Rotator Cuff Tears

By Ron Romanelli, MD

The shoulder is a very interesting joint. It has the most motion than any other joint in your body. If you think about it we use our shoulder every day for almost any activity that we need to do. We really don’t even notice that we have a shoulder until it becomes hurtful.

The shoulder joint has a global motion, what I meant by that is it allows us several degrees of freedom of movement. Our shoulder girdle consists of the shoulder blade (socket), the upper humerus (ball) and the clavicle. The shoulder and arm is essentially suspended from our body. There are some large muscles around the shoulder and then there are the rotator cuff muscles which have to do with the rotation and elevation of a ball within our socket.

The four muscles that make up the rotator cull include the supraspinatus, infraspinatus subscapularis and Teres minor muscles. There is also ligaments and the glenoid labrum ring or O-ring in the joint that helps render stability to our shoulder.

During shoulder movement, typically a synchronous movement of the scapula along with the humerous allows the muscles to work together to move the arm in a nice smooth delicate motion. Overuse of the shoulder as well as imbalance of the muscles contribute to tendon tears and internal derangement of the shoulder.

Roator cuff tears can occur due to several factors. Mechanical impingement from bone spurs and overuse rotator cuff tendinitis can lead to tendon degenerative changes over time. Acute injury to the shoulder can lead to failure of the rotator cuff. Next we have to consider aging and genetics that also contribute to degenerative tears in the rotator cuff tendon. Next, if the combination of all these factors working together which can cause degenerative rotator cuff tears and pathology.

Rotator cuff tears can be partial or complete. The complete tears are classified as small, medium, large, and massive. The most common rotator cuff tear is the supraspinatus tear. This is the muscle that elevates the arm forward and upward.

Just like fractures every rotator cuff tear seems to have its own personality. Therefore we treat those injuries based on the personality of the tear and injury as well as the situation of the patient. What I mean by this is that not all rotator cuff tears are alike nor not all rotator cuff tears need to have surgery.

Surgery is reserved for people who have persistant pain and/or weakness of the shoulder that is not able to be treated with conservative measures. We typically start with the history of the injury and the evaluation of the patient. Initial treatment consists of medications and occasionally cortisone injections, and physical therapy. If our conservative treatment fails then surgical treatment will be needed. This again depends on the age of the patient as well as the type of tear that is present.

Most of the time when patients come in with shoulder pain we can diagnosis and treat them with conservative methods and approximately fifty to seventy-five percent of the time the patient will get better. If patients fail conservative treatment and are unable to perform the tasks they desire, then shoulder surgery is needed.

Historically, rotator cuff tears have been treated with open surgical techniques. Currently the majority of orthopedic surgeons utilize arthroscopic surgical techniques for rotator cuff pathology. These techniques are performed in an outpatient facility such as the Orthopedic Surgery Center of Illinois using a specialized team of nurses and nurse anesthetists and anesthesiologists. We utilize a very light minimal general anesthetic as well as a shoulder pain block and local anesthesia typically to perform these procedures. The shoulder blocks and local anesthesia typically will numb up the shoulder for approximately 24 hours after the procedure. This way patients can have this procedure performed as an outpatient and then utilize ice and take pain medications for just a few days after the procedure.

We typically utilize cutting-edge techniques for performing these procedures. The orthopedic surgeons at OCI have under taken specialized training to perform this procedure. Most of us utilize a double row rotator cuff tear technique which is able to repair the tendon to the bone more securely, which we feel is the best way possible for the best recovery and outcome.

When dealing with rotator cuff surgery the patient needs to understand that there is a physiological healing process that must occur before we load the tendon. It takes approximately six weeks time to have the bone and tendon bond together. Then the next six weeks we work on range of motion and strengthening progress to achieve success.

Patients need to understand though that getting an unhealthy rotator cuff tendon to heal back to the bone is somewhat of a lengthy process. Approximately three to six month after the injury we still recommend strengthening program to continue. Typically the maximum healing will occur six months to a year after the surgery. This is not to say that patients don’t feel better soon after the procedure. Patients usually can tell a difference within a week or so after surgery because they do not experience as much pain as they had preoperatively. What I’m trying to say is that we need to understand that rotator cuff tendon healing may take a little bit longer time to heal before we allow unlimited use. Certain people tend to heal faster than others and certain people can have some complications associated with the rotator cuff surgery. The typical problems that occur after a rotator cuff surgery would be stiffness and the need for more physical therapy than usual. Infection, bleeding, and nerve injury are all very rare.

The prognosis of rotator cuff surgery is sometimes dependent on the personality of the tear and the age of the patient. Remember there are small tears, medium tears, large tears, and massive tears. Of course the small and medium rotator cuff repairs usually have an excellent prognosis, especially when we perform this on younger individuals. Small and medium rotator cuff tears can still heal in older individuals, but this depends on how long the tear has been present as well as the physiological age of the patient. When we deal with a massive rotator cuff tear the prognosis is not always as good.

Please remember that there may be acute tears in a normal shoulder that usually will heal well. That is the type of injury that happens when you had no problem with your shoulder and all of a sudden injure your rotator cuff. The patients that are difficult to treat have been having some shoulder pain for awhile and may have had some rotator cuff damage already and then go on to tear the rotator cuff completely and are unable to lift their arm. These cases are very difficult to treat and occasionally need to be treated with a reverse total shoulder replacement. This is a total joint procedure that is performed for older people who have extremely poor rotator cuff tendon tissues. This is a decision we have to make after we evaluate the patient and perform a MRI scan so we can see what is actually going on with the rotator cuff. If the rotator cuff has fat atrophy that means it has not been working normally for a long time, therefore the surgical results will not be good. Also people have a bad prognosis if they are smokers, because this will inhibit the healing of the tendon back to the bone.

One of the extremely important ways for you to recover after your rotator cuff surgery is by going to physical therapy. We know that the role of the physical therapist valuable in teaching the patients the proper techniques and protocols for success after rotator cuff surgery. Therefore we rely on our PT specialist at Midwest Rehab to come up with a custom treatment plan for each particular problem based on the patient’s surgical findings and individual rotator cuff tear.

The best way to deal with your rotator cuff problem or shoulder pain is to be evaluated by your orthopedic surgeon. We will be able to perform a special physcial examination on your shoulder, take x-rays, and decide whether a MRI would be needed. Once we evaluate the problem we can decide what the best treatment plan would be for your particular issue. We always start with a history and physical evaluation, the possibly anti-inflammatory medications, cortisone injections, and physical therapy before resorting to surgery.

The physicians at the Orthopedic Center of Illinois are always striving to do our best to give you the proper medical care and service you deserve.

Advances in the Management of Sports Knee Injuries

By Rodney Herrin, M.D.
Board Certified Orthopedic Surgeon
Orthopedic Center of Illinois

Anterior Cruciate Ligament Injuries
There have been significant advances in the management of sports knee injuries, with the primary focus  on  attempting  to restore the normal anatomy. The anterior cruciate ligament is an important stabilizer of the knee. (See Figure A)A ACL picture  Once the ligament is injured, the knee may “give way “.  When this occurs, additional injury may occur to the knee including injury to the meniscus or the articular cartilage of the knee.  Therefore, often times when the anterior cruciate ligament is injured, surgical intervention is recommended. Anterior cruciate ligament reconstruction has evolved toward reconstruction of the ligament on an anatomic basis. A better understanding of the anatomy has helped with our reconstructive techniques and improvement in our surgical technology. By paying more attention to the anatomy we are able to improve the results for our patients.

When an anterior cruciate ligament reconstruction is being performed in the setting of a relatively acute injury, typically the attachment sites of the anterior cruciate ligament on the femoral and tibial sides are present.  These attachment sites can be used as references for reconstructing the anterior cruciate ligament.  In this setting, the center of the attachment sites of the anterior cruciate ligament can be marked with electrocautery.  The goal is then to try to place the tunnels for the reconstruction in those locations. The anterior cruciate ligament typically cannot be repaired and therefore must be reconstructed.  This may be done using either the patient’s own tissue (autogenous tissue) or using a donor tissue (allograft tissue). The autogenous graft options include the use of a bone patellar tendon bone graft, hamstring graft, or a quadriceps tendon graft.  The allograft options include bone patellar tendon bone, tibialis anterior, as well as Achilles tendon just to name a few.  Generally autogenous tissue is used in the younger athletes, which may help decrease the risk of re-injury.  As the patient matures, both autogenous or allograft tissue are reasonable options. Figure B demonstrates an anterior cruciate ligament reconstruction. The procedure is typically B ACL recondone arthroscopically.  There are a multitude of options for fixation of the grafts, the type of fixation used is partly dependent on the graft choice.  For example, a graft that has a bone plug attached to it, such as a bone patellar tendon bone graft, will typically use interference screws.  However, there are many acceptable options.

A current trend after anterior cruciate ligament reconstruction, is to proceed somewhat slowly when it comes to rehabilitation and returning  to sports.  It is felt that trying to return the athlete to their sport too rapidly may increase the risk of reinjury to the knee.

The meniscus is a fibrocartilaginous structure that helps protect the joint surfaces of the knee, and is commonly injured. We have learned that the more it can be preserved the better. Most commonly a torn meniscus is treated with a partial meniscectomy, preserving as much of the meniscus as possible. In some instances the meniscus is torn in such a way that the meniscus can be repaired. There many techniques that are available to help us with that task. The meniscus may be repaired with sutures that are C meniscal repairplaced from inside the knee to the outside of the knee.  This technique is still considered the gold standard, however there are many evolving techniques that are very helpful for meniscal repair.  These include techniques that are considered “all inside”, which has the advantage of being somewhat less invasive.  Figure C is an example of an “all inside” meniscal repair technique.

Meniscal Root Repair
Occasionally the meniscus is torn at its posterior root attachment.  Once that occurs, the meniscus is essentially rendered nonfunctional and no longer protects the knee as it is designed to do.  Repairing the meniscal root tear can be quite beneficial to the patient and the techniques to do so have significantly improved with the improvement of technology.  Essentially sutures are placed at the root of the meniscus and then a drill hole is placed in the area of the meniscal root attachment.  D meniscal root repairOnce that has been done, the sutures are pulled through the drill hole that has been made and the sutures are tied over a button. (See figure D)  This pulls the meniscus back to its anatomic attachment and restores the hoop stresses in the meniscus that protects the knee.

Meniscal Transplant
In certain circumstances, the meniscus cannot be preserved.  If a significant portion of the meniscus has been removed and the patient becomes symptomatic related to the absence of the meniscus, the patient may be a candidate for a meniscal allograft transplant. (See figure E)  To be a candidate, however, the patient needs to have E Meniscal transplant relatively normal articular cartilage and have satisfactory alignment of the lower extremity.  The procedure involves transplanting an appropriately sized donor meniscus into the knee of the patient.  The procedure is primarily done for improved symptoms and paint relief, but, is not typically performed with the goal of returning the patient to significant sporting type activities. It has not been proven that the meniscus transplant protects the knee from developing degenerative changes in the future.  The procedure can be technically demanding and does require obtaining the appropriately sized meniscal transplant.  In the appropriate patient however, it can be a reasonable option to consider.

Articular Cartilage Problems
The articular cartilage in the human knee has a limited blood supply and therefore, once injured, it cannot heal itself.  There are numerous ways to try to manage articular cartilage injuries and a great deal of research that is being done regarding treatment of these injuries.  The treatments can range from a technique known as microfracture to techniques such as autogenous chondrocyte implantation (ACI).  The technique of microfracture (See figure F) has been around for decades, but it is currently being F microfracturemodified to potentially help it be more successful. The technique of microfracture involves a process where the body fills the defect in the articular cartilage with fibrocartilage.  Although this is helpful to patients, the fibrocartilage is typically not as long lasting as normal hyaline articular cartilage.  Currently, the goal in management of articular cartilages problems is to develop cartilages more similar to hyaline articular cartilage, which is normally present in our knees.  Hopefully, this cartilage will be more durable and have longer benefit for the patient.  Methods that attempt to regenerateG ACI closer to normal articular cartilage include techniques such as Autogenous Chondrocyte Implanation (ACI).  This is a technique where the patient’s own articular cartilage cells are harvested and cultured and then re-implanted. (See figure G) Additionally, research into techniques that involve the use of stem cells, for example, may prove beneficial in the future.

Patellar Problems
Problems from the patellofemoral joint can come in several varieties  and may be related to patellar pain, patellar instability, or arthritis of the patella femoral joint.  Typically, patellofemoral pain in a patient with a normally aligned patellofemoral joint is managed nonoperatively.  Proper rehabilitation techniques, including strengthening of the core and pelvic musculature, as well as the quadriceps and hamstring musculature, can be helpful.

The problem of lateral patellar instability can be extremely disabling. Techniques continue to evolve toward restoration of normal anatomy and can be quite helpful to this group of patients. When a patella dislocates, often times the medial restraining structures become injured and may result in the patella becoming chronically unstable.   These injured structures can be addressed in the form of a medial patellofemoral ligament reconstruction.H  mpfl (See figure H)  Essentially, this technique uses tissues to reconstruct the medial patellofemoral ligament, which acts as a restraint from having the patella dislocate laterally.  Additionally, care must be taken to make certain that the distal portion or “pull” on the patella is aligned properly as well.  If alignment is found to be problematic, then realignment of the distal portion of the patella with a tibial tubercle osteotomy may be indicated as well to allow for proper “pull” on the patella. If there are problems with alignment of the patellofemoral joint, then all contributing factors should be addressed.  By stabilizing the patellofemoral joint, the patient then can often times be much more active and have a knee that feels more reliable.

The alignment of the knee is very important for proper function of the knee and that principle applies should any sort of reconstructive procedure be needed, as well.  Typically the weight bearing axis of the knee passes from the center of the hip, to the center of the knee, and down to the center of the ankle.  If the knee is malaligned, there will be increased force and potentially increased wear through the compartment where the alignment is passing through.  A malaligned knee would be a contraindication to the procedure such as an articular cartilage restoration procedure or a potential meniscal allograft.  Fortunately, there are techniques that have assisted in making the osteotomy more reproducible and also decreasing the morbidity of the procedure. These procedures can be done by either a closing wedge technique or an opening wedgeI Opening wedge HTO technique, but the tendency appears to be more for the opening wedge technique. (See figure I)  Additionally, the procedure can be done in the young active patient to try to help preserve the knee rather than perform an arthroplasty (replacement) of the knee.  For example, if the patient has significant wear and symptoms coming from the medial compartment of the knee, an osteotomy can be performed that allows for the alignment to be transferred to the more normal lateral compartment of the knee.  This can allow the patient to remain active in activities without concerns over the arthroplasty loosening or wearing out.  It is another technique in the armamentarium of orthopedic surgeons practicing the technique of joint preservation surgery. As our technology for fixation and alignment has improved it has helped with our patients outcomes and potentially has decreased the risk of complications.

When performing a surgery the surgical technique is extremely important, however just as important, is the proper postoperative rehabilitation.  Advancement is occurring in and a great deal of research is going on in the area of orthopedic rehabilitation. For example, we have learned that in patients with patellofemoral joint problems, strengthening the muscles of the core and pelvis is just as important ,if not more so, than strengthening the muscles about the knee. Additionally, we have learned that going a little slower with rehabilitation after an anterior cruciate ligament reconstruction may decrease the risk of reinjure.

In summary, the techniques to manage sports knee injuries continues to evolve and improve.  It is an exciting area of orthopedics.  At the orthopedic Center of Illinois, our board certified physicians are dedicated to keeping up with the latest techniques to allow us to provide our patients with the best current orthopedic and sports medicine care.

This article was published in the July-September 2015 edition of ”FYI from OCI”, a quarterly publication created by the Orthopedic Center of Illinois. To see the full publication, click HERE.

Osteoporosis: Diagnosis and Treatment

May is Osteoporosis Prevention Month and a great time to become proactive about your bone health.

By Kari Senica, M.D.osteoporosis-bone

Osteoporosis is a bone disease characterized by low bone mass, deterioration of bone tissue, and disruption of bone architecture, compromising bone strength and increasing the risk of fracture.

It is estimated by the National Osteoporosis Foundation that approximately 9.9 million Americans have osteoporosis and an additional 43 million have low bone density. About one out of every two Caucasian women will experience an osteoporosis -related fracture at some point in their lifetime.

Fractures and their complications are the relevant clinical consequences of osteoporosis. The most common fractures are those of the vertebrae (spine), hip, and wrist.

By definition, any adult over 50 who sustains a fracture of the spine, hip, shoulder or wrist from a low energy trauma (a fall from a standing height) is considered to have osteoporosis. The diagnosis of osteoporosis can also be established by measurement of bone mineral density (BMD).

If you have sustained one of these fractures, you will need further workup with a bone mineral density test and appropriate lab work. There are also several recommendations for all patients to preserve bone strength including adequate intake of calcium and vitamin D, lifelong participation in regular weight-bearing and muscle-strengthening exercise, smoking cessation, avoiding excessive alcohol intake and preventing falls.

Only 23% of women over the age of 67 who have sustained an osteoporosis-related fracture receive a BMD test or take medication to treat osteoporosis. We don’t want you to become a statistic. We can help. Schedule a consultation or your BMD test today by calling (217) 547-9100.

Minimally Invasive Treatment of Sciatica

By Joseph Williams, M.D.
Board Certified Orthopedic Surgeon
Orthopedic Center of Illinois

Sciatica is a term that is commonly used to describe the pain an individual has radiating down an extremity. Patients will come to the office with complaints of severe pain down one leg or, less commonly, down both legs. The term is often overused and not all cases of self-diagnosed “sciatica” are actually correct.

sciatic anatomy

Sciatic nerve anatomy.

The sciatic nerve is the largest nerve in the lower body. It is made up of multiple nerve roots that originate in the low back, the lumbar spine and sacral spine. These nerve roots join together within the pelvis and form the sciatic nerve.   This nerve then travels down the back of the leg innervating the muscles and providing sensation to the leg.

Sciatica is typically the term used to describe pain that one experiences in a leg, however, there is usually numbness or tingling and possibly weakness occurring as well.  As stated previously, the sciatic nerve provides innervation to multiple muscles in the leg and also sensation to specific locations of the leg. Thus, if there is enough dysfunction within the sciatic nerve, the person could very well experience more than just pain.

graphic disc herniation

A bulging disc pressed on the sciatic nerve.

The most common cause of sciatica pain is compression of one of the nerve roots that makes up the sciatic nerve. This compression is usually in the form of a disc herniation in the lower lumbar spine, typically, at the L4 – L5 disc or the L5 – S1 disc. These herniations protrude into the spinal canal and compress the nerve roots before they exit the spine and travel into the pelvis.  This compression of the nerve root will then initiate an inflammatory reaction. The nerve will swell, and the patient will experience immediate pain. As the inflammation grows, the pain will become more intense. Thus, the source of the pain is usually in a nerve root before it actually combines to help form the actual sciatic nerve.

Another group of people will experience sciatica pain not as a result of an acute disc herniation, but rather a chronic condition called disc degeneration.  These people are often older, and the pain may develop more slowly. The degenerative condition will cause collapse and bulging of the disc and ultimately result in a gradual narrowing of the spinal canal. The specific location of this narrowing is within the lateral recess, or the periphery of the canal. As this narrowing becomes more severe, the nerve root or roots will become compressed within the canal.  Again, the inflammatory cascade is initiated, causing the nerve to swell and pain to occur.

There are a variety of ways to treat sciatica, and the treatment depends on the cause.  A thorough physical exam needs to be performed in order to help determine the diagnosis. Typically, the treatment is initiated with a regimen of oral medications.  These medications can include non-steroidal medication, muscle relaxers and pain medications. In some cases, an oral dose of steroids is provided. In addition to medication, activity modifications are commonly required. The patient will receive instructions to refrain from any strenuous activities, including work related-activities and some hobbies.

If symptoms are poorly controlled with limited activity and/or medication, symptoms are worsening, or a physical exam warrants next steps, an MRI of the lumbar spine will be required. The timing of this MRI is somewhat controversial, because a significant number of sciatica cases will actually resolve with these simple treatments and time.  Those patients who experience symptoms and who do not respond to medication and rest may require further diagnostic workup. An MRI is always needed in the face of progressive weakness.

Typically, every effort should be given to first pursue the least invasive options. However, once a successful MRI has been obtained, another set of treatment options becomes available, including epidural steroid injections and possible surgical interventions. The epidural steroid injection is often times the first line of treatment for patients who do not get resolution with medications and activity modifications.  Epidural steroid injections are common and place steroid solution at the nerve root responsible for the pain symptoms. They are performed in a operating room with the use of X-Ray. The actual technique can often be performed in a matter of minutes, and they are low risk compared to other treatment options. Up to three injections can be performed in a twelve month period. Injections are a great option for those patients that do not wish to pursue a surgical option or individuals with medical problems that preclude a surgical procedure.

The last option for a patient with sciatic pain would be surgical intervention, and can be accomplished with minimally invasive techniques. The mainstay of surgical treatment for both disc herniation and/or a degenerative bone spur will involve a laminotomy. A laminotomy is a surgical procedure that involves removal of a small portion of the bone. It is a safe procedure, and the most common procedure performed on the spine. There are minimally invasive techniques that can be utilized that can decrease the pain associated with the procedure and offer quicker recoveries.

A patient with a disc herniation will undergo a laminotomy and removal of the disc herniation. Again, this surgery is done as an outpatient procedure—meaning the patient will not need to stay in the hospital. Typically, patients do not receive any formal physical therapy after the procedure. However, they are commonly restricted in their activities for a total of six weeks postoperatively. These restrictions can include limitations as to the amount of weight they can pick up and avoidance of strenuous activities including repetitive bending, lifting and twisting. These restrictions are required to avoid another disc herniation from occurring. Surgical results are often very successful and predictable. Often times, patients will have some tingling in the extremity that improves with time, and usually experience almost complete relief of the pain in the extremity. Symptoms can fully resolve with time as the nerve heals.

Sciatic nerve pain is a very common and debilitating condition. However, with proper diagnostic workup, successful treatment is possible. Typically, treatment starts with nonsurgical options. However, if this approach is unsuccessful, epidural steroid injections and possibly surgery are often utilized to resolve symptoms and return the patient to a pain free lifestyle. If you are experiencing the symptoms explained in this article, please do not hesitate to call our office and schedule a consultation. Our physicians want you to live pain free and can help you get the relief you need.

This article was published in the April-June 2015 edition of ”FYI from OCI”, a quarterly publication created by the Orthopedic Center of Illinois. To see the full publication, click HERE.

Orthopaedic Surgery Center of Illinois Wins Prestigious Press Ganey Award

By Leo Ludwig, M.D.2014-guardianaward-hires

As the medical director of the Orthopaedic Surgery Center of Illinois (OSCI), it is my pleasure to present to you our yearly quality report card. OSCI is located across the street from the Orthopedic Center of Illinois in the Koke Mill Medical Center.

On a yearly basis, we evaluate our case types and volumes, certain quality reports, as well as patient satisfaction. This data is analyzed with the goal of providing our patients with the best quality outpatient experience and outcomes. The Affordable Care Act (Obamacare) is drastically changing the landscape of medical practice in the United States and is more closely monitoring healthcare facilities to provide the highest quality care at the lowest price. OSCI is excelling at this goal.

OSCI utilizes the nationally recognized Press Ganey satisfaction survey to measure patient satisfaction. I am proud to announce that OSCI, for the second year in a row, has been awarded the 2014 Press Ganey Guardian of Excellence Award. Press Ganey has more than 10,000 clients nationally and less than 5% received this award, which is given to healthcare facilities that rank above the 95th percentile in patient satisfaction for 12 consecutive months. OSCI is the only facility in Central Illinois to receive this designation. This award is a tribute to the care provided by the staff and physicians at OSCI.

osci graph

Click to enlarge.

More than 3,000 patients annually receive healthcare services at OSCI. As you can see in the graph, the most common surgical procedures performed are arthroscopic procedures of the knee and shoulder. Various hand surgeries, as well as fixation of bone fractures, are other common procedures. Newer procedures such as hip arthroscopy and outpatient spine surgery continue to grow in volume. Additionally, our pain management physicians are busy performing lumbar and cervical epidural steroid injections. In 2014, we began to offer cataract surgery and the program has been very successful with 225 cataract surgeries completed.

From a quality standpoint, 100% of the patients undergo a safe surgery checklist, 100% receive appropriate and timely antibiotics to help prevent infection, the complication rate is less than 1%, and the infection rate is less than 1%. In addition, the cost of providing care for these procedures at OSCI is significantly less expensive than the services provided in a hospital outpatient surgical department. As you can see, providing high quality care in a lower-cost facility is exactly what is necessary in today’s healthcare environment. If you, a family member, or friend requires one of these outpatient procedures, please talk with your physician about the possibility of having your procedure at OSCI.

LeoLudwig copyDr. Leo Ludwig is Medical Director at OSCI and a surgeon at the Orthopedic Center of Illinois. His special areas of interest are shoulder surgery, arthroscopic surgery of the shoulder and knee, and minimally invasive total joint replacement.

Preventing Throwing Injuries

By Barry Werries, MD
Board Certified Orthopedic Surgeon

????????????????????????????????????????????????????????????????????Of all the athletic activities studied, throwing a ball creates one of the greatest forces across the elbow and shoulder. These repetitive forces make the shoulder and elbow susceptible to both acute and chronic overuse trauma. The incidence of baseball pitchers having shoulder or elbow pain is becoming an epidemic.

Even though the most common symptom is pain, there are other subtle signs and symptoms of an arm injury, such loss of strength and range of motion. The elbow or shoulder can have catching or locking or the player may have numbness in the arm. The player may have ball control problems or decrease in ball velocity. There may be changes in the mechanics which may actually cause damage somewhere else in the body. Other signs of fatigue may be an upright trunk or dropped elbow during pitching or increased time between pitches.

Risk factors for these injuries are the amount of pitching and pitching while fatigued. Other risk factors include pitching on multiple teams, pitching year round, playing catcher when not pitching, poor pitching mechanics, increased ball velocity, and poor physical conditioning. Injuries to the back or legs or loss of flexibility can alter the chain of events that contribute to the act of throwing and put more stress on the arm.

When a child who is not skeletally mature is exposed to throwing, the body will make some anatomic adaptations at the shoulder that may be protective. Although it is apparent that there should be a limit to the number of pitches to decrease injury, there may be an increased likelihood of injury in athletes who start pitching in high school than those who have been throwing in early childhood.


Click to enlarge.


Click to enlarge.

The USA Baseball Medical/Safety Advisory Committee has made recommendations on the limits of the number of pitches. Some organizations such as Little League Baseball have instituted these limits into their rules. These limits should also include pitches in practice, and coaches should be aware of pitch counts with players who play on other teams. Just as important as the number of pitches, the same committee has also made recommendations on days of rest after pitching. I am a firm believer that the body needs time to recover from the stresses of pitching, and I do not advocate throwing every day. Despite the emphasis on pitch count in a game, there is also evidence that the accumulation of pitches within a season is just as important to the health of the throwing arm. It is recommended to avoid any overhead throwing for 2-3 months per year and no competitive pitching for at least 4 months per year.

Unfortunately, little leaguers are throwing breaking balls at the age of 11 or 12. There has been a higher incidence of shoulder pain with curveballs and elbow pain with sliders. With proper mechanics, the curveball may not put increased stress on the elbow. Many young pitchers, however, have difficulty with the proper technique to throw a curveball, so there should be more emphasis on throwing a changeup at a young age. A safe approach is to wait until the age of 14 to start throwing curveballs and the age of 16 for sliders.

Proper throwing mechanics are very important to preventing arm injuries. Even though a pitcher is successful in games, throwing with improper pitching technique is like an engine leaking oil; the arm will eventually break down. If a pitcher does not correct his mechanic flaws, then his injuries will recur despite even surgical repair. Thus, it is advisable to have a coach who is knowledgeable of the proper throwing mechanics to work with a pitcher.

A majority of the throwing injuries occur in the beginning of the season because the players have not built up their strength. An excellent program for strengthening the arm is the Thrower’s Ten Program which focuses on the rotator cuff, scapular stabilizers, and forearm muscles. Many of the throwers who have arm problems have scapular dyskinesia. Scapular dyskinesia is when the scapula or shoulder blade is moving abnormally which creates shoulder/arm dysfunction and injury.

Many athletes focus on arm strengthening but they ignore the core/trunk and lower body strength which accounts for more than 50 percent of the kinetic energy to throw a ball. Core trunk stabilization focuses on strengthening the spinal and pelvic stabilizers and abdominal musculature. Weakness of lower body muscles, especially the hip abductors and hamstrings, have been identified in athletes with shoulder and elbow injuries. It is also important to build up the endurance of the lower body, and I prefer an interval sprinting program over jogging for baseball players.

The loss of flexibility of particular joints in the throwing athlete will predispose them to arm injuries. In the shoulder, throwing athletes have the loss of internal or forward rotation which is addressed by stretching the posterior, or back, of the shoulder. Care should be taken when stretching the front of the shoulder because most overhead athletes have stretched out their anterior capsule, which is in the front of the shoulder. In the lower body and trunk, the lumbar (low back) inflexibility, hip rotation deficit and hamstring tightness can also increase the risk of arm injury. It is also recommended to stretch for 5 minutes after playing.

In summary, a pitcher should focus on proper throwing technique, good physical conditioning and flexibility, avoid excessive stress on the arm and allow the arm to recover from the stress of throwing will help decrease the chances of an arm injury.

This article was published in the October-December 2014 edition of ”FYI from OCI”, a quarterly publication created by the Orthopedic Center of Illinois. To see the full publication, click HERE.

Advances in Arthroscopic Management of Rotator Cuff Disease

By Ron Romanelli, M.D.

We all take for granted the complicated mechanics that allow our bodies to literally and figuratively move through our daily tasks. Only when we stop and reflect on this, do we realize the true complexity of our musculoskeletal system. Specifically, our shoulders enable us to perform various jobs, often not fully appreciated until an injury occurs. One of the most common injuries we see and treat at OCI is a rotator cuff tear.

The shoulder has a wider range of motion than any other joint in the body. This joint consists of an “O” ring around the shoulder socket, as well as a capsule and surrounding rotator cuff muscles. The rotator cuff is a group of four muscles and their corresponding tendons that wrap around the front, back and top of the shoulder joint.

The most common symptom of a rotator cuff problem is weakness or pain. Usually, it is described as general discomfort and is exacerbated with certain movements of the shoulder. Like many orthopedic conditions, the mechanics of rotator cuff problems can be separated into repetitive use injuries and traumatic injuries. Over time, repetitive use of the shoulder may wear out the tendon, and a rotator cuff tear can develop. Traumatic injuries, such as falling on an outstretched arm, can also cause rotator cuff tears.

As we age, overuse of our shoulders can cause several different issues, including tendinitis, impingement and rotator cuff tears. When tendons in the joint become irritated or damaged, we call it tendonitis. Impingement occurs when the fixed acromion bone on the top of the shoulder constantly rubs the rotator cuff resulting in shoulder aches and pains. Impingement syndrome can also develop into a rotator cuff tear.

A rotator cuff tear is diagnosed by listening to the patient’s history and completing a physical exam, as well as X-rays and an MRI. Typically, when evaluating patients, MRI scans are utilized not only to assess the size of the tear, but also assess the anatomy of the rotator cuff. Initially, we treat the problem with conservative management using medications, exercises and physical therapy with occasional cortisone injections. If conservative measures fail, surgical procedures for this problem become necessary. The most common reason for surgery is persistence of pain despite injections. When pain persists or weakness prevails, arthroscopic surgical techniques can typically give reliable pain-relieving outcomes.

Traditionally, surgeons used an open surgical technique to access the injury which involved a larger incision and splitting of the muscle. Now, most cases of shoulder surgery are treated with arthroscopy. Some time ago, our surgeons made the transition from open rotator cuff repair to arthroscopic rotator cuff repair after countless hours studying and refining techniques to provide the best leading-edge care to our patients. Not only can small repairs be done this way, but large rotator cuff repairs can be performed safely and effectively with excellent results.

The word arthroscopy comes from two Greek words: “arthro” (joint) and “skopein” (to look). It is a minimally invasive procedure which entails small incisions and small tubes called cannulas. During arthroscopic repair, the surgeon inserts a small camera called an arthroscope into the shoulder joint through the cannulas. The camera displays pictures on a video screen. These images are viewed to guide miniature surgical instruments and arthroscopic repair techniques. Arthroscopy allows us to diagnose the problem because we can see inside the joint, as well as examine the type of rotator cuff tear that is present, which enables us to deliver a more accurate surgical repair.

The current standard for arthroscopic repair involves special instruments that pass through the torn rotator cuff tissue, through the tendon and are anchored to the bone with sutures and knots. Another technique involves knotless sutures that tension the cuff to the bone. Both of these approaches avoid cutting muscles to access the damage, therefore requiring less pain and smaller cosmetic scars.

Arthroscopic surgery is performed on an outpatient basis using a light general anesthetic, as well as local anesthesia for patient comfort. Our surgeons at OCI also perform a shoulder block, or anesthetizing/numbing of the shoulder, so the patient does not have pain when they wake from the operation. OCI patients have excellent pain management results due in part to the anesthesia and shoulder block, in conjunction with a multi-modality utilization of medications. This means patients receive anti-inflammatory medications preoperatively, anti-nausea medications, and minimal narcotic medications, resulting in minimal pain postoperatively.

Advances in Arthroscopy
Through the years, arthroscopic surgery has been refined due to advances in technology which have created multiple ways to approach repair of rotator cuff tears. Companies have improved fixation methods, as well as the techniques to assist surgeons to give their patients the best outcomes. Current research is focused on sutures with growth factors and/or injectable agents to help with healing in difficult rotator cuff repairs.

We now have multiple options for bone anchors with sutures that are single loaded, double loaded, or triple loaded. Surgeons typically perform sliding knots and non-sliding knots in order to repair rotator cuff tears, but there are also knotless techniques. We select our tools and techniques specifically for each patient and their unique injury. Techniques include a single row or double row repair or a transosseous-equivalent repair. Special anchors allow us to not only suture the muscle down to the bony footprint of the rotator cuff, but also allows us to place sutures on the side, which is a double reinforcing type of repair. All of these options mean there is no one way to correct a rotator cuff injury.

We utilize early physical therapy to assure patients achieve their best outcomes. Tendon healing typically takes six weeks, during which
time we perform gentle, passive motion on the shoulder. The second phase is a strengthening program, typically from six to 12 weeks. It generally takes at least six months to a year to reach maximum medical improvement for the majority of rotator cuff tears. The patient, doctor and therapist work together as a team to achieve excellent results and eliminate pain and suffering related to rotator cuff problems.

Arthroscopic results are good to excellent for 95% of small tears, but as the tear progresses to a large size tear, the success rate decreases. Success is dependent on the age of the patient, the size of the tear, and the length of time the tear has been present. Often times, early evaluation and treatment are necessary for good results.

Neglecting a rotator cuff tear not only means declining surgical success rates, but patients experience arthropathy, an imbalance of the shoulder which can lead to secondary arthritis. This end-stage problem of a rotator cuff tear that is not fixed may lead to a need for a reverse shoulder replacement. Putting off treatment will only result in prolonging the discomfort, and over time, can create more damage. If you have shoulder pain, please contact us to set up an appointment with one of our talented surgeons to begin the diagnostic and, if necessary, treatment process.

This article was published in the July-September 2014 edition of ”FYI from OCI”, a quarterly publication created by the Orthopedic Center of Illinois. To see the full publication, click HERE.

Causes of Knee Pain and How to Get Moving Again

By Kari Senica, MD
Board Certified Orthopedic Surgeon

OsteoarthritisKnee1Are you experiencing swelling, stiffness and decreased range of motion in your knees? These are several of the symptoms associated with “wear and tear arthritis”, known as osteoarthritis. At the Orthopedic Center of Illinois (OCI) , we treat many patients with osteoarthritis. In fact, it is the most common type of arthritis in the knees and the leading cause of disability in the U.S. It’s estimated that osteoarthritis affects 13.9% of adults age 25 and older and 33.6% of adults older than 65. According to the Centers for Disease Control (CDC), an estimated 27 million adults had been diagnosed with osteoarthritis by 2005.

Cartilage in the knee is very important because it protects the underlying bone at the joint surfaces and acts as a shock absorber. It provides a smooth, frictionless surface for movement. Osteoarthritis involves the destruction and breakdown of this cartilage and can affect the other structures in the knee including the lining of the joint, the ligaments and bone. In the early stages of osteoarthritis, pain may be more intermittent and noticed only with overuse. In the later stages of disease, it may cause pain even at rest or at night.

At OCI, we diagnose osteoarthritis based on the patient’s history and on findings from a physical examination. Classic red flags include joint space narrowing, bone spurs, and increased density of bone or bone cysts on X-rays.

Several factors increase the likelihood of an osteoarthritis diagnosis including advancing age, gender– women are more at risk than men– family history and weight. Previous trauma to the knee can also increase osteoarthritis, including ACL or meniscal tears, or other injuries that did not require prior surgical treatment.

After a patient is diagnosed with Osteoarthritis at OCI, we begin individualized treatment with nonsurgical techniques, focusing on decreasing pain and swelling and improving function. Treatments might include physical therapy, exercise and weight loss. Many patients see improved results from increasing muscle strength, which helps reduce the load on knee cartilage, and a variety of physical therapy movements, including aquatic therapy, can improve range of motion.  Of course, weight loss is strongly encouraged for patients. Every pound a patient can lose results in an astonishing fourfold reduction in the stress on the knee per step. If these non-surgical approaches do not improve a patient’s symptoms, the surgeons at OCI will then discuss appropriate options.

If you are concerned about knee pain or other issues related to your joints, ligaments, tendons or muscles, please reach out to our team of super specialists. The physicians at OCI have served Springfield and the surrounding communities for more than 40 years, and we are dedicated to improving the lives of our patients. We want to help you obtain a pain-free lifestyle, and return to the activities you love.

For more information about the services discussed in this article, or to schedule an appointment, call (217) 547-9100.

Advances in Hip and Knee Joint Replacement

By D. Gordon Allan, MD, FRCS(C)

Over the past several years, there have been many changes to techniques used for hip and knee replacement surgeries. Some changes have presented challenges, but many of the changes have reduced the length of hospital stay, postoperative pain and total recovery time. In this article I will outline some of these important changes and discuss how they impact patients.

minimalinvasive2-300x288Minimally Invasive Surgery
Several years ago, the term “minimally invasive surgery” was applied to joint replacement. I believe it was mostly a marketing tool to boost a surgeon’s case volume and complete in aggressive markets. There is hardly anything minimally invasive about a surgery that can produce life altering complications. The term “minimally invasive” was coined to reflect the use of a dramatically shorter incision during surgery, yet patients experienced new challenges do to the change in technique. Initially, negative outcomes included significantly longer surgeries and more complications (fractures, component malpositioning, poor fixation, etc.) that resulted in early failure and reoperation. We no longer measure success by striving to make very small incisions. However, length of incisions has decreased over time and there are many more important variables that hasten recovery and reduce discomfort.

Reduction of Inflammation
Both before and in the days after surgery, anti-inflammatory medicines are utilized. The use of Celebrex and Decadron (a steroid) help tremendously with postoperative pain. A recent study demonstrated that the use of Decadron before and the day after surgery decreased pain, narcotic use, nausea and length of hospital stay. Decadron is a cost-effective and well-known medicine.

Pain Control
It has been known for years that the avoidance of intravenous narcotics speeds recovery, reduces nausea and improves attendance at therapy sessions, hence promoting an earlier discharge. Despite this, many surgeons continue to use a PCA pump (patient controlled analgesia) in the mistaken belief that it is somehow beneficial to the patient.

Spinal anesthesia is preferred over a general anesthetic as there is much less nausea and confusion, plus there is no “hangover” feeling. Patients are more alert and ready to participate in therapy. Most times, particularly for knee surgery, a nerve block is done to provide hours of pain relief without the need for narcotics.

I use multimodality pain management that includes Celebrex, Decadron, intravenous acetaminophen (Tylenol), Tramadol (a synthetic opioid pain medicine), oxycontin (a long acting oral narcotic), Norco (a short acting oral narcotic) and a muscle relaxant. Intravenous morphine is reserved for intense, immobilizing pain. Combined with a nerve block, these patients are not over sedated. The different modalities are used synergistically to reduce pain while avoiding the sedative effects of high-dose intravenous narcotics.

This approach has greatly reduced my patient’s length of stay and most healthy individuals, with good help at home, can be discharged the day after joint replacement. In contrast to years ago, patients would routinely spend three nights in the hospital and many older patients would be discharged to a nursing home.

Blood Loss Reduction
Several years ago, patients would either predonate their own blood or have family members donate for them. This practice is not any safer than using banked blood and actually is more costly. Most of this blood was wasted, and this practice is no longer utilized.

Currently we use a medicine called tranexemic acid given intravenously during surgery. This drug reduces the body’s natural tendency to break down clotted blood and thereby reduces surgical and post operative blood loss. As a result, only a very small minority of total joint patients requires a blood transfusion.


Top: Total Knee Replacement
Bottom: Partial knee replacement

Partial Knee Replacement
Patients with osteoarthritis localized to one part of their knee may be candidates for partial knee replacement. The advantage of partial versus total replacement is that the recovery period is faster and the knee feels more normal. The cruciate ligaments are retained so motion, stability and nerve feedback is maintained. Patients with severe deformity or inflammatory arthritis (i.e. Rheumatoid arthritis) are not candidates. Alignment of partial knee replacement is crucial to their longevity. One way proper alignment can be achieved is with robotic assisted surgery.

Computer Navigated/Robotic Assisted Surgery
Computer navigated surgery has been around for years but has failed to demonstrate clear advantages in routine cases over traditional bone preparation for hip and knee replacement. This technique adds considerably to the operative time and expense. Occasionally, when there is significant bone deformity, surgical navigation can be a great assistance.

Recently, computer navigation has been merged with robotic assisted surgery. This technique known commercially as MAKOplasty® has been very effective in preparing the bone and assuring optimal alignment of partial knee replacement and cup placement in total hip replacement. I have been using this technique since 2012 and have been very pleased with the results.

Direct Anterior Approach for Total Hip Replacement
This approach is unique in that no muscles or tendons are cut and the posterior hip capsule is untouched. As a result, patients recover very rapidly, their hips are stable and they do not have to follow the usual posterior hip precautions. A special operative bed that helps with gaining access to the hip facilitates this surgery. Both Springfield hospitals have two of these beds. I have been doing this approach since 2008 and have done more than 600 cases in this fashion. Most patients leave the hospital the following day and are often free of walking aids within days. The direct anterior approach has radically changed my hip practice.

New Thoughts on Anticoagulation
For years, total joint patients were vigorously anticoagulated with blood thinners after surgery as surgeons feared blood clots could be fatal if they traveled to the lungs. We used such drugs as Coumadin or Heparin. Recently it has been found that we are actually causing more complications and expense with this approach. I now assess the individual risk of each patient for the development of clots and treat most patients less aggressively than in the past. As a result, they are experiencing less surgical bleeding and fewer infections.

Importance of High Surgical Volume
Many studies have demonstrated that surgeon and hospital volume play a very large roll in the complication rate of joint replacement surgery. The high volume creates very good data for objective outcomes. Each year, I complete more than 500 primary and revision joint surgeries, and both Springfield hospitals are high volume joint centers.

Metal on Metal Bearings
Some early failures of metal on metal total hip prostheses have been in the news over the past few years. The ASR cup by Depuy is the most well known of these implants. Not all metal on metal bearings will fail, but it is very important for these patients to have very close follow-up to detect bone and soft tissue damage before it becomes irreparable. These implants can fail from poor wear at the bearing surfaces, loosening of the cup and through corrosion at the junction of the metal ball and stem. Yearly exams along with X-rays are essential. If problems are suspected, a blood test to determine the level of Cobalt and Chromium can be done, and a specialized MRI can look for tissue destruction and fluid collection. If problems are encountered, a change of the bearings is required.

Life-Long Follow Up of Prosthetic Joints
All joint replacements need to be followed with periodic X-rays throughout the patient’s life. Bearings will wear very slowly over time and this can produce a reaction by the body against the foreign particles created by this wear. In turn, this can lead to destruction of the bone around the implants which, if allowed to go on unchecked, can result in the loosening of the implants or even fracturing of the bone. This could be a catastrophic event that may be very difficult to repair. Therefore, X-ray assessment is essential every few years. Often, the bearings can be changed out in a relatively minor surgery if wear is detected.

Antibiotics Prior to Dental Procedures
Dental procedures or other interventions can allow bacteria into the bloodstream; therefore, joint replacement patients are prescribed antibiotics prior to these procedures. While there is no clear consensus, most physicians would agree that patients should take antibiotics for two years following a joint replacement. I currently ask my patients to use antibiotics whenever they see the dentist, indefinitely.

Pre-Operative Assessment
We are now very focused on ensuring that our patients’ health is optimal prior to embarking on elective joint replacement. We ask that our diabetic patients have excellent control of their sugars, and we decline surgery until their hemoglobin A1C is less than 7. We ask smokers to quit several weeks prior to surgery. We test everyone for Methicillin Resistant Staphylococcus Aureus (MRSA), and those who test positive receive treatment before surgery and a different antibiotic during surgery. We also test for malnutrition (protein level in blood) and vitamin D deficiency, which are corrected prior to surgery. Very obese patients are at risk for many complications, foremost of which are infection and implant malpositioning. We typically ask that patients reduce their body mass index (BMI) to less than 40 prior to surgery.

Although joint replacement surgery is largely a very successful and life-changing surgery, it should not be entered into without ensuring that the patients’ medical status is optimized and that a high volume, experienced surgeon and facility are selected. In doing so, the outcome should be maximized and the risk of complications minimized.

For more information about the services discussed in this article, or to schedule an appointment, call (217) 547-9100.

This article was published in the April-June 2014 edition of ”FYI from OCI”, a quarterly publication created by the Orthopedic Center of Illinois. To see the full publication, click HERE.

Why Ankle Pain and Sprains Won’t Heal

By O.B. Idusuyi, M.D.
Board Certified Orthopedic Surgeon

A sprained ankle is one of the most common orthopedic injuries. In the United States more than 25,000 such injuries occur every day. Although most of these resolve completely, chronic residual ankle symptoms still persist in about 20% to 40% of treated patients. In the following article, I will outline potential causes of persistent pain after an ankle sprain

ankle diagram

Fig. 1

What is an Ankle Sprain?
A sprain is actually an injury to the ligaments of the ankle joint, which are elastic, band-like structures that hold the bones of the ankle joint together and prevent excess turning and twisting of the joint (Fig 1). During normal movement, the ligaments can stretch slightly and then retract back to their normal shape and size. Sprained ankles often result from a fall, sudden twist, or a blow that forces the ankle joint out of its normal position. Ankle sprains commonly occur while participating in sports, wearing inappropriate shoes, or walking or running on an uneven surface. The anterior talofibular ligament is one of the most commonly involved ligaments in this type of sprain. Approximately 90% of ankle sprains are inversion injuries.

Diagnosis of Ankle Sprain
Patients who sustain ankle sprains will experience pain or soreness over the injured ligaments, loss of function, swelling, bruising, difficulty walking, and or stiffness in the joint. These symptoms may vary in intensity, depending on the severity of the sprain. A severe sprain may be diagnosed in patients who report hearing or feeling a popping sensation, followed by immediate swelling and the inability to walk or finish their athletic endeavor after an inversion injury. In evaluating your injury, the orthopedic surgeon will obtain a thorough history of your symptoms followed by a lower extremity examination. X-rays or other advanced imaging studies may be ordered to help determine the severity of the injury.

The goal of treating an ankle sprain is to prevent chronic pain, instability and disability. The first phase of routine ankle sprain treatment consists of rest, ice, compression, elevation, and usually the use of anti-inflammatory medications. We recommend an air cast for a low-grade ankle sprain while severe sprain requires a longer immobilization walking boot or a short leg cast for three weeks.

The amount of therapy that a person can handle will depend on their level of pain and the grade of sprain they experienced. It is not recommended to return to sports or extreme physical activities until hopping on the ankle is achieved without pain. Wearing high-top tennis shoes may also help prevent ankle sprains if the shoes used are laced snug and if the ankle is taped with a wide, nonelastic adhesive tape.

Residual Pain after Ankle Sprains

ankle 2

Fig. 2

Ankle pain not responding to treatment, stiffness, locking, swelling, giving way or numbness may persist several months following an ankle sprain. A careful patient history and physical examination is needed to assess the presenting complaint, mechanism of injury, level of activity, and exact location of the issue.

The orthopedic surgeon must rule out missed diagnosis and associated injuries at the time of initial ankle sprain (Table 1). A partially treated or untreated ankle sprain may lead to chronic ankle instability, a condition marked by persistent discomfort and a “giving way” of the ankle. Weakness in the leg may also develop. Improper or insufficient rehabilitation may lead to impaired neuromuscular control, impaired propioception and postural control.

Tbale 1Persistent pain with catching or locking in the ankle joint could be related to damage to the cartilage with intraarticular loose bodies within the ankle joint or an osteochondral defect (Fig. 2). Pain on direct palpation of bony prominences in the leg ankle and foot may indicate missed fractures at the time of initial injury (Table 1). Palpating for the area of maximal tenderness along the tendons and directly over the syndesmosis can rule out peroneal tears and chronic high ankle sprains. In teenagers with persistent ankle pain and recurrent ankle sprains, the foot should be examined for stiffness of the joint below the ankle to rule out “tarsal coalition” – a condition characterized by abnormal fusion of foot bones.

Burning or shooting pain, numbness and tingling may indicate stretch injury on the cutaneous nerves surrounding the ankle either from significant twisting at the time of initial sprain or from chronic swelling of the ankle. In my experience, this condition leads to a prolonged recovery requiring 9 to 12 months for complete resolution of symptoms.

Magnetic resonance imaging (MRI) evaluation is particularly useful in demonstrating chondral injury, bone bruising, radiographically occult fractures, sinus tarsi injury, tendon tears, degeneration, and impingement syndrome.

The initial management of chronic ankle instability is a robust structured program of functional and prophylactic rehabilitation. Failed rehabilitation is an indication for surgical repair

While ankle sprains are very common injuries seen by orthopedists and general practitioners alike, appropriate three-phase functional rehabilitation can provide excellent results with a minimum of co-morbidities. When symptoms persist after several months, the examining physician must assess for potential missed diagnosis, inadequate ankle rehabilitation and associated injuries.

If you are experiencing ankle or foot pain, call (217) 547-9100 today to set up an appointment with one of our specialists.