Friday, January 21, 2011

Winter fun, injury-free

Luke’s Health Watch

By Dr. Tony Buoncristiani

Along with the snowy winter months come a multitude of activities—skiing, snowboarding, skating, hockey, sledding and snowmobiling, to name a few. Unfortunately, such activities may land you in the ER or you local orthopedist's office. The most common injuries seen during the winter months are regional and somewhat sport-specific. Skiing (alpine and Nordic) is enjoyed by most and instantly knee injuries come to mind. The most common nonoperative knee injury is a medial collateral ligament (MCL) or "inside" ligament sprain. Fortunately, this is usually treated with conservative bracing.

Common surgical knee problems resulting from twisting or pivoting injuries include anterior cruciate ligament (ACL) tears and meniscal cartilage tears. There are about 200,000 ACL injuries and 100,000 reconstructions that occur in the United States per year. The ACL functions as one of the primary stabilizers of the knee that provides "front-to-back" (translational) and "cutting/pivoting or side-to-side" (rotational) stability. When the frequency of participation is considered, a higher prevalence of injury is observed in females over males, at a rate 2.4 to 9.7 times greater for females depending upon the sport. ACL surgery continues to improve with cutting-edge technology such as performing a more "anatomic" or "double-bundle" reconstruction, which mimics more closely the normal anatomy of the knee. This will hopefully provide more stability and decrease arthritis compared to a traditional "single-bundle" reconstruction. However, long-term follow-up studies are needed.

The meniscus acts as the "shock absorber" of the knee, with 50 percent of the joint load transmitted through the meniscus in full knee extension and 85 percent in 90 degrees of flexion. Whether a meniscus is repaired or removed is determined upon the location of the tear (i.e., if there is a good blood supply to heal it) and complexity of the tear. Interestingly, removing 15 to 34 percent of the meniscus, which is commonly performed with a "partial" menisectomy procedure, increases the focal joint contact pressure by 350 percent. Therefore, its damage/removal may result in the development of arthritis and a repair should be performed whenever possible.

Wrist injuries (fractures and sprains) are not only commonly seen with snowboarding, but also routinely result from slipping on an icy surface and landing on an outstretched hand. Such falls can also result in shoulder dislocations and rotator cuff tears. First-time dislocators can usually be managed conservatively with physical therapy. However, recurrent shoulder dislocations or instability usually require surgical stabilization (i.e., repair the labral cartilage, similar to the meniscus in the knee, and capsule to "tighten" the shoulder).

The rotator cuff is comprised of four tendons that provide stability to the shoulder and allow the larger muscle groups (i.e., deltoid) to power the shoulder through various arm movements. Acute traumatic rotator cuff tears are usually treated with surgical repair, but a trial of conservative management may be attempted. In contrast, chronic rotator cuff tears are usually initially treated conservatively but may require surgical repair if pain and deficits persist after conservative management/physical therapy has failed. Arthroscopic shoulder surgery is constantly improving to hopefully provide better outcomes. However, the recovery after rotator cuff surgery is very slow to allow proper tendon healing.

Head injuries (i.e., concussions) are also common with winter activities. Of note, one does not have to experience a loss of consciousness ("knocked-out") to sustain a concussion; one can simply have his or her "bell rung" and experience amnesia. Interestingly, the adolescent developing brain is at more risk with devastating consequences if return to sport occurs too soon and a second injury or "hit" occurs. Fortunately, concussion management programs (e.g., ImPACT) have started to be implemented through various organizations in the Wood River Valley to hopefully safely return our athletes to sport.

Injury prevention is important. Proper protective equipment appropriate to each activity is essential. Adequate conditioning is important because many injuries occur when we are fatigued. Pre-participation warming up and stretching are never performed enough.

Be safe and have fun!

Dr. Tony Buoncristiani is a Sports Medicine and Shoulder Fellowship-trained, board-certified orthopedic surgeon. He can be contacted at 622-3311 for further questions.

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