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