Coming Soon!

Here's a list of what to look out for in the coming weeks:

• What's up with my kneecap? Patellofemoral injuries/pain
• Knee Explosion: Prognosis/Recovery for Ligament/Mensicus Injuries
• Why are My Shoulders So Tense?:  Tightness or Passive Insufficiency?
• SHOES.SHOES.SHOES:  What is right for YOU??

Carlos Boozer Injury Update: Turf Toe?

Per request from the great Cherine K., here is an update in regards to Carlos Boozer, PF for the Chicago Bulls.   I'm sure many of you may be wondering how Boozer ended up with turf toe, when clearly he plays a sport that is played on a wood surface.  Was Boozer participating in some drills on a turf surface when they occurred? Or is this yet another semi-shady incident like his early season hand fracture that required him to get surgery after tripping over his bag.  

Unfortunately for conspiracy theorists, turf toe is a rather common injury whose name arises from its association for sports played on rigid artificial turf surfaces such as football/soccer/rugby.  However, because this injury is common to these sports, does not mean that these injuries are specific to this surface.  

Turf toe occurs secondary to hyperextension of the 1st metatarsophalangeal joint (big toe), resulting in a sprain of the ligaments on both the dorsal and plantar surfaces.  Constant running, planting, and pushing off are all examples of possible methods of injury to obtain this diagnosis. In addition, flexibility of the sole and toe box of athletic shoes can increase the likelihood of injury. Therefore, it makes it easier to see how this injury could occur in a basketball player, just the same as a football player.  The prognosis of this injury is dependent on the severity of the sprain.  A grade I sprain would typically be 1-2 weeks recovery, a grade II sprain (mild/moderate ligament tearing) would mean a 4-6 week recovery, and a grade III sprain might potentially necessitate surgery to repair torn ligaments.  

What is concerning about the Boozer injury is that he "felt something pop" in his right foot, causing him to miss the last 18 minutes of their win against the Pacers. Even though he had a MRI confirming the diagnosis, no word has been released as to the severity of the sprain.  Clinically, normal turf toe would necessitate a 1-2 week recovery period, so it remains to be seen how he will be able to function over the course of a seven game series.  Much like the Derrick Rose injury, he will more than likely be given pain killing injections, but if there is severe tearing of the ligaments, the Bulls may be in some trouble.

I hope this post was educational and useful. I hope everyone is having a great and relaxing weekend.  Until next time!

-Dr. Joshua Cacho, DPT

Disclaimer:
The information, including opinions and recommendations, contained in this website is for educational purposes only. Such information is not intended to be a substitute for professional medical advice, diagnosis or treatment. No one should act upon any information provided in this website without first seeking medical advice from a physical/physical therapist.

What it Means When a Pitcher Has to See Dr. James Andrews for Elbow Soreness: A Stephen Strasburg Update

Have you ever been watching ESPN and heard the name Dr. James Andrews?  Dr. Andrews is a board certified orthopedic surgeon, who is best known for performing orthopedic surgeries on professional athletes. Due to his skill as an orthopedic surgeon, his name is now somewhat of a alarm for sports fans, as it means one of their favorite players may be heading to the disabled list.  For the purposes of this post, we will be discussing ulnar collateral ligament (UCL) injuries in overhead throwing athletes, using Washington Nationals pitcher Stephen Strasburg as our example.


On August 17, 2009, the Washington Nationals signed Strasburg to a record breaking 4-year, $15.1 million dollar contract out of San Diego State University.  One year later, Strasburg hit the disabled list with elbow pain, only to later find out he had torn his UCL.  

First off, let's discuss how/why this injury happens.  The overhead throwing motion is extremely stressful on the elbow and over the course of a pitcher's career, the amount of pitches thrown adds up.  This amount of stress may eventually lead to stretching/fraying/tearing of the UCL.  In 2002,  Lyman, S., et al., examined the effect of pitch type, pitch count, and pitching mechanics on risk of elbow and shoulder pain in youth baseball pitchers, finding that the greatest determinant of injury likelihood is that of pitch count.  We will later discuss the implications in development/training of both young and mature athletes.  

At this time, let's review the surgery to repair this torn ligament.  Named after former Los Angeles Dodger's pitcher Tommy John (who was the first professional athlete to successfully undergo the operation), this surgery was invented by Dr. Frank Jobe, and involves the reconstruction of the UCL via graft (cadaver or homograft).  Dr. Michael M. Reinold, PT, DPT, SCS, ATC, CSCS, rehab coordinator for the Boston Red Sox notes that "Although our success rates are close to 85-92% in elite pitchers, other studies have shown only 74% of high school pitchers return to play."  

What does this mean for Stephen Strasburg?  Estimated return to play is roughly 8-12 months, therefore Strasburg will miss the 2011-2012 season, as there is no need to rush him back early and risk further injury. What will be interesting is to see how his performance is affected following his rehabilitation phase.  Many pitchers who have undergone this surgery have reported being able to throw harder than before their initial injury.  Does this mean Strasburg will end up like the kid from that movie Rookie of the Year?  Are people justified in thinking to have this surgery electively in order to throw faster?

According to Dr. Jobe, this is somewhat of a misconception.  He explains this scenario as more of a return to previous function, rather than hyperimprovement.  Job states that, "When a pitcher comes in with elbow problems, you often see that their ligaments were already wearing out well before. Maybe four or five years ago they could throw a 95 mile an hour fastball, but they've had that ability diminished as the ligament's been stretched. What the surgery does is restore the ligament's stability to where it was four or five years ago. A pitcher might say the operation did it, but it's just more stability in the arm contributing to better mechanics." Following the surgery, the patient will typically begin their rehabilitation program which can last up to 12 months.  Early on the focus is on regaining range of motion, eventually moving towards strengthening and participating in a throwing program.

Ok now that we have discussed the injury, surgery, and prognosis/rehabilitation, let us now look at the implications in amateur/professional sports.  As noted earlier, pitch count is the primary determinant for likelihood of injury in the overhead throwing athlete.  Combined with the increase risk of injury following fatigue, a pitcher throwing excessive innings is a high risk candidate.   Limitations on pitches thrown or consecutive games thrown, such as those employed by the Little League World Series are key is decreasing the risk for young athletes.  Parents also may be wondering if their child is at risk by attempting to throw breaking pitches.  Dr. Jobe's answer to this question is the following: "I don't think throwing the curve puts that much more stress on the arm. I think learning how to throw it does. That's why Little League kids get in trouble. They want to throw a curve so they spend every afternoon throwing to their dads, trying as hard as they can to get it. Then if they're good, the coach wants to win. If it's the playoffs, the same kid might pitch three days in a row."  Again, we see that pitch count should be of primary concern.

Alright, that's enough for now. That was an extremely long post.  Hope it was educational.  If you have any comments or suggestions, feel free to email me at jcachodpt@gmail.com, or contact me via facebook.  Hope everyone had a good Wednesday.  Until next time!

Ankle Sprains: My Own Worst Enemy

Today's post will be somewhat of a continuation of my previous posts in regards to Kobe Bryant and Derrick Rose, but hopefully more applicable to the general public.  We will first go through the potential types of ankle injuries, then discuss treatment, and finally we will examine the effect of shoes on ankle injury prevention.

The mechanism of ankle sprains occur in either a lateral or medial direction, with the lateral injury (inversion sprain) being the more common of the two.  Inversion sprains may involve ligamentous damage to the anterior talofiblular ligament, posterior talofibular ligament, calcaneofibular ligament, and the posterior tibiofibular ligament.  As the severity of your injury increases, so goes the potential damage to these ligaments. Medial injuries (eversion sprains) are rare in comparison to inversion type sprains, and typically involve injury to the deltoid and tiobiofibular ligaments.  Another type of ankle sprain is a high ankle sprain, also known as a syndesmotic ankle sprain, as it involves the syndesmotic ligaments that connect the tibia and fibula.  This injury is common when the tib-fib comlex rotates laterally.  

As stated many times throughout this blog, I would recommend seeing your physician/physical therapist if you are unsure as to how to deal with this injury or if you feel as though your injury is severe.  There is no substitute for skilled care, as your healthcare professionals are the leading experts in dealing with these afflictions.  With this is mind, in the event we are dealing with a minor injury, let's take a look at how you can deal with these injuries.

Our first step in managing these injuries is to first follow the PRICE principal. Following this principal can limit the amount of swelling in your ankle/foot and allow for quicker return to function.  

•  Protect the injured area 
• Rest the injured area
• Ice the injured area
• Compress the injured area
• Elevate the injured area 

Our next step is allowing the ankle to heal, without causing further restrictions at the knee/hip/back because of altered gait/overprotecting the ankle.  This would entail keeping activity to a minimum (don't jump right back into the activity that got you hurt in the first place!), but making sure to keep the ankle moving/exercising within pain tolerance.  Strengthen via walking/exercise and you should be ready to take the next step in about 2-3 weeks.

Now that our ankle is nice and strong, are we ready to get back to action? Potentially.  If you feel as though you aren't confident in your ankle, you are potentially lacking proprioceptive input in your ankle. What does this mean? Well, you have a strong ankle, but you also have a dumb ankle.  Brandi L. Ross, ATC, states, "Proprioception is defined as the ability to establish a sense of position in space, especially at a joint.  This function is associated with the joint mechanoreceptors and are interrelated. If the mechanoreceptors are damaged when an ankle sprain occurs, proprioception will be affected, which  results in a reduction in the body's ability to balance. Thus, proprioception will not be an effective mechanism for reducing the chance for further injury. Reeducation of the mechanoreceptors becomes a vital key to returning an individual to a perceived sense of stability."  After 4-6 weeks of incorporating proprioceptive exercise to your normal strengthening program, you should be ready to go!

Here are some examples of exercises you can do, but if you aren't feeling confident, don't rush it.  Start slow and eventually work your way up to the more advanced exercises.  Furthermore, if you as though you aren't progressing and you are still dealing with a lot of pain after a month or so, I implore you to see a physician/physical therapist.

Finally onto a discussion of footwear.  One would be lead to believe that the higher the ankle support along the side of a shoe, the less likely you are to experience an ankle injury.  In fact, it was more or less taboo to wear a low-top shoe in basketball because of fear of ankle injury.  This couldn't be farther from the truth.  

Countless research has been done on this subject and one conclusion is clear: the height of your shoe's ankle support has no bearing on the incidence of ankle injury.  If you step on someone's foot and roll your ankle, there is nothing you can really do about that.  But what you can reduce, is the amount of stress placed on the ankle during abnormal positions.  Via the exercises shown above, the body is able to react quicker to abnormal situations, decreasing the likelihood of a repeat injury.  When it comes to selecting a shoe, pick what feels comfortable on your feet, and what you feel is going to allow you to perform at a high level.  

Hope this post helps with your ankle injuries! If you have any questions, feel free to email me at jcachodpt@gmail.com.  Hope everyone is having a great week!

Derrick Rose Injury Update

This post is for Luis Soto, as I gotta give Derrick Rose some love on the injury blog.  Derrick Rose went down early in the first quarter with an ankle sprain, but still managed to play 43 minutes in their loss to the Indiana Pacers.  This makes it two top NBA superstars dealing with ankle injuries, but I highly doubt that these injuries will play a factor (at least game status wise) in the upcoming game 5s this week.


Alarm was raised throughout the Chicago Bull Nation as Derrick Rose was spotted walking around in a CAM boot and also had a MRI taken on his injured ankle.  According to SB*Nation, "Chicago Bulls point guard Derrick Rose also said he will in Tuesday's Game 5 vs. the Indiana Pacers after an MRI that was performed revealed no structural damage to his sprained left ankle."  Ok Luis, you can breathe a sigh of relief now.  


What does this mean for the game? Much like Kobe, Derrick Rose will more than likely receive a cortizone injection, allowing him to play pain free for the game.  This may allow him to play close to full strength, but he will definitely be feeling after the shot wears off.  We've seen this plenty of times in the past, as NBA superstars bear through the pain for a shot at glory.... but here's to hoping we don't see another Brandon Roy type situation, leaving Derrick Rose without that explosiveness that makes him oh so dangerous.  


In my clinical experience, given an orthopedic setting in which patients are seen 2-3 times per week, an injury of this type would require roughly 4-6 weeks of skilled physical therapy.  Taking into consideration Derrick Rose's level of physical fitness, and the fact that other than playing basketball, his only other job will be to rehab his ankle... total healing time could be cut down to the 2-3 week range to return to 100%.  


In conclusion, don't fret Bulls fans.  NBA players play banged up all the time and by this time in the season, unless you are Brian Scalibrine hiding at the end of the bench, chances are you havent been 100% since about the 5th game of the season.  


If you have any other questions regarding injuries in professional sports, or want an opinion on an injury you may be dealing with, feel free to email me at: jcachodpt@gmail.com.  I hope everyone has a great week!

Running with Lateral Knee Pain?

This topic is one I have discussed on regularity, as I have had this question posed to me by countless numbers of family and friends.  If any of you endurance runners out there have experienced pain down the side of your knee after running a few miles, there is a good chance you are dealing with tightness of your iliotibial band or IT band for short.  This is not a 100% diagnosis of all knee pain in runners, but it is very common to this population.  The reason why the IT band acts up is typically due to insufficient strength of the gluteal muscles (maximus/medius), typically leading to the TFL/ITB complex overworking and subsequently tightening.  When this happens, the ITB does not glide properly over the lateral knee joint during movement, eventually leading to inflammation.

How do you know if this post can help you?  Here are a few of the common signs and symptoms of ilitotibial band syndrome.

• Pain over the lateral (outside) portion of the knee joint.
• Swelling over the location of discomfort.
• Snapping or popping sensations while the knee is in flexion.

Ok now on to the good stuff.  Now the remedy for this one is no quick fix.  In fact, if you are dealing with this type of injury for a long time, I would recommend seeing a physical therapist (or  MD for a referral first depending on the state). But my recommendation is a combination of modalities, stretching, and exercise.

Here are a few exercises and stretches typically recommended to help out this issue:

foam roll ITB stretch

no foam roll?

I hope that this post can help some of you out with your knee pain.  Again, I reiterate the fact that these are recommendations and if you are having continued knee pain or difficulty, please consult a physician or physical therapist.  Good luck everyone and I hope you are having a good week!

Kobe Bryant- ThreePeat in Jeapoardy?

For those of you who were watching last night's Lakers/Hornets game, some may have seen Kobe limp off the court with about 2 minutes to go after getting tangled up with the Hornets' Willie Green.  Early indications looked like a repeat of a previous ankle sprain a few weeks ago, but via ESPN-Los Angeles and speaking with Stephania Bell, DPT via Twitter, it seems as though it may be more of a forefoot sprain than the typical ATF/Inversion sprain.  While this may be disconcerting to Laker fans, Kobe should be ready, although banged up, for game 5.  While typically a sprain/strain of this type would require roughly 3-5 weeks of rehab to return to 100%, the Laker's training staff and given Kobe's level of physical fitness will have him ready to play sooner than later (more than likely a cortizone shot later as well).  The Lakers biggest problem in threepeating will prob not stem from this injury, but rather their mediocre play as of late.... But I'll keep those opinions to myself at this time.  Hope this sheds some light on the issue.  Happy Monday to all!

Photo via AP-Yahoo Sports.

Welcome!

Hello and welcome to The Injury Blog! My name is Joshua Cacho and I am a licensed doctor of physical therapy in the state of California.  I hope to use this as a forum to give my medical opinions of injuries occurring in professional sports, as well as answering any questions that you might have.  Please feel free to email me at jcachodpt@gmail.com and I'll try to answer you via the blog or via email as quickly as I can!