Lower Back Pain with Dr. Jason Tarno

In Southern Nevada many people are active in athletic activities. Sometimes they injure their low back. Which activities tend to generate most of the low back injuries?

Injuries to the low back can happen with just about any sports related activity. Some sports, however, tend to subject the low back to stresses that can lead to injury more than other sports. Weight lifting, football, baseball, softball, and golf are examples of some sports where we tend to see low back injuries most often.

What symptoms are common to people with low back pain?

The symptoms of low back pain range from muscle stiffness and soreness, to actual spine pain, to discogenic pain. When a nerve is compressed, symptoms can involve pain or weakness in the lower extremities.

How common is low back pain?

Quite common. It is actually the number one occupational (work related) injury, and is the second leading cause of missed days of work. As we age, the back tends to be more susceptible to injury. Not all back problems cause back pain. Some disorders like herniated discs can cause pain in the legs.

How can you determine where the problem lies?

A good tool for the physician is a complete patient interview and medical history along with a thorough physical examination. However, diagnostic studies are also helpful in determining the athlete’s problem.

What type of diagnostic tests?

Diagnostic tests to find the cause of low back pain include x-rays, MRI, CT scan, nerve conduction studies, and bone scans.

Will an x-ray show nerve or disc disorders?

No, an x-ray will not show the nerves or the actual disc. X-rays do show the entire spine, however, and give the physician a sense of the integrity of the disc based on the amount of space between the discs. They are also helpful in determining any slippage of one spine on another (instability) and looking for arthritic changes. Therefore, x-rays are usually the first diagnostic tests utilized when evaluating back pain complaints.

How does an MRI differ from a plain x-ray?

An MRI gives the physician a better idea of what is going on with the actual discs, spinal canal, and nerves. It does not replace the need for plain x-rays because the MRI takes image slices of the back, whereas the x-ray gives the entire “lay of the land.”

Is there any radiation exposure to the athlete with an MRI?

No, MRI stands for Magnetic Resonance Imaging. With this modality of imaging, magnetic waves are used to create computerized pictures of the body part in question by taking cross sectional views. Therefore, there is no exposure to radiation.

What is your feeling regarding manipulation of the spine?

The word manipulate stems from the latin words manus and pulus. Manus translates to “hand’ in English, and pulus translates “to the skillful use of.” Manipulate then means by definition: the skillfull use of hands. Using that definition there are many areas that would qualify in some way as manipulation. Massage therapists, physical therapists, chiropractic physicians, and osteopathic physicians all perform different levels of manipulation. In that regard, I am a big believer in manipulation of the spine.

What is the difference between chiropractic and osteopathic manipulation?

A chiropractic physician (D.C. – doctor of chiropractic) is skilled in the use of chiropractic manipulation. An osteopathic physician (DO – doctor of osteopathy) is trained in the use of osteopathic manipulation. A D.C. does not perform surgery, admit to hospitals, or prescribe medications. An osteopathic physician is trained in the use of manipulation, but also is able to perform surgery, admit to hospitals, and prescribe medications.

So would it be beneficial to an individual with low back pain to seek manipulation when they have low back pain?

Manipulation or adjustments of the spine can be helpful in some athletes. But there is no one form of therapy or treatment that works for everyone. That is why medicine is an art and not an exact science. What works for one athlete may not necessarily work for the next. The goal of the medical professional is to use any acceptable modalities that they possess in order to get the athlete back to a functional level as quickly and as safely as possible.

- Jason M. Tarno, D.O., is Board Certified and Fellowship trained in Sports Medicine. Dr. Tarno is an associate of Crovetti Orthopaedics and Sports Medicine.

For further information call: 990-2290.

Or visit us at: www.CrovettiOrtho.com

Common Golf Injuries with Dr. Jason Tarno

Many people in Southern Nevada participate in golf. Is golf considered a sport and do people actually get injured playing this game?

Webster defines the word “sport” as:

1. an athletic activity requiring skill or physical prowess and often of a competitive nature

2. diversion, recreation.

Therefore, by definition, golf is a sport, and people occasionally do get hurt playing this game. Studies have shown that golf is actually one activity that ranks high on the list for head injuries, depressed skull fractures being the number one type. Unfortunately this happens when someone swings a club and accidentally strikes a bystander in the head. These types of injuries are rare and purely accidental. More commonly, the injuries from playing the game tend to affect the wrist, elbow, shoulder, and low back. These injuries tend to be either acute or chronic.

How do acute injuries differ from chronic injuries?

Acute injuries tend to occur from missing the ball, taking a fall, slipping, etc. The injuries that are chronic in nature are most commonly due to overuse, and are often caused by having poor swing mechanics. In some instances golfers can injure themselves to the point of requiring surgery to return to the links.

How does someone injure their wrist playing golf?

The wrist is usually injured if there is significant or consistent impact of the club head with the ground. When this type of impact occurs, it is the left wrist (in a right-handed golfer) that takes most of the load, and becomes injured. Likewise, a tendonitis can occur in the thumb region of the left hand secondary the impact of the club with the ground. This is termed DeQuervain’s disease.

Rarely, a fracture of a small bone in the wrist called the hamate bone can occur during the actual golf swing. This injury occurs in the hand grasping the end of the club (the left hand of a right-handed golfer).

What types of elbow injuries are most common in golfers?

The most common problem for golfers at the elbow is pain to the medial (or inside) aspect of the elbow. This has been termed over the years “golfers elbow” because of the frequency of this complaint in golfers. The muscles that allow flexion in the hand and at the wrist have tendons that originate at the medial aspect of the humerus (the arm bone) termed the medial epicondyle. With overuse, or improper swing mechanics, these tendons can become inflamed, and very painful. Golfers elbow most commonly occurs in the back elbow (right elbow of a right-handed golfer). A golfer using his or her arms to generate acceleration of the club head through the swing instead of their legs and shoulders are at risk for developing this syndrome.

A rare complication can also occur along with golfers elbow called ulnar neuritis. The ulnar nerve lives in the same area of the elbow as the flexor tendon attachments. When the arms are used to accelerate the club head through the swing this nerve can be stretched, causing irritation of the nerve, and numbness down to the pinky finger.

What types of shoulder injuries are most common?

Rotator cuff injuries are the most common. Rotator cuff tendonitis, and even rotator cuff tears can occur in either shoulder. For the most part, cuff tendonitis tends to occur in the younger age golfers, while cuff tears tend to occur in the older age golfers. Again, the most common mechanism for these injuries is improper swing mechanics.

What types of back injuries are most common?

While it certainly is possible to injure a disc while golfing, the most common back injury is lumbar sprain or strain.

What is the difference between a sprain and strain?

A sprain generally refers to injury to ligaments (connectors of bone). Strains are injuries to the muscle itself. The lumbar area of the back is the lower section of the back made up of five lumbar vertebrae. During the golf swing, the lumbar vertebrae and the surrounding muscles are under a tremendous load. If a golfer suffers from improper swing mechanics it is possible to over-rotate this area increasing the load, resulting in a very painful injury.

It is obvious that mechanics play a vital role in the evolution of injury patterns in golfers. What advice do you have for someone that has played golf for many years versus someone that is just beginning to play golf?

Poor swing mechanics are the number one cause of injury to golfers. The key for any golfer, whether they are just beginning to golf or have been golfing for a number of years is to get proper instruction regarding hand placement, and proper swing mechanics. For someone who has golfed many years, if they begin to develop an overuse type of injury, they may be having a breakdown in their mechanics. Having a golf pro evaluate their swing would help to find any breakdowns in mechanics, and help to prevent injury.

Additionally, it is very important for any golfer to have a conditioning program that includes strengthening of the abdominal muscles, low back, upper and lower extremities and shoulders. Their conditioning program should also focus on flexibility of these same areas.

Is a warm up time important?

A time to “warm up” the muscles, tendons, and ligaments before each game of golf is vitally important. Start slowly with some gentle stretching, and easy walking, and then rotate the shoulders and back with a club for assistance. Eventually work up to hitting the ball. In doing so, you will increase blood flow into the muscles that will be used during the game. This will also aid in decreasing the risk of injury to those same areas.

- Jason M. Tarno, D.O., is Board Certified and Fellowship trained in Sports Medicine. Dr. Tarno is an associate of Crovetti Orthopaedics and Sports Medicine.

For further information call: 990-2290.

Or visit us at: www.CrovettiOrtho.com

Wrist Injuries with Dr. Jason Tarno

Southern Nevadans that are active in athletic activities often injure their wrists. What are some of the most common activities that cause wrist injuries?

Any activity can cause a wrist injury. However activities that subject the wrist to trauma such as volleyball or basketball expose the wrist to greater chance of fracture. In addition, repetitive activities such as tennis, or sports that place constant pressure on the wrist such as weight lifting can cause sprains or tendonitis.

Can you discuss fractures at the wrist?

The wrist itself is composed of eight carpal bones in addition to the two bones of the forearm, the radius and ulna. Wrist fractures can occur from a variety of mechanisms. In athletics, the most common mechanism for a fracture is a fall with on an outstretched hand.

What is the most common type of wrist fracture?

The most common wrist fracture is a fracture of the scaphoid bone. The scaphoid bone is one of the eight bones of the wrist and it is located at the base of the hand on the thumb side. Scaphoid fractures make up about 60 percent of wrist fractures. This injury occurs during a fall on an outstretched wrist, especially if the wrist is bent at an angle greater than 90 degrees. The next most common wrist fractures are of the radius and ulna. Of course, any bone of the wrist is subject to fracture.

What are the signs and symptoms of a scaphoid fracture?

Signs of scaphoid fracture include pain and tenderness on the thumb side of the wrist. Localized swelling may occur and gripping objects may be painful. In addition athletes will have pain when pressure is applied near the base of the thumb.

Are there any complications for an athlete that does not get proper treatment of a scaphoid fracture?

Scaphoid is latin for “boat shaped”. Unfortunately, because of the shape of this bone, it has a poor blood supply. Because of this poor blood supply, the possibility of avasular necrosis increases without proper treatment.

What is avascular necrosis?

Avascular necrosis (AVN) is a term that describes death of a bone after injury due to lack of blood supply. Bo Jackson, is probably one of the most famous people that has had this problem. Of course his problem was not at the wrist but at the hip.

Can you discuss tendonitis?

Tendons are fibrous cords that connect a muscle with bone. Tendonitis is the inflammation of the tendon which usually occurs as a result of repetitive use.

What are the signs and symptoms of tendonitis?

A pain in the front of the wrist is a common symptom of tendonitis. There may also be pain with gripping. Occasionally, thickening or swelling can be felt in the area where tendonitis occurs. Bending and extending the wrist is usually painful.

Can you give an example of an activity that commonly produces tendonitis?

Cyclists who ride for extended periods put pressure on their wrists while the hand is bent in an awkward position. A common injury seen in ten speed bike riders is tendonitis of the extensor carpi ulnaris (ECU). This tendon, which extends the wrist and fifth finger, is on ulnar (pinky) side of the wrist and can be compressed and irritated after chronic strain from bike riding.

What is DeQuervain's tenosynovitis?

This condition, which was named after a Swiss surgeon, is the irritation of the tunnel which houses two tendons of the thumb. It can be caused by an activity that places the thumb in an awkward position for an extended period of time. Because of the resulting swelling, the narrowing of the tunnel makes it difficult for the tendons to pass smoothly. Signs of this condition include pain on the thumb side of the wrist which can travel up the forearm, a ‘clicking’ or ‘clunking’ sensation as the tendons pass through the swollen tunnel and difficulty gripping.

How does a wrist sprain occur?

Much like the majority of wrist fractures, wrist sprains occur during falls onto outstretched hands. A sprain is an injury to a ligament. A ligament is a band of fibrous tissue which connects two bones.

Is a sprained ligament the same as a torn ligament?

Yes and No. Sprains are categorized by grades. In a Grade I tear, some of the fibers are torn, but the main ligament is still intact. The ligament is stretched, but not torn. On the other hand, a Grade III tear involves the complete tearing (or rupture) of a ligament. Ligaments tend to have a poor blood supply, which is why torn ligaments take a long time to heal.

What are the signs and symptoms of wrist sprains?

Of course the severity of symptoms will vary with the degree of sprain. However, wrist sprains typically present with wrist swelling, pain at time of injury, and with movement, local tenderness and warmth over the area of the sprain. In severe sprains, an athlete might feel a tearing sensation or even hear an audible pop.

- Jason M. Tarno, D.O., is Board Certified and Fellowship trained in Sports Medicine. Dr. Tarno is an associate of Crovetti Orthopaedics and Sports Medicine.

For further information call: 990-2290.

Or visit us at: www.CrovettiOrtho.com

Running Injuries with Dr. Jason Tarno

Running has been a popular sport since the 1970’s. Because of the climate in Las Vegas, many people enjoy running year round. What are some common injuries that runners sustain?

Most of the injuries that runners sustain are due to the chronic impact of the lower extremities, ie: the feet, shins, and knees. The common injuries to the feet involve fractures, stress fractures, tendonitis, and plantar fasciitis. The common injuries to the shins involve shin splints and tibial stress fractures. The knees can present with pain to the kneecap or to the actual joint itself.

What is the difference between a fracture and a break?

The term fracture is the medical term for a broken bone. The meaning is the same, and the words are used interchangeably.

What is the difference between a fracture and a stress fracture?

A fracture is caused when a bone is overloaded by some outside stress. Usually this outside stress is an acute twist or impact of the bone. A stress fracture occurs when the bone is overloaded over time. Initially, the bone tries to adapt to increases in stress by laying down more bone. However, if the impact, or stress is more than what the bone can keep up with, eventually the bone starts to develop microfractures. This causes pain. Pain is a signal to the body to stop or back off from the activity that is being performed. If the athlete does not listen to their body and continues to impact the bone, eventually the bone can completely fracture.

What is plantar fasciitis?

The plantar fascia is a band of tissue that is on the plantar aspect (or bottom) of the foot. It begins at the heel bone (calcaneus) and attaches to the toes. It acts to support the tendons and the arch of the foot. With overuse, the tissue can become inflamed and tight. This disorder is very common in runners and can be tough to treat in active people.

You mention the arch of the foot. Are people affected differently if they have flat feet vs. a high arch?

If the arch of the foot has flattened out (flat foot), the impact of running is increased in the foot because the shock absorption that the arch provides is not present. The foot becomes floppy, and without the shock absorption that the arch provides, the first and second toes take on a lot more of the impact load. This can lead to stress fractures in the toes. If the arch of the foot is too high, the foot becomes rigid. The impact load then travels up the leg to the shins (tibia), knees, or hips. Occasionally, even the low back takes on some of the load.

What is the difference between shin splints and a stress fracture?

The term shin splints is also known as medial tibial stress syndrome. As the name implies, there is stress to the medial or inside aspect of the tibia (shin bone). The stress does not refer to the bone itself; however, but to the muscles that attach to the tibia. A stress fracture, as detailed above, is an actual defect in the bone itself.

You mentioned above that runners could injure their knees. Can you expound on that?

Runners do not often twist or hyperextend their knees during their activity like football or soccer players do. Running is a straight ahead, impact type of sport. Most of the problems; therefore, have to do with degenerative disorders. The shock absorbers in the knee called the meniscus can become thinned and lead to degenerative tears. This can lead to swelling in the knees. Occasionally, the undersurface of the kneecap, or patella, can become inflamed as well. Exercises for the quadriceps can help pain in this area.

It seems like there are a lot of disorders that can happen with running. Do you recommend against running as an activity?

No. Many people love to run, and simply, cannot function without their daily run. I think that if someone is having constant pain with their activity, they should see their sports physician, because it could be the start of something significant, as described above. There is another population of people that run because they think that they have to run in order to “get in shape” or lose weight. Those people need to know that there are other activities that can provide aerobic benefits without the constant impact to the lower extremities.

- Jason M. Tarno, D.O., is Board Certified and Fellowship trained in Sports Medicine. Dr. Tarno is an associate of Crovetti Orthopaedics and Sports Medicine.

For further information call: 990-2290.

Or visit us at: www.CrovettiOrtho.com

Frozen Shoulder with Dr. Jason Tarno

Las Vegas is a place where people of all ages tend to be very active. Tennis, racquetball, and golf are activities that many people enjoy even in their later years. In these sports the shoulder can become injured, and these athletes can wind up with a stiff shoulder. What is this stiffness and why does it occur?

Stiffness of the shoulder is known medically by the term adhesive capsulitis. This term refers to a tightening of the shoulder capsule that covers the shoulder joint. It was first described in the late 1800's, and is defined as a condition of the shoulder that is characterized by painful restriction of motion of the shoulder. It tends to affect women more commonly than men, and is seen most often in the fifth, sixth, and seventh decades of life. It can occur in either the dominant or non-dominant shoulder.

How is this different from “frozen shoulder?”

There is no difference. Both terms refer to the same disease process and are used interchangeably in the medical literature.

What are the causes of this type of shoulder stiffness?

Causes of adhesive capsulitis can be broken down into primary causes and secondary causes. In primary causes, the individual cannot identify a specific injury. Researchers are still attempting to identify the cause in these cases. Secondary causes stem from injuries such as fractures or rotator cuff injury. Other secondary causes stem from diseases such as thyroid disorder or diabetes.

Do x-rays show anything?

The diagnosis of adhesive capsulitis is really made on clinical exam. Painful range of motion with restriction of motion is the real key to diagnosis.

What is the treatment for this disorder?

Treatment consists of range of motion exercises. Physicians write a prescription for physical therapy, and the patient works closely with a therapist to increase their shoulder motion. The patient is monitored every four to six weeks for progress on their motion. If improvement is measured, then therapy is continued. If the patient seems to plateau or decrease their range of motion, a procedure called manipulation under anesthesia is performed.

What is manipulation under anesthesia?

The patient is taken to the operating room and given anesthesia to allow them to relax and to go to sleep. Once the patient is asleep, the orthopedic surgeon takes the arm and moves the shoulder through its range of motion to break down scar tissue. Once the patient awakens they are placed on medication for pain and they resume their physical therapy routine.

Are medications helpful?

Occasionally a steroid injection is offered to help with pain and inflammation. This also can aid in the progress of physical therapy. If the patient has diabetes, care must be taken in monitoring glucose levels, because steroid injections can elevate sugar levels.

How long does this problem usually last?

This disease process can last for as short as 6 months to as long as 2 years, and sometimes even longer. The key is to find a good physical therapist, to keep a positive attitude, and not to give up. Most patients do well with treatment.

- Jason M. Tarno, D.O., is Board Certified and Fellowship trained in Sports Medicine. Dr. Tarno is an associate of Crovetti Orthopaedics and Sports Medicine.

For further information call: 990-2290.

Or visit us at: www.CrovettiOrtho.com