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In Motion April 2011

Rotator Cuff Injuries: You Don’t Have to be an Athlete

Rotator cuff injuries. We often hear about baseball pitchers who experience them, but perhaps you have, too. Maybe you were lifting weights in the gym or putting boxes on an overhead shelf when you heard a “pop” and felt a sudden pain in your shoulder. Or maybe you tripped and landed awkwardly on your shoulder.

Also referred to as shoulder tendonitis, a rotator cuff injury is a tear, strain or irritation in the rotator cuff muscles and tendons. It is a common cause of pain and disability among adults over age 40. Fortunately, about half of all rotator cuff injuries heal with self-care measures or exercise therapy.

“The shoulder joint and its extraordinary formation of bones, muscles and tendons are incredible,” says Frank Sabo, Jr., MD, a general orthopaedic surgeon. “While it provides your arm with the greatest range of motion of any joint in your body, its lack of stability makes the shoulder joint vulnerable to injury.”

Acute injury, chronic overuse, gradual aging or inflammation (caused by tendonitis, bursitis or arthritis) to any of the rotator cuff’s four muscles or the ligaments that attach the muscle to the bone can cause significant pain and affect the joint’s range of motion.

“Normal wear and tear after age 40 can make you more susceptible to a rotator cuff injury,” says Dr. Sabo. “Or, you may experience an injury by lifting or pulling something that is too heavy, or when a force is applied to the arm while it's in an unusual or awkward position, such as in a fall.” In addition, construction workers, baseball pitchers, tennis players and others who regularly use repetitive motions have a greater risk of having a rotator cuff injury.

How do you know if you have a rotator cuff injury? “The most common symptoms are pain and weakness in the shoulder,” says Dr. Sabo. “It also may be hard to raise your arm above your head, to extend your arm directly to the side or in front, or sleep on the affected side of your body.”

The seriousness of the injury can range from a mild strain and inflammation to a partial or complete muscle tear requiring surgery. “If a sudden tear occurs, there may be a snapping sensation with immediate pain and weakness in the arm,” says Dr. Sabo. “With long-term wear or repetitive overhead activity, the symptoms may develop slowly over time.”

Take an over-the-counter medication, such as aspirin or ibuprofen, if the pain is mild. If the injury is more severe, early treatment using the “R.I.C.E.R.” (Rest, Ice, Compression, Elevation and Referral) regime is recommended for the first 48 to 72 hours. After this period, use a heat lamp or a heat-based cream to increase blood flow to the area. Massage is also helpful in increasing blood flow and reducing scar tissue. Moving the shoulder slowly and gently will promote healing, too.

See your doctor if the pain in your shoulder is severe, lasts more than one week, or if your arm feels weak or you are unable to use it. Most times he or she will recommend ice, rest, and aspirin or ibuprofen. A gradual exercise rehabilitation program for strengthening the rotator cuff may be recommended. More severe injuries can require surgical repair.

“As with anything else, prevention is the best medicine,” says Dr. Sabo, who recommends warming up properly and conditioning shoulder muscles and tendons with stretching and strengthening of the shoulder joints.

To make an appointment with any of our rotator cuff specialists, please call 440.312.6242.

Surgical Treatment Options for Spine Problems

This is a very exciting time in spine surgery – new innovations and devices are continuously being developed. Most of these devices and techniques are designed to treat very specific types of spinal problems. Therefore, it is critical that the right treatment and device is carefully selected based on the patient’s medical symptoms and problems. For most patients, traditional approaches to surgical treatment still promise the best outcome for success and pain relief.

disc replacement

Eight weeks after disc replacement surgery, this patient returned to work and light exercise without restrictions. He ranked both his back and leg pain as 0 out of 10.

For instance, artificial disc replacement is now available for the lumbar and cervical spine. These devices replace a painful, degenerated disc with a device that allows continued motion at the spinal level needing treatment. Both fusion and artificial discs relieve pain by removing the painful tissue, but the artificial discs allow continued motion at the treated level while fusion stops motion permanently. Artificial discs may prevent wear and tear changes that occur years after fusion surgery, so they are particularly useful in young patients. However, they are not helpful in patients with severe arthritis of the spine, or who have had extensive previous surgery. They cannot be used to treat problems like stenosis or lumbar disc herniation, where pressure on the spinal nerve is the main cause of the medical condition, but they are useful in cervical disc herniations, where fusion is often needed after disc removal.

The X-stop® device is designed specifically to treat moderate levels of spinal stenosis with minimally invasive techniques. However, it is not intended to treat severe stenosis, or problems of instability or back pain.

Minimally invasive techniques allow surgeons to correct major spinal problems with less blood loss, less pain and less downtime than ever before. This includes the development of newer instruments and methods, such as microendoscopic devices that allow surgeons to operate through a tube using video control, as well as the surgical techniques that enable placement of screws, rods, or cages through minimal incisions.

New biological materials (BMP – bone morphogenetic protein) stimulate more reliable fusions without the need for potentially painful bone graft harvests. New techniques developed through the Cleveland Clinic now allow us to harvest the patient’s own stem cells from inside the vertebral body, and use those to stimulate fusion.

While laser surgery is one of the most heavily advertised techniques in spine surgery, often offered as a “cutting edge” technique, but lasers have been used in spine surgery for more than 20 years, and success has been documented only in a few very selected applications. “While most surgeons have access to lasers for spine surgery, few chose to use them, as microsurgical methods consistently prove more successful and reliable,” states Robert McLain, MD, an orthopaedic surgeon who specializes in spine surgery.

Even though all of these innovations and advances are specific in nature, they have also led to advances in the ways we can carry out the traditional procedures needed by many patients – providing benefits for patients with all kinds of back and spine problems. The key to success is to work with your surgeon to find the best solution to your specific problem.

To make an appointment with any of Cleveland Clinic’s spine specialists, please call 440.312.6242.

Knee Resurfacing Allows Return to Life’s Simple Pleasures

As Doreen Aquilla knelt down on the ground during a CPR class, she felt an excruciating pain in her right knee. She knew something was wrong.

“At first it was just my right knee that was painful, but then my left one started to hurt. Over time, I ended up with two painful knees,” recalls Doreen.

As a grocery store customer service representative, Doreen spends her entire workday mobile and without much time to sit down. When she had knee pain, Doreen’s workday would drag on forever.

“I went from working eight hours a day to six because of the discomfort in my knees,” says Doreen, “Eventually, I had to drop down to four hours. I was limping, in a great deal of pain and crying all of the time.”

Doreen went to her doctor and received cortisone shots, but they didn’t help much. The next step was arthroscopic surgery; it only relieved her pain for a short while. That was when her physician suggested she see James Williams Jr., MD, an orthopaedic sports medicine surgeon, for a solution.

Tired of being in constant pain, Doreen was excited at the prospect that someone might be able to provide her relief. “I told Dr. Williams that I need to work, and I can’t with this pain. He said he thought he could help me and that made me happy,” says Doreen.

Dr. Williams suggested that Doreen have an innovative procedure called knee resurfacing. “This procedure, which is relatively new to the United States, is the wave of the future,” commented Dr. Williams. “I had been waiting for the right patient for this procedure and Doreen was that patient.”

What makes this procedure so unique is that the implant is made to specifically fit the patient’s bony surfaces of the knee. During surgery, the damaged portions of the articular cartilage are removed and replaced with a metal surface that is cemented to the bone. The knee resurfacing surgery lasts about as long as a knee replacement surgery, but has more advantages because it is less invasive, a smaller portion of the bone is cut away and it is customized to fit each patient’s knee.

“With this surgery, only the damaged surface is replaced,” explains Dr. Williams. “There are three compartments to the knee. Doreen had only two areas that were damaged and needed repair. A knee replacement would have unnecessarily replaced all three areas.”

Knee resurfacing is ideal for the younger, more active patient. It keeps more of the bone in tact and typically lasts 10 to 15 years. This procedure can easily be converted to a full knee replacement, if it is needed down the road.

After surgery, Doreen stayed in the hospital for three days; she was up and walking within 24 hours. She began inpatient therapy while in the hospital and continued therapy on an outpatient basis twice a week for several months; she also did exercises at home to help with the recovery process.

Dr. Williams stresses the importance of rehabilitation. “You can have the best surgeon in the world, but if you don’t keep up with your rehab you won’t get the results you desire. Doreen worked hard and was motivated and that is why she was able to get back to where she wanted to be.”

“My pain is gone and I’m able to bend my knees. I wasn’t able to do that before. It’s amazing! Now I’m able to bake cookies with my sister, walk up the stairs and get down and play with my grandchildren,” says Doreen, “that’s all I wanted – to be able to enjoy the simple things in life that I wasn’t able to do before I had my knee resurfacing.”

To make an appointment with any one of Cleveland Clinic’s knee specialists, please call 440.312.6242.

Don’t Let a Sprained Ankle Keep You Out of the Game

Virtually everyone has sustained a twisting injury or sprain to one of their ankles. In fact, sprained ankles are the most common type of athletic injury.

There are two major ligaments that provide stability to the outside part of the ankle. These are the calcaneofibular ligament (CFL) and the anterior talofibular ligament (ATFL). Under normal circumstances, these ligaments provide stability by resisting stresses that tend to invert the ankle or cause it to turn in. A sprain occurs when there is some degree of stretching or tearing of these ligaments. This stretching of the ligament produces the characteristic swelling, bruising and pain on the outside of the ankle.

In general, these symptoms vary depending on the amount of stretching of the ligaments that has occurred. Physicians and trainers will frequently grade ankle sprains from I-III to describe the severity of an ankle sprain.

You may also here of athletes having what is called a "high ankle sprain." This type of sprain is much less common. It occurs when the entire ankle and leg are twisted outward, unlike the more common ankle sprain which occurs when the ankle twists inward. The reason it is called a "high" ankle sprain is because the injured ligaments actually extend from the ankle all the way up the leg almost to the knee.

Pain, swelling, and bruising may actually be worse on the inside of the foot and ankle. It is important to diagnosis a "high" ankle sprain because the recovery from it is generally much longer than for a standard ankle sprain.

Treatment of the Sprained Ankle

If the patient cannot bear any weight on the injured ankle, it is best to have the injury evaluated by a professional to rule out a broken ankle. Once a sprain is diagnosed, treatment should begin as soon as possible. In most cases, an initial course of R.I.C.E. therapy is the best practice. R.I.C.E. stands for Rest, Ice, Compression, and Elevation.

Bearing weight on the ankle will not cause additional damage, so light walking using an ankle brace is encouraged. If weight-bearing is extremely painful, a walking boot and/or crutches may be used. “However, if the pain and need for crutches persists for more than three to seven days, an orthopedic surgeon should be consulted,” says Mark Berkowitz, MD, an orthopaedic surgeon who specializes in treating the foot and ankle.

Prompt initiation of physical therapy is the most critical part of recovery from an ankle sprain. An effective therapy regimen will help restore motion, decrease pain, and most importantly, restore the strength and balance of the ankle. Strengthening the tendons on the outside of the ankle (the peroneals) is essential to the ankle “feeling” stable and preventing future sprains. Rehabilitation also is necessary to regain proprioception, or the ability to sense the position of the foot on the ground and to adapt to uneven surfaces.

In conclusion, unfortunately, most people will sprain an ankle at some point in their lives. But with prompt treatment and a well designed therapy program, return to sports and other activities can be achieved.

To schedule an appointment with any of Cleveland Clinic’s foot and ankle specialists, please call 440.312.6242.

Making the Change from Athlete to Active Adult

What happens to high school and collegiate athletes when structured practice and competition are over for good? Making the transition from a performance mentality to a healthy lifestyle mentality will maintain fitness long after you walk off the field for the last time.

Redefining Exercise

Exercising for performance is different from exercising for wellness.

  • Just because a specific exercise benefits performance does not mean that it’s good for you. Maximal lifting may make you stronger for football, but continuing extreme lifting into later life will likely cause orthopaedic problems.
  • Real life does not mimic the off-season, pre-season, in-season and post-season rhythm of athletics, which provide necessary rest for the body and prevent overtraining. Former athletes can wind up pushing their bodies to extremes all year. This can cause long-term problems, including chronic injuries that may prohibit exercise altogether.
  • Moderation is vital. A long-term exercise plan should be reasonable. Exercise is as much a physiological stress on your body as heat, humidity and cold. It’s difficult to maintain high levels of physical performance indefinitely without rest.
Finding a new motivator

When improving athletic performance is no longer your primary motivation for exercise, it’s crucial to find another one – something that won’t change. This may be:

  • Maintaining a healthy weight
  • Preventing a chronic illness that runs in your family, such as heart disease
  • Effectively managing stress
  • Improving sleep patterns
  • Enjoying higher energy levels

Everyone is different, so look for your own motivator – something outside sports performance that will ensure consistent exercise throughout life.

Moderate workouts ideal

With a reasonable approach to exercise, you can meet national guidelines for health and fitness, and maintain a strong physical fitness level throughout your life.

Exercise regimens should incorporate the following four components of fitness:

  1. Cardiovascular exercise (American Heart Association recommendations): At least 30 minutes of moderate-intensity cardio most days of the week (divide into 10-minute segments if you prefer). Walking is fine! Alternatively, do 20 minutes of vigorous cardio exercise three times a week.
  2. Resistance/strength training: Using free weights, machines, calisthenics, exercise balls, bands or Pilates twice a week to exercise all major muscle groups and keep up lean muscle mass. You can get by with two sets of 12 reps. If time is tight, try a short strength workout with multi-joint resistance exercises: pushups, squats, lunges, leg presses, chest presses, rowing. (Don’t worry about isolating individual muscle groups. In a pinch, try simple pushups to work the biceps, triceps, chest, upper back and abdominal muscles.)
  3. Balance and agility training: Doing crunches on a ball or biceps curls while standing on one foot to improve strength and balance. Can be combined with strength/flexibility exercises, such as pilates or yoga.
  4. Flexibility/Stretching: Can be done at a completely different time of day – at the office, after your morning shower, etc. Stretching at your desk, or at home while watching TV, can be helpful.

Exercising for health and wellness can easily fit into a working lifestyle. A moderate fitness regimen takes just one hour, three to five times a week. However, you can spread the different components of exercise throughout your week; if you can’t exercise for an hour, do just 30 minutes of cardio or strength training and make up the rest later in the week. Exercise need not be done perfectly to be effective.

Putting sports back in your life

“Finally, just because you no longer have a coach directing practice does not mean your days of chasing a ball are over,” says Heather Nettle, MA, Coordinator of Exercise Physiology Services at Cleveland Clinic Sports Health. Athletes become athletes because of the joy they find in sports and activity. If your playing days ended in high school, try participating in intramural and recreational athletics in college to maintain an active lifestyle and prevent the boredom that active athletes often feel in the gym. If your playing days ended in college, consider joining a tennis club or a racquetball, softball or baseball league as an adult to help compensate for any sense of loss. Throughout the seasons, incorporate outdoor sports such as skiing, hiking, cycling and running into your life.

To make an appointment with any of Cleveland Clinic’s exercise physiologists, please call 440.312.6242.

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