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

Twisted Ankle with Dr. Jason Tarno

What are the most common injuries that you see for basketball players?

I think without question ankle injuries lead the way. Of course, knee injuries are not far behind.

What are the common injury patterns of the ankle?

Typically the ankle is injured with an inversion or eversion stress. These terms relate to which way the sole of the foot goes. With an inversion injury, the sole of the foot turns in, and the lateral or outside ligaments are stressed. With an eversion injury, the sole of the foot turns out (or to the side), and the inside ligament is stressed. If the force is significant enough, the bone can actually fracture, or break.

How many bones make up the ankle?

On the medial side of the ankle there is one main ligament called the deltoid ligament. It is a large triangular shaped ligament that attaches the tibia to the talus. It is usually injured with an eversion stress at the ankle. On the lateral, or outside of the ankle, there are three ligaments that connect the fibula to the talus and calcaneus (heel bone). The ligaments are named by what they attach to and their position at the ankle. The first ligament is called the anterior talo-fibular ligament (ATF). This is the ligament that is most commonly injured with an ankle inversion. The next ligament is the calcaneo-fibular ligament (CF). The last ligament on the lateral aspect of the ankle is the posterior talo-fibular ligament (PTF). In some cases all three ligaments can be sprained and the ankle becomes very unstable.

What is the difference between a sprain and a strain?

A sprain refers to an injury to a ligament. Ligaments connect bone to bone. Sprains are graded from grade I to grade III, which refers to the degree of tear. In a grade I sprain, most of the ligament is intact, and just a few fibers are torn. A grade III sprain refers to a complete tear or rupture of the ligament or ligaments. A strain refers to injury of a muscle.

Is it necessary to get an x-ray if someone twists their ankle?

There are no absolutes as to when to take or not to take an x-ray. Physicians train for many years, and often it is still a judgement call on the part of the physician. But, if the athlete cannot weight-bear on the foot and ankle, it probably warrants an x-ray.

Why is it that after an ankle sprain there is often a black and blue mark to the lower aspect of the foot?

This is called dependent edema. That means that there has been swelling in the ankle that has traveled to the lower aspect of the foot due to gravity. The black and blue color is from blood that has accumulated in the tissues. Blood has iron in it that stains the skin for a week or two. This usually resolves itself after the athlete regains weight-bearing status.

- 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

Dealing with Arthritis with Dr. Jason Tarno

Many seniors remain active in sports such as golf, tennis, walking, and cycling. Arthritis is a common problem with the aging athlete, and can slow down their activity level. What nonsurgical measures can be used to treat the athlete with arthritis?

It is important to determine what type of arthritis the athlete has first. Treatments are different depending on what type of arthritis is involved. Probably the most common form of arthritis in the senior athlete is termed osteoarthritis (or OA).

Is OA similar to rheumatoid arthritis?

No. OA is the type of arthritis that occurs from years of “wear and tear” on the joints. Rheumatoid arthritis is an autoimmune disorder in which the person’s own immune system attacks the joints. There are characteristic differences in clinical presentation between the two as well as characteristic differences on X-ray.

Many older athletes do not want to go through surgery. What types of nonsurgical things can be done for people that suffer from OA?

There are really several treatments that can be offered. Unfortunately, nothing has been found that stops the advancement of the disease. Currently, physicians treat OA by aiding people with their pain.

How important is weight loss in regards to OA of the hip or knee?

When discussing OA of the hips or knees, weight loss cannot be overemphasized. For every pound that a person reduces of their body weight, it is roughly equivalent to like losing three to four pounds off of the joints. Therefore, someone that reduces their body weight by 10 pounds in essence takes 30 to 40 pounds off of their hips, knees, and ankles. Unfortunately, some people that have advanced disease are unable to increase their activity because of pain, and have difficulty losing weight.

How does physical therapy help someone with OA?

Physical therapy seems to help some people by strengthening the muscles around the arthritic joint, thereby reducing some of the stress on the joint itself.

What are your thoughts on supplementation such as glucosamine/ chondroitin?

The jury is still out on the effectiveness of this kind of supplementation in the medical literature. These products are termed supplements and are not pharmaceuticals.

Therefore, they are not monitored by the FDA, and the public needs to be careful as to what it is they are actually buying. Many people claim that these supplements help relieve their arthritic pain in their joints. Some people see no change in their pain at all. Fortunately, there does not seem to be a lot of bad side effects from these supplements. The main side effect tends to be water retention which can elevate blood pressure. I would recommend to anyone that is considering taking glucosamine that they have their blood pressure monitored by their primary care physician before beginning any supplementation, and have it checked periodically as well.

What is viscosupplementation?

This refers to a new type of treatment for OA of the knee. It has not been approved as yet for any other joints of the body, although research is being performed on the shoulder and elbow. There are two types of medications in this class OA treatments. Each are injectable medicines that are injected in the knee joint weekly for either 3 or 5 weeks, depending on which medication is used. The medicines act as a sort of lubricant in the knee and can give pain relief for 6 months to a year.

Why are steroid injections offered to some patients?

Steroid medication is used as an anti-inflammatory agent to treat pain. Some people have such advanced disease that the above listed treatments no longer offer them any relief. The positive with steroid injections is that they can be given to just about any joint in the body. The downside is that there is a limited number of times a person can receive this medication due to side effects that can occur.

It really seems like there are a lot of choices for physicians and senior athletes when it comes to osteoarthritis.

Depending on the stage of OA that the person has, that can be true. Physicians always try to exhaust all conservative measures prior to discussing a surgical procedure. Hopefully, as new advances are made in this area, more conservative treatments will be developed.

- 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

Inflammation with Dr. Jason Tarno

Often when an athlete is injured, they experience swelling to the injured body part. Can you comment on how this swelling occurs?

Yes. When an injury occurs to an extremity, tiny blood vessels called capillaries are often injured. This produces leakage of fluid from the bloodstream, giving rise to swelling. Pain produced from the injury causes the heart to beat faster, which results in more blood pumped to the injured area. In addition, an inflammatory response is made by the body.

What is inflammation?

Inflammation is a chemical response that the body produces in response to an injury. This chemical reaction causes swelling and pain. The entire process is called an inflammatory reaction, and lasts about 2-3 days. Because of the swelling involved, range of motion in a muscle or joint is limited. Therefore, swelling is one of the worst enemies of the athlete. Anything that helps to diminish the inflammatory response, and the associated swelling that goes along with it, will help get the athlete back to activity faster.

How do physicians treat the inflammatory response after an injury? Is it better to use heat or cold to prevent swelling?

There are many ways to diminish the affects of the inflammatory response. The initial stages consist of RICE therapy. Physicians generally do not advise the use of heat during the initial 48 hours after an injury. Heat causes the body to produce more swelling because of the increase in blood flow to the injured body part. Conversely, when ice is applied to an injury, it decreases blood flow thereby diminishing swelling. Compression and elevation also aid in diminishing blood flow the injured area.

What types of medications are helpful in reducing the inflammatory response?

Two types of medications are typically used to control swelling and inflammation. They are steroids and non-steroidal anti-inflammatory drugs (NSAIDs).

What exactly are steroids?

Steroids are naturally occurring hormones that the body produces to combat stress. Some steroids build up tissue (anabolic), and other steroids break down tissue (catabolic). Physicians use catabolic steroids, like prednisone, to fight the effects of inflammation. The medicine may be in the form of an injection or an oral pill.

Are there any side effects?

Yes, but they are relatively rare. Sometimes the injectable form of a steroid may cause a small area of the skin to shrink or die (necrosis). Rarely, oral steroids can cause damage to the hip bone (avascular necrosis), if taken for a long period of time. Moderate weight gain can occur because steroids cause water retention. If a steroid is injected into a tendon, it may weaken the tendon and cause rupture. These side effects are all very rare, however.

What are NSAIDs?

NSAIDs stands for non-steroidal anti-inflammatory drugs, and are a class of drugs which act to diminish inflammation. They do not act as hormones like steroids do. Instead NSAIDs block inflammatory chemical pathways in the body. Ibuprofen is a common anti-inflammatory drug that is currently offered over-the-counter.

Are there any side effects to NSAIDs?

Yes. There is a small chance (1-2%) of stomach ulcer when taking an NSAID. This risk of ulcer is decreased if the medication is taken with food. NSAIDs may also cause shortness of breath in people with a history of asthma. Therefore, it is best if these medications are taken under the supervision of a physician.

Are NSAIDs painkillers?

No. A common misconception that patients tend to have is that if the NSAID does not take away their pain, they will stop taking it. It must be emphasized that while anti-inflammatory medications can decrease some of the effects of pain, their main role is to decrease inflammation and swelling. By decreasing the swelling, much of the pain of most injuries will markedly subside.

- 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 Knee Injuries with Dr. Jason Tarno

The knee is commonly injured. What are the most common injuries to the knee in sports?

Twisting injuries are by far the most common. This can happen with the quick change-of-direction inherent in any sport, or after landing awkwardly after a jump.

What are the bones at the knee?

The bones that make up the knee joint consist of the femur (thigh bone), the tibia (shin bone), patella (knee cap), and fibula (A smaller long bone just lateral to the tibia. This bone is non-weight bearing).

What are the ligaments at the knee?

There are four major ligaments in the knee. On the outside (lateral) and inside (medial) of the knee are the collateral ligaments. They help keep the knee straight. Any weakness or tearing of these ligaments can cause the knee to bow or become knock-kneed depending on which ligament is injured. Within the knee joint itself, there are two ligaments that attach from the femur to the tibia and give stability to the knee with stopping/ starting. These ligaments are termed the cruciate ligaments (Cruciate is Latin for cross). The two ligaments cross one another, one in front, the anterior cruciate ligament (ACL), and the one behind, the posterior cruciate ligament (PCL). The ACL is very critical in sports such as basketball, soccer, football, etc… where there are rapid changes in direction. Without this ligament, the tibia can translate forward on the femur with change of direction. This leads to extreme instability with sporting events. Also, when the knee gives out, the joint surfaces of the femur and tibia can be damaged, leading to arthritis.

What kind of shock absorber is in the knee?

The knee possesses a rubbery type of shock absorber between the femur and tibia, which we call meniscus. The meniscus is made of cartilage. There are two menisci in the knee – a medial and lateral. Occasionally the menisci can be damaged, leading to pain, swelling, stiffness, and sometimes a feeling of “locking” within the knee joint.

What is the difference between an x-ray and an MRI?

X-ray imaging uses very small amounts of radiation, projected from a tube through your body and onto a film plate. Structures in your body block a portion of the rays and result in different shades of exposure on the film plate. Denser structures, such as bone, will block more rays and show up as a lighter image on the exposed film you see. MRI stands for magnetic resonance imaging. This is an imaging technique that utilizes magnetic fields in an interaction with atoms from a person’s body. A computer analyzes the information, and an image is produced.

Is there any radiation exposure with an MRI scan?

No. There is no radiation exposure. The magnetic field is safe for any person unless certain metal devices have been placed, such as a cardiac pacemaker.

What is better: an x-ray or an MRI?

It really depends on what type of information the physician is trying to obtain. X-rays are very helpful in looking at bony abnormalities. They give a better “lay of the land” type of view of the body part in question. Ligaments, tendons, and muscles do not show up on plain film x-rays, but physicians can often make assessments about them based on what the osseous (bony) structures look like. The MRI gives very good information regarding integrity of ligaments, tendons, muscles, and cartilage.

We often hear about an athlete injuring their knee, having an MRI, and then going for arthroscopic surgery. How is arthroscopic surgery different from a “regular” surgery?

Arthroscopic surgery is generally an outpatient procedure that usually does not take as long as open surgery. Two to three small incisions are made at the knee (each about 1 cm) in length. Instruments are then placed within the joint. One of the instruments is a video camera, and that is attached to a monitor that the surgeon uses to visualize the joint. The surgeon can then remove any debris or tears within the knee. The benefit of this type of surgery is that it is shorter, has less anesthesia, and usually shorter rehab periods.

Is physical therapy necessary after a knee injury?

Depending on the injury, the patient and the physician make that decision in concert. Usually after a surgical procedure, some type of therapy is prescribed. During surgery the knee is subjected to stresses that it is not normally exposed to. These stresses, combined with the need to strengthen the athlete’s knee from the initial injury, require a specific amount of therapy and rehabilitation tailored to the athlete’s individual need.

- 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

Throwing Injuries with Dr. Jason Tarno

Spring is just about here and many athletes will be out playing softball and baseball. What types of injuries are most common in this group of athletes?

Because the motion of throwing is not a natural motion, injuries to the shoulder and elbow tend to head the list of injuries. With each throw, a small amount of trauma is placed upon both of these joints. Over time, injuries occur due to overuse.

What are the most common disorders seen in the shoulder?

Probably the most common injury is a tendinitis of the rotator cuff muscle. Technically the rotator cuff is not a single muscle, but a muscle group made up of four separate muscles, which act to externally rotate and raise the arm. Another injury which is not as common is a tear of the cartilage around the shoulder blade called the labrum.

How are the two disorders different?

Pain in rotator cuff disease is caused and is referred down the deltoid, or outside of the arm. Doing simple things like putting on a shirt, combing the hair, or driving a car can cause significant pain. Some people even have pain at night that keeps them awake. Pain with a torn labrum is more of a deep aching pain that occurs with overhead activities of the arm.

You said that throwing is not a natural motion. What do you mean by that?

The act of throwing any projectile, whether it be a baseball, softball, or rock creates tremendous stress on the ligaments that hold the elbow together as well as the muscles of the shoulder.

How can an athlete protect their shoulder from injury?

Most injuries in throwing athletes tend to develop from overuse. Because of the warm climate in Southern Nevada, many of these athletes participate in baseball related activities on a year round basis. While the exercise and competition is a good thing, it is important for individuals to listen to their body and to back off when appropriate. A proper warm-up period is critical no matter the age of the athlete. Of course the older the athlete, the more crucial the warm-up period time becomes.

Should an athlete try and play through shoulder pain?

It depends on what is causing the pain. There is a saying of: “no pain, no gain.” In the case of shoulder tendonitis; however, playing through the pain can eventually lead to a tear of the muscle. Therefore, it is important to back off activity and let the shoulder heal. Taking time off and allowing muscles to heal can prevent lost time later in a season.

What types of problems can occur with the elbow?

The elbow takes the greatest beating during the throwing motion. Once the arm is cocked back, the next motion to take place is the acceleration phase of the throw. During this point, tremendous amounts of stress are applied to the elbow, especially the inside ligament called the medial collateral ligament (MCL). If enough force is applied, the ligament can tear.

What players tend to have this injury most commonly?

Pitchers are by far the most common players. With the number of throws required to make during innings as well as warm-up throws before games and between innings, a lot of micro-trauma is incurred about the elbow. Outfielders occasionally tear this ligament as well because of the long throws that they are required to make.

What can be done for the MCL if it in fact is torn?

The MCL can be surgically reconstructed if needed. This surgery was first performed by Dr. Frank Jobe, team physician for the LA Dodgers. It has since become well known as “Tommy John surgery,” because it was first performed on the famous Dodger pitcher.

Does everyone that ruptures their MCL need it to be surgically reconstructed?

Absolutely not. According to Mark Schickendantz, M.D., team consultant for the Cleveland Indians, “the only people that need this ligament are overhead throwing athletes.” Therefore, for the average person, reconstruction of the ligament is not usually recommended. For an elite throwing athlete, however, more force can be generated during the throw if this ligament is present.

Can someone still throw without the MCL?

Yes. In fact, there are even a few major league athletes that have ruptured this ligament and never have had surgery to reconstruct it. These athletes have really had to strengthen their wrist flexors, however.

What other disorders can occur at the elbow?

There are several things that can happen. Two common things are tendonitis from overuse, and degenerative changes from the repetitive motion of throwing.

What do you mean by degenerative changes?

This refers to arthritic changes that affect the actual elbow joint secondary to chronic overuse.

After an injury to the shoulder or elbow, how should an overhead throwing athlete strengthen themselves?

Probably the best way to approach this is on a case by case basis. The key thing to keep in mind is that the shoulder, elbow, and wrist all play an important role during the motion of throwing. Because of this, when any of the three are injured, special emphasis should be placed on all three areas with regards to rehabilitation so that when the athlete resumes throwing, there are no weak links in the chain. It is important to have a good therapist and a physician that understands the mechanics of the throwing motion to oversee any type of rehabilitation protocol.

- 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

Sports Medicine Terms with Dr. Jason Tarno

What exactly is a joint?

In medical terms a joint is the connection between two separate bones. The knee joint is a connection of ligaments and muscles around two bones, the femur (thigh bone) and tibia (shin bone). Wherever two bones connect there is a joint. Around this joint are ligaments, which connect the bones together. Tendons attach around the joint so that when the muscle flexes, the joint moves.

What is the difference between a strain and a sprain?

A strain is a pull of a muscle. A sprain refers to an actual tear of a tendon, or ligament. Sprains are graded as either grade I, II, or III. Grade I sprains represent a minor tear (just a few fibers are torn). Grade III sprains are complete tears of either the tendon or ligament. When a muscle is torn, we call it a rupture or tear. Strained muscles usually heal on their own with rest and ice. Sprains often heal on their own as well. Sometimes, however a joint must be immobilized with a cast so that the ligament or tendon can scar together and heal. Occasionally a sprained ligament or tendon must undergo surgery in order to be corrected. It really depends on which tendon or ligament and the grade of the sprain. Ruptured muscles usually do not heal without surgery.

What is the difference between a ligament and a tendon?

A tendon is the end of a muscle that attaches a muscle to bone. There is a tendon at each end of a muscle. A ligament is a soft tissue structure that connects a bone to a bone.

What is the difference between a broken bone and a fracture?

There is no difference. The medical term for a broken bone is a termed fracture.

What is meant by the terms medial and lateral?

Medial refers to the inside part or closest part to the body and lateral refers to the outside part or furthest part from the body.

What is a meniscus?

Meniscus is a term used to refer to the cartilage between the femur and tibia in the knee joint. The meniscus acts as a shock absorber between these two knee bones. There are two separate menisci in each knee. One on the medial side and one on the lateral side. They are “C” shaped structures, and therefore have a front and back or anterior and posterior aspect to each side. If these structures tear, they tend to become trapped between the femur and tibia during flexion and extension of the knee, which can cause a locking of the knee joint. If your doctor says that you have a tear in your posterior medial meniscus they are referring to a torn piece of cartilage at the back of the inside of your knee.

What do the terms proximal and distal refer to?

When physicians or surgeons are trying to describe where an injury or fracture is they want to use terms to help them form a picture in their mind. The term proximal is used to describe something that is closest to the body on an extremity. Distal refers to the farthest part past midpoint of an individual bone or extremity. For instance, if someone were to sustain a fracture to their tibia, the physician or surgeon would describe it as being either proximal (close to the knee joint), midshaft, or distal (closer to the ankle joint).

In closing...

Hopefully this has been helpful to some of the readers. As one can see, these terms often build on one another and if you do not understand the very basics of this medical “lingo” it can be hard to follow your physician or surgeon when they rattle off some long list of fancy sounding terms. If you do not understand what your physician is telling you, make sure that they put it into plain English (or Spanish for some readers) so that you can understand exactly what is wrong. Knowing what is wrong with you and understanding how it happened is half the battle toward getting better!

- 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

Understanding Medical Tests with Dr. Jason Tarno

Often when an athlete is injured certain tests are performed. Can you discuss some common medical tests for sports related injuries?

Of course every injury is different, and many disorders can be diagnosed in the office with a good history of the problem and good physical exam. Most orthopedic injuries require an x-ray as an initial screening for injury to the bone. Broken bones or fractures can be diagnosed most often with a simple x-ray. Sometimes it is difficult to diagnose the injury with an x-ray and further testing is needed. Tests such as MRI, CAT scan, and bone scans have been developed, which aid the physician greatly in making an accurate diagnosis, which helps the physician direct proper treatment.

If an x-ray looks mostly at the bone why do physicians order an x-ray with injuries that seem to be strains of ligaments or muscles?

While the common x-ray has lost its luster in the last 20 years with the popularity of MRI and CAT scans, a great deal of information can still be gleamed from a radiograph, or x-ray. Fractures and dislocations are seen very well. Sometimes an injury that seems like it is a soft tissue injury such as a sprain or strain actually involves an avulsion fracture of bone where the tendon attached.

What is worse, a fracture or a broken bone?

Both terms mean the same thing. Physicians typically use the term fracture to refer to a broken bone because it is the proper term in the medical literature.

What is an MRI?

MRI stands for Magnetic Resonance Imaging. This is a special test that uses a large magnet and computer to process information into a picture of the bones and soft tissues. Several pictures are taken of the injured body part in three different views, each about 1-2 mm apart. This test has become one of the most commonly ordered tests in sports medicine for soft tissue injuries such as ligament, tendon, and cartilage tears.

Is this the test that makes someone lay in a tunnel?

In some cases the patient lies on a flat bed that moves into a circular structure, which then takes the images. Some people that are claustrophobic often select an “open MRI” in which the tube that the patient goes into is open on each end. Crovetti Orthopaedics and Sports Medicine offers an open MRI for our patients. A typical scan requires about 30-45 minutes to perform.

How is a MRI different from a CAT scan?

A CAT scan is a Computed Automated Tomography scan and is similar to a MRI in that several pictures are taken of the injured body part. The CAT or CT scan does not use magnetic energy, however, and is therefore the desired test for anyone with metal such as a pacemaker. CT looks at bone better than MRI; however, the MRI looks at the soft tissues much better than the CT scan.

What is a bone scan?

This is a test in which an IV is started and the patient is administered a type of contrast material that collects in areas of high bone turnover such as a fracture, bone infection, or bone tumor. In athletes this test is often used to rule out a stress fracture.

It seems like surgeons and physicians have a lot of good tools at their disposal in order to diagnose athletic injuries.

That is true. However, no matter what test is used, it should never take the place of a good history and physical exam.

- 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

What's new in Knee Replacement with Dr. Mike Crovetti

What is it...Really?

Knee replacement surgery is typically done for Arthritis of the knee.  Simply, Arthritis of the knee occurs when the smooth surfaces of the knee become rough.  The smooth surface at the end of the thigh bone, the top of the shin bone and behind the knee cap is called cartilage.  In reality, it looks white and shiny and feels very hard just like a cue ball in the game of pool.  When the smooth cartilage becomes rough due to age or trauma most commonly, this is called Arthritis.  I often think of taking rough sandpaper and sanding away the smooth white surface. Hopefully this gives you a picture in your head of why it may hurt so much! Check out this picture inside a knee with arthritis.

I have always been troubled by the term “replacement”. And after performing several thousand knee replacements, that hasn’t changed.  I feel like patients think we remove the end of the thigh bone and the top of the shin bone and actually put a new hinge in.  In reality, we “resurface” or “remodel” the ends of the bones and replace the rough cartilage with smooth metal and plastic. Matching the curves and the motion of the knee as best we can.  In fact, as a surgeon I do my best to save as much of your knee as possible, including the sparing of ligaments, bone, tendons, and the cutting of as little muscle as possible! 

 

What knee is right for me?

In my experience, most patients are surprised to hear that there are options!  First, it is important to do a little explaining about the knee, then to explain why there are options today.

The thigh and shin bones come together to make the hinge of the knee.  The knee cap is in front and the ligaments are on the sides and middle.  The knee is made of three parts or the technical term is compartments.  The compartments are the medial or inside of the knee, the lateral, or outside of the knee and the knee cap and the groove that it rides back and forth in.  We have technology today that allows surgeons to replace all three of the compartments called a Total Knee Replacement, one of the compartments called a Unicompartmental Knee (a UNI) or new cutting edge technology that replaces two of the three compartments and is called a Bicompartmental Knee (a BiComp).

The right knee for you has three main factors. They are age, activity level and most importantly which of the three compartments has arthritis.  Interesting enough, arthritis can affect one,  two or most often  all three.  Younger patients may have only one or two compartments affected by the arthritis and may be a candidate for a Unicompartmental or BiCompartmental Replacement.  These are often referred to as the  “Ligament Sparing” Knees  because ALL four of the important ligaments in your knee are saved.  While it might amaze you how much you can do with a knee replacement, a Uni or BiComp replacement may make those activities feel more normal and, frankly, may even get to the point where it feels like that old knee you loved for so many years!

Which knee is right for you is based on listening to your story about your knee, examining the knee and finally an x-ray or MRI.  An x-ray will tell the surgeon if the bones are getting closer together because the smooth cartilage covering is wearing out, the famous bone on bone arthritis.  The MRI will actually show us the cartilage covering and help you and I create a thought out plan for your replacement and where it should be performed, in or out of the hospital.

 

Hospital or No Hospital?

Traditionally, knee replacement or remodeling of the knee has been done in a hospital.  The surgery took a couple hours, the hospital stay was several days and some patients required additional care in a rehabilitation hospital.  Patients were often older and had more medical problems that required the safe care of a hospital.  Today I can perform most knee replacements in less than an hour, through smaller incisions and have created an accelerated outpatient recovery center and program for patients to get home quicker!  For more about benefits of the Coronado Surgical Recovery Suites or to find out if you are a candidate, click below!

Coronado Surgical Recovery Suites

- Mike Crovetti, D.O. is a Board Certified Orthopaedic Surgeon. Dr. Crovetti is the owner of Crovetti Orthopaedics and Sports Medicine in Las Vegas, NV.

For further information call: 990-2290.

Or visit us at: www.CrovettiOrtho.com