FAQ’s

When do you know that other methods of managing an injury are not working and surgery is required?

When weeks to months pass while seriously working on non-operative management and minimal or no progress is enjoyed. Even then, surgical solutions can only be considered when they carry an overwhelming chance of improving the situation.

What sometimes causes numbing in my hands after a long bike ride, or in one of my feet after a walk or run? Is this nerve-related, or circulation. What type of conditioning can be done to prevent it?

I have the same problem whenever I do a 100-mile ride. It is from compression of the ulna nerve at the base of the hand. Wear good gloves. Change the position of your hands frequently. Consider triathlon bars. For the feet, make sure you have the best running shoes, and make sure they are not too tight. And stay away from the doctor for all these problems.

Is there any one sport more likely than another to injure knee or shoulder joints and muscles?

The ACL is at risk more in Football, basketball, volleyball, and soccer. The shoulder is more at risk in throwing athletes. I wouldn’t choose my sport, though, based on injury avoidance. Sports are for fun.

Why is it that a shoulder dislocation in a young person is almost always likely to result in future dislocations, as I have read?

Children and young adults do not regularly develop much joint stiffness after an injury. But stiffness and loss of motion limits the instability associated with dislocations. Since young people don’t get it, their “loose” shoulders stay loose – contributing to future instability.

Older people get stiff, which limits instability. Still in all, I’m 47 and would prefer – despite this – to be young and a bit “too loose” over old and stiff!

What is an MRI? When should I have an MRI?

An MRI is a fancy imaging study that can demonstrate lesions both in bone and soft tissue, using the magnetic resonance of hydrogen ions. Over the past 15 years, it has gained popular acceptance by coaching staffs, insurers, lawyers, and misinformed athletes – as the “be-all” and end-all of imaging studies. Unfortunately, its use has supplanted not only the patient’s history and physical exam, but also common sense! Many professional football players have an MRI after every knee sprain during the season. These examinations will nearly always lead to unnecessary surgery.

It is expensive. An MRI costs at least $1000 per body part. It should only be used when a patient’s history and physical exam does not clearly indicate a provisional diagnosis, or a reasonable course of treatment.

At the Sanders Clinic, an MRI is not a substitute for a patient evaluation. For example, the cost of a KT-1000 exam for ACL and PCL integrity is about $150. If the side-to-side difference is greater than three mm, then the ACL is torn. This examination is more accurate than an MRI, because it is an actual stress test of the ligament’s integrity, rather than a static photograph. This test can be done in the Training Room or Clinic and takes 10 minutes. When the travel and waiting time is factored in, an MRI proves far more time-consuming yet no more accurate.

I'm a motocross rider with an ACL injury and my Buddy says that I should have an allograft. Can you tell me why an autograft from the opposite knee might be preferable?

Even proponents of allograft reconstruction don’t say that those grafts are stronger. They are dead, then frozen, and then thawed. Can those things make a tissue stronger? I don’t think so!

The reported advantage of the allograft is that the recipient knee does not have to suffer the trauma of a graft harvest – in addition to an ACL reconstruction. On that subject, I agree completely.

Unfortunately, since the dead graft must be revascularized and then repopulated with live cells, it takes approximately a year away from sports. And even after a year, it’s never strong enough to resume the activity that initially prompted the injury. That’s why there are articles in the American Journal of Sports Medicine that advocate its use in “non high risk athletes and sedentary people over the age of 40.”

The quintessential opposite of that description from the journal is a motocross rider!

Now if a living isogenetic graft coming from a source other than the injured knee were used, the bone-to-bone healing would heal the bone plugs in one month. And the only thing remaining is recovery from the surgery.

That is what we do with the contralateral graft. It is live tissue. It is strong. It does not further compromise the already injured and vulnerable knee.

The downside is that while the athlete is working the ACL knee in rehabilitation, he must also do rehabilitative exercises on the graft leg – which never hurts but must overcome some weakness over the first three months. As a practical matter, this changes little in the gym for the average athlete, who generally works both legs anyway.

My daughter is 14 years old. She plays lacrosse, softball and basketball. She tore her ACL last week. Currently she is on rehab. Her doctor says that her growth plates are still open and she is too young for the regular surgery. I hate to have her miss out on competitive and school sports for two years. What should we do?

What to do with a junior high aged athlete with open growth plates has often been debated. Previously, surgeons have been reluctant to drill through the open growth plates for fear of causing a growth disturbance.

We have found that with appropriate patient selection, the performance of an anterior cruciate ligament reconstruction using the patella tendon secured by buttons (our standard procedure) is both safe and effective – even with growth plates that have not fully closed.

This can be accomplished in athletes who are not significantly shorter than their like sexed parent or sibling, have growth plates that are no longer wide open, and have reached Tanner Stage 4 sexual development.

To determine the Tanner Stage for an adolescent male, go to:
http://www.fpnotebook.com/Endo/Exam/MlTnrStg.htm

To determine the Tanner Stage for an adolescent female, go to:
http://www.aafp.org/afp/990700ap/209.html

After reconstruction of the anterior cruciate ligament, these young athletes are no longer at excessive risk for further episodes of knee subluxation (giving way) and subsequent injury to the menisci. At 90 days post surgery, nearly all are able to return to their favored sport without a knee brace. We know that these are the most athletically active years in a young person’s life and believe it is no longer necessary to cause these young people to give up the activities which they covet most.

Lastly, we must keep in mind that these youngsters are exactly the ones that continue to put their knees at risk when they return. Typically 10 to 15 percent of them will retear their reconstruction as a result of another equally serious accident. In order to prevent such recurrence, we have initiated a program to improve balance and neuromuscular coordination.

My son is a junior. He's a running back at a five-A school. Colleges are already looking at him. He tore his ACL in the game last Friday night and they want to operate this week. Should we let them?

Absolutely not! My friend and teacher Dr. Don Shelbourne of Indianapolis, IN conclusively proved that the incidence of severe stiffness limiting ones ability to go back to sports is dramatically increased when operations on the ACL are done “acutely.” In other words, when they are done while the knee does not yet have full motion and is still filled with blood. The accelerated ACL rehabilitation of the “well-prepared” knee more than compensates for the waiting time between when the injury occurred and when the surgery takes place. Furthermore, there’s no need to miss a week of school.

This knee requires an immediate Reconditioning Program. And surgery can be performed over the Christmas holidays. Your son will then be ready for spring practice. There are no emergencies in knee ligament surgery. Emergency knee ligament surgery is only performed in order to prevent athletes from getting a second opinion from someone more knowledgeable about ACL surgery!

How do you know when ACL Reconstruction surgery is necessary?

If your ACL is torn and you play basketball, soccer, rugby, lacrosse, football, hockey, or enjoy rock climbing and do not want to give up these activities, ACL Reconstruction may be the best choice for you. It should also be considered if you are a policeman or a fireman and cannot give up those activities. If you are not athletic but your knee continues to give way or feel that it is “coming apart,” the surgery may be a consideration.

Is any other surgery required following ACL Reconstruction, to remove screws or make other adjustments?

Occasionally surgery is necessary for stiffness. That is now very unlikely if you scrupulously follow the accelerated rehabilitation program. We use buttons for fixation rather than screws now. The buttons are smooth and rarely irritate the overlying tissues, so they almost never need to come out.

How long does an ACL Reconstruction last? How long will I be under?

The reconstruction should last your whole life. In elite teenage athletes who return to sports, 15 percent will re-tear their reconstruction. In elite athletes over thirty, about five percent will experience a re-tear. When a re-tear occurs, a second reconstruction can be done. In sedentary people, re-tears are nearly nonexistent.

Surgery lasts about one hour. Total anesthesia time is about 90 minutes.

I heard that there could be permanent numbness on the front of the knee following such surgery. Is this true?

For about one year there is numbness around any surgical scar, but this usually goes away.

What complications are likely, following ACL Reconstruction? Are there any permanent limitations? And what can be done to avoid those that may exist?

Some of the complications of the surgery include infection, risk of Thromboembolic disease (blood clots) and a re-tear as described above. And permanent stiffness of the joint is the possible limitation. But, we take a proactive approach to avoiding complications and any potential for permanent limitations. Patients are given an anticoagulant immediately following surgery to reduce the very small risk of Thromboembolic disease associated with such a surgery. Infections are avoided by following a carefully outlined plan for wound care and medication in ACL Reconstruction postoperative care. A reconditioning program to strengthen the knee and reduce swelling before surgery, as well as strict adherence to ouraccelerated rehabilitation program following surgery, has proven to significantly reduce the risk of stiffness to about one percent. The program also gives athletes the greatest chance for a successful reconstruction and reduces risk of a re-tear.

Which is the best graft choice when planning an ACL Reconstruction?

Glad you asked! The best tissue is an autograft bone-tendon-bone preparation. The bone in the preparation heals better to the host bone than the tendon of a hamstring graft. The best place to get this bone-tendon-bone graft is the patient’s opposite leg. When you do this, most athletes can be back in half as much time as when we take the graft from the injured knee.

We do not use autografts from the hamstring tendons. Although these grafts can be strong, healing must occur between the host bone and the tendon. Bone to tendon healing is not as reliable as the bone to bone healing, which occurs with the patella tendon autograft. Not infrequently, we have seen these grafts stretch out. For that reason, most surgeons who use the hamstring graft employ a postoperative brace for four to six weeks which extends from the hip to the ankle. Such a brace will interfere with our accelerated ACL rehabilitation, and prevent return to sports by three to four months.

Why don't you use screws in ACL reconstruction? Why buttons?

Three reasons. The first and most important is that bone screws placed in the bony tunnel between the bone plug and the host bone limits the amount of contact between the bone plug and the host bone. This in turn limits the ability of the bone plug to heal to the host bone. The button is set on the outside of the bone tunnel and does not interfere with bony healing.

The second reason is that with our button technique the tension on the graft is adjustable. This is impossible with bone screws. With screws, it is very possible to make the graft too tight, subsequently capturing the knee and permanently limiting Range of Motion.

The third reason buttons are used is that the bone screws can irritate the overlying skin. When this happens, it is sometimes necessary to do a second operation in order to remove them. The surface of the button is smooth and will almost never irritate the overlying skin.

I heard that arthritis is sometimes caused by an injury. Is this true?

Yes, an injury which causes a derangement of joint mechanics, such as a tear of the ACL or meniscal cartilage in the knee, a recurrent dislocation of the shoulder, or a tear of the rotator cuff can lead to arthritis which occurs long before old age.

How do you know what is simply "aching joints" and what might be the onset of arthritis?

Take Advil and keep active when your joints ache. It they immediately get better, keep doing it and stay away from the doctor.

Is it possible to avoid arthritis? If not, how can it be delayed?

The most important thing to do is keep your body mass under 25. Get a medical evaluation and treatment for your injuries, when taking Advil doesn’t do the trick.

Are some people more prone to arthritis than others, such as athletes - for example - whose joints and tendons endure greater stress and injury over the course of their life?

NO. Arthritis occurs in the absence of treatment for an injury, or when an athletic injury is poorly treated.

When do you know that other methods of managing an injury are not working and surgery is required?

When weeks to months pass while seriously working on non-operative management and minimal or no progress is enjoyed. Even then, surgical solutions can only be considered when they carry an overwhelming chance of improving the situation.

What sometimes causes numbing in my hands after a long bike ride, or in one of my feet after a walk or run? Is this nerve-related, or circulation. What type of conditioning can be done to prevent it?

I have the same problem whenever I do a 100-mile ride. It is from compression of the ulna nerve at the base of the hand. Wear good gloves. Change the position of your hands frequently. Consider triathlon bars. For the feet, make sure you have the best running shoes, and make sure they are not too tight. And stay away from the doctor for all these problems.

Is there any one sport more likely than another to injure knee or shoulder joints and muscles?

The ACL is at risk more in Football, basketball, volleyball, and soccer. The shoulder is more at risk in throwing athletes. I wouldn’t choose my sport, though, based on injury avoidance. Sports are for fun.

Why is it that a shoulder dislocation in a young person is almost always likely to result in future dislocations, as I have read?

Children and young adults do not regularly develop much joint stiffness after an injury. But stiffness and loss of motion limits the instability associated with dislocations. Since young people don’t get it, their “loose” shoulders stay loose – contributing to future instability.

Older people get stiff, which limits instability. Still in all, I’m 47 and would prefer – despite this – to be young and a bit “too loose” over old and stiff!

What is an MRI? When should I have an MRI?

An MRI is a fancy imaging study that can demonstrate lesions both in bone and soft tissue, using the magnetic resonance of hydrogen ions. Over the past 15 years, it has gained popular acceptance by coaching staffs, insurers, lawyers, and misinformed athletes – as the “be-all” and end-all of imaging studies. Unfortunately, its use has supplanted not only the patient’s history and physical exam, but also common sense! Many professional football players have an MRI after every knee sprain during the season. These examinations will nearly always lead to unnecessary surgery.

It is expensive. An MRI costs at least $1000 per body part. It should only be used when a patient’s history and physical exam does not clearly indicate a provisional diagnosis, or a reasonable course of treatment.

At the Sanders Clinic, an MRI is not a substitute for a patient evaluation. For example, the cost of a KT-1000 exam for ACL and PCL integrity is about $150. If the side-to-side difference is greater than three mm, then the ACL is torn. This examination is more accurate than an MRI, because it is an actual stress test of the ligament’s integrity, rather than a static photograph. This test can be done in the Training Room or Clinic and takes 10 minutes. When the travel and waiting time is factored in, an MRI proves far more time-consuming yet no more accurate.

Can anti-inflammatory drugs be harmful? How long can they be taken for an injury?

Anti-inflammatories can injure the lining of the stomach, causing stomach distress and/or bleeding. They can diminish platelet function and cause excessive bleeding. Newer anti-inflammatories are safer. They include Bextra, and Celebrex. They are, however, expensive. Anti-inflammatories can be prescribed over an indefinite period if there are no evident complications, but regular follow-up visits with a physician must occur.

When should cortisone injections be considered, and how safe are they?

They can be safely given in the shoulder or elbow for tendonitis and bursitis, when patients are in severe pain that does not remit with exercises and anti-inflammatories. Two shots may be given over a three to six month period. After that, further shots can debilitate the quality of the tendon tissue.

Cortisone in the knee is of such temporary value that we rarely administer it for arthritis. The one exception that I, not infrequently, have is someone needing to “get well” for a short time for an event, such as walking down the aisle at their granddaughter’s wedding.

I see a lot of information on the Internet regarding Magnetic Sports Therapy bracelets and creams that can help reduce inflammation and pain resulting from common injuries such as carpal tunnel, tennis and golfer's elbow, bursitis and even some neck and shoulder problems. Do such products really work?

There is no scientific evidence that they help any painful condition. A placebo will benefit nearly 60 percent of cases if the practitioner is enthusiastic about it. Unfortunately, the placebo effect diminishes over a couple of weeks. Magnets are good for the refrigerator door.

Are braces beneficial to injured limbs? Can they prevent further injury to the limb?

No pure scientific evidence exists that they reduce further injury. All studies that have shown braces to be effective have been financed by brace manufacturers. In the l980s when coaches used prophylactic knee braces for high school football players, we had an epidemic of femur fractures occurring above the brace. Knee ligament injuries are preferable to femur fractures. However, a knee brace can offer some moderate relief in mild knee arthritis.

Is it possible for compression shorts and cinch straps to actually reduce the risk of injury in running or jumping activities?

No, but they decrease the “parachute affect” and will make you run faster.

I'm very active and involved in a number of sports. What are some things I can do - exercises, vitamin supplements, etc., to avoid knee injuries? Shoulder injuries?

To avoid knee injuries, maintain yourself at an ideal weight. Keep your BMI (body mass index) under 25. Stretch before participating in sports. Work in the gym on closed chain quadriceps strengthening exercises. Take Nutriex, which includes Glycosaminoglycans and Chondroitin Sulphate.

To avoid shoulder injuries, keep your scapula rotators strong. These include the levator scapulae, rhomboids, and serratus anterior and posterior. The exercises include shoulder shrugs against resistance. Stretch your shoulder into maximal internal and external rotation before sports. Take Nutriex, which includes Glycosaminoglycans and Chondroitin Sulphate.

Is it inevitable that "hard core" athletes will eventually need some type of knee or shoulder surgery?

No. Stay strong and fit and keep your weight down, and you will probably only know orthopaedic surgeons on the social basis.

Won't exercising with an injury only cause more damage?

No!! Exercise increases the blood supply to the joint. It strengthens the muscles around the joint. It increases cardiovascular fitness, and imparts a sense of overall well-being.

Of the rehabilitation devices available, what would be the ones you most recommend?

As always, the simplest is the best. There is the Cryo/Cuff®, which administers cold therapy and compression for nearly all body areas. For the knee, the simple Step box is cheap, and easy to use for closed chain quadriceps exercises. The Elite seat stretches the stiff knee into extension better than most surgeons can in the operating room with less pain and expense. Theraband is excellent for shoulder exercises and couldn’t be simpler.

If an injury occurs several times at the same location, does repair and recovery become increasingly difficult each time?

If it is a serious injury and it doesn’t recover fully, recovery could be increasingly difficult. If the area is properly rehabilitated and fully recovered, then it would be as a first-time injury if injured again.

As an athlete, I can't afford to work on a lengthy reconditioning exercise program to see if my injury improves. Wouldn't surgery be the quickest way to take care of the problem and get back in the game?

That depends on the condition we are talking about. If you have a torn ACL you are right. But you’d best wait until the knee quiets down, otherwise there is a 15 percent chance of permanent stiffness precluding high level activity.

Remember though, after surgery, you will need a reconditioning program anyway. Moreover, during our reconditioning program nearly all athletes can continue to be active in their sport.

How much time will I need to take off work for a surgery?

For office or sedentary workers: An ACL Reconstruction, one week; Shoulder or Knee arthroscopy, three to four days; an upper extremity surgery, two to three days.

What is the difference between a podiatrist and an Orthopedic surgeon and when is it a wiser choice to see an Orthopedic surgeon?

The biggest differences:

    • An Orthopaedic surgeon is a Doctor of Medicine, who graduates from Medical School. A podiatrist does not graduate from Medical School but rather podiatry school and is not a Doctor of Medicine.
    • An Orthopaedic surgeon has a global understanding of a patient’s musculoskeletal health and a podiatrist addresses primarily localized foot and ankle problems.

A podiatrist is a doctor of “podiatric” medicine (DPM) and is also referred to as a podiatric physician or surgeon. They are qualified to diagnose and treat certain conditions of the foot, ankle, and related structures of the leg. Podiatrists complete four years of training in a podiatric school and variable amounts of hospital residency training.

Podiatrists may be eligible for board certification after advanced training, clinical experience and testing; the certifying bodies for a podiatrist are the American Board of Podiatric Medicine and the American Board of Podiatric Surgery. These governing bodies are not certified by the American Board of Medical Specialties, which is the umbrella organization for certifying medical specialty boards such as Surgery, Internal Medicine, Pediatrics, Obstetrics and Gynecology, or Psychiatry and Neurology.

While some believe that a podiatrist is most qualified to care for injuries and conditions of the foot, as it is their only focus, they may overlook the importance of the patient’s health in general as well as the role that the broader musculoskeletal system plays in most foot and ankle problems. While, many podiatrists are well trained and knowledgeable, the care of these problems are often better suited to a Doctor of Medicine, namely, an Orthopedic surgeon, certified by the American Board of Orthopaedic Surgery (ABOS) with special interest in the foot and ankle, as indicated by membership in the American Orthopaedic Foot and Ankle Society (AOFAS).

An Orthopedic surgeon is a Doctor of Medicine who graduates from college and then four years of medical school obtaining a Doctor of Medicine (MD) degree. This education is followed by no less than five years in an Orthopedic surgical residency in an academic hospital program and most commonly one or more fellowship years additionally. Board certification is achieved by meeting strict standards and passing an examination established by the American Board of Orthopaedic Surgery. Subspecialty certification may also be obtained. Areas of specialization may include Orthopedic Sports Medicine, and Surgery of the Hand.

Orthopedic surgeons are members, or invited “fellows,” of prestigious professional orthopedic organizations such as the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Surgeons (ACS). Depending on areas of particular interest, other such organizations in which they hold membership may also include the American Orthopaedic Foot and Ankle Society (AOFAS), the American Orthopaedic Society for Sports Medicine (AOSSM), the Arthroscopy Association of North America (AANA), and the American Society for Surgery of the Hand (ASSH).

General Orthopedic surgeons are qualified to work within any of the specialized areas identified above – though remain globally focused on the overall musculoskeletal system and the impact an injury or condition may have overall. This is important as many of today’s chronic diseases, such as diabetes and arthritis, are manifestations of systemic disease and can have a devastating impact on the musculoskeletal system – though present initially in a particular limb. If the broader damage is not recognized and only the injury or condition presenting a specific limb is treated, other problems are inevitable.

While a podiatrist may effectively “manage” certain localized conditions of the foot such as callosities, diseases of the nail, and diabetic foot ulcerations, an Orthopedic surgeon is trained to identify and correct (both non surgically and surgically when indicated) hard to detect load pressure points, deformities, and stress and fragility fractures in the lower extremity before it turns into crisis management and limb salvage.

The ability to identify musculoskeletal problems early and “proactively” address them can make the difference in not only quality of life but extension of life.

Are those who work long hours on a computer more likely to be affected by carpal tunnel syndrome (CTS)?

Many workers in the field believe that this is true. We believe that patients can avoid these repetitive use injuries by rotating their duties such that they can rest their hands for a period of time during the day. Ergonomically designed keyboards are also available. Remember, most CTS is related to hormonal changes such as menopause, pregnancy, thyroid disease and diabetes. Other causes are Rheumatoid Arthritis, Osteoarthritis, and fractures.

If a cast is not put on my little boy's broken arm, could it heal improperly and cause problems in the future?

That depends on the location of the fracture. Most importantly, if the fracture is in poor position and needs to be set, it can. Fortunately though most kids’ fractures are benign, because as the bone grows – it will grow itself straight. This is called remodeling. It does not occur in adults.

My children are on a swim team and most frequently perform the "butterfly" stroke. But, I heard that this type of activity could result in shoulder problems later. Is this true and are there any sports more likely to cause future damage over others if begun young?

No, there is no evidence of a particular stroke or sport more likely than others to cause injury to the developing joints, tendons or muscles of children.