Here Comes Volleyball Season: We Are Ready in the Ortho World!

Volleyball season is fast-approaching. Today, let’s discuss the four most common areas of injury, treatment and prevention.

Volleyball was my sport as a youth. I played all year-round, and if I wasn’t in practice or a tournament, I was working out. But is the constant wear and tear on our bodies without rest hurting us even at a young age? In parts, yes. We commonly see athletes whose injuries could have been prevented with a short period of rest or prevention methods. Let’s talk about that:

1.     Ankle

Most common: ankle sprain. It comes as no surprise that ankle injuries are one of the most common injuries seen in volleyball. Initial treatment includes RICE (rest, ice, compression, and elevation). However, it is always wise to see an orthopedic provider who can help guide you in treatment, prevention, and return to play. What many people do not know is younger children and teenagers’ growth plates are still open and are also at risk of injury with a twist of the ankle. When growth plates are still open, they are the most vulnerable and at risk for a Salter-Harris fracture which involves the growth plate. After growth plates close, the ligaments become the most vulnerable. I like to tell my patients that ligaments are like the candy Laffy Taffy. Once they are stretched out, they don’t necessarily return to their original state. Thus, prevention and strengthening are imperative.

Prevention: ankle range of motion, strengthening, and balance exercises; keeping footwear up to date; purchasing well-fitting and high-quality footwear; and ankle braces during practice and games.

2.     Knee

Most common: patellar tendonitis (chronic) and ACL tears (acute)

Patellar tendonitis, also known as jumper’s knee, is very common due to the amount of jumping volleyball requires. Many times, the athlete will localize the pain right under the kneecap at the proximal aspect of the patellar tendon. Our office utilizes diagnostic ultrasound to look at the characteristics of patellar tendon, identify if there is tearing, compare it to the unaffected size, and determine if there is any new blood vessel formation (neovascularization). Prevention and treatment include stretching and strengthening exercises, a period of rest from jumping, and a patellar tendon strap. Short-term anti-inflammatories can helpful. In difficult cases, we can turn to platelet-rich plasma injections (PRP). Those with an open growth plate at the tibial tuberosity are at risk of developing Osgood-Schlatter’s.

Anterior Cruciate Ligament (ACL) tears: Volleyball is relatively high risk for ACL tears due to potentially landing awkwardly after a jump or during pivoting maneuvers frequently required. The ACL is under the most load when the knee is under sudden valgus (knock-kneed) stress. The best preventative options are to strengthen the outer hip, upper thigh, and gluteal muscles along with jump-training techniques to help protect the knee. If diagnosed with an ACL tear, treatment can be conservative or surgical. Those who wish to continue participating in high-risk sports generally opt for surgical intervention.

3.     Shoulder

Most Common: Impingement, Labral Tears, Instability, and Rotator Cuff Tendinitis

Those who are hitters in volleyball are at risk for all of these shoulder conditions. Once again, relative rest, recovery, and strengthening are imperative in preventing these conditions. Improvement in form and hitting techniques are often helpful. Injections (occasional steroid, but more commonly PRP) can play a role in more difficult cases.

4.     Low Back

Most Common: Lower Back Strain/Sprain (acute) or Spondylolysis

Volleyball requires repetitive bending, twisting, and hyperextension movements which put the low back in vulnerable positions. The biggest takeaway is if you or your child is experiencing low back pain that is not relieved after a couple weeks, please see an orthopedic provider. This could indicate a spondylolysis (a stress fracture) or stress reaction in the bones of the lumbar spine. Low back strains/sprain can be muscular or ligamentous and tend to improve within 2 weeks. If that’s not the case, then we often look for spondylolysis or even disc problems.

As mentioned, strengthening and adequate rest while allowing our bodies to recover are the best ways to prevent these common injuries. However, if these injuries occur and you or your child’s symptoms are unresolved beyond a week or two, please give us a call!

Taylor Moore, NP

What Does "Being Proactive Over Reactive" Mean?

Proactive Interventional Orthopedics (PIO)…a concept we will continue to promote. What does it mean in orthopedics to be proactive over reactive? Here are some examples and brief explanations:

Choose maintenance and more long-term injections over short-term steroid/cortisone injections: platelet-rich plasma (PRP) and hyaluronic acid injections often produce a more clinically significant and longer duration of benefit than steroid injections. For your knee and hip arthritis, tennis and golfer’s elbow and plantar fasciitis, just to name a few, choose these injections.

A course of physical therapy over exercises you simply found online: patient outcomes are generally better when you work with a physical therapist over Dr. Google or YouTube. We have fantastic relationships with physical therapists across Middle Tennessee and can work with you to find the best fit.

Regular use of supplements over prescription or over-the-counter medications: there’s a time and place for prescription meds when managing orthopedic conditions. However, for long-term management, we prefer options like curcumin/turmeric, collagen, and glucosamine/chondroitin. That being said, it’s always wise to consult with a physician before starting new supplements.

Don’t wait for your pain or disability to reach high levels before you seek treatment: orthopedic conditions treated early after the onset of symptoms and when pain and dysfunction are at a low level typically respond better to less-invasive treatments, and this early treatment can lower the risk of further damage to the joint or tissue.

Choose a specialist over a primary care physician for your orthopedics needs: PCPs work really hard and a do a great job to care for your overall health, but they do not necessarily have the expertise, the tools such as on-site imaging and advanced equipment or the time to dedicate to your orthopedic conditions.

Healthy eating patterns over a fad diet: weight loss is a vital part of the treatment plan when it comes to weight-bearing joint problems like hip and knee osteoarthritis. Through a variety of options, we can help you a structure a plan to gradually lose weight in a manner that the weight will stay off and through means that can be maintained for the long-term.

As always, let us know if we can help you overcome an injury, treat an orthopedic condition or find the pathway to greater wellness with an improved quality of life!

F. Clarke Holmes, M.D.

Will Platelet-Rich Plasma (PRP) Injections Replace Cortisone?

The answer to this question is simple: Yes, No and Maybe. Platelet-Rich Plasma injections have taken the orthopedic world by storm. Why is this? They are safe. They are natural. They can be done in the office in a short period of time. They may prevent surgery in some cases. They can be disease-altering, not just symptom-reducing. Most importantly, in many cases of tendon, ligament and joint problems, they are EFFECTIVE.

PRP injections involve drawing blood from a patient’s vein, typically in the arm. Then, the blood is centrifuged (spun) to separate out the red and white blood cells, while simultaneously concentrating your own platelets. Our platelets are known to have numerous growth factors that serve many beneficial roles in our musculoskeletal tissues. This concentrated solution is then injected under ultrasound-guidance back into an area of damage, such as a partially torn tendon, the plantar fascia or an arthritic joint. We believe that these platelets help to modulate unhealthy inflammation that resides in damaged tissues. This helps over the long-term to reduce pain and subsequently, improve function. In some cases, damaged soft tissue can heal in the presence of these concentrated platelets. In other cases, the deterioration often seen in cases of osteoarthritis can be slowed or halted. Thus, there are some preventative benefits of PRP.

Cortisone injections, known medically as steroids, have been around for decades. They simply are very strong anti-inflammatories. They can reduce pain and swelling within hours to days of an injection. However, they are known to have catabolic, or “breakdown” effects, meaning, numerous exposures to steroids can worsen the structure and strength of a soft tissue or joint. They also can produce short-term systemic side effects, including fluid retention, headache, insomnia, changes in emotions, skin flushing/redness and increases in blood sugar, particularly in diabetics. Cortisone injections are still used quite frequently to treat tendonitis, arthritis and disc problems in the spine.

Now, back to the question in the title. In our practice, we still use both types of injections. However, the percentage of PRP injections is increasing, while the percentage of cortisone is dropping. Why? We want our patients to have “game-changing” treatments whenever possible. We want conditions to improve over the long-term. We want to stop that deterioration process and to promote healing when possible. Also, we know that in the case of cortisone injections, some patients feel so good, so quickly, that they are prone to re-injure themselves. Thus, short-term improvement, but long-term worsening with some cortisone injections.

Thus, how do we choose what type of injection to recommend to a patient? Here are some examples:

-A 60-year-old woman will be traveling on a bucket-list trip to Italy in one week. Her arthritic knee is painful and swollen, and she needs some quick relief to really enjoy this trip. We choose a CORTISONE injection to provide that relief. She will likely feel better within a few days of the injection and will probably see a benefit for 1-3 months.

-A 35-year-old runner tore his ACL at age 20 and had successful surgery. Now, he has mild osteoarthritis of the knee that is stiff in the morning, aches after long runs and occasionally swells. He is a great candidate for PRP. PRP should help his keep inflammation down, reduce his aches and preserve his cartilage in his knee for years to come.

-A 65-year old woman has had 2 weeks of lateral hip pain after a trip to the beach with frequent walking. She can’t sleep on the side of her painful hip and going up stairs is difficult. We diagnose her with trochanteric bursitis and gluteal tendonitis. A CORTISONE injection here may do the trick. She has an acute inflammatory response and needs some relief to simply sleep better at night and handle her activities of daily living with less pain.

-A 24-year-old recreational basketball player has patellar tendonopathy and pain every time he jumps and lands. Symptoms have been present for 6 months and despite physical therapy, a brace and NSAIDS, he is only 50% better. We offer him 1-2 PRP injections. We need to promote healing of that tendon. We want long-term reduction in symptoms and tissue improvement, so that he can continue to play basketball and with reduced risk of tearing the tendon. Plus, we never inject cortisone in or around certain tendons, including the patellar and Achilles tendons, due to the risk of tendon rupture.

-A 70-year-old has mild to moderate hip and knee osteoarthritis. He can play golf a couple days a week, but relies on frequent doses of ibuprofen after his golf games and on days he plays with his grandchildren. His hoping to avoid joint replacement in his lifetime and knows that long-term use of NSAIDs is not good for his blood pressure, stomach or kidneys. We offer him PRP as a great option, with an injection into the knee and hip joints on the same day. He then will return a month later for his 2nd set of injections. After that, we hope and expect that he will have less pain and better function for 6 to 24 months, while also lowering his chances of joint replacement in the intermediate future. These PRP injections can be safely repeated months to years later, if necessary.

These are everyday examples of how we customize our treatments for patients based on their symptoms, diagnosis and goals. Age of the patient can play a role, but one is never “too old” to have a PRP injection. When head-to-head studies compare PRP to steroid injections, PRP is declared the “winner” the large majority of the time. Thus, we know that for long-term benefits of many joint and tendon problems, PRP is the better choice.

In conclusion, cortisone/steroid injections are not going away any time soon. They still play a role in helping patients in select situations. However, the world of orthobiologic injections such as PRP will only continue to expand as we strive to find more natural and less-invasive ways to treat a variety of orthopedic conditions.

The Top 3 Activities that Lead to Summer Injuries in Adults

What are the top 3 activities that lead to summer injuries for adults?

1) Yard work- often a situation of doing too much at one time. Repetitive bending, lifting, pushing and trimming frequently lead to low back, neck, shoulder and elbow issues. Our advice- spread the work load among several family members and among several days. Instead of 4 hours of work on one day, divide the work load into 2-3 days. Get as close as you can to something you are lifting or trimming. Doing these with your arms further away from your body can overload the spine, joints and tendons. 

2) Tennis and golf- these are great warm-weather sports, but lead to a elbow tendon and low back problems quite frequently. The same concept discussed above applies: avoid overuse situations. Play 9 holes instead of 18 on some days. If you are a middle-ager, don't expect to play 72 holes on a weekend and not feel some aches and pain. With tennis, consider playing with a 2-handed backhand. Play some doubles, not just singles, as this can decrease your reps, but lead to similar enjoyment of the game. 

3) Running and power walking- many love just being outdoors for these fitness activities, while others are starting to train for 1/2 and full marathons in the fall. A couple of pieces of advice: if training for a race, follow a program/regimen. 12 weeks to train for a 1/2 marathon, 18 weeks for a full. To all: update your athletic shoes every 9-12 months or if any wear is present on the tread. Also, make sure your other shoes are supportive. Flimsy sandals and flip-flops lead to foot, ankle and knee problems, especially if these areas are already being stressed by other fitness activities. When it comes to summer shoes, to some degree, you get what you pay for. A quality pair of sandals or flip-flops will run you $50-$100. 

Enjoy the summer!

Should My Son Play Tackle Football?

"Should my son play tackle football" is a question I receive on a very frequent basis. Parents are more concerned than ever about the risks that come with playing this collision sport. The first question I ask the parent in return is "Does your son really want to play tackle football?" Football is a rigorous, gladiator-style sport. It often pushes boys towards their limits with regards to commitment, fear, body contact and fitness level. These "pushes" can be a positive thing for your son, but if he is not enthusiastic about playing this sport, then your question has been answered. I strongly discourage participation in football if your son doesn't want to be on that field. 

Here are the reasons your son SHOULD play football:

• He becomes part of a team, something bigger than himself. Bonding is often very high among football teammates, as they adopt an "in the trenches together" mentality
• Courage, dedication, loyalty, sportsmanship and confidence are valuable character traits that often develop with a successful football experience
• Improved fitness levels- football is a sport requiring endurance, speed, quickness and power, with some positions emphasizing more of these traits than others
• Mentoring- many football coaches become like father-figures to young men, teaching them important life lessons while teaching them football as well

Here are the reasons your son should NOT play football:

• First and foremost, he doesn't want to play
• The risk of injury. Here are some important injury-risk considerations:

1. Size and strength deficits- if your son is physically less developed than many other peers competing in football, then his risk is increased. If the team or league is allowing 140 lb. boys block and tackle 225 lb. boys and vice-versa, then the smaller boy's risk is much greater. In the youth leagues, rules are often in place to reduce this effect. In the high school environment, it is up to the coaches to ensure the safety of the smaller athletes.
2. Concussions- we could create an entire blog on this subject, but in a nutshell, concussions are common at all levels of football. Contrary to most conditions in medicine, concussion symptoms in younger football players often last longer than those more mature. New evidence is suggesting that the earlier the age one starts having concussions, the greater the risk of long-term problems such as memory deficits and depression, just to name a few. Also, the multiple concussions likely create a cumulative effect, meaning several concussions in a relatively short period of time create more long-term damage than one concussion or a few concussions separated by many years. Simply put, someone playing tackle football for 10 years is much more likely to have more concussions, whether diagnosed or not, than one playing for only 3 years. Improved equipment such as helmets and better tackling techniques may reduce the severity and risk of concussions, but no equipment or rule adjustment can significantly reduce or eliminate concussions. 
3. Orthopedic Injuries- minor contusions and sprains are part of the game for nearly every player and heal without consequence. However, some fractures and ligament sprains, although appropriately treated, leave football players with long-term pain and dysfunction. For example, despite a successful ACL-reconstruction surgery after an ACL tear, 50% of athletes have knee arthritis within 12 years of the injury. In addition, repetitive microinjury to the back likely leads to an increased risk of disc problems in the cervical and lumbar spine. 

When weighing the risk of injury as it relates to football participation, consider not only the immediate impact of injury, but also the long-term implications of concussions and orthopedic injuries.

If there is an opportunity to play flag football, then I encourage one to play this version for as long as possible. In my opinion, tackle football is a sport that be re-joined or joined for the first time at a later age, perhaps 9th or 10th grade without a major roadblock to success. Years of tackle football does not necessarily guarantee success at higher levels such as high school or college. In fact, beginning tackle football at a young age can lead to burnout or injuries that derail one's ability and desire to continuing playing into middle and high school. 

In conclusion, the decision of whether your son plays tackle football or not must be one thoughtfully considered by and discussed among the athlete and his family members. Risks and benefits for your child should be carefully weighed.

F. Clarke Holmes, M.D.

Impact Sports Medicine and Orthopedics, PLLC