Education

By Dennis Rodin, MD., as featured in the Republican-American, April 28, 2013

Technological advancements have defined the start of the 21st century. With society clamoring for faster computers, more powerful smartphones, and crisper images on their LED televisions, companies are struggling to keep up with demands. These expectations have also extended to the medical industry where doctors and patients alike want more efficient and less invasive ways to diagnose and treat diseases. As an orthopaedic surgeon specializing in sports medicine, I have seen this first hand in the field of arthroscopic surgery.

Arthroscopy is a form of surgery where small incisions are made in order to introduce a camera into a joint. Attached to the camera is a fiber optic light cable that illuminates the joint. The camera basically acts as a cam corder with the image displayed on a video monitor. The picture’s quality has recently been enhanced with the introduction of high definition capabilities in the equipment. The surgeon watches the images on the monitor while holding the camera in one hand, and surgical instruments in the other. Also attached to the camera apparatus is an inflow tube which delivers fluid into the joint. The pressure is closely monitored and controlled by a special pump. The fluid helps distend the joint and aid in visualization. The small incisions that are made are called portals. Multiple portals can be made to place various instruments into the joint in order to cut, remove, or debride tissue. By working through small incisions measuring only 5-10 mm in length, large incisions are avoided. This means less soft tissue dissection and decreased risk of injury to surrounding structures such as arteries and nerves. Because less soft tissue is violated, patients typically have less pain after surgery. Arthroscopy can theoretically be performed in any joint, but is most commonly done in the knee, shoulder, ankle, wrist and hip.

The knee is the most common joint in which arthroscopy is performed. According to the American Orthopaedic Society for Sports Medicine, more than 4 million knee arthroscopies are performed worldwide each year. The camera, or arthroscope, commonly used in the knee measures 4 mm in diameter. With only 2 portals made, a surgeon can trim a meniscus tear, remove a loose body, or shave articular cartilage. Sometimes, additional portals are made to gain better access to hard to reach areas. Ligament reconstruction, such as anterior cruciate ligament (ACL), can also be performed arthroscopically. For routine procedures such as meniscectomies, patients can place weight on their leg immediately after surgery and begin range of motion exercises. With appropriate rehabilitation, athletes can return to sport within 3-6 weeks.

Significant advances have also been made in arthroscopic procedures of the shoulder. This involves the instrumentation used as well as implants that are placed for rotator cuff and labral repairs. Patients who have experienced shoulder dislocation and recurrent instability typically injure the labrum which is a ring of cartilage around the socket of the joint. This can be repaired through 3 portals with implants measuring as small as 3 mm. Unlike the knee where the skin incision is very close to the joint, shoulder portals have more soft tissue to traverse and are usually maintained with a cannula. This allows easy passage of instruments in and out of the joint without getting hung up in the soft tissue. Another common injury in the shoulder is a rotator cuff tear. This involves the muscles that raise the arm up overhead. Through 3 – 4 small incisions, the tendon can be repaired back to the bone using various instruments that help pass the suture through the tendon as well as placement of the implants. When open incisions are made, muscles and tendons have to be dissected to gain access to the site of injury. This can mean more pain and swelling postoperatively, as well as a longer recovery. The advances in shoulder instrumentation and implants have revolutionized the field of shoulder arthroscopy, particularly over the last 10 years.

Medical advancements seem to be keeping pace with technology, and this is improving the quality of care to patients. The progress of arthroscopic surgery is a perfect example. With newer instruments and cutting edge video technology, orthopaedic surgeons can treat joint related problems in a way that is less invasive and more tolerable to patients.

By Eric Olson, MD

Rotator cuff problems are the most common cause of shoulder pain in individuals greater than 40 years old. When someone has inflammation involving the bursa, which cushions the rotator cuff or the tendon is just strained but not torn, physical therapy and activity modification can help someone to improve and manage their symptoms two thirds of the time. If the rotator cuff tendon is torn completely through, however, frequently the best treatment is to have the tendon operatively repaired back to the bone from which it tore. This often helps relieve the night pain, pain with reaching and improve the power of the shoulder for active individuals with rotator cuff tear.

The operative treatment of rotator cuff tears has evolved through the course of my professional lifetime and has become a particular interest of mine. As a little boy, my mother gave me a puzzle to solve every Christmas. I enjoyed the challenge of trying to “figure it out.” As a consequence, my mother provided increasingly difficult and challenging puzzles. Later, during the 1960’s when macramé belts were popular, I earned money custom making belts for my mother’s friends, essentially earning money through tying knots. In medical school I was fascinated by the technology of arthroscopy, which was evolving first in the knees and later in the shoulder. In the 1980’s, surgeons learned to use the arthroscope to treat painful, inflamed bursae in the shoulder and to shave down “bone spurs” but when the tendon was torn, the shoulder needed to be opened through a traditional incision in order to get the tendon fixed down to the bone. In the 1990’s, while working at Walter Reed Army Medical Center, Dr. Pat St. Pierre and I did basic science research in which we showed the rotator cuff tendon could be repaired to bone without the creation of a “trough”, which allowed new implants that enhance the fixation of tendon to bone to be developed.

In 1999, I attended an Arthroscopy Association of North America course in Chicago in which I learned how to perform arthroscopic knot tying. This opened up a new world for me once I realized it was possible to tie knots just as well outside of the body and slide them into the body through little tubes. After working to develop my skills with knot tying in 2000, I started performing arthroscopic rotator cuff repairs in the Waterbury area. Over the subsequent decade, there have been significant advances in the quality of the equipment, implants, as well as a better understanding of the biomechanics and biology necessary to achieve predictable rotator cull healing. These advances allow operations to be performed on an outpatient basis with much less postoperative pain than occurred with traditional open surgery.

Performing a complex arthroscopic rotator cuff repair is analogous to building a ship in a bottle, a difficult but achievable task in a small space. Fortunately, the things I have enjoyed in my life have gotten me ready for this task. I have always loved puzzle-solving; I learned to tie knots efficiently and securely making macramé belts and hand tying my bow ties most days. I have been interested in photography and technology, which has made the use of the arthroscope visually stimulating. I have performed in basic science research which has allowed improvements in rotator cuff repair techniques for myself and others. Consequently solving each patient’s puzzle provides me with an opportunity to help them feel better while doing something I enjoy!

My current goals are to make the outcomes of patients who have undergone arthroscopic rotator cuff repairs as predictable and positive as possible. Working together with the operating room team and skilled physical therapists postoperatively, I am optimistic that we will have greater success in the future.

By Dennis Rodin, MD

Did you ever wake up from a sound sleep holding on to a painful shoulder? How about trouble putting that dish away on the top shelf of your cupboard? Unable to grab your briefcase in the backseat of your car? You’re not alone. Shoulder pain is often brushed aside as just another sign of aging, but it doesn’t have to be. There is a reason behind that pain, and many options to improve your quality of life.

Pain in the shoulder can be coming from several different places. The most common cause is an inflammatory process called bursitis. The bursa is normal tissue that is found throughout the body. In the shoulder, the bursa overlies the rotator cuff and allows it to glide freely between bony surfaces. When it becomes inflamed, it can lead to pain, limited range of motion, and even weakness.

Initial treatment is aimed at controlling the inflammation and restoring function. Taking NSAID’s (non-steroidal anti-inflammatory drugs) such as ibuprofen and naprosyn can be helpful. Activity modification is also important. You should avoid, or at least limit, those activities that aggravate the pain which may include lifting, pulling, reaching overhead, or repetitive motions of the arm. If your symptoms persist, consideration for an exercise regimen focused on the rotator cuff muscles can help. These can often be performed at home, but formal physical therapy is sometimes required. A cortisone injection is also an option. This is placed in and around the bursal tissue to diminish the inflammation.

Another common cause of pain is a rotator cuff tear. The rotator cuff is a group of four muscles that control overhead range of motion as well as rotation of the arm. This can tear from a traumatic injury but more often is simply a degenerative process that occurs with aging. Not all rotator cuff tears are symptomatic, but those that are can respond to the same exercise program and cortisone injections used to treat bursitis. If the pain does not respond to conservative management, or function of the arm is severely compromised, surgery is performed to repair the tendon.

Other factors that can affect your shoulder include the biceps tendon, arthritis of the joint, or even neck pain. Just remember that having shoulder pain is not something that you have to put up with. Once the proper diagnosis is made, a conservative approach can often improve your pain and function.

By Dennis Rodin, MD as featured in the Republican-American, September 22, 2013

Sports-related concussions have gained a lot of attention over the past several years. The media has brought this to the forefront with coverage of injuries to NFL players as well as a current lawsuit against the league. This lawsuit, the largest in sports history, involves over 4500 former NFL players suing the league for allegedly concealing information linking concussions to long term brain damage. Management policies of the injury, including criteria for return to play, have come into question. We have recently been reminded of the severity of concussions when Kevin Kolb, quarterback for the Buffalo Bills, sustained another concussion during a pre-season game which is thought to be career-ending. The NHL has not been immune to this problem either with current star Sidney Crosby missing substantial playing time and former players Eric and Brett Lindros having had multiple concussions forcing Brett to retire at the age of twenty. The increased awareness of concussions and its potential long term effects is now seen at the high school level also. This is particularly relevant this time of year with football season underway.

A concussion is a traumatic brain injury caused by direct or indirect forces to the head, face, neck, or elsewhere on the body. Symptoms are typically broken down into four categories – physical, cognitive, emotional, and sleep. Physical complaints most commonly involve headaches but may also include dizziness, nausea, and poor balance. Cognitive effects involve short term memory loss and difficulty with concentration. Irritability, anger, and sleep disturbance can also be seen.

Initial treatment of concussions is rest. This means removal from sport and avoiding any strenuous form of exercise. Cognitive rest is now also regarded as vital in the recovery process. Students may need to miss time from school until their memory and mental processing have returned to normal. Most concussive symptoms resolve within two weeks. Before consideration for return to play is made, an athlete must be symptom-free at rest. Then they are started on a rehabilitation program which entails a slow transition back to both physical and cognitive activities. If a player is returned too soon, they are at increased risk of developing second impact syndrome which can have catastrophic results including death. This is most commonly seen in the adolescent athlete.

The US Centers for Disease Control and Prevention (CDC) estimate that 1.6 – 3.8 million sports related concussions occur annually. Many of these occur in high school athletes with the most numbers seen in football players. Adolescents are more vulnerable to concussions when compared to adults. This may be because their brains are not fully developed, and skulls are thinner at younger ages.

Changes in concussion protocols have trickled down from professional sports to collegiate and high school levels. This has led to rule changes including increased protection of “defenseless” players and barring tackling when leading with the head. Medical professionals and coaches now understand the need to err on the side of caution when dealing with concussions, and immediately removing a player from action suspected of having a head injury. Increased media coverage of this injury has led to a change in culture among football players. Players, coaches, parents, and medical professionals alike have taken a more cautious approach in dealing with concussions. “Getting your bell rung” is a more serious injury than once thought.

By Dennis Rodin, MD, as featured in the Republican-American, July 14, 2013

We’ve all sprained an ankle, tweaked a knee, or strained a hamstring. But what does that really mean? I guess innately we all know what it means in a general sense, but what is actually going on in the deep tissues? Patients can become very descriptive when they try to explain an injury. I get a good idea as to what the diagnosis is after taking a patient’s history. There are many cue words that help me out – sprain, strain, tweak, pull, twist, catch. All of these words mean something more to me when I find out the specific body part and mechanism of injury. These terms are often used interchangeably, but they actually refer to specific structures. When patients finish explaining their injury, they often stop and ask, “So is it a sprain or a strain?” Well let me explain.

A sprain refers to injury of a ligament. Ligaments are fibrous bands that span from one bone to another. Their main purpose is to stabilize a joint. When a ligament is torn, this can lead to joint instability. A strain involves injury to a muscle or tendon. The tendon connects the muscle to bone. A strain can lead to weakness or loss of motion of a joint. The severity of a sprain or strain is described in the same manner. A mild injury is classified as Grade 1. This is the least serious injury and occurs when a ligament or muscle is stretched. Although there may be tearing at a microscopic level, the structure itself remains intact. A moderate, or Grade 2, injury refers to partial tearing of fibers where a serious, Grade 3, injury is complete dissociation of fibers of the ligament, muscle, or tendon.

Initial treatment is similar for both sprains and strains. Utilizing the RICE (rest, ice, compression, elevation) protocol can help diminish pain and swelling. Ultimate treatment depends on the specific structure injured. A Grade 3 ankle sprain is typically managed conservatively, while a Grade 3 knee injury (i.e. ACL tear) can lead to surgery. Treatment of Grade 3 strains depend more on whether it is a muscle tear versus a tendon rupture. Muscle tears are almost always treated conservatively. Their rich blood supply means good healing potential. A tendon rupture typically does not fare as well. That is why tendon ruptures (i.e. Achilles, quadriceps, rotator cuff tears) are often surgically repaired.

So which is worse: sprain or strain? One can’t say that a muscle tear is worse than a ligament tear or vice-versa. Like determining appropriate treatment, this would depend on the specific structure injured. The patient’s interests also have to be taken into consideration. A Grade 2 ankle sprain may ruin a runner’s summer, while a shoulder strain would do the same for a tennis player. The worse injury is always in the eye of the patient.

Although sprain and strain are often used interchangeably when describing injuries, they actually refer to different anatomic structures. A sprain is a ligamentous injury, while a strain pertains to the muscle-tendon unit. Treatment depends not only on whether the injury is a sprain or strain, but more importantly on what specific ligament, joint, muscle, or tendon is involved.

By Dennis Rodin, MD

Tennis elbow is one of the most common conditions that I see in the office. Although commonly seen in tennis players and other racquet sports, you do not have to be a tennis player to suffer from this affliction. This can affect young mothers caring for their children and workers that perform repetitive activities over the course of the day. This is an overuse type of injury that can interfere with activities of daily living.

What is tennis elbow? Typically, it is a nagging discomfort felt on the outside of the elbow. The pain can be brought on with simple tasks such as lifting, gripping, or even using a computer. Another term for it is lateral epicondylitis. The pain can range from just being a nuisance to severe discomfort where even brushing your teeth is difficult to accomplish. Most people do not recall any specific injury that started their symptoms. It has a gradual onset, which can slowly worsen over time.

The problem involves a tendon that extends, or straightens out the wrist. With repetitive activities, this tendon gets overworked and starts to wear down. Small tears can develop where the tendon inserts on to bone. In severe cases, the tendon can detach completely. This particular muscle-tendon unit stabilizes the wrist when grasping an object, and therefore causes pain with simple daily tasks. Watch your wrist the next time you lift that pot of coffee. Those with tennis elbow are probably using their opposite hand.

How is it treated? The majority of patients respond to conservative management involving a specific exercise program and activity modification. The exercises are geared to strengthen the unhealthy tendon. One important point to remember is not to push through the pain. This often exacerbates the problem. For those that are uncomfortable with simple day-to-day tasks, a brace can be worn for pain relief. This acts as a cuff at the top of the forearm and can alleviate some of the discomfort. If the exercise regimen is not helping, then a steroid injection may be helpful. This can settle down any associated inflammation from the condition and give pain relief. A minority of patients does not respond to this conservative approach, and may require surgery to clean up the unhealthy tendon.

The same quality of pain can also be felt on the inside of the elbow. This is called golfer’s elbow, or medial epicondylitis. Rather than affecting the wrist extensors, this involves the tendon that flexes the wrist. The ulnar nerve lies adjacent to this tendon. When it gets irritated, you can feel numbness or tingling radiating down the forearm to the ring finger or pinky. The treatment for medial epicondylitis is the same as that for lateral tennis elbow.

If you do develop elbow pain that just does not seem to get better, call your doctor to confirm the diagnosis. Get started on the exercise program and be patient! This usually takes a minimum of 6 – 8 weeks to show signs of improvement.

By Dennis Rodin, MD as featured in the Republican-American, May 26,2013

Spring is not just the time for flowers to bloom, and grass to grow. It is also the start of baseball season. The Yankees, Red Sox, and yes, even the Mets, are gearing up for the dog days of summer. But baseball has also started locally with little league games occupying the fields of every town, and playoffs coming for high school teams. It is no coincidence that I tend to see lots of baseball related injuries in children and adolescents this time of year. One of the most common complaints is that of elbow pain.

Elbow pain is not uncommon to see in throwers. Although mainly seen with pitchers, kids can experience pain regardless of the position that they play. The diagnoses can vary and are dependent on the age of the patient. The elbow has numerous growth plates and each growth plate, or physis, fuses at a different time. This can make diagnosing an injury on X-ray very difficult, and it is often necessary to get a comparison view of the opposite elbow. Elbow injuries in the skeletally immature are frequently seen due to the repetitive motions of throwing.

Throwing is broken down into different phases. In the cocking and acceleration phases, there is increased load on the inside (medial) of the elbow. This force puts tension on the medial structures including the physis, ligament and muscle tendon unit. This force is called a valgus stress. I like to use the analogy of bending a paper clip; if a paper clip is repetitively bent back and forth, eventually it will break.

The knob of bone felt on the inside of the elbow is called the medial epicondyle. Its growth plate can become irritated from repetitive valgus forces. This is usually seen in children younger than 10 years old. Kids typically report pain with throwing, weakness, and decreased velocity. The growth plate itself can become inflamed which is called an apophysitis. Some times the bone itself can be pulled from the physis, resulting in a fracture. Treatment usually consists of a period of rest and immobilization followed by a stretching and strengthening program. Patients may return to throwing when their pain resolves, but this can require missing an entire season. Surgery is considered for fractures of the epicondyle that are malaligned or displaced.

Another structure that can become injured on the medial side of the elbow is the ulnar collateral ligament. This is diagnosed clinically and confirmed on MRI. This injury typically improves with conservative management. Surgery is reserved for elite level athletes with a reconstruction of the ligament. This has become a very common procedure in professional baseball pitchers and is referred to as “Tommy John surgery.” Pitchers typically return to competition one year after surgery.

While valgus loads on the elbow cause stretching of the medial structures, the outside portion of the elbow (lateral) is compressed. This can lead to fragmentation of a particular bone called the capitellum. Kids will have the same complaints of pain with throwing, but their physical exam will show tenderness on the outside of the elbow. The bone appears irregular on plain X-rays. This diagnosis is called Panner’s disease and is usually seen in boys younger than 10 years old. Symptoms typically resolve with rest but may take several months to dissipate.

In the adolescent age group, lateral sided pain is more indicative of an osteochondral lesion. This is a defect of the cartilage and underlying bone. This fragment can become unstable and cause locking sensations of the elbow. The lesion can be seen on X-ray and initial management involves rest, immobilization and anti-inflammatory medication. Occasionally surgery is necessary to remove a loose fragment and to drill the bone which promotes a healing response.

One of the most common baseball related injuries is elbow pain. This typically has an insidious onset and is caused by repetitive stresses to the elbow in the throwing motion. Kids are not only throwing during the spring and summer. Some athletes participate in fall leagues and winter clinics and never have a prolonged period of rest. The incidence of elbow pain can be limited by decreasing the frequency and duration of throwing. Pitch counts are important to consider and vary depending on the age of the child. Current recommendations can be found at the American Academy of Orthopaedic Surgeons (AAOS) website.