Just a quick Thursday morning post, ESPN is reporting that Buster Posey's X-rays have come back positive for a broken ankle. In addition, reports are now showing that he may have injuries to the ligaments of his left knee. Pending an MRI, the severity of the break has yet to be announced, but we will discuss prognosis of a clean break versus one requiring an ORIF. Needless to say, Buster is more than likely done for the season and the long-term potential of his career may be in jeopardy.
The results of the MRI will more than likely determine the course of action that the orthopedic surgeon take to bring Buster back to playing health. Here are a few scenarios that include potential prognosis for returning to play:
Scenario 1: Fractured bone without additional ligamental injury; Treatment: CAM (walking) boot and physical therapy; Time out: 6-8 weeks; Prognosis: Should return to full ability with no loss of function.
Scenario 2: Complete fracture with ligamental injury. Likely treatment: ORIF (open reduction, internal fixation) and physical therapy; Time out: 4-6 months; Prognosis: Given age, should return to close to full strength with minimal limitations.
Here's a picture of the ORIF. Note that hardware that is inserted will be a limitor of what he is able to gain back functionally. The more hardware, the less movement he will be afforded.
Scenario 3: Complicated fracture, in which the bone is completely shattered. Likely treatment: ORIF and physical therapy; Time out: Out for the year; Prognosis: May not ever get back to original playing ability. Given the severity of this injury, significant limitations may be present for the rest of his life.
Just a reminder, the these are only three possible scenarios of what may come about in the future with Buster's ankle. The commentary provided is just what I have experienced in the clinic, and is in no way a definite answer to the question of how long he will be out. Professional athletes do typically have a shorter recovery period than the normal lay-person, but given the money involved, the Giants will not rush him back into action. As a medical professional, here's to hoping that his injury is not too severe and he will be able to play to the potential he has shown in his young career.
Have any questions or comments? Please feel free to email me at jcachodpt@gmail.com and I will get back to you as soon as possible.
This week's topic: patellofemoral pain syndrome (PFPS). For those of you who aren't familiar with this terminology, patellofemoral pain syndrome is characterized as pain originating from the areas underneath or around the patella (kneecap), due to abnormal forces being placed upon the patellofemoral joint. This can result in potential irritation to the underlying articular cartilage (chondromalacia), irritation/inflammation of the synovium, and finally damage to the bones themselves. Common signs and symptoms that accompany patellofemoral pain syndrome are anterior knee pain that occurs with activity, and is exacerbated with ascending/descending stairs/hills.
The question that may be running through your mind, is WHY DOES THIS HAPPEN? As stated earlier, the probable cause for PFPS is abnormal forces acting upon the patellofemoral joint. In my clinical experience, it seems as though muscle imbalances (tightness/weakness of certain muscles) seem to be one of the primary causes of this issue. Weakness of the quadricpes/gluteal musculature and tight hip flexor musculature seem to be quite prevalent in my encounters in the clinic.
Prior to jumping right into treatment, it's important that we use a special test to verify that the individual is suffering from PFPS. For these purposes, we will use the eccentric step down test, which a study conducted by Nijs et al, determined that it's results are most likely to indicate PFPS. The test can be completed as shown in the following video:
Finally, let us examine treatment of patellofemoral pain syndrome. Before we start, let me remind you that the information presented on this blog should not be used as a substitute in any manner for skilled services. In addition, I am in no way making diagnoses or providing treatment via the blog. This blog is solely intended to educate the readers in the area of injuries/rehabilitation. If feel as though you may need help, please see your physician or physical therapist (in direct access states) for a referral/evaluation. As stated earlier, we will be focusing on fixing the muscle imbalances of the lower extremities. Use the following stretches and exercises to help with your PFPS:
Let me apologize for the lack of posts in the past couple weeks. When I started the blog off, I was writing 1-2 articles per day and I got a bit burnt out. Needless to say, from here on out, I am going to try to do a lengthier post every other week, and then post the sports stuff whenever something important comes up. Tiger Woods' latest knee pain/achilles tendonitis will probably be my next professional sports subject, so keep an eye out for that one golf fans. Thanks again for reading my blog! Keep checking it out for new updates!
Have you ever reached the end of a long school and work day and felt an annoying tightness and soreness extending from the top of your shoulders and into the neck? Chances are you are dealing with what has been aptly described as "student shoulder" or in clinical terminology, soft tissue limitations of the upper trapezius, levator scapulae, and other shoulder girdle musculature. When this happens, the typical response is to have a friend/family member/significant other come and massage the affected area for a bit... The problem is that within a matter of time, the pain/tightness/soreness comes back. This can be extremely aggravating, and potentially debilitating in certain situations.
In order to address this issue in the best way possible, we must first separate ourselves into two categories. Our first category is people with postural tightness of the upper trapezius secondary to a passive insufficiency of the scapular stabilizers (your back is weak), or the second group in which the upper trapezius is actually tight from excessive activity. For the purpose of this post, we will use a quick and easy screen to figure out which of the two categories you fit in. Use the following picture and subsequent instructions to get through the test:
Begin the screen by sitting in a relaxed slouched position like in figure A.
Feel the muscles extending from your shoulder, up to the neck-record what your feel.
Next, assume a nice, tall posture like the one in figure B.
Once again feel the same muscles and record what it feels like.
Ok, now that our screen is completed, categorization of your type can be completed. For the purpose of this blog, we will refer to postural tightness as Type 1 and overwork tightness as Type 2.
You probably have TYPE 1 tightness if your muscles were tight in the slouched (figure A) posture, but relaxed in the tall posture (figure B).
You probably have TYPE 2 tightness if your muscles were tight in both slouched and tall postures.
Treatment Options:
Depending on the severity of your issue, I would recommend consulting with a physician/physical therapist in the event skilled services are required. If you are dealing with a minor affliction, here are some options you can try...
If you are dealing with Type 1 tightness, this is typically caused by a passive insufficiency of the posterior shoulder girdle musculature. What this means is that because your posterior shoulder girdle muscles are weak, we assume the slouched posture as in figure A. The shoulders have now been drawn forward to weakness of the back muscles and potential tightness of the anterior musculature. This forward position pulls the upper trapezius on stretch, leading to that tight feeling. Because the trapezius is already on stretch, there is no need to stretch it. The key is to stretch the anterior musculature (pectorals) and strengthen the posterior musculature. Here are a few examples of things you can do:
Ok on to Type 2, or overwork muscles of the upper trapezius. In many individuals, the upper trapezius is a frequently overworked muscle. This is typically due to weakness of the other back muscles, leaving the upper trapezius to do all the work. For this scenario, the upper trapezius is actually tight and should be stretched in addition to strengthening of the posterior musculature. In this case, skilled services from a PT may be necessary as the individual may have issues properly activating the right muscles. But here is a few options you can try out:
Alright, I believe that is all for this post. Again, please consult with your physical/physical therapist prior to engaging if you are dealing with a specific injury. Hope this can help ease some of your tension!!
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.
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!
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!
