Monday, March 28, 2016

Scoliosis in Sports

    Scoliosis is a spine deformity in the side-to-side (or lateral) plane of more than 10 degrees of angulation.  The majority of the time this occurs spontaneously during the pubertal growth spurt in an individual with normal spine development, up until that time.  Currently this type of scoliosis is called “idiopathic”, meaning there is no known cause.  However genetic researchers are finding more and more associations between patients’ genetics and the development of scoliosis.  

     There is nothing the patient or caregiver did, or didn’t do, to cause the scoliosis to occur.  Most individuals with idiopathic scoliosis are involved, to some degree, in athletic endeavors whether it be recreational or high-level competition at the time they are diagnosed with scoliosis.  Often sports are interwoven into their day-to-day activities, so a new diagnosis of scoliosis raises questions about what sporting activities, and level of participation, a person with scoliosis may participate.  Despite the lateral curvature of the spine, the bony stability of the spine is normal, without instability.  

     There is no increased risk of damage to the spine during athletic participation when compared to a similar individual whose spine is absolutely straight.  We encourage all patients with scoliosis to be as athletically active as they desire, as the benefits of an active lifestyle are well-known.  Even patients whose scoliosis requires brace use we encourage sports participation.  The brace can be removed, they can participate in their sport then the brace can be re-applied after completion of the sporting event. 

Monday, March 7, 2016

Its Just a Wrist Sprain

by Charles Goldfarb, MD

A Wrist Sprain seems like such an innocent diagnosis.  And I would expect that almost every possible wrist injury has been called a Wrist Sprain at some point.

The classic Wrist Sprain patient in my office is the teenager who comes in about 2 months after the high school football season is over with a wrist that is still sore.  The story is predictable- a fall during a game and immediate pain in the wrist.  The parents and the trainer do not notice any real deformity and only a little or no swelling.  The pain gets better fast.  And the player returns to playing football.  But the pain never quite goes away completely. The pain lingers and eventually he finds his way to my office.  Unfortunately, this all-too-common situation is rarely a Wrist Sprain may not actually be a sprain.

The definition of a sprain is an injury to a ligament around a joint.  More information can be found here or here.  Ligament injuries are a big part of sports medicine because every single joint is stabilized by a ligament.  When an ankle is twisted or an elbow is dislocated or a knee is 'blown out', these are all ligament injuries.  It is impossible to read the sports section of the local newspaper or scan through the sports sites on the Internet without reading about a sports star with a ligament injury.  The injury occurs when a force is placed across the joint and the liagment is needed to stabilize the joint.  If the force is too much, the ligament (or ligaments) tear.

The wrist is different than some of the other joints because many injuries around the wrist are not actually sprains. But occassionally, a Wrist Sprain may really be just that- a ligament injury to the wrist.  The classic wrist ligament injury is to the scapholunate ligament.  An injury to the scapholunate ligament is a serious injury as we, the hand surgeons, do not have a perfect treatment.  Sometimes we can put sutures into the ligament and sometimes we can move ligaments around to support it.  But often times, we do not have a perfect treatment.  Other possible ligament injuries include the lunotriquetral ligament, the volar radiocarpal ligaments, and others.
One other common wrist injury is to the TFCC- the triangular fiborcartilage complex.  The cartilage is similar to a ligament as it is a supporting structure  on the pinky side of the wrist which provides support and stability in a way similar to the knee meniscus.    Future blog posts will review each of these injuries.

The reason that the wrist is different from other joints is that because many patients labeled as having a Wrist Sprain do NOT, in most cases, actually have a wrist sprain.  Instead they often have a fracture of the bones around the wrist.  Most common in this situation is a fracture of the scaphoid bone.  Such patients may have some pain at the base of the thumb and they may have limited wrist motion.  The proper diagnosis can be made with an x- ray although more advanced imaging (CT scan or MRI) may be required.  Or the may have a radius fracture, an ulna fracture, or a fracture to one of the other bone is the wrist (the carpal bones).  Here are two examples of a scaphoid bone fracture.

The scaphoid bone is the wrist bone at the base of the thumb.  The arrow marks the fracture.

A close up view of another scaphoid bone fracture.

So a Wrist Sprain may not really be a wrist sprain.  It can also be a fracture or a cartilage injury. While not every patient with a Wrist Sprain needs to see an orthopedic surgeon or a hand surgeon, if the pain lingers for more than 1-2 weeks, I would recommend that the patient see the pediatrician or the orthopedic specialist.

Charles A. Goldfarb, MD
My Bio at Washington University

Wednesday, March 2, 2016

Rehabilitation for Ankle Sprains

by David Piskulic, DPT, SCS, ATC/L
St Louis Children's Hospital Physical Therapy

     Ankle sprains are one of the most common injuries in sports participation.  In fact, the ankle accounts for about 1/3rd of all sport-related injuries.  In their lifetime, 1 in 5 individuals who are physically active will sustain a lateral ankle sprain, which is when the foot turns in and the ligaments on the outside of the ankle are either damaged or torn.  Incidence of these ankle sprains is highest in our young athletes, between 15-19 years.  While the incidence of these injuries is well known, proper rehabilitation of the injury and knowing when to get back to sports participation can be difficult to determine.

How Do I Start Care for an Ankle Sprain?

     After your athlete sustains an ankle injury, observe for common signs and symptoms: localized pain, swelling that builds up and may lead to discoloration, a popping sound during the injury, and difficulty moving the ankle or foot.  Be especially aware of difficulty bearing weight on the leg or even difficulty walking, as this may be a sign of a more severe ankle sprain or fracture.  If you suspect a severe injury, follow-up with your physician for a full evaluation.

     Once an ankle sprain is determined, the old method of rest, ice, compression, and elevation (often referred to as “R.I.C.E.”) still stands tried and true.  The athlete should rest from activity, ice the area of pain for up to 15-20 minutes, maintain compression with a wrap, and elevate the ankle above the level of the heart.  All of these initial treatments will help with overall circulation and decrease excessive swelling.  More severe sprains may require use of a boot or air-cast that can be acquired from and applied by your physician.

Figure 1 : Examples of wraps and bracing to treat ankle sprains.

When Can I Move My Ankle?

      While you initially want to protect the injured ankle ligaments and restrict ankle movement to let them heal, light range of motion exercises can help prevent stiffness and improve circulation to allow proper blood flow for healing and reduction of swelling.  Some simple exercises are completing the “ankle alphabet”.  The athlete will “draw” letters of the alphabet with their big toe, moving their ankle through pain-free range of motion.  This can be accomplished by starting with small letters and gradually making bigger letters once pain improves.

Figure 2 : Examples of "ankle alphabet" exercises
When Can I Walk?

     Early weight bearing has been linked to improved outcomes in rehabilitation of ankle sprains.  It is important for the athlete to “normalize” their walking pattern and to have their heel touch the ground first with their toes forward, then roll through their step and gently push off from their toes.  If use of a larger boot or brace limits ankle mobility, have the athlete roll through their step with their toes forward as much as possible.  If the athlete is having difficulty pushing off from their toes during walking, they may benefit from completing a heel raise exercise.  The athlete can complete the exercise on both legs at the same time and then progress to single leg heel raises as their strength improves.
Figure 3 : Example of proper walking mechanics at the foot and ankle

Figure 4 : Example of a heel raise exercise with heels elevated

     In addition to the athlete having a normalized walking pattern, they should also work on balance exercises to assist with stabilizing the ankle.  Several studies have been done on specific types of exercises, use of equipment and special supplies, but the main conclusion these studies have is that any type of exercises that challenge an athlete’s single leg balance, such as balancing on uneven surfaces, promote improvement in overall stability of the ankle joint.  This can be accomplished by having the athlete balance on 1 leg on a flat surface while pain free for up to 30 seconds.  When the athlete reports no pain with these exercises, they can start single leg balancing on uneven surfaces, such as thick carpeting or a couch cushion, and practice sport specific drills, such as throwing and catching a ball.  These types of balances programs are even recommended as a pre-season work-out and have been correlated to decreased incidence of injuries among athletes.

When Can I Play Sports Again?

     This is usually the most important question asked after sustaining an injury, not only by the patient but by the parents as well.  And don’t worry, parents, clinicians want your young athlete to return to their sport or activity as soon as possible!  We just want to make sure they’re safe and healthy to do so.
     Some tests to complete with the athlete are single leg balancing, pain-free walking and running without favoring their injured leg, performance of sport specific skills without any form of contact from other players or teammates, and equal performance of jumping and hopping on each leg.  Your rehabilitation specialist of choice should be able to help your athlete in finding exercises and activities for them to complete to properly train their injured ankle and get them fully prepared to return to their sport.

How Do I Keep From Getting Injured Again?

     In a perfect world, everyone would be able to participate in their own sport or activity free from aches, pains, and injuries.  However injuries are very much a part of the sports world and unfortunately will continue to occur despite our best efforts.  That being said, there are still many things to do to avoid a higher incidence of future injury.  This includes several aspects of sports training, including continued training in balance exercises throughout sports participation, completion of a thorough return to sports test with your medical provider, and continued use of ankle support with use of a functional lace-up ankle brace or taping.  These have been found to reduce the incidence of ankle sprains when returning to sports following injury.  Consult your physician, physical therapist, or athletic trainer for their recommendations on functional bracing and for assistance with application of ankle taping.