1. Sports Related Injuries William Kesto, MD

2. Sports Related Injuries In the over 55 crowd Over 1 million sports related injuries a year

3. Who are the Culprits You…the athlete…just can’t stop can you? The sports you play The body you live in

4. What’s this?

5. What?

6. Defined Pickle-Ball is a hybrid of Badminton, Tennis and Table-tennis, a three in one game, played with wooden paddles and a perforated plastic ball. It can be played on a normal Badminton court or on any hard surface such as driveways, parks, cul-de-sacs, playgrounds, tennis/volleyball/sepak takraw courts.

7. Pickleball!!!!! Ok now I get it See many injuries from this game Not that the game is dangerous, just extremely popular Never knew the game existed…now I do

8. Golf Now this game I knew about but… I never knew you could play so much of it…

9. Behind door #3

10. Some others Swimming Walking Tennis Biking Travel

11. Prevention General principles – Stretch prior to activity: shouldn’t hurt – Warm up prior to activity: break a sweat – Make sure you’re in good enough shape to participate – Ease back into activity – Don’t play through the pain

12. Prevention No magic bullet If you play…there is a chance you’ll get injured.

13. Injuries Shoulders Elbows Knees

14. Shoulder Bones and Ligaments

15. Shoulder Anatomy: muscles and tendons PosteriorAnterior

16. Shoulder Injuries – Overuse: fatigued tendons and muscles – Subacute: fatigued tendons and muscles that now slowly begin to tear/wear out: pain is increasing – Acute: Fell, threw too hard, swung to hard, now your shoulder hurts

17. Shoulder Overuse – Tendonitis: irritation/inflammation of a tendon Pain down the side of the shoulder with overhead and behind the back activity Nighttime pain – Tendonopathy: “sick” tendon Similar pain complaints Pain may have been evident for a longer period of time

18. Shoulder Treatment – Make sure that’s all it is: xrays and MRI – Non-steroidal anti-inflammatories – Ice – Physical Therapy – Corticosteroid injection

19. Shoulder Subacute – Progression of an overuse injury – Had occasional pain before, now it hurts worse and more frequently

20. Shoulder Subacute – Xrays for the bones – MRI for the soft tissues – If unremarkable Non-steroidal anti-inflammatories Ice Physical Therapy +/- Corticosteroid injection

21. Shoulder Acute – Xray and MRI – Treatment depends on the findings

22. Shoulder In general the work up for overuse, subacute, and acute shoulder pain is the same Radiographs are a must MRI Indications: Drop arm sign, external rotation lag sign, dislocation I like to know what I’m dealing with before treating it

23. Shoulder Concerning injuries – Pain does not improve with conservative management – Positive findings on xray Fracture Arthritis

24. Shoulder Concerning injuries – Positive findings on MRI (found something wrong) Rotator cuff tear Labral tear Biceps tendon tear

25. Shoulder What next? – Shoulder arthroscopy – “Clean up the shoulder” – Repair torn tendons

26. Shoulder Recovery – Worst case scenario is cuff repair 6 weeks: Healing phase – Typically start therapy at 3 weeks – Full time sling 3 weeks/part time 3 weeks 6 weeks: Rehab 6 weeks: Strengthening Typically 3-4 months…start resuming previous activities…SLOWLY

27. Knee Good news about shoulder pain is we don’t walk on our hands The knees are a different story

28. The Knee: Anatomy A diarthroidal joint: a hinge joint 3 separate comparments – Patellofemoral: knee cap and femur – Medial: “inside part of the knee” – Lateral: “outside part of the knee”

29. The Knee Two main types of cartilage in the knee – Articular cartilage: a thin lining of resilient connective tissue that serves as padding and an ultra low friction surface – Meniscal cartilage: serve to deepen the contact of the femur on the tibia, provide stability, distribute force

30. The Knee Joint reaction force in the knee is about 3 times body weight when walking This is absorbed by the menisci and articular cartilage

31. The Knee 4 main ligaments in the knee – Anterior Cruciate Ligament (ACL) – Posterior Cruciate Ligament (PCL) – Medial Collateral Ligament (MCL) – Lateral Collateral Ligament (LCL)

32. Von Mow “The human joint functions so well… that we are totally unaware of it until there is a problem”

33. The Knee Problems of the knee – “Tendonitis” – Meniscal tears – Ligament injuries – Cartilage injuries – Arthritis

34. Tendonitis Tendon: strong piece of tissue that attaches a muscle to bone Tendonitis: irritation/inflammation of a tendon Typically responds well to rest, ice, anti- inflammatories, and focused PT

35. Meniscal Tears Disruption of the continuity of the meniscus of the knee

36. Mechanism of injury Twisting: sports Turning: sports Deep knee bends: sports Pivoting: sports

37. Meniscal Tear Symptoms – Focal pain, typically intermittent – Swelling – Nightime pain – Pain with activity – Catching/locking

38. Meniscal Tears Treatment options – Physical Therapy – Injections – Arthroscopic surgery remove/fix the tear 80-90% better by 6-8 weeks

39. Ligament injuries ACL – Fix in active, physical individual – NO real age restriction – Contraindicated if significant arthritis PCL – Fix when symptomatic – Contraindicated if significant arthritis

40. Ligament injuries MCL – Brace for six weeks – Weight bearing as tolerated LCL – Brace – Fix if part of a complex of lateral injuries

41. Cartilage injuries Damage to the articular cartilage of the knee

42. Cartilage injury

43. Typically unclear severity until the time of arthroscopy Variety of treatments dependent on the severity – “smooth down” – Microfracture

44. Cartilage injury Cartilage transplant – Treatment for smaller, focal cartilage defects – An attempt to prevent the progression to osteoarthritis Not useful in degenerative arthritis

45. Knee injuries Problem – “Just had the knee scoped. Doc told me I had a torn meniscus and he scraped some arthritis out of there”

46. Knee injuries Meniscus tear with mild/mod arthritis – Rather common – Meniscus tear is the “mechanical” problem – Treatment based on 6 weeks of observation – If symptoms are improving, monitor – If not or worsening, then consider viscosupplemenation

47. What is Viscosupplementation? It is a solution of hyaluronan. Hyaluronan is the lubricant and shock absorber in joints. Osteoarthritis reduces the body’s ability to produce hyaluronan. Without it, the patient experiences the pain of OA as the joint wears out.

48. How long will it last? It varies from patient to patient, depending on a number of factors: age, weight, stage of the disease, etc. Maximum benefits can be seen up to 12 weeks from the last injection In general, the beneficial effects last from 6 months to a year No contraindication to a repeat injection series

49. Elbows 90% of the time it’s an overuse injury

50. Lateral and Medial Epicondylitis

51. Treatment Treatment consists of – Rest: take some time off! – Ice – Compression – Elevation – Anti-inflammatories

52. Treatment For recalcitrant cases – Consider corticosteroid injection – Platelet rich plasma injection Most of the time these go away. Some require surgery

53. New Horizons in Treatment Always working on better fixation techniques More anatomically correct But what about just trying to make the body heal better?

54. Platelet Rich Plasma High concentration of functionally viable platelets and their associated growth factors Extracted from a small amount of patients blood: 9-18cc Spun through a simple centrifugation process to form a dense suturable fibrin matrix scaffold Delivered arthroscopically/open and placed directly into the tear site to stimulate a reparative healing response for soft tissue and bone repair

55. FactorTarget Cell/TissueFunction PD-EGF (epidermal growth factor) Blood vessel cells, outer skin cells Fibroblasts, and many other cell types Cell growth, recruitment Differentiation, skin closure Cytokine secretion PDGF, A+B (platelet-derived growth factor) Fibroblasts, smooth muscle cells, chondrocytes, osteoblasts, mesenchymal stem cells Potent cell growth, recruitment Blood vessel growth, granulation Growth factor secretion; matrix formation w/BMPs (collagen and bone) TGF-ß1 (transforming growth factor beta1) Blood vessel tissue, outer skin cells Fibroblasts, monocytes TGF gene family includes the BMPs Osteoblasts – highest levels of TGF-βr Blood vessel (+/-), collagen syn. Growth inhibition, apoptosis (cell death) Differentiation, activation IGF-1,2 (insulin-like growth factor1,2) Bone, blood vessel, skin, other tissues Fibroblasts Cell growth, differentiation, recruitment Collagen synthesis w/PDGF VEGF/ECGF (vascular endothelial GF) Blood vessel cellsCell growth, migration, new blood vessel growth Anti-apoptosis (anti-cell death) bFGF (basic fibroblast growth factor) Blood vessels, smooth muscle, skin Fibroblasts, other cell types Cell growth Cell migration, blood vessel growth Platelet-Derived Growth Factors

56. Applications Direct liquid form injections of concentrated platelets for the various tendonitis problems Clot form applications with extended growth factor release for cuff repairs, etc…

57. Conclusion Sports and athletics are a vital part of our lives As we continue to play, the likelihood of injury increases There are many treatment options available

58. Conclusion My role as an orthopedic surgeon is not to tell you no but rather to “Keep your life in motion.”