms persist, we will often start treatment with anti-inflammatories and basic stretching exercises.  Additional treatment includes formal physical therapy programs.  And lastly, many patients respond very nicely to a steroid injection, which can often be curative.  If symptoms recur another round of additional treatment as noted above is often successful.

In contrast to hip bursitis, hip arthritis usually presents differently.  Hip arthritis is loss of the smooth cartilage surface of the hip joint due to age or previous trauma.  Hip arthritis symptoms are often described as a more gradual, aching onset of pain that worsens with increased activity, such as prolonged walking.  In addition, as symptoms progress, decreased motion and stiffness are common.  An important difference is the location of pain.  As opposed to hip bursitis that is often on the outer aspect of the hip, hip arthritis typically presents with pain more localized to the groin and upper thigh area. In some cases, because of the nerve distribution in the hip joint, symptoms can extend to the knee as well and masquerade as knee symptoms.

Initial treatment for mild to moderate hip arthritis is usually moderation of activity, weight loss, and anti-inflammatories.  As we’ve talked about previously with knee arthritis, weight loss can significantly decrease hip arthritis symptoms.  For some patients that develop more advanced arthritis but want to delay surgery, a hip steroid injection can provide some relief, but it’s often relatively short-lived.  Once symptoms begin to affect daily life and function, patients will often consider total hip replacement.  And while there are risks with hip replacement surgery, it’s one of our most successful and rewarding orthopedic surgeries.

Dane Glueck, MD
Images from AAOS (orthoinfo.aaos.org)

Wednesday, August 22, 2012

A Lesson on Arthritis


Everyone has heard of arthritis, seen ads on TV for arthritis medicine, and has a friend or family member with arthritis.  As a shoulder and elbow surgeon, every day that I work I am going to talk to people who have arthritis.   My partners who do hip, knee, and hand surgery also see arthritis patients on a daily basis.  In this newsletter we'll talk a little bit about the diagnosis, causes, and treatment of arthritis.


What is arthritis? 
Arthritis is the destruction of cartilage in a joint.  Cartilage is the smooth covering of the end of a bone that allows a joint  to move smoothly.  Think of the smooth white covering on the end of a raw chicken leg--that's cartilage.  When the cartilage starts to wear away, that's arthritis.  Once all the cartilage has worn away, that's what people call "bone on bone" arthritis.  Arthritis can affect any joint in the body, but is most common in the knee, hip, and hand.


How do I know if I have arthritis?
We diagnose arthritis with an x-ray in our office.  There are many problems which can cause pain in joints, but arthritis is one of the few that will always show up on x-ray.  For that reason, arthritis is fairly easy to diagnose. 


What causes arthritis?
For most people, it's just a part of getting older.  The cartilage loses the ability to regenerate and keep up, and starts to break down.  Many people have a genetic component as well.  They are predisposed to getting arthritis because their parents had it.  Arthritis is also associated with being overweight.  Weight loss is the single most effective treatment for arthritis of the knee.  Finally, broken bones or injuries around a joint can cause arthritis.  But remember, for most people it just happens for no specific reason.


How is arthritis treated?
Arthritis does not have a cure.  There are really four treatments for arthritis:
1) medicines:   We usually use tylenol or anti-inflammatories like ibuprofen.
2) injections:   Normally either cortisone or lubricating injections like Synvisc
3) physical therapy:   Helps to maintain motion and strength in the affected joint
4) surgery:  replace the damaged joint entirely


What is a joint replacement?
Joint replacements remove the degraded cartilage and replace it with a metal and plastic joint.  Joint replacements are most common in the knee, hip, and shoulder.  Joint replacement is generally a very successful operation, but it is a last resort.  Like any surgery, there are risks to joint replacement.  If someone continues to have pain despite injections, medicines, and therapy, then joint replacement surgery may be an option.

Have more questions?   Please feel free to come in and see us, or visit our website at SPBJ.net.

Wednesday, August 15, 2012

Why Do My Fingers and Hand Tingle and Hurt?


There may be several causes but the most common cause is carpal tunnel syndrome.  The most common symptoms include numbness, a tingling feeling, and pain in the hand on the palm side involving the thumb, index finger, long finger, and part of the ring finger.

What Causes Carpal Tunnel Syndrome?
A nerve (the median nerve) runs through a tight space in the wrist along with tendons.  This space is called the carpal tunnel and doesn’t allow much extra room for swelling and inflammation around the nerve.  This causes the nerve to be compressed, which creates the symptoms we just reviewed.

What Are The Most Common Symptoms of Carpal Tunnel Syndrome?
Most patients will have the numbness, tingling, and pain in the fingers on the thumb side of the hand.  In addition, most symptoms are worse with activity such as driving or using the hands for an extended period of time.  Many patients also note that their symptoms are worse at night and they wake up and let their arm hang over the side of the bed or reposition their hand to try to relieve the symptoms.

How Do I Know It’s Carpal Tunnel Syndrome?
Often a good physical exam can help clarify the diagnosis of carpal tunnel syndrome.  The doctors at SPBJ will assess the hand for loss of muscle strength or tone, evaluate for decreased sensation, and also evaluate if tapping or compressing the area around the nerve worsens symptoms.  In addition, tests such as nerve studies will help confirm if the nerve is compressed by showing that the nerve signals across the wrist are abnormal or delayed.

How Do We Fix Carpal Tunnel Syndrome?
In mild cases the doctors at SPBJ will start with conservative treatment like anti-inflammatories and a wrist brace.  If symptoms are more advanced, then a steroid injection can be helpful for some patients.  If symptoms have been present for a longer time and tests show more advanced compression at the nerve, then carpal tunnel release surgery may be a good option.

How Does the Carpal Tunnel Release Surgery Work?
It’s relatively simple in that we want to relieve the pressure on the nerve by decompressing the space around the nerve.  A small incision is made in the area and the tight band of tissue around the nerve and tendons is released.  The surgery is an outpatient surgery.  The patient goes home that day with a bandage around the incision and gradually returns to activity over several weeks as the incision heals.


Written by Dane Glueck, M.D.



Tuesday, August 14, 2012

Mars, Venus, and Painful Knees



There is no question that men and women are built differently in many ways.  This premise extends to our knees and how orthopedic surgeons treat their pain. 

Knee arthritis continues to be a growing epidemic in our patient population at St. Peters Bone & Joint.  We’re not alone in this.  Across the nation total knee replacement is one of the fastest growing operations with nearly 600,000 performed per year. 

Knee arthritis is the gradual loss of cartilage (the smooth tissue lining the knee joint) over time that eventually causes pain, loss of motion, and abnormal alignment of the knee joint.

Interestingly, women undergo about 2 out of 3 of the total knee replacements performed in the United States.  Even then, good data shows that women often wait longer, or even go without knee replacement, when compared to men with the same level of arthritis.  One study showed that the degree of underuse for joint replacement was seen in both sexes, but underuse was three times greater in women than men!   This often means progressive pain and loss of function before treatment is provided.
Furthermore, men and women’s anatomy is different.  For example, the width and thickness of the knee is less in women than in men.  In addition, many women are knock-kneed and many men are bow-legged (valgus and varus respectively).  These differences require the surgeon to perform the surgery differently in each case to obtain good alignment and good results.

Dr. McAllister, Dr. Spezia, and Dr. Glueck all specialize in performing total knee replacements for both men and women at St. Peters Bone and Joint.  So, whether you’re from Mars or Venus, if you have progressive knee pain and arthritis we’d appreciate the opportunity to treat your knees and get you moving again!
Improving Patient’s Pathway to Recovery
St. Peters Bone and Joint Surgeons Standardize Pain Control Protocol
for Their Total Knee Replacement Patients
St. Peters Bone and Joint is constantly striving to improve our patients’ satisfaction and outcomes.  As noted in the previous article, total knee replacements are on the rise in the U.S. and right here in St. Charles County. 

Drs. Glueck, McAllister, and Spezia specialize in total knee replacement.  We’ve worked together to combine the best techniques and the most recent literature to minimize the patient’s pain and maximize their function.  We’ve also working with the staff at Barnes St. Peters Hospital and Progress West Hospital to implement the program within the hospital system.

The protocol includes decreasing pain through different methods such as:  nerve blocks, inserting numbing medication in the knee during the surgery, and utilizing different types of medication such as anti-inflammatories in combination more typical pain medications.  In addition to employing different methods for pain control, the surgeons also implement these methods throughout the process.  This means that patients typical receive the medications before, during, and after the surgery.  This has shown to provide a big benefit in improving patients’ pain as compared to older methods that only gave pain medicine after the surgery, when the pain cycle was already underway and more difficult to control. 

Many of our recent patients that had a similar procedure performed elsewhere years ago have commented on how quickly they’ve recovered and how happy they are with the current protocol and our approach to their recovery process.

We look forward to working with you to decrease your pain and improve your function through our state-of-the-art total knee pathway to recovery.

Written by Dane Glueck, MD

What Are The Parts Of A Total Knee Replacement?


One of the most common questions we hear at St. Peters Bone & Joint Surgery is something like, “Exactly what happens when you do a knee replacement and what is it made of?” 
It first might be helpful to clarify that when we say “total” knee it means we’re talking about replacing the worn out ends of the bones on both sides of the knee.  This is in contrast to a partial knee replacement where typically just the inner half of the ends of the bones that are replaced.  In addition, a total knee replacement does not remove the ligaments on the inside or outside of the knee (the collateral ligaments).  Those ligaments are maintained and continue to support and stabilize your knee after the replacement.


As arthritis worsens the cartilage and the ends of the bones wear down.  The parts of the knee replacement simply replace those worn out ends with metal components.  The components are typically made of either a cobalt-chrome alloy or titanium.  A very hard, durable plastic called polyethylene fits between the metal, allowing the ends to glide smoothly as the knee bends, much like a normal knee.
Patients also ask about how much the knee components weigh.  The answer:  between 15 – 20 ounces.









*  images courtesy of American Academy of Orthopaedic Surgeons

Wednesday, August 8, 2012

How Do I Lose Weight with Knee Arthritis Pain?




This is one of the most common underlying frustrations for our patients at St. Peters Bone and Joint.  They feel pinned down by their knee pain and get in a cycle of:  weight gain leading to knee pain which leads to less activity which leads to more weight gain and more knee pain.

First, the good news:  fortunately, a little weight loss goes a long way for your knees.  This is a case of one equals four.  For each pound you lose your knees feel as if you’ve lost four.  This is due to how weight translates through the knee joint.

The first key:  doing something is better than doing nothing.  There is good research that shows that knees that move (even arthritic knees) typically do better than knees that don’t.  Our joints and cartilage respond positively to motion, which keeps them more limber and functional.  So, let’s break the cycle of pain > inactivity > weight gain > more pain.  We need to move to keep our joints healthy and to decrease the weight the pounds on our joints.

Ok, so what activities are best for painful, worn out knees?  The answer is:  activities that move our body and get our heart working but don’t pound on our knees.  Again, doing something is better than nothing, so pick a walk around the block over the couch this evening.  However, if the walk is painful then “cross-train” with lower impact activities like riding a stationary bike, swimming or walking in a pool, or using the elliptical trainer at the gym instead of the treadmill.  Some may say that they don’t have a stationary bike or pool.  If that’s the case then please check out your local Y or gym.  Many are reasonably priced and the cost will likely be returned to you very quickly with less pain, less medications for painful knees, and less visits to the doctor.

P.S. – A quick note on losing weight with food choices.  I recently listened to Michael Pollan (www.michaelpollan.com) speak and he had a very simple piece of advice:  If you’re standing in front of the fridge with the door open looking for a snack then grab an apple.  If you’re not hungry enough to eat an apple then you’re probably really not hungry.  I think your knees will thank you.


Written by Dane Glueck, MD

Tuesday, August 7, 2012

Female High School Athletes and ACL Tears – An Epidemic Preventing ACL Tears and Treating Them When They Occur


Research has shown a 2 to 10 time increase in ACL injuries in females compared to males.  As more girls participate in high school sports this has created an epidemic of knee injuries that limits their ability to continue their athletic career and predisposes them to arthritis and further surgery in the future.

Why Do The Injuries Occur?
Much of the blame tends to fall on anatomy.  Girls and women have an increased “Q angle” – or, what might be better understood as “knock kneed”.  This changes the forces across the knee when an athlete lands or plants their foot and increases the risks of an ACL injury.

How Can The Injuries Be Prevented?
While we can’t change anatomy, athletes can decrease the risk of injury with a training regimen that puts the knee and the body in a better position when landing occurs.  Trainers and therapists can work with female athletes to increase their core trunk strength and to limit landing with the knee in a “knock kneed” (also called valgus) position. 

One recent study showed a remarkable benefit with a warm-up and core-strengthening program as noted by the lead researcher: 
“We showed a statistically significant reduction – by almost two-thirds – in ACL injuries in (participating) female teenage soccer players in a coach-directed neuromuscular warm-up program,” said Markus Waldén, MD, PhD, …  “Interestingly, players (who complied) had a reduction in other acute knee injuries as well.”

What Happens When There is an ACL Tear?
When an ACL tear does occur it is unfortunately typically a season ending injury. The data also shows that young females are at an increased risk for additional knee surgery after an ACL surgery.  This is probably because their initial risk factors were high and their younger age allows an opportunity to play the sport or activity again that may have led to the first injury.

Bracing and physical therapy are an option for a high school female athlete with an ACL tear.  However, due to the high likelihood of recurrent episodes of further giving way episodes and additional injury to the knee, many high school girls will consider and proceed with an ACL reconstruction.

There are multiple options for ACL reconstruction methods.  The primary goal is to achieve a stable knee with a new ACL graft that is similar to the original anatomy and function.  Surgery is typically an outpatient surgery.  Physical therapy is a mainstay of the treatment following surgery and is one of the primary to keys to a good outcome.  In addition, patience is important, as additional literature reports waiting for approximately one year before returning to high-level sport activity.

Information included from AAOS, Timothy E. Hewett, PhD, and Barry P. Boden, MD.

Written by Dane Glueck, MD – St. Peters Bone and Joint Surgery

Monday, August 6, 2012

Feelin' Hot, Hot, Hot!

This summer in the Midwest sure has been a hot one.  Thankfully, a break in the oppressive temperatures appears to be here—just in time for the start of the high school fall sports practice season.  While the weather will be relatively cooler, two-a-day practices on days with highs in the 90s and high humidity still put athletes at risk for heat injury.  Fortunately, heat injury is largely preventable with a little common sense.

When an athlete exercises, the body’s temperature is elevated and the body sweats to cool itself down.  Body fluid and critical electrolytes are lost in the process.  If fluids and electrolytes are not replaced, dehydration occurs, increasing the risk of heat injury.

 Symptoms of heat injury may include:
  • Cramps
  • Chills
  • Dark urine
  • Dizziness
  • Dry mouth
  • Weakness
  • Thirst
  • Headaches
  • Nausea and vomiting
  • Confusion

Heat-related illness can be prevented.  Athletes should stay hydrated before, during and after exercise.  Light, loose clothing should be worn and skin should be exposed as much as possible.  They should train appropriately to be ready for the heat, usually starting with short, low intensity workouts that may gradually increase over 7-14 days.  This allows the body to get used to the conditions safely.
 
Coaches and parents play an important role in prevention, as well.  Each should strive to be able to recognize early signs of heat injury.  Practicing during the early morning or later evening hours decreases risk.  Additionally, workouts should be altered when heat and humidity are high, and when individual athletes are not ready for the heat.
Hydration is the most important way to prevent heat illness.  Athletes should drink at least 16 ounces of water or sports drink one hour prior to exercise.  During exercise, they should continue to drink regularly, about 4-8 ounces every 15-20 minutes.   If an event lasts longer than one hour, or if there will be multiple bouts of exercise in a day (like a tournament), a drink containing carbohydrates and electrolytes should be used.  Most sports drinks will do the trick.  Otherwise, plain water is fine.
If you see any signs of heat illness, you may be dealing with a life-threatening emergency.  Do not hesitate to call for an ambulance early on if an athlete seems to be in trouble.  While you are waiting, begin cooling the athlete by getting him or her to a shaded area.  Consider placing the athlete in a pool of cold water, if available.  If not, placing ice bags or cold towels around the neck, armpits, and groin will help.  Provide cool beverages if the athlete is able to drink.  Act quickly, as these interventions may save someone’s life.

Brandon Larkin, MD

Wednesday, August 1, 2012

My Kneecap is On Fire!


Patellofemoral pain syndrome is the most common knee condition affecting athletes and physically active adults.  It affects womenespecially adolescent femalesthree times more often than men.  Pain is caused by unbalanced motion between the patella (kneecap) and its groove on the femur (thigh bone).  The normal patella moves up and down when the knee is bent and straightened (as in running or cycling).  Sometimes, however, the patella moves from side to side too much during this motion or the contact between the patella and the femur is unequalcausing pain.  The condition goes by many names--Runner's knee, patellofemoral stress syndrome, patellalgia, and chondromalacia patella are a few.
The exact cause of this type of knee pain is unknown.  There are no nerve endings in the cartilage on the under surface of the kneecap, so it probably does not come from there.  Some believe that the pain originates from stress on the bone that is attached to the cartilage.
Regardless of the cause of the pain, patellofemoral pain syndrome can limit both athletic and day to day activity.  The pain usually comes on gradually rather than after a single traumatic event.  Early on, it is typically a dull knee stiffness or ache that is present early in activity.  As you get warmed up and moving, the pain may actually improve.  Symptoms may reappear hours later, after resting.  As patellofemoral pain syndrome progresses, the pain may be present throughout activity.  It is often worsened by descending steps, squatting, or standing from a chair.  Sometimes, a crunching or sandpaper sensation called "crepitus" can be felt and heard with movement of the kneecap.  With advanced cases, the knee may start to give out when walking or running.
Diagnosis of patellofemoral pain syndrome can be challenging.  There is no single test that confirms the condition.  In fact, some athletes can have a completely normal physical examination.  Your doctor will take into account the history of symptoms and pain during specific activities.  X-rays and occasionally MRI can be helpful.
Treatment of this painful condition is overwhelmingly non-surgical.   Weakness not only around the knee, but in the hips, lower back, pelvis, lower leg and abdominal muscles must be corrected.  Flexibility exercises are also very important.  Those with flat feet may need orthotic inserts to correct alignment problems that contribute to knee pain.  Braces and taping are also often used to give pain relief while an athlete starts the process of strengthening.  While these external devices may help reduce pain, they do not cure the problem.  Therefore, improvement in strength and flexibility are vital.  Ice, anti-inflammatories and acetaminophen are also used to help with pain.
Patellofemoral pain syndrome is a common problem in active people.  If your knees are aching, call for an appointment and take the first step to getting back on the road.

Written by Brandon Larkin, MD