Conditions

At Advanced Orthopedic & Sports Medicine Specialists, we treat all kinds of conditions. Please see the list below to learn more.

Achilles Tendinitis

Achilles tendinitis represents a multitude of problems around the Achilles tendon. Diagnosis of tendinitis may involve inflammation around the sheath covering the tendon or it may involve disease within the tendon itself or it may involve inflammation around the area of tendon insertion. Careful physical examination can help determine the type of Achilles tendinitis the patient has. Most episodes of Achilles tendinitis result from a small, seemingly insignificant injury which develops into recurrent pain. Often times, tendonitis is aggravated by overuse and abrupt increases in physical training. There are multiple nonoperative treatments for Achilles tendinitis and most involve a period of immobilization and anti­inflammatories. If Achilles tendinitis is troubling you, the physicians at Advanced Orthopedic & Sports Medicine Specialists will be happy to give you an evaluation.

Achilles Tendon Injuries

Achilles tendon tears are a common injury in middle­aged men. They usually occur in sporting activities which require running or jumping or can occur when pushing an object. This article reviews Achilles tendon tears and discusses treatment options.

Acute Achilles tendon tears usually occur in middle­aged men during athletic activities. Most ruptures occur when pushing off with the foot while the knee is straight. The most common sporting activities that it occurs in are basketball, running and tennis. Tears can also occur with everyday activities such as hiking, pushing an object or stepping into a hole.

When a tear occurs a person will note a sharp pain or a pop in the back part of his ankle. Frequently, he feels as if he has been shot. If one is participating in a sporting activity he will frequently fall. One will also note significant weakness when walking and will feel like he has no strength and will not be able to walk upstairs.

On physical exam of an Achilles tendon tear the findings include a palpable defect at the area of the tear. When compared with a normal ankle in which the Achilles tendon is a palpable cord, the affected tendon has a loss of contour. One test that is diagnostic for tear is to have one lay on his stomach on the examination table and bend both knees to 90°. With inspection, the physician will note the position of the feet, the ankle without a tear will be pointed slightly towards the ceiling, while the ankle with a tear will be more at a 90 degree angle. If the calf is squeezed the foot will not move up and down in the ankle with a tear while the opposite side the foot will move up and down (video link). This test is usually diagnostic for an Achilles tendon rupture.

Radiographs of the ankle are usually taken and are frequently normal. Occasionally, an area of calcification may be seen.

Usually, an MRI is not obtained as the diagnosis can be made with very good accuracy based on the history and physical. If the diagnosis is in doubt then an MRI can be very helpful.

Most Achilles’ tendon ruptures occur in the watershed area of the tendon. Approximately 2­6 cm proximal to its insertion on the heel bone the tendon has an area of decreased blood supply in this area is prone to degenerative changes. Most frequently a person with a rupture will not have tenderness in that area prior to the injury.

Treatment Options

The treatment options for an Achilles’ tendon rupture include surgical and nonsurgical management. Nonsurgical management involves placing the foot and ankle in a cast with the foot pointed down. The cast is usually kept on for approximately one month. At that time, the cast is removed and the ankle over a period of two weeks is gradually brought up to 90°. Then a walking cast or boot can be used for another month. At 10­12 weeks following the initiation of treatment physical therapy can be started.

Surgical management involves making an incision over the inner aspect of the tendon.

The tear is identified and the two ends of the tendon are freshened up. A large stitch or suture is placed between the two ends and the two ends are then sewn together. The incision is then closed and a partial cast is placed with the foot pointed down. This splint (partial cast) is removed in 14 days. The sutures are then removed and the patient is shown stretches to gradually bring the foot and ankle to a 90° angle. Once this is accomplished a removable boot can be placed in the patient can start weight­bearing.

The advantages of nonsurgical management are cost, less time off work and the fact that a surgical procedure is not performed. There are some disadvantages. The risk of re­rupture is approximately 8%. Another disadvantage is the fact that there is a longer period of non­weight­bearing. Patients may also note slightly less strength as well as a decreased ability to get back to the same level of athletic activity.

The advantages of operative management is a lower risk of re­rupture (1%). Patients will also note slightly greater strength and a greater ability to return to athletic activities. Disadvantages include a risk of infection, the incision not healing, as well as the risks of anesthesia.

I base my treatment on a patient’s expectations and goals. If one is more sedentary, then it is not unreasonable to consider nonoperative management. In a patient who is involved in sporting activities and is very active, I usually recommend surgical management because of the lower risk of re­rupture as well as probability of improved strength.

Follow­-up

Following a period of a immobilization with surgical or nonsurgical management and once the brace and cast are removed, physical therapy is started. Physical therapy involves working on Achilles Tendon Injuries range of motion and stretching as well as strengthening. They also work on proprioception (balance).

It takes approximately 5­6 months for the tendon to reach full strength and it may take longer for one to get their strength back. Once strength is back to 80­-90% , full activities may be resumed.

ACL Tear

Located in the center of the knee, the ACL is a strong band of tissue that prevents the shin bone (tibia) from extending excessively beyond the thigh bone (femur). ACL injuries are common and usually sports­related—especially associated with basketball, football and skiing.

The four primary stabilizers of the knee are the ACL, the PCL (Posterior Cruciate Ligament), the MCL (Medial Collateral Ligament) and the LCL (Lateral Collateral Ligament). These ligaments function in concert with the muscles and cartilage of the knee to help control motion. Proprioceptive (nerve) fibers in these ligaments and the capsule of the knee joint augment this control via reflex feedback.

Patients with ACL tears usually describe a twisting or hyperextension of the knee. The patient may also feel a “popping” in the knee that is associated with immediate swelling. Typically, there is a significant effusion (excess fluid inside the knee) when the patient is first evaluated. A complete examination of the knee should be done to rule out associated injuries such as a fracture or a meniscus tear. The Lachman test is the best way to assess a knee for an acute ACL rupture. Range of motion should also be documented. Usually, the patient has difficulty fully straightening the knee immediately after the injury. This may be due to swelling or entrapment of the ACL stump in the intracondylar notch. Occasionally, a displaced bucket handle tear of the meniscus or a sprain of the medial collateral may present in conjunction with an ACL tear and lead to frank locking of the knee.

AC Separation

An AC joint separation commonly results from a fall onto the tip of the shoulder, especially with the arm tucked into the side. A separation occurs when the end of the clavicle pulls apart from the acromion.

The acromioclavicular joint is located between the portion of the shoulder blade known as the acromion and the collarbone. Acromioclavicular (AC) joint separation is a common reference to a partial or complete disruption of the AC joint and surrounding ligaments.

An AC or shoulder separation is a fairly common injury, especially among young adults and athletes. A separation should not be confused with a dislocation; the two injuries are very distinct, having different signs, symptoms, and treatments.

The AC injuries are classified according to the degree of ligament and joint capsule damage. This injury varies in severity from grade I ­ VI with the classification dependent on the degree of soft tissie disruption and the position of the collarbone(clavicle).

The recommended treatment for most AC separations (grade I ­ III) is non­surgical. Treatment involves application of ice, use of a shoulder immobilizer or specially designed sling, early motion and medication to treat pain and inflammation.

Grade IV ­ VI AC separations are usually treated surgically.

Severe Grade III separations may, in rare cases, require surgery to stabilize the shoulder joint while the damaged ligaments heal.

If non­surgical treatment does not result in a pain free and functional shoulder after six months, surgery may be considered, which may offer significant improvement for the injured joint.

Signs and Symptoms

  • A “bump” may be present over the tip of the collarbone.
  • Symptoms can range from tenderness over the joint to a complete separation of the AC Joint, with considerable swelling and obvious deformity of the shoulder.
  • Bluish bruising may appear soon after the injury.
  • A popping or tearing sensation inside the injured shoulder may occur with movement.
  • The inability to lift the arm away from the body due to severe pain.

Contact the Doctor if …

  • Pain, swelling or bruising becomes worse despite treatment.
  • Unexpected side effects occur from over the counter or prescription medications.
  • The development of pain, numbness, coldness or weakness in the arm.
  • Unexplained symptoms develop.

Ankle Instability

Each day over 20,000 Americans sprain their ankle. About 90 % of these people will recover without residual symptoms, however 10­15% will continue to have problems with the ankle.

The true definition of a sprain is an injury to a ligament, or the tissue that holds adjacent bones together. Ankle sprains are broken down into three grades. A grade one ankle sprain is a minor injury to the ligament that does not result in a complete tear nor does it result in any elongation of the ligament. A grade two sprain is slightly more severe because it elongates the ligament but does not completely tear the ligament. Grade three sprains are the most severe of the ankle sprains and these often involve tearing of more than one ligament.

Most patients can be treated with rest, ice, compression, and occasionally immobilization for a period of time. Physical therapy can be helpful in reducing swelling and strengthening the supporting muscles that stabilize the ankle. Ankle sprains can take up to 3 months to reach a full recovery. If one continues to have problems then further work up may be required.

Residual problems range from unrecognized fractures, tendon tears, recurrent instability, nerve injuries and more. An MRI or perhaps another imaging study can often be helpful in recognizing some of these hidden problems.

Arthritis of the Knee

Three basic types of arthritis may affect the knee joint.

1. Osteoarthritis (OA) is the most common form of knee arthritis. OA is usually a slowly progressive degenerative disease in which the joint cartilage gradually wears away. It most often affects middle­aged and older people.

2. Rheumatoid arthritis (RA) is an inflammatory type of arthritis that can destroy the joint cartilage. RA can occur at any age. RA generally affects both knees.

3. Post­traumatic arthritis can develop after an injury to the knee. This type of arthritis is similar to osteoarthritis and may develop years after a fracture, ligament injury or meniscus tear.

Symptoms of Arthritis

Generally, the pain associated with arthritis develops gradually, although sudden onset is also possible. The joint may become stiff and swollen, making it difficult to bend or straighten the knee. Pain and swelling are worse in the morning or after a period of inactivity. Pain may also increase after activities such as walking, stair climbing or kneeling. The pain may often cause a feeling of weakness in the knee, resulting in a “locking” or “buckling.” Many people report that changes in the weather also affect the degree of pain from arthritis.

Making the Diagnosis

Your doctor will perform a physical examination that focuses on your walk, the range of motion in the limb, and joint swelling or tenderness. X­rays typically show a loss of joint space in the affected knee. Blood and other special imaging tests such as an MRI may be needed to diagnose RA.

Treatment Options

  • In its early stages, arthritis of the knee is treated with conservative, nonsurgical measures.
  • Lifestyle modifications can include losing weight, switching from running or jumping exercises to swimming or cycling, and minimizing activities such as climbing stairs that aggravate the condition.
  • Exercises can help increase range of motion and flexibility as well as help strengthen the muscles in the leg.
  • Using supportive devices such as a cane, wearing energy­absorbing shoes or inserts, or wearing a brace or knee sleeve can be helpful.
  • Other measures may include applications of heat or ice, water exercises, liniments or elastic bandages.
  • Several types of drugs can be used in treating arthritis of the knee. Because every patient is different, and because not all people respond the same to medications, your Orthopedic surgeon will develop a program for your specific condition.
  • Anti-­inflammatory medications can include aspirin, acetaminophen or ibuprofen to help reduce swelling in the joint.
  • Glucosamine and chondroitin sulfate are oral supplements may relieve the pain of osteoarthritis.
  • Corticosteroids are powerful anti­inflammatory agents that can be injected into the joint.
  • Hyaluronate therapy consists of a series of injections designed to change the character of the joint fluid.
  • Special medical treatments for RA include gold salt injections and other disease­ modifying drugs.

Surgical Treatment

  • If your arthritis does not respond to these nonoperative treatments, you may need to have surgery.
  • Arthroscopic surgery uses fiber optic technology to enable the surgeon to see inside the joint and clean it of debris or repair torn cartilage.
  • An osteotomy cuts the shinbone (tibia) or the thighbone (femur) to improve the alignment of the knee joint.
  • A total or partial knee arthroplasty replaces the severely damaged knee joint cartilage with metal and plastic.
  • Cartilage grafting is possible for some knees with limited or contained cartilage loss from trauma or arthritis.
  • Orthopedic surgeons are continuing to search for new ways to treat arthritis of the knee.
  • Current research is focusing on new drugs as well as on cartilage transplants and other ways to help slow the progress of arthritis.

Achilles Tendinitis

Achilles tendinitis represents a multitude of problems around the Achilles tendon. Diagnosis of tendinitis may involve inflammation around the sheath covering the tendon or it may involve disease within the tendon itself or it may involve inflammation around the area of tendon insertion. Careful physical examination can help determine the type of Achilles tendinitis the patient has. Most episodes of Achilles tendinitis result from a small, seemingly insignificant injury which develops into recurrent pain. Often times, tendonitis is aggravated by overuse and abrupt increases in physical training. There are multiple nonoperative treatments for Achilles tendinitis and most involve a period of immobilization and anti­inflammatories. If Achilles tendinitis is troubling you, the physicians at Advanced Orthopedic & Sports Medicine Specialists will be happy to give you an evaluation.

Achilles Tendon Injuries

Achilles tendon tears are a common injury in middle­aged men. They usually occur in sporting activities which require running or jumping or can occur when pushing an object. This article reviews Achilles tendon tears and discusses treatment options.

Acute Achilles tendon tears usually occur in middle­aged men during athletic activities. Most ruptures occur when pushing off with the foot while the knee is straight. The most common sporting activities that it occurs in are basketball, running and tennis. Tears can also occur with everyday activities such as hiking, pushing an object or stepping into a hole.

When a tear occurs a person will note a sharp pain or a pop in the back part of his ankle. Frequently, he feels as if he has been shot. If one is participating in a sporting activity he will frequently fall. One will also note significant weakness when walking and will feel like he has no strength and will not be able to walk upstairs.

On physical exam of an Achilles tendon tear the findings include a palpable defect at the area of the tear. When compared with a normal ankle in which the Achilles tendon is a palpable cord, the affected tendon has a loss of contour. One test that is diagnostic for tear is to have one lay on his stomach on the examination table and bend both knees to 90°. With inspection, the physician will note the position of the feet, the ankle without a tear will be pointed slightly towards the ceiling, while the ankle with a tear will be more at a 90 degree angle. If the calf is squeezed the foot will not move up and down in the ankle with a tear while the opposite side the foot will move up and down (video link). This test is usually diagnostic for an Achilles tendon rupture.

Radiographs of the ankle are usually taken and are frequently normal. Occasionally, an area of calcification may be seen.

Usually, an MRI is not obtained as the diagnosis can be made with very good accuracy based on the history and physical. If the diagnosis is in doubt then an MRI can be very helpful.

Most Achilles’ tendon ruptures occur in the watershed area of the tendon. Approximately 2­6 cm proximal to its insertion on the heel bone the tendon has an area of decreased blood supply in this area is prone to degenerative changes. Most frequently a person with a rupture will not have tenderness in that area prior to the injury.

Treatment Options

The treatment options for an Achilles’ tendon rupture include surgical and nonsurgical management. Nonsurgical management involves placing the foot and ankle in a cast with the foot pointed down. The cast is usually kept on for approximately one month. At that time, the cast is removed and the ankle over a period of two weeks is gradually brought up to 90°. Then a walking cast or boot can be used for another month. At 10­12 weeks following the initiation of treatment physical therapy can be started.

Surgical management involves making an incision over the inner aspect of the tendon.

The tear is identified and the two ends of the tendon are freshened up. A large stitch or suture is placed between the two ends and the two ends are then sewn together. The incision is then closed and a partial cast is placed with the foot pointed down. This splint (partial cast) is removed in 14 days. The sutures are then removed and the patient is shown stretches to gradually bring the foot and ankle to a 90° angle. Once this is accomplished a removable boot can be placed in the patient can start weight­bearing.

The advantages of nonsurgical management are cost, less time off work and the fact that a surgical procedure is not performed. There are some disadvantages. The risk of re­rupture is approximately 8%. Another disadvantage is the fact that there is a longer period of non­weight­bearing. Patients may also note slightly less strength as well as a decreased ability to get back to the same level of athletic activity.

The advantages of operative management is a lower risk of re­rupture (1%). Patients will also note slightly greater strength and a greater ability to return to athletic activities. Disadvantages include a risk of infection, the incision not healing, as well as the risks of anesthesia.

I base my treatment on a patient’s expectations and goals. If one is more sedentary, then it is not unreasonable to consider nonoperative management. In a patient who is involved in sporting activities and is very active, I usually recommend surgical management because of the lower risk of re­rupture as well as probability of improved strength.

Follow­-up

Following a period of a immobilization with surgical or nonsurgical management and once the brace and cast are removed, physical therapy is started. Physical therapy involves working on Achilles Tendon Injuries range of motion and stretching as well as strengthening. They also work on proprioception (balance).

It takes approximately 5­6 months for the tendon to reach full strength and it may take longer for one to get their strength back. Once strength is back to 80­-90% , full activities may be resumed.