Sports Medicine

Ankle Pain & Instability

Ankle pain is usually associated with arthritis, impingement, or instability. Chronic ankle arthritis, like knee arthritis, usually develops slowly over time and is usually caused by an injury or deformity. Local swelling, stiffness, aching pain, and symptoms worsening with activity are hallmarks of ankle arthritis. Sometimes rheumatic conditions can lead to more acute pain and swelling. Ankle impingement presents in similar fashion, but is less predictable and more specific in its location. Instability is linked to anterolateral pain and feelings of looseness or “giving out.” Frequently other conditions such as FHL or peroneal tendonitis can cause ankle pain. This pain is usually more of a sharp burning pain and usually courses along the tendon.

Adhesive Capsulitis (Frozen Shoulder)

Shoulder stiffness may be caused by several disease processes. Adhesive capsulitis, or “frozen shoulder” is most commonly seen in women in their 40s and 50s. The cause is not fully understood, but may be related to stress, and is certainly more aggressive in patients with diabetes. The joint lining, deep to the rotator cuff, becomes inflamed and results in loss of range of motion. Treatment involves anti-inflammatories, either by pill or injection, and physical therapy. Rarely, surgical release of the capsule and manipulation of the joint many be recommended.

Arthritis, or loss of the cartilage covering the ball and socket, may be the cause of a stiff shoulder. Some patients may experience a loss of range of motion secondary to rotator cuff issues, including calcific tendonitis.

Back Pain in Athletes

Back pain for that athlete is often caused by muscular injuries, such as sprains or strains, or minor muscle inflammation. Improper form when training or weight lifting can lead to these sprains and / or strains. Treatment most often involves rest, heat and anti-inflammatories as well as strengthening exercises and stretches. Disc injuries and compression fractures are also common in athletics and require expert assessment and treatment. 

Hip Pain / Injury

Hip pain is a common complaint among athletes and can have many causes. The pain can emanate from the hip joint itself (groin pain) or can come from injury or strain to structures around the hip, i.e.. bursa, tendons or muscles.

There are some questions that can help the doctor assist in making the correct diagnosis which can aid in effective treatment.

Was there an injury to the hip?

Acute injuries to the hip may occur with running or jumping sports and most often involve muscle or tendon strains. These injuries usually include the hip flexors (front of thigh) or hip adductors (muscles on inside of thigh). Symptoms include tenderness, swelling and muscle spasms. The doctor may order X-rays of the hip and pelvis or on occasion order a MRI to further assess the injury. Treatment of these injuries is dependent on the nature of the injury but most often can be treated with rest, ice, anti-inflammatory medication, strengthening and stretching exercises. The assistance of a physical therapists or athletic trainer may be necessary to allow the athlete to return to sports.

These injuries cannot be completely prevented but some factors that may decrease the prevalence of injuries include:

• Hip adductors stretches
• Hip adductor and abductor strengthening
• Pelvic stabilization exercises
• Core stability including strengthening of lumbar spine (low back) and abdominal muscles

What activity makes your pain better or worse?

Often a patient with hip labral tears will have pain with twisting maneuvers. They may also complain of pain in the groin going up or down stairs or getting in and out of a car. Areas around the hip where you can press on to cause pain usually indicate a source of pain outside the joint, i.e., muscle, tendon or bursa.

What is the location and characteristics of your pain?

Deep pain in the groin area is more indicative of an injury or condition effecting the joint injury and include hip labral tear and or femoral acetabular impingement (FAI). Pain on the outside of the thigh may represent a bursitis (trochanteric bursitis). Pain in the front of the hip may represent a tendonitis or hip flexor condition. Your doctor will evaluate these areas and may obtain various studies including X-ray or MRI or even a MR arthrogram. This is a special type of MRI which includes an injection of dye into the hip joint to enhance the ability to pick up injury or tears including labral tears or impingement. In cases of FAI a CT scan may sometimes be ordered to better assess the bone around the hip joint.

Knee Instability

There are many causes of knee instability. The knee has four main ligaments that connect the bones together. These are the Anterior Cruciate Ligament (ACL), the Posterior Cruciate Ligament (PCL), the Medial Collateral Ligament (MCL) and the Lateral Collateral Ligament (LCL). An injury to one or more of these ligaments can make the knee feel unstable. Sprains or tears of the knee ligaments usually follow an injury and may be associated with swelling. Twisting, hyperextending and hyper flexing the knee can all cause knee ligament injuries. In addition to swelling and pain, many patients complain of a sense of looseness, sloppiness or giving way of the knee following a knee ligament injury. MCL, LCL and PCL tears are often treated without surgery. Nonsurgical treatments include use of a brace, ice, anti-inflammatory medications (NSAIDs) and physical therapy. Some ligament injuries, including ACL tears can require surgery.

Knee swelling, also called a knee effusion or “water on the knee” can also make the knee feel unstable by increasing the space between the femur, tibia and patella. There are many causes of knee swelling including injuries such as ligament tears, meniscus tears, patella dislocations and fractures. Infections of the knee can cause significant swelling. Inflammation of the knee can also cause swelling.

Tears of the meniscus are another cause of giving-way of the knee. In addition to a sense of knee instability, meniscus tears are often associated with clicking, popping and sharp pain. Meniscus tears can occur following an injury but can also be caused by minor trauma or even squatting deeply.

Patellar instability, or an unstable kneecap, can cause knee instability. There are many causes of patellar instability such as an abnormally shaped femur or an abnormally aligned knee (valgus or knock-knee deformity) and ligamentous laxity (loose or double joints).Patella dislocations can occur in an otherwise normal knee following a twisting injury. Patellar dislocations are common in young athletes and can lead to recurrent episodes of knee instability. Initial treatment of patella dislocation is often nonsurgical with ice, bracing, medication (NSAIDs) and physical therapy. Surgery can be required in some cases.

What causes knee instability?

An injury to one or more of these ligaments can make the knee feel unstable. Sprains or tears of the knee ligaments usually follow an injury and may be associated with swelling. Twisting, hyperextending and hyper flexing the knee can all cause knee ligament injuries. In addition to swelling and pain, many patients complain of a sense of looseness, sloppiness or giving way of the knee following a knee ligament injury. MCL, LCL and PCL tears are often treated without surgery. Nonsurgical treatments include use of a brace, ice, anti-inflammatory medications (NSAIDs) and physical therapy. Some ligament injuries, including ACL tears can require surgery.

Knee swelling, also called a knee effusion or “water on the knee” can also make the knee feel unstable by increasing the space between the femur, tibia and patella. There are many causes of knee swelling including injuries such as ligament tears, meniscus tears, patella dislocations and fractures. Infections of the knee can cause significant swelling. Inflammation of the knee can also cause swelling.

Tears of the meniscus are another cause of giving-way of the knee. In addition to a sense of knee instability, meniscus tears are often associated with clicking, popping and sharp pain. Meniscus tears can occur following an injury but can also be caused by minor trauma or even squatting deeply.

Patellar instability, or an unstable kneecap, can cause knee instability. There are many causes of patellar instability such as an abnormally shaped femur or an abnormally aligned knee (valgus or knock-knee deformity) and ligamentous laxity (loose or double joints).Patella dislocations can occur in an otherwise normal knee following a twisting injury. Patellar dislocations are common in young athletes and can lead to recurrent episodes of knee instability. Initial treatment of patella dislocation is often nonsurgical with ice, bracing, medication (NSAIDs) and physical therapy. Surgery can be required in some cases.

Knee Pain

Although knee pain can have many sources, there are some questions that may help your doctor make the correct diagnosis and select appropriate treatment.

Did your knee pain begin following an injury?

If you had a recent injury, your knee may be painful due to a sprain of a ligament or a tear of the meniscus, which is a shock-absorbing pad of cartilage between the bones. Either of these problems may cause your knee to have sudden pain with twisting or turning motions. They may also make your knee feel unstable, loose, wobbly, or want to give out. Direct blows to the knee (for instance, hitting your knee on the ground or another player) can also cause contusions, which are deep bruises of the bone or soft tissue structures around your knee. Fractures of the bones at your knee (the femur, tibia or patella) can be painful and limit your ability to put weight on your injured leg.

If you have not had any recent injuries, your knee may be painful from tendinitis or arthritis. Tendinitis is an inflammation of the tendons around the knee. Arthritis is a wearing of the cartilage that covers the bony surfaces of your knee. In addition to asking you questions about your knee pain, your doctor will examine your knee to determine which structures are injured. They may order X-rays or an MRI to determine what is injured and to guide treatment.

Is your knee pain more sharp, or stabbing with certain motions (for example, twisting or squatting)?

Sharp, stabbing pain is more characteristic of meniscus tears or loose bodies. A loose body is a piece of bone or cartilage which has come loose and is floating within the knee. Ligament sprains tend to be worse with twisting as well. Knee pain due to arthritis is more often aching or sore. It is worse with walking and may occur even at rest.

Is your knee swollen?

Knee swelling which follows an injury often means there has been significant structural damage to your knee meniscus tears, ACL (anterior cruciate ligament) tears, fractures and patella (knee cap) dislocations can all cause significant swelling.

In the absence of an injury, knee swelling can be due to a flare-up of arthritis. This can be caused by doing more physical activity than your knee is accustomed to.

Where is most of the pain?

Pain on the front of the knee can be due to irritation of your patella.  This is sometimes called chondromalacia and is often worse with stairs. Anterior knee pain can also be caused by tendinitis of the patella tendon or quadriceps tendon. These are tendons that attach to the top and bottom of your knee cap. These problems all tend to give more of an aching pain or soreness.

Pain on the medial, or inside, part of your knee may be caused by a sprain of the medial collateral ligament (MCL) or a tear of the meniscus. These tend to follow an injury and are often associated with pain with bending the knee, twisting or squatting. Arthritis of the knee can cause medial knee pain, as well.

Lateral knee pain (pain on the outer aspect of your knee) can be caused by a sprain of the lateral collateral ligament (LCL) or a tear of the lateral meniscus. Like MCL sprains and medial meniscus tears, these problems usually follow an injury. Similarly, lateral knee pain can be due to arthritis as well.

is your knee locking, catching or giving out?

Meniscus tears can cause locking or catching of your knee and may even make it feel as if it wants to give out. Loose bodies can do the same. Giving out is commonly caused by an injury to one of the ligaments which support the knee. MCL and ACL ligaments are common following an athletic injury or fall. Dislocations of the patella usually follow a twisting injury and cause the kneecap to feel painfully out of place with a locked knee.

Shoulder Dislocation & Instability

Shoulder instability can be due to a traumatic dislocation or can be due to looseness of the joint. The shoulder is a ball and socket joint. A dislocation occurs when the ball (the proximal humerus) comes out of the socket. This usually follows an injury and is painful. Treatment involves putting the ball back into the socket. In an athlete this can sometimes be done on the field by an athletic trainer or physician. Most dislocations are reduced, or put in, in an emergency room. Dislocations of the shoulder can cause structural damage to the shoulder including tears of the labrum, fractures and rotator cuff tears.

Once the shoulder is put in, most patients are treated for a period of weeks in a sling for comfort, followed by physical therapy to regain strength and range of motion in the shoulder.

Some patients who dislocate their shoulder develop instability. The shoulder can start to 'come out' on a regular basis. This sometimes responds to physical therapy but can require surgery.

Some patients develop shoulder instability without any injury. This is also called multidirectional instability and can be caused by structural looseness or muscle weakness. Multidirectional instability usually responds to physical therapy and rarely requires surgery.

Shoulder Pain

There are many causes of shoulder pain. Common causes of shoulder pain include arthritis, rotator cuff pathology (tears, tendinitis, and bursitis), biceps tendon pathology and traumatic injuries such as dislocations, separations and fractures.

Shoulder arthritis commonly involves the glenohumeral joint. This is the main ball and socket joint of the shoulder and is made up of the humeral head and the glenoid (the socket). Patients with glenohumeral arthritis tend to be older and both males and females can be affected. Patients with glenohumeral arthritis complain of a deep ache within the shoulder and stiffness. The pain can be present both with activity and at rest. The stiffness may make it hard to reach into a back pocket or reach overhead. Shoulder arthritis can be treated with oral anti-inflammatory medications (NSAIDs). Physical therapy or steroid injections are sometimes helpful. For patients whose arthritis cannot be treated adequately with these methods, shoulder replacement is a safe and effective option.

Rotator cuff pathology is probably the most common cause of shoulder pain in patients who are middle-aged and older. The rotator cuff is a series of 3 muscles (the supraspinatus, infraspinatus and subscapularis) which surround the glenohumeral joint and allow it to move normally. The rotator cuff can cause pain due to tendinitis(inflammation of the rotator cuff tendons) or bursitis (inflammation of the bursa, a filmy layer or fluid-filled sack which allows the rotator cuff tendons to glide). Some people can develop bone spurs in the shoulder as they age. These prominences on the bone can rub on the rotator cuff. This is sometimes referred to impingement syndrome. The rotator cuff can also tear away from the bone. This is called a rotator cuff tear. Patients with rotator cuff pathology usually complain of pain in the deltoid area (the area on the lateral part of the shoulder where a sergeant’s patch would sit). Night pain is common and may be indicative of a rotator cuff tear. Rotator cuff tears usually require surgery but tendinitis and bursitis can usually be successfully treated without surgery. NSAIDs, steroid injections and physical therapy are usually helpful. In addition to a history and physical exam, X-rays and MRI may be needed to help diagnose a rotator cuff tear.

The biceps tendon is another common source of shoulder pain. Pain due to biceps pathology is usually located on the front of the shoulder and may be made worse with rotational movements (such as reaching around into a back pocket or putting on a jacket or seatbelt). Biceps pain can be due to inflammation, instability of the tendon, or partial tears of the tendon. Biceps pathology is often associated with tears of the rotator cuff, specifically the subscapularis tendon. Treatment of biceps tendon pain can be nonsurgical with oral medication (NSAIDs), steroid injections and physical therapy. Surgery is sometimes required, often done arthroscopically (using a camera through small incisions rather than making a larger open incision).

Shoulder pain which starts following an injury can be simply a bruise or strain. Fractures of the clavicle and humerus, shoulder dislocations and acromioclavicular joint separations are all common following an injury. Shoulder pain which begins following an injury should be evaluated by your physician or an orthopaedic surgeon.

Shoulder Stiffness

Shoulder stiffness may be caused by several disease processes. Adhesive capsulitis, or “frozen shoulder,” is most commonly seen in women in their 40s and 50s. The cause is not fully understood, but may be related to stress, and is certainly more aggressive in patients with diabetes. The joint lining, deep to the rotator cuff, becomes inflamed and results in loss of range of motion. Treatment involves anti inflammatories, either by pill or injection, and physical therapy. Rarely, surgical release of the capsule and manipulation of the joint many be recommended.

Arthritis, or loss of the cartilage covering the ball and socket, may as well be the cause of a stiff shoulder. Some patients may experience a loss of range of motion secondary to rotator cuff issues, including calcific tendonitis.

ACL Tear

The anterior cruciate ligament (ACL) is one of the four main ligaments providing stability to the knee. The ACL provides stability to anterior stress and rotation. Tears of the ACL are common in athletes, especially females. Over 100,000 ACL surgeries are performed in the United States each year. ACL tears can occur from contact (a football player hit on the knee) and non-contact (twisting) injuries. Athletes who tear their ACL often report feeling a tear, pop or a sense of having the knee "shift." ACL tears are usually associated with significant swelling and a sense of instability. Athletes may feel their knee is "sloppy," "loose," or "wobbly." Female athletes are at 3-5 times increased risk of ACL tear versus males in the same sport. This is felt to be due to different bony and ligament anatomy in a female’s knee, different muscle activity patterns (females jumping, landing, and running differently than males) and looseness of the knee associated with hormonal changes during a female’s menstrual cycle.

ACL tears can usually be diagnosed based on history and physical examination. X-rays are usually taken to ensure there are no fractures. An MRI may be used to confirm the diagnosis.

Surgery is usually recommended to reconstruct the ACL in young patients and athletically active patients of any age. Without surgery, many patients are unable to return to sports that involve cutting and pivoting, even with physical therapy and use of a brace. Lower demand, older patients can be managed successfully without surgery with very little risk of later arthritis. In younger, more active patients, nonsurgical treatment is associated with an increased risk of tearing the meniscus which can lead to premature arthritis.

Initial management of an acute ACL tear usually involves ice, nonsteroidal anti-inflammatory medications (NSAIDs, such as Ibuprofen, Naprosyn and others) and physical therapy to allow swelling, inflammation and stiffness to subside.

ACL surgery involves reconstructing the injured ligament with the patient’s own tendons or allograft (cadaver) tissue.

Adhesive Capsulitis (Frozen Shoulder)

The exact cause of adhesive capsulitis or frozen shoulder, is not completely understood. Patients frequently present with a sudden painful loss of range of motion. At times a small injury is reported, but usually there is no inciting injury. Adhesive capsulitis is much more common in women, and is much more aggressive in patients with diabetes. The typical age of onset is in the 40’s and 50’s. Social stressors may play a role in its onset. The capsule, or joint lining, becomes inflamed, and causes true stiffness.

Management usually starts with anti-inflammatory medication, either in the form of pills or injection of steroid into the shoulder. Physical therapy is frequently helpful as well. In patients who have a persistent loss of motion despite these measures, surgical release of the capsule and manipulation of the joint may be recommended.

Ankle Sprain

Ankle sprains are one of the most common sporting injuries that bring a player to an orthopaedic surgeon’s office. They do, however, occur in athletes and non-athletes alike. A typical ankle sprain occurs with inversion of the ankle (rolling the ankle) which causes a stretch of the lateral ligaments that stabilize the joint. There are 3 ligaments that span the ankle from the lateral fibula (the smaller of the 2 leg bones that make up the ankle joint) to the foot. The anterior talofibular ligament runs on the front of the fibula and is the most commonly injured. The ligaments may be stretched or even completely torn but most always heal without surgery. A "high ankle sprain" refers to an injury to the ligaments that hold the larger tibia to the smaller fibula in the leg. These are more severe injuries and can be associated with medial ankle pain and swelling and may more often make the athlete unable to bear weight.

An ankle sprain can cause swelling, pain, stiffness and make the patient unable to bear weight on the leg. After the first couple of days, the swelling and bruising can start to go down into the foot or toes as the fluid drains to the lowest spot.

When I evaluate a patient with an ankle sprain, I carefully palpate (push on) the different structures of the ankle and foot to determine which is damaged. I also examine the foot and leg for swelling and numbness, specifically on the top of the foot. When the bones are more tender than the ligaments I am more concerned about the person having an ankle fracture. I routinely do X-rays of the ankle and sometimes of the tibia and foot as well if I am concerned about a fracture or injury to those areas based on my exam of the patient.

If you have had an ankle sprain, especially if you are unable to bear weight on the leg, you should seek evaluation with your physician or an orthopaedic surgeon.

Anterior Knee Pain

Anterior knee pain is a common condition that results in pain in the front part of the knee. Pain may come from the patella (kneecap), the patellar tendon (under the kneecap), the quadriceps tendon (over the kneecap), or the top of the tibia (shin bone). These conditions are called patellofemoral syndrome, patellar tendinitis, quadriceps tendonitis, and Osgood-Schlatter Syndrome, respectively.

Patellofemoral syndrome or "runner's knee" is a condition when the underside of the kneecap tracks incorrectly in the groove of the femur and results in anterior knee pain. It can result in pain when climbing or descending stairs or sitting for long periods of time. This irregular rubbing can result in irregularity of cartilage (chondromalacia) under the kneecap which can cause clicking, grinding or creaking when bending the knee. Initial treatment should include rest, ice, and anti-inflammatory medicines (NSAIDs). Sometimes a brace can be used initially to help relieve symptoms and allow limited activity and exercise to continue. Treatment usually focuses on the leg muscles using home exercises and physical therapy. The condition is usually improved with quadriceps strengthening such as with bicycling. Hamstring flexibility as well has hip muscle strength helps improve the kneecap position when exercising, thus causing less pain.

Patellar tendinitis or "jumper's knee" is when the tendon underneath the kneecap becomes inflamed or irritated with overuse from running or jumping. If left untreated and if the pain continues, the tendon can become chronically injured and then much more difficult to treat. Initial treatment should include rest, ice, and anti-inflammatory medicines. Sometimes a brace can be used initially to help with symptoms to allow exercise and activity before complete recovery. Treatment should then focus on flexibility of the quadriceps, hamstrings, and calf muscles.

Quadriceps tendinitis is when the tendon above the kneecap becomes inflamed. It is much less common than the other causes of anterior knee pain but still can be quite challenging to treat. Initial treatment should also consist of rest, ice, and NSAIDs. Physical therapy and rehabilitation may be required as this condition can place a person at higher risk for quadriceps tendon rupture.

Osgood-Schlatter syndrome is when the growth plate at the top front of the shin bone (tibia) becomes irritated and inflamed. It occurs in young people who have open growth plates and are still getting taller. It is more common in young people who do sports year round, especially those that have a lot of running and jumping. If left untreated, it can permanently damage the growth plate. Rest, ice and occasionally, NSAIDs can be used to help relieve the pain. The bad news is that usually needs a period of rest and limited activity to subside. The good news is that it almost always goes away on its own when growth slows or stops!

As you can see, most of the conditions causing anterior knee pain can be treated with rest, ice, and NSAIDs. They rarely require surgery, but if they don't seem to be getting better after following this advice, you should seek medical advice from your doctor or a sports medicine specialist!

Articular Cartilage Injury

The term "articular cartilage" refers to the slippery surface that is present on the ends of bones as they form joints. It is comprised of a very specialized type of tissue known as hyaline cartilage. It is designed to be able to withstand impact stresses and constant weight bearing and is also very smooth to allow the bones, which comprise the joints, to slide in relation to one another.

Articular cartilage injury can be either chronic or acute. With aging and with arthritis conditions, a loss of the articular cartilage results in exposure of the underlying bone, which can be quite painful. Acute injuries to the articular cartilage can occur as fractures of the underlying bone and can also occur with acute ligamentous injuries of the joint. Injuries of the articular cartilage are very common following patellar dislocations, and can arise from the undersurface either of the patella or the end of the femur. Another common cause for articular cartilage defects is a condition known as osteochondritis dissecans. This frequently occurs in adolescence and involves an interruption of the blood supply to the underlying bone. This area of diseased bone can become brittle, fracture and thus create a defect in the overlying articular cartilage.

Because acute articular cartilage injuries often arise as a result of a traumatic injury such as a patella dislocation or a tear of the anterior cruciate ligament, the symptoms are usually that of the acute injury. This usually includes pain and swelling. MRI is the best study to evaluate for an acute injury of the articular cartilage. X-rays are often obtained initially to rule out a fracture.

The treatment of acute articular injuries depends on many factors and can range from simple things like ice and rest, but can also include arthroscopic surgery and major joint reconstruction.

Femoral Acetabular Impingement (FAI)

This is a condition where there is abnormal contact between the ball and socket components of the hip. This abnormal contact can result in damage to the hip lining (labrum) or the articular cartilage (covering the ball or socket). This occurs in predominantly in young active adults.

Symptoms of FAI often include hip pain and loss of motion. FAI is diagnosed with a medical history, physical examination and X-rays. Often an MRI or MR arthrogram is obtained to evaluate the degree of articular degree of arthritis and for assessing labral tears and bone configuration. CT scan may also be obtained to further assess the bone on both the ball and socket side of the hip.

In cases of FAI with associated labral tears, hip arthroscopy can be used to repair or trim (debride) the labrum in addition to trimming the bone causing impingement either on the ball or socket side of the joint or both.

Gluteus Medius / Minimus Tears

In patients who have failed nonoperative management/treatment of gluteus medius or minimus tears and have ongoing pain and or weakness, surgical repair of these tendons through arthroscopic or mini-open approach can be performed.

Knee Sprain

A knee sprain is usually caused by a twisting injury to the knee but can also occur as a result of a fall, a direct blow, or a sudden deceleration. A sprain is a broad term that generally implies an injury to one of the ligaments which make the knee stable. These ligament injuries can range in severity from a minor stretching injury, where the ligament is swollen and inflamed, to a complete tear of one or more of the ligaments. Most knee sprains involve minor stretching injuries to the medial collateral ligament (MCL). Knee sprains can also result in complete tears of the anterior cruciate ligament (ACL) which can require surgery.

Most knee sprains cause pain. When pain is severe, it may become difficult to walk or even support your weight with the injured leg. Knee sprains can also cause stiffness and a sense of instability.

Some symptoms which can occur following a knee sprain can suggest a more severe injury and should be seen by a doctor. These include swelling, the inability to put weight on the leg, catching, locking and giving-way episodes. In addition to performing a physical examination, your doctor will typically perform X-rays to ensure that there is no fracture. MRI imaging may be required for some knee sprains as well.

Many knee sprains are successfully treated without surgery. Your doctor may recommend the use of ice, a supportive brace, crutches and anti-inflammatory medications (NSAIDs) which can help relieve pain and swelling.

Hip Conditions

• Labral Tears
• Femoral Acetabular Impingement
• Loose Bodies
• Recalcitrant Trochanteric Bursitis
• Gluteus Medius / Minimus Tears

Labral Tear

The labrum is a piece of cartilage that surrounds the socket of the shoulder in a ring-like fashion. The shoulder is a ball and socket joint. The socket is called the glenoid and is much more shallow than the socket of the hip joint. As such, the bony socket of the shoulder has little inherent stability. The labrum acts as a rim, deepening the socket by approximately 200% and making the shoulder more stable. The top of the labrum (the 12 o' clock position on a clock face) is also the place where the biceps tendon anchors into the shoulder.

Tears of the inferior half of the labrum, both anteriorly and posteriorly, are usually caused by instability of the shoulder, either a full or partial dislocation. A partial dislocation, where the shoulder starts to slip out but then goes back in, is also called a subluxation. In young patients, almost all shoulder dislocations and subluxations cause labral tears. A tear of the anterior labrum is also referred to as a Bankart lesion.

Tears of the superior labrum are also called SLAP tears and are problematic because they disrupt the anchoring point of the biceps tendon. SLAP tears can occur in a number of ways including falls on an outstretched arm, forceful extension of the elbow or with overuse and throwing.

Inferior labral tears usually cause recurrent episodes of instability or recurrent shoulder dislocations. If the shoulder is subluxing, this may cause the arm to "go dead" temporarily. In young patients this often requires surgical repair, as physical therapy and bracing may not be effective. In addition to a history and physical examination, your surgeon will likely order X-rays and often an MRI. When surgery is needed it can usually be done arthroscopically (without a formal incision) on an outpatient basis. A sling is worn following surgery and physical therapy is required before returning to sports.

SLAP tears don’t typically cause instability, although they can cause dead-arm symptoms in throwing athletes. More often, they are associated with sharp pain which is worse with certain activities (driving, throwing, overhead activities) or positions of the shoulder. Pain is typically deep within the anterior-superior shoulder. SLAP tears may cause clicking, popping or locking of the shoulder. Despite this, SLAP tears may respond to physical therapy and often do not require surgery. When rehabilitation fails, the surgical treatment of SLAP tears is very similar to the repair done for instability. Recovery is similar as well.

Loose Bodies

Loose cartilage or bone fragments can occur within the hip joint in certain medical conditions (synovial chondromatosis) or can be a result of a trauma (hip dislocations/subluxation). Hip arthroscopy can be used to remove these loose bodies.

Meniscus Tear

The meniscus is a piece of cartilage that sits in the knee between the femur and tibia. There is both a medial and lateral meniscus and they have several important roles in the normal function of the knee. The primary function of the meniscus is to increase the contact area between the femoral condyle (the rounded medial and lateral ends of femur) and the tibial plateau (the flat surface of the top of the tibia). By increasing conformity and contact between the femur and tibia, the meniscus acts as a pad or shock absorber within the knee. The meniscus (particularly the medial meniscus) also helps maintain stability in the knee in the case of ligament injury. Loss of the meniscus can lead to an increase in the amount of force placed on a given area of the articular cartilage in the knee. This can lead to wear of the cartilage and arthritis of the knee in some cases.

Meniscus tears are one of the most common causes of knee pain presenting to an orthopaedic surgeon. Meniscus tears can occur in a number of ways. In young patients, meniscus tears usually occur with a significant injury, such as hyper flexing the knee or twisting the knee during sports. As people age, the meniscus loses some of its toughness and can tear following minor activities. Older patients may feel a pop in the knee just from squatting down to get something off the floor.

Patients with meniscus tears usually report a sharp pain in the knee, medially or laterally, that is often made worse with squatting or twisting activities. In addition to sharp pain, meniscus tears can cause mechanical symptoms such as locking or giving-way of the knee. Some patients also report painful clicking or a sense of something moving around in the knee.

Diagnosis of a meniscus tear can usually be made by taking a history from the patient and examining the patient’s knee. Although the meniscus cannot be seen on X-rays, X-rays are typically taken to make sure there are no fractures and to look for arthritis in the knee. Once a meniscus tear is suspected, an MRI can confirm the tear and rule out other injuries. Treatment of a meniscus tear does not always require surgery. Ice, nonsteroidal anti-inflammatory medications (NSAIDs, such as Ibuprofen, Naprosyn and others) and steroid injections can all be helpful. Temporary use of a brace or physical therapy to decrease swelling and restore range of motion can also help. With use of these treatments, some patients may become symptom free.

When symptoms do not respond to nonsurgical treatment, surgery for meniscus tears is generally very effective and involves limited recovery time. Surgery for meniscus tears is accomplished using a knee arthroscopy or scope. A knee arthroscopy involves using a camera and small instruments through two small incisions to remove the torn part of the meniscus. The majority of meniscus tears are treated by removing the torn piece as only approximately of 15% of all meniscus tears are potentially repairable. When the meniscus tears in such a way that it can be repaired, this is often done arthroscopically but typically has a longer recovery time. Nevertheless, if the meniscus is repairable, preserving the meniscus leads to the lowest risk of developing arthritis in the future.

Patella Instability

The patella or "kneecap" is located within the extensor mechanism of the knee between the quadriceps tendon above and the patellar tendon below. The undersurface of the patella is somewhat triangular in shape and allows it to slide within a groove on the end of the femur known as the trochlea. Patellar instability refers to an alteration in the normal tracking of the patella.

Patellar instability may be caused by a traumatic event or may arise atraumatically from underlying anatomic causes. In a traumatic dislocation, the cause is usually a twisting injury with the foot planted. It may also be caused by a direct blow to the side of the patella. Almost universally, the patella dislocates laterally. In a true dislocation the patella pops out of its usual groove along the trochlea and remains out until manually reduced. A subluxation, or transient dislocation, occurs when the patella pops either part way or fully out of its groove, but then immediately pops back into place. Both a subluxation and dislocation usually result in significant bleeding into the joint with visible swelling appreciated. At times the acute instability event may cause fractures from either the patella or the femur.

Atraumatic instability of the patella is usually caused by anatomic variations that significantly increase the potential for the patella to slide out of its usual tracking position. For example, with trochlea dysplasia, the usual concave surface on the end of the femur is too shallow and it is associated with an increased risk for patellar instability. Likewise, there is great variability in the alignment of the actual extensor mechanism. In patients whose patellar tendon attaches to far laterally, there is alteration in the soft tissue balance and patellar instability or subluxations may be the result. Patients that are congenitally are "loose jointed" have as well been observed to have an increased risk of developing patellar instability.

Rotator Cuff Tear

Rotator cuff disorders are the leading cause of shoulder pain in patients middle-aged and older. While problems with the rotator cuff tendons can be painful and debilitating, with proper treatment, most patients are able to return to all of the activities they enjoy without pain.

What Is the Rotator Cuff?

The rotator cuff is a series of 3 muscles which surround the shoulder joint. The shoulder joint is a ball and socket made up of the head of the humerus (the ball) and the glenoid, which is the part of the scapula that acts as the socket. The socket of the shoulder is very shallow, unlike the hip joint which is much deeper. As such, it is inherently unstable. The rotator cuff muscles act by compressing the ball into the socket, which keeps the ball centered. When the rotator cuff is not functioning, either because it is torn or weakened, the ball moves abnormally on the socket. In the short term, this can cause pain and weakness. With time this abnormal motion can cause degenerative arthritis of the shoulder joint. In addition to rotator cuff tendon tears, the rotator cuff can become painful because of tendinitis (inflammation of the rotator cuff tendons) or bursitis (inflammation of the filmy tissue that covers the rotator cuff and allows it to glide past the bones of the shoulder).

Rotator Cuff Signs and Symptoms

Most patients with rotator cuff problems are middle-aged or older. Patients typically complain of pain in the deltoid area, or the place a sergeant’s patch would lie on your arm. The pain is usually aching and may be present both during activities and at rest. Reaching over your head may become painful. Some patients wake up at night with pain. While your rotator cuff may become painful due to an injury or overusing it, pain can come on gradually with no apparent cause.

When I evaluate a patient with rotator cuff pain, I ask about their general health including whether or not they smoke. I ask if it is the dominant hand that is affected and what they do for work. I also ask about things they enjoy out of work, such as sports or hobbies. I always do a complete examination of the shoulder, looking for focal areas of tenderness, stiffness and checking the rotator cuff for weakness. I always take X-rays of the shoulder to look for evidence of arthritis or large rotator cuff tears. While rotator cuff tears are best seen on MRI, X-rays are helpful in determining if a rotator cuff tear can be repaired. Based on my history and examination, I determine whether I think a rotator cuff tear is likely. If that is the case, an MRI is ordered.

Rotator Cuff Treatment

Many times the rotator cuff is inflamed but not torn. When that is the case, most patients can be treated without surgery. If I see a patient with rotator cuff-type pain and they have no weakness, I usually treat them without surgery initially. The first step is to decrease inflammation which helps relieve pain. Anti-inflammatory medications (nonsteroidal anti-inflammatory drugs or NSAIDs) can be helpful. These include medications like Ibuprofen or Naproxen. There are many such drugs most differ in how often and how much you need to take. I often inject cortisone, a steroid, into the area around the rotator cuff. This works much like NSAIDs but is more potent and without some of the side-effects of the oral medications.

Once the inflammation subsides, I recommend that patients see a physical therapist. This can be very helpful to restore strength and range of motion. By strengthening the rotator cuff muscles, the normal motion of the ball and socket joint can be restored. Nonsurgical treatment of rotator cuff tendinitis or bursitis is usually successful. Surgery can sometimes be necessary if nonsurgical treatment fails.

Recalcitrant Trochanteric Bursitis

In patients with trochanteric bursitis who have failed extensive nonoperative management including activity modification, icing, stretching, cortisone injection and physical therapy occasionally surgical hip arthroscopy can aid in more definitive treatment. This procedure involves arthroscopic release of the ITB (iliotibial band) and removal of the inflamed trochanteric bursitis.

Shoulder Separation

A shoulder separation refers to an injury to the acromio-clavicular (AC) joint. This is the joint on top of your shoulder where the collarbone (clavicle) is linked to the acromion, which is a part of the scapula. The injury usually is caused by a blow to the side or the top of the shoulder. The ligaments which join the bones together are torn to varying degrees, and pain and a prominence on the top of the shoulder result. Management of the injury is usually ice, rest, sling, and graduated return to activities. The "bump" on top of the shoulder will be permanent, though usually patients have minimal long term problems. Occasionally, surgery to realign the joint will be recommended for severe separation.

Many patients present with a painful bump over the AC joint with no history of trauma. Osteoarthritis frequently effects this joint and causes pain with overhead and cross body maneuvers. Weight lifters may also cause a chronic injury, termed "osteolysis" which causes the end of the clavicle to absorb and results in pain. Injection of the AC joint may be recommended for both of these conditions, and surgical treatment where the end of the clavicle is removed to recreate a space is an option for patients with persistent pain.

Shoulder Tendinitis & Bursitis

Tendinitis refers to an inflammation of a tendon. In the shoulder, inflammation and tearing of the rotator cuff tendons is probably the single most common cause of shoulder pain among middle-aged and older patients who present to an orthopaedic surgeon. The rotator cuff is a continuous sleeve, or cuff, of tissue that surrounds the glenohumeral joint (the ball and socket joint of the shoulder). The socket of the shoulder is very shallow and the rotator cuff functions to center the ball on the socket. The clavicle (collarbone) and acromion are bones which sit on top of the rotator cuff. As people age, some may develop a prominence or spur on the underside of these bones which can narrow the space available for the rotator cuff and cause pain. This is referred to as rotator cuff impingement. The subacromial bursa as a filmy layer of tissue that allows the rotator cuff tendons to glide under the bony structures. Bursitis refers to an inflammation of this tissue and is indistinguishable from tendinitis.

Pain due to a rotator cuff problem (either tendinitis, bursitis or even a rotator cuff tear) usually is aching in character and located over the lateral shoulder, the area where a sergeant’s patch would sit. It may be worse with overhead activity. Rotator cuff tears can also cause weakness and night pain.

As long as the rotator cuff tendons are not torn, treatment of shoulder tendinitis and bursitis typically does not require surgery. In addition to physical therapy and oral anti-inflammatory medications (NSAIDs such as Ibuprofen and Naproxyn), injection of a steroid (commonly called cortisone) into the inflamed bursa can give significant relief. When I evaluate a patient with shoulder tendinitis, I usually perform X-rays to evaluate for boney impingement. I also carefully examine the patient’s rotator cuff for any weakness. If the patient is weak, I am concerned about a rotator cuff tear and usually order an MRI. In addition, if the patient isn’t made better by the treatments discussed above, I order an MRI to rule out a rotator cuff tear.

Surgery is sometimes needed for shoulder impingement and can be done arthroscopically.

Stress Fracture

A stress fracture is a crack in a bone that occurs because of repetitive stress that progressively weakens an area and can result in a fracture. Each of these individual stresses will not result in a fracture, however, when they occur repetitively, they result in progressive weakening of the bone. Most common in the leg and foot, they usually occur in running and jumping athletes. The most common site is the shin (tibia) but also can occur in the foot and upper leg (femur). They may result from a change in training, such as running more miles, running and jumping on hard surfaces, adding new, more intense workouts, or even changing shoes. Occasionally, it can indicate that there is a problem with bone density. Pain that occurs in the leg or foot with weight bearing and gets worse with running or walking should always be evaluated by a doctor. Pain from tendinitis, muscle strains, and shin splints can be mistaken for a stress fracture but should still be evaluated. If left untreated, a stress fracture can go on to a full fracture which can require surgery. Most stress fractures will heal on their own but usually require several weeks of rest from activity and exercise. If you suspect that you have a stress fracture, stop the activity that causes the most pain and seek medical advice.

Tendinitis & Bursitis

Tendinitis is when a tendon, which attaches a muscle to a bone, becomes inflamed or irritated. Bursitis is when a bursa becomes inflamed or irritated. A bursa is a small, fluid-filled sack that usually sits in areas of friction in the body, such as where a tendon or skin may rub over a bone. Tendinitis and bursitis may exist together or separately and may cause pain deep in a joint or may cause swelling, pain, redness, and warmth. Tendons and bursa exist in every joint in the body so can result in pain almost anywhere! The most common sites for tendinitis and bursitis are the shoulder, elbow, hip, and knee.

The rotator cuff is a series of four muscles in the shoulder that work to hold the "ball in the socket." The muscles start on the shoulder blade and their tendons insert on the humerus at the shoulder. The tendons each have bursae that keep them from catching and rubbing. Their tendons and bursae can become inflamed with overuse, especially with overhead activities. Pain is often worse at night and sometimes can result in loss of range of motion. Rest, ice, and anti-inflammatory medicines (NSAIDs) should be used initially to calm the pain and swelling. If these are not effective after a period of time, stronger medicines or even a corticosteroid injection may be needed to reduce pain and inflammation. Often, physical therapy or home exercises may be necessary to help reduce the chances of the pain coming back.

In the elbow, tendinitis usually occurs in the outside (“tennis elbow”) or the inside (“golfer’s elbow”). Both are usually from overuse and can become chronic. Treatment includes stretches, ice, and NSAIDs. If this is ineffective, sometimes an injection of corticosteroid can be given to reduce pain and aid in healing. When bursitis occurs in the elbow, it is usually over the olecranon, or point of the elbow. It results in swelling, sometimes as big as a golf ball over the end of the elbow. It usually results from minor trauma to the elbow. It can usually be treated with compression, ice and NSAIDs. Usually it is not terribly painful and resolves on its own. If it is red, hot and swollen, it should be evaluated by a medical professional as it may be infected.

In the knee, the most common site of tendinitis is at the iliotibial band, or ITB, on the outside of the knee. This is a very common condition in runners and causes pain on the outside of the knee but rarely any visible swelling. Sometimes it can even cause the knee to feel "locked." Treatment usually included rest from running, ice, and NSAIDs. To help prevent it from reoccurring, stretches for the ITB, as well as strengthening exercises for the hip are helpful. Bursitis in the knee usually is prepatellar or "in front of the kneecap." It results in swelling, warmth, and redness over and in front of the knee. It usually results from kneeling or minor trauma. It usually goes away on its own with compression, ice, NSAIDs, and avoiding kneeling.

When pain occurs in the outside of the hip, it is usually caused by bursitis or tendinitis. Several muscles insert on the greater trochanter (the bump on the outside of the hip). They can become inflamed from overuse and also from inflexible muscles. Treatment includes rest and NSAIDs. If this is ineffective, physical therapy and sometimes a corticosteroid injection can be helpful.

Tendinitis and bursitis are the most common causes of pain in a joint that did not suffer an injury. If they came on suddenly, you should seek medical advice as this could indicate a tendon tear that could need surgery. Pain that does not respond to a period of rest and anti-inflammatory treatments should also be evaluated by your doctor or a sports medicine specialist.

ACL Reconstruction

The Anterior Cruciate Ligament (ACL) is a cord of tissue connecting the femur (thigh bone) to the tibia (leg bone) at the knee. The knee is connected by 4 major ligaments: the Medial Collateral Ligament (MCL), Lateral Collateral Ligament (LCL), Posterior Cruciate Ligament (PCL) and the ACL. The ACL prevents excessive anterior translation of the tibia and also controls rotation of the knee. When the ACL is torn, the knee can move abnormally leading to instability and meniscus tears.

ACL tears are common in athletes and often require surgery to provide a stable knee which allows a return to sports and decreases the risk of a meniscus tear in the future.

Prior to Surgery

Prior to surgery, many patients require a period of 1-3 weeks of physical therapy to decrease swelling and inflammation and restore normal range of motion. If surgery is performed on an acutely inflamed knee there is a higher risk of arthrofibrosis post-operatively. This means that the knee fills with scar tissue and becomes very stiff, delaying recovery and sometimes requiring additional surgery.

ACL Surgery

ACL reconstruction involves removing the torn ACL and replacing it with a graft of new tissue. Much of the surgery is done arthroscopically. This means that small, 4-5 mm incisions are made and a camera and instruments are used inside the knee to perform the surgery without an open incision. During surgery, the surgeon uses drills to make tunnels in the bone at the site of the old ACL. Meniscus tears, when present, are repaired or trimmed. The ACL graft is then pulled into the joint and fixed with any one of a number of devices. Most ACL surgery is done on an outpatient basis. There are many choices for anesthesia but many patients have a regional block. This means that the leg is numbed up with an injection and the patient gets medication during surgery to make them relaxed or even fall asleep completely. General anesthesia is an option as well.

Graft Alternatives

There are several graft alternatives, the most common are patella tendon grafts, hamstring grafts or cadaver grafts (allografts). Patella tendon grafts are also called bone-tendon-bone (BTB) grafts. The surgeon makes a 5-7 cm incision on the front of the knee from the patella (kneecap) to the tibia and removes the central 1/3 of the tendon with a block of bone from the patella and tibia. This graft is then secured to the bone with metal screws. The screws stay in forever unless the ACL fails and needs to be re-done. In the past, advantages of the BTB graft included a lower rate of failure and more rapid healing of the graft into the bone. With current techniques, hamstring grafts have a similar success rate. Disadvantages of the patella tendon graft include pain when kneeling for up to a year or longer, more postoperative pain, and a larger scar. There may be a slightly higher incidence of arthritis under the kneecap in future years but data is inconclusive. Many surgeons reserve BTB grafts for male athletes in collision sports (football, hockey).

Hamstring grafts are harvested through a 2-3 cm incision just to the medial side of the knee. The hamstring tendons are stripped off the muscle. The hamstring muscle is left in place and most people form a new hamstring which takes up to a year. Most studies show that there is minimal (10%) loss of hamstring strength and most patients don’t sense that the muscle is weak. The graft is then pulled into the knee and fixed with any of a number of screws or devices. Advantages of hamstring grafts include less anterior knee pain, less postoperative pain, a small scar, less trouble getting back range of motion (although it can still be a problem). In the past, hamstring grafts had a higher rate of loosening and failure than patella tendon grafts. With newer, stronger implants to secure the graft, this no longer seems to be the case.

Cadaver grafts (allografts) are ligaments (commonly hamstring, Achilles tendon or patella tendon) harvested from a dead person which are screened for disease and then sterilized and used as a graft. Advantages of allografts are decreased surgical time, smaller scars, and there are lack of donor-site problems such as pain and weakness. In most studies allografts have a high rate of success but a slightly higher failure rate than the patient’s own tissue. In addition, allografts take longer to incorporate into the surgical knee than the patient’s own tissue which can lead to a higher rate of re-tear. While rare, some patients can have an immune reaction to the graft which leads to rapid failure.

Recovery

Recovery from ACL surgery takes many months. The worst pain is within the first 48 hours and patients are given pain medication on discharge. Crutches are needed for anywhere from a few days to several weeks depending on the patient. A brace is usually worn for several weeks when you are up ambulating. There are often stitches which can’t get wet for 1-2 weeks. I usually have my patients come in 2-3 days following surgery to check the surgical site, perform an X-ray and review instructions. Many patients have significant swelling which can be painful. An aspiration can be performed to remove the fluid from the knee with a needle, which lessens the pain. Physical therapy starts 3-5 days after surgery. The goal is to restore range of motion and regain strength while not putting too much stress on the graft as it heals. Most people attend physical therapy 2-3 times per week for 3-6 months. I allow patients to start on an exercise bike 1-3 weeks after surgery. Jogging is 3 months on average, and a return to full sports is usually allowed at 6-9 months. After surgery on a right leg, most people can’t drive for 8-10 weeks.

Ankle Arthroscopy

Arthroscopy, or minimally invasive surgery performed using small instruments using real-time imaging with a miniature surgical camera, is used in treating some ankle conditions, including ankle impingement and ankle instability. Surgeons can repair several forms of cartilage, ligament, bone, and tendon damage in the ankle structures using this approach.

Ankle Sprain

Initial treatment of an ankle sprain follows the RICE philosophy (Rest, Ice, Compression, and Elevation). Patients are given crutches to use for at least a couple of days. If the ankle is very swollen and painful, immobilization in a brace, or even a cast, can be helpful to make the swelling come down.

In athletes, they often start physical therapy with a therapist fairly early (in the first 1-2 weeks) to allow them to return to sports safely and quickly. In the non-athlete, physical therapy may not be needed; the patient can often do exercises at home. The most common cause of recurrent injuries to the ankle are an inadequate amount of strengthening and rehabilitation. The athlete is sometimes recommended to wear a brace on return to sports for 3 months to try to decrease the risk of a re-injury.

Approximately 15% of patients fail to respond to this standard treatment and may require repeat X-rays, MRI, further physical therapy or even surgery.

Articular Cartilage Resurfacing

As noted earlier, the articular cartilage is the slippery surface at the end of bones that allows smooth gliding to occur within the joint. There are several options available to treat patients with articular cartilage defects. These treatments apply to acute articular defects, not the more diffuse articular cartilage damage present in arthritis.

The most common method to treat articular cartilage defects is an arthroscopic procedure termed microfracture. The purpose of the operation is to insight a healing response within the defect by performing multiple perforations of the underlying bone. This is performed with an awl and promotes bleeding, which in turn forms a fibrocartilage repair tissue, which helps to resurface the bone. This repair tissue is not as sturdy as the native hyaline cartilage, but is certainly a smoother surface than the underlying bone and leads to decreased pain and resolution of symptoms in many patients. Following surgery, the patient typically needs to keep weight off of the affected joint for 6 weeks or longer and full recovery may take 6-12 months.

Another option available to surgeons is a procedure called OATS (osteoarticular transfer system). This operation involves harvesting bone plugs with intact articular cartilage present from other areas of the knee and then exchanging them for dowels taken from the area of articular cartilage deficiency. This is frequently performed with an incision (open procedure) and has a goal of restoring hyaline cartilage to the defect. As with all of these resurfacing procedures, a period of protected weight-bearing is indicated following the procedure.

For larger defects, an option exists to take a large dowel of bone to exchange and thus fill the defect. This requires use of allograft bone (cadaver bone).

Autologous chondrocyte implantation (ACI) is the final option available for articular cartilage defect treatment. This is a two-stage operation where first chondrocyte cells are harvested in an arthroscopic procedure. These small samples of tissue are then grown to form a specimen that has large numbers of chondrocytes or cartilage forming cells present. These are then, in a separate open procedure, implanted into the defect beneath a thin layer of tissue. This procedure as well has the theoretical advantage of restoring hyaline-like cartilage to the area of defect.

There are pros and cons of all of these described procedures. Many of these complex issues require thoughtful preparation, both on the part of the surgeon and on the part of the patient.

Chondromalacia Patella / Patellar Pain

Pain in the anterior aspect of the knee is very commonly encountered and has many different etiologies. The most common cause for pain, especially in older patients, involves wear and tear on the backside of the patella, a condition known as chondromalacia patella. The cartilage on the back of the patella is the thickest in the body, as it is subjected to the greatest joint forces anywhere in the body. It has been noted that from rising from a seated position, the patella experiences forces equal to 3-5 times the body weight. Nonoperative management for patellofemoral arthritis is usually indicated with hamstring stretching, quadriceps strengthening and weight loss frequently advised.

Patellofemoral pain can also be caused by soft tissue issues. Synovial bands, termed plica (meaning shelf), can be a common cause of anterior knee pain, especially in younger patient's under 20 years of age. These bands of tissue get caught beneath the patella and cause snapping frequently just to the inner side of the patella. Hamstring tightness is frequently observed in these patients and vigorous quadriceps strengthening and hamstring-stretching programs are indicated. At times activity modification and sport change may be indicated. For patients with longstanding issues, at times arthroscopic removal of these bands may be indicated.

Instability of the patella may also cause symptoms in the anterior aspect of the knee. If the patella is moving abnormally with flexion and extension of the knee, excessive joint pressure forces can occur and this may be the cause of symptoms. As is the case with most conditions, nonoperative measures are first attempted, especially strengthening of the medial quadriceps muscle. At times surgical realignment procedures may be indicated for patients with prolonged symptoms.

For those patients with severe degenerative changes involving the patellofemoral joint, joint replacement either in the form of total joint replacement or in selected patients, a selective resurfacing of the patellofemoral joint may be indicated.

Hip Arthroscopy Procedures

Hip arthroscopy has been used for many years but has been limited due to the technical demands of this procedure. Over the last few years an improvement in the diagnosis of hip conditions and significant improvement in surgical technique and instruments have greatly increased the ability of the surgeon to treat hip disorders arthroscopically. It is not used to treat arthritis and therefore is usually performed on patients less than fifty years old with non-arthritic hip conditions.

Arthroscopy of the hip requires a special operating table to detract the hip to allow space to place instruments and fluid into the joint. This is a highly specialized procedure that requires extensive experience.

What conditions can be treated?

• Labral Tears
• Femoral Acetabular Impingement
• Loose Bodies
• Recalcitrant Trochanteric Bursitis
• Gluteus Medius / Minimus Tears

Knee Arthroscopy

A minimally invasive procedure, arthroscopy allows your doctor to examine tissues and joints inside the knee in great detail. During an arthroscopic procedure, a thin fiber optic light, magnifying lens and tiny television camera are inserted into the knee and is performed often to confirm a diagnosis made after a physical examination and other imaging tests. In some instances, it is then possible to treat the problem through the small incisions around the joint. Because it is minimally invasive, knee arthroscopy offers many benefits to the patient over traditional surgery such as no cutting of muscles and tendons, smaller incisions, less bleeding and scarring. Knee injuries that are frequently treated using arthroscopic techniques include but not limited to: meniscus tears, mild arthritis, ACL and PCL tears, and patellar (knee cap) misalignment.

Labral Repair

Depending on the tear pattern it can be treated with debridement (trimming/removal) or with repair utilizing sutures (stitches) to reattach the labrum to the rim of the socket.

Treatment for patients diagnosed with a labral tear in the shoulder is based on location of the tear, activity level, and degree of functional impairment. Many tears of the superior labrum (SLAP tear) will cause pain with overhead activity or repetitive activity above shoulder height. Stretching of the posterior capsule and specific exercises to strengthen the muscles of the shoulder blade and rotator cuff often provide relief. Surgical repair is often necessary for overhead athletes or those with ongoing pain despite attempted therapy. Anterior labral tears result from shoulder instability. This occurs as a result of dislocation or repetitive abnormal shifting called subluxation. Active patients, athletes, and those at high risk for repeat dislocation (laborers) usually require surgery to stabilize the shoulder. Less active patients or those with shoulder instability without a labral tear (multidirectional instability) are usually treated with physical therapy exercises, with surgery only necessary for those with severe functional impairment or multiple dislocations. Most labral repairs are performed arthroscopically with excellent recovery of function and return to sports.

Patella Instability

A first time episode of patella dislocation is usually treated with rest, bracing, and anti-inflammatory medication. Physical therapy is often recommended after the swelling and pain have resolved. Most people will recover fully and return to all activities after full quadriceps strength is obtained. A functional brace to stabilize the patella is usually necessary for return to activities and sports. If x-rays or MRI show evidence of fractured cartilage, an arthroscopy is necessary to surgically remove or repair the loose pieces. Repair or reconstruction of the stabilizing ligament of the kneecap is often performed at the same time to reduce the chances of repeat dislocation. For those patients without cartilage damage, surgery is necessary only for repeat episodes of instability or debilitating pain.

Patients with chronic instability of the patella without dislocation are treated with bracing, stretching and strengthening exercises, and anti-inflammatory medications. Chronic instability often comes from poor alignment of the kneecap joint, which can often be helped with therapy to optimize the entire leg from hip to foot, and foot orthotics may be prescribed as well. Most people will see significant improvement with nonoperative treatment. For those who fail to improve with these treatments, realignment surgery is considered. These procedures may include realignment of the bone (osteotomy), reconstruction of the stabilizing ligament of the patella, or a combination of the two.

Rotator Cuff Repair

When a rotator cuff tear is diagnosed based on history, examination or MRI, I often recommend surgery. While the symptoms of a torn rotator cuff tendon may improve with time, the tendon seldom heals and pain usually returns. Unfortunately, when a torn rotator cuff is neglected, it can become much larger with time. Surgery becomes more difficult and sometimes the tear may become large enough that it cannot be repaired. This can lead to the painful stiffness of arthritis.

Rotator cuff surgery has evolved over time. Most rotator cuff repairs are performed as an outpatient procedure, with patients going home after surgery. Most rotator cuff repairs can be done arthroscopically at this point. The surgeon makes several small (5mm) incisions around the shoulder and introduces an arthroscope, or camera, into the shoulder joint. The rotator cuff tendon is repaired by sewing it to the bone.

Following surgery, I typically have patients wear a sling for several weeks to allow the tendon to heal down to the bone. Early home exercises are recommended to avoid getting a stiff shoulder. This is followed by several weeks of physical therapy to regain all of your strength and range of motion. Rotator cuff repair surgery has, overall, a very high success and low rate of potential complications. Most patients can return to all activities with excellent relief of pain.

Tendinitis

If conservative treatments do not effectively address the symptoms of tendinitis, surgery may be considered. The location, severity, and physical source of the tendinitis will determine the surgical approach. Debridement, or surgical removal of tissue, may be necessary. Repair surgery is typically recommended if there is a tendon tear.

Shoulder Arthroscopy

A number of shoulder procedures can be performed using the minimally invasive approach of arthroscopy. Surgeons can use the arthroscope and small surgical tools to repair rotator cuff damage, correct shoulder impingement and instability, and repair soft tissue structures like the labrum.