The 4th International Conference on Concussion in Sport Held in Zurich, November 2012

Written by admin on April 17, 2013 – 9:28 pm -

“This paper is a revision and update of the recommendations developed following the 1st (Vienna 2001), 2nd (Prague 2004) and 3rd (Zurich 2008) International Consensus Conferences on Concussion in Sport …

The new 2012 Zurich Consensus statement is designed to build on the principles outlined in the previous documents and to develop further conceptual understanding of this problem …

While agreement exists pertaining to principal messages conveyed within this document, the authors acknowledge that the science of concussion is evolving, and therefore management and return to play (RTP) decisions remain in the realm of clinical judgement on an individualised basis…

This consensus paper is broken into a number of sections

1. A summary of concussion and its management, with updates from the previous meetings;

2. Background information about the consensus meeting process;

3. A summary of the specific consensus questions discussed at this meeting;

4. The Consensus paper should be read in conjunction with the SCAT3 assessment tool, the Child SCAT3 and the CRT (designed for lay use).

Please read the following for more information/ details:
Consensus Statement on Concussion in Sport – BJSM

“At a press conference held at the American Academy of Neurology’s (AAN’s) 2013 Annual Meeting, the release of new AAN guidelines for the evaluation and management of sports-related concussion (SRC) were announced. The recommendations update the 1997 AAN sports concussion practice parameter and were published online in Neurology on March 18, 2013.[1] The new guidelines attempt to address uncertainty and inconsistency in the management of concussion and mild traumatic brain injury (TBI) by addressing 4 clinical questions:

1. For athletes, what factors increase or decrease concussion risk?

2a. For athletes suspected of having sustained concussion, what diagnostic tools are useful in identifying those with concussion?

2b. For athletes suspected of having sustained concussion, what diagnostic tools are useful in identifying those at increased risk for severe or prolonged early impairments, neurologic catastrophe, or chronic neurobehavioral impairment?

3. For athletes with concussion, what clinical factors are useful in identifying those at increased risk for severe or prolonged early postconcussion impairments, neurologic catastrophe, recurrent concussions, or chronic neurobehavioral impairment?

4. For athletes with concussion, what interventions enhance recovery, reduce the risk for recurrent concussion, or diminish long-term sequelae?

The new AAN recommendations — divided into preparticipation counseling; assessment, diagnosis, and management of suspected concussion; and management of diagnosed concussion — were nicely summarized at the press event by lead authors Christopher C. Giza, MD, and Jeffrey S. Kutcher, MD. However, some areas of the guideline are open to interpretation, particularly when it comes to deciding when it is acceptable to allow an athlete with a suspected concussion to return to play. The following summary serves as a guide to the new report, highlighting the major recommendations and providing additional clarification based on comments from Drs. Giza and Kutcher…”

Please read the following for more information/ details:
New Concussion Guidelines – An Analysis


Posted in Injury Prevention, Sports Medicine | No Comments »

Sports & Health: Guidelines for Young Pitchers

Written by admin on April 15, 2013 – 7:54 am -

Cary, NC – It’s that “Field of Dreams” time of year and many young baseball players dream of throwing a perfect game and becoming the team “Ace.” The path to greatness begins much earlier and requires learning proper mechanics and maintaining pitching fitness.

Work Before Play – Strength & Conditioning

All young athletes should perform off-season strengthening and conditioning. Even If your youngster has become a one-sport athlete, focusing solely on baseball, he should not actually play year round.

Year-round play (11-12 months straight) has been associated with increased incidences of both minor and severe injuries. Even minor injuries can derail training and development, and put your athlete behind other players once practices and games begin.

Work with your athlete’s coach to determine what training and strengthening drills should be done, and strictly follow that program.

Pitchers Need 3 Months Off

Young pitchers need a three-month rest period from baseball each year. This means three months without any games, drills and practices; however, athletes should continue to follow their off-season training program.

Because adolescent players are still growing and developing, they must be careful to avoid over-training. Taking time off, while it can be disappointing, is critical to the long-term health and success of any athlete.

Lower the Pitch Count

Younger pitchers should have lower pitch counts. Pitchers as young as seven and eight years old should pitch no more than 50 pitches each game, with the number of maximum pitches per game increasing until players are 17 or 18, when pitches are capped at 105 per game.

A pitcher might think he feels up to pitching more than the recommended number of pitches during a game, but by failing to follow the guidelines he will likely find himself injured or overly sore.

Mechanics Prevent Injury

Pay strict attention to the proper mechanics of pitching. This will involve working with your athlete’s coach, and more specifically, his pitching coach, to ensure that he is using proper form and techniques.

It is critical to learn how to perform each pitch properly. Developing proper habits early can prevent future injury.

Age- Specific Pitches

Learning different pitches is age-specific. Fastballs and change-ups are to be learned and used exclusively early in a pitcher’s career.

As tempting as it might be for an elementary school-aged pitcher, the curveball should not be used earlier than age 12. A slider should not be attempted until age 16.

It is important to consult your athlete’s coach and trainer before serious training begins, so that they can also be involved. Your child’s physician can also be a valuable resource in helping you know when learning new pitches and skills is appropriate.

Play Ball!

For a long-lasting baseball career, these are important guidelines to follow and will make a critical difference in young athletes’ health and ability to excel in the sport.

Story by Dr. Mark Galland, a Board Certified Orthopaedic Surgeon specializing in sports medicine, practicing at Orthopaedic Specialists of North Carolina in Wake Forest and North Raleigh. Photo by Greg Westfall.

The above article was published on April 11, 2013 in Cary Citizen.


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The Broström Procedure: Restoring Stability To Loose Ankles

Written by admin on April 12, 2013 – 10:42 am -

The arrival of spring’s warmer weather brings with it the desire to get more active. We are spending more time on the tennis courts, the golf course, the ball field, etc., providing opportunities to burn some energy and have fun … but unfortunately, being active also carries with it a risk of accidents and injury.

The ankle sprain is one of the most common injuries sustained by athletes and non-athletes alike. Simply stated, the “sprain” is a stretching or tearing of the lateral (outside) ligaments of the ankle: anterior talofibular ligament (ATFL), the calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). One or all of these ligaments may be damaged in a sprained ankle, and though uncommon, other ankle ligaments may also be damaged. The classic mechanism of such an injury is “rolling,” or inverting, the ankle after landing on another player’s foot or stepping on an uneven playing surface. This inversion mechanism of injury causes the ligaments to stretch, partially tear, or completely rupture. Very severe injury or repeated injury may ultimately result in chronic ankle instability. This results in decreased function of the ankle joint and becomes quite a nuisance for competitive athletes.

The primary treatment in both acute and chronic cases begins with external stabilization using ankle braces. This is combined with a rigorous rehabilitation program guided by a physical therapist. When conservative treatment measures fail and instability of the ankle becomes a daily issue, surgical intervention may be considered. The Broström procedure is primarily used to repair the ATFL; however, the CFL (and even more rarely, the PTFL) may be repaired during the procedure as well. By repairing these damaged ligaments, proper ankle mechanics and function are restored. The ultimate goal is to restore the ankle to its pre-injury state. The procedure has a 90% success rate, and athletes usually return to play within three-four months.

Recovery time after the surgery may vary depending on each patient’s response. Typically, there is a six-week period of time when the ligaments are allowed to heal. During these six weeks, the patient will be non-weight bearing or limited weight bearing status (in a boot) and only allowed to do light range of motion activities. After the initial six-week healing time, physical therapy is introduced to help regain proper ankle strength, range of motion, proprioception, and restoring a normal gait (walking without a limp). Returning to high level activities may take up to six months; however, it may be sooner depending on each individual.

Unfortunately, ankle injuries are a common result of today’s active lifestyles. If you happen to fall victim to an ankle injury and traditional treatments just don’t seem to help, remember that there are other alternatives available, and the Broström procedure may be the answer for you.

Dr. Mark Galland is a Board Certified Orthopaedic Surgeon specializing in sports medicine, practicing in Wake Forest and North Raleigh. He serves as team physician and Orthopaedic consultant to the Carolina Mudcats, High-A Affiliate of the Cleveland Indians of Major League Baseball, as well as several area high schools and colleges. Dr. Galland can be reached at 919-562-9410 or by visiting www.orthonc.com or www.drmarkgalland.com, or on Twitter @drmarkgalland.

Matt Rongstad, ATC/LAT is a post-graduate fellow of the GOSM program at OSNC.

The above article was published in Circa Magazine (April-May-June 2013).


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The Injured Ankle: When Is An Ankle Injury More Than Just A Sprain?

Written by admin on April 11, 2013 – 10:24 pm -

You stepped in a hole, landed on another person’s foot, tripped on a root, or simply took an awkward step. We’ve all done it – that is, “tweaked” our ankle and assumed it must be just a simple ankle sprain. You push through the pain limping for awhile, waiting, expecting your ankle to return to normal. The swelling slowly reduces, but the bruising worsens until you cannot take a step without intense pain. Unfortunately, a more significant injury is present. How do you know when an injury isn’t just an ankle sprain, but rather an injury that could prove an impediment to your active lifestyle?

Many conditions can, initially at least, be confused with a simple ankle sprain. Fractures are the most common, and can involve bones of the ankle or nearby portions of the foot. Most frequently injured are the malleoli – the ankle bones that protrude the most, each resembling a small golf ball on each side of the ankle. Another common fracture site is the talus, which lies between the malleoli. Last, and technically not an actual bone of the ankle, is the fifth metatarsal that connects to your pinky toe; it is a part of the midfoot, but is often injured by a similar mechanism as other ankle injuries. Perhaps the most serious soft tissue injury of the ankle is the now-infamous high ankle sprain. This is an injury to the ligaments that connect the two lower leg bones, the tibia and fibula, together at the ankle. This often requires surgical correction, or at the very least, immobilization and restricted weight-bearing for several weeks.

Clinicians have a variety of tools available to make the correct diagnosis. The Ottawa Ankle Rules is one such tool that is particularly important in the athletic setting – on the court and on the field, and is routinely used to determine when an x-ray is necessary. The rules are somewhat technical in nature, but can be easily summarized as any direct tenderness of an ankle or foot bone, combined with the inability to walk four steps, indicate the need for medical attention. As in all cases, the rules are generalized and one should seek medical attention for any injury that one deems serious. The true inability to bear weight is a red flag that should dictate the need to seek professional medical attention.

The initial treatment for all of these injuries is immediate use of R.I.C.E. (Rest – Ice – Compression – Elevation) and should be continued for at least three days to decrease pain, swelling, and bruising. A physician skilled and experienced in treating sports injuries should be consulted as soon as possible. Sports medicine specialists are usually orthopaedic surgeons with additional training or certification in sports medicine. These physicians frequently care for a number of athletic programs and teams, and are well versed in the diagnosis and treatment of a variety of athletic injuries.

Preventing these injuries is always preferred to treating them, but is not always possible. Select footwear appropriate for the sport or activity. It must fit well, providing support and stability to the foot and ankle. If a history of multiple ankle sprains is present – a sign of underlying ankle instability – it is good practice to employ ankle taping or to wear lace-up ankle braces during activity. Perhaps most important is maximizing strength, endurance, and balance, which are best obtained with sport-specific drills performed as a part of a supervised rehabilitation program.

Ruby Floyd is a senior athletic training student at Western Carolina University, studying this semester at the GOSM program.

Dr. Mark Galland is a Board Certified orthopaedic surgeon specializing in sports medicine, practicing in Wake Forest and North Raleigh. He serves as team physician and orthopaedic consultant to the Carolina Mudcats, High-A Affiliate of the Cleveland Indians of Major League Baseball, as well as several area high schools and colleges. He can be reached at 919-562-9410 or by visiting www.orthonc.com or www.drmarkgalland.com, or on Twitter @drmarkgalland.

Above article published in Circa Magazine (January-February-March 2013, p. 46)


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Mystery Knee Pain Not In “Head”, But In “Rear End”

Written by admin on March 18, 2013 – 2:59 pm -

“Patellofemoral pain syndrome (PFPS) is one of the most common presentations to sports medicine practitioners. In a large study of 2519 presentations to a sports medicine clinic, 5.4% were diagnosed with PFPS, accounting for 25% of all knee injury presentations.”

“There is growing evidence to support the association of gluteal muscle strength deficits in individuals with patellofemoral pain syndrome (PFPS) and the effectiveness of gluteal strengthening when treating PFPS. ”

For more information on this topic, please view the below attachment from British Journal of Sports Medicine by Christian J Barton, Simon Lack, Peter Malliaras, and Dylan Morrissey.

Gluteal Muscle Activity and Patellofemoral Pain Syndrome


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“Platelet-Rich Plasma May Have Edge in Jumper’s Knee”

Written by admin on March 14, 2013 – 6:55 am -

By David Douglas: NEW YORK (Reuters Health) Mar 07

Platelet-rich plasma (PRP) injections might be more helpful to athletes with jumper’s knee than focused extracorporeal shock wave therapy (ESWT), according to Italian researchers.

Dr. Mario Vetrano told Reuters Health by email that both approaches “seem to be safe and promising as part of the treatment of jumper’s knee patients. However, both treatments share the same disputes: lack of hard evidence through randomized clinical trials and no standardized treatment protocols.”

To compare outcomes, Dr. Vetrano and colleagues at Sapienza University of Rome studied 46 athletes with tendonopathy due to overuse of the knee extensor mechanism.

They randomized their patients to receive either two autologous PRP injections over two weeks under ultrasound guidance, or three sessions of focused ESWT. Both groups then went on to a standardized stretching and muscle strengthening protocol.

Given minimal or no pain after four weeks, patients were allowed to gradually return to previous training activity. Complete return to sports took place in accordance with the patient’s pain tolerance and recovery.

A blinded reviewer made assessments before and up to 12 months after treatment. The findings were published online February 13th in The American Journal of Sports Medicine.

Both groups showed benefit, and there were no significant between-group differences in outcome measures at two months. No clinically relevant side effects were seen in either group.

However, at six and 12 months, the PRP group showed significantly greater improvement in Victorian Institute of Sports Assessment-Patella questionnaire and pain visual analogue scale. At 12 months, the PRP group also had significantly better modified Blazina scale scores.

Both approaches seem promising, but “given current knowledge,” say the investigators, “it is impossible to recommend a specific treatment protocol.”

Nevertheless, as Dr. Vetrano concluded, “The analysis of our study showed comparable results in both treatment groups at short term, with better results in the PRP group at six and 12 month follow-ups.”

Original Study Published in American Journal of Sports Medicine by Mario Vetrano, MD, Anna Castorina, MD, Maria Chiara Vulpiani, MD, Rossella Baldini, PhD, Antonio Pavan, MD, and Andrea Ferretti, MD.

Abstract available

__________________________

For more information on Platelet-Rich Plasma (PRP) therapy, please read my article at www.orthonc.com.


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“It’s Not Funny”

Written by admin on March 8, 2013 – 12:24 pm -

Have you ever hit your “funny bone”? You know that spot on the elbow that causes a stabbing pain/ tingling (parathesia) down into your forearm and hand. In fact, when you hit the inner side of your elbow the sensation is anything but funny, right? The temporary tingling, stabbing pain, and inability to move wrist/ fingers comes from an ulnar nerve contusion (bruise), not an injury to the bone.

The ulnar nerve runs through an area in the elbow called the cubital tunnel, and when the elbow is flexed this area opens up so that the nerve is stretched and minimally protected by soft tissue. The nerve lies on top of bone, and is only protected from the outside by your skin in this position, therefore most ulnar nerve contusions will occur when the elbow is flexed instead of extended.

This nerve innervates muscles that move the forearm, wrist and fingers, while also providing sensation to the inner forearm, pinky side of the palm, and palmar aspects of the medial fourth and fifth digits (inside of ring and pinky fingers).

Ulnar nerve contusions may result in symptoms of varying duration, but usually things will return to normal with time. Icing the area should be done with caution (due to the superficial nature of the nerve), anti-inflammatories may be helpful, and upon return to activity one may wish to invest in padding for the area.

The ulnar nerve (at the elbow) can also be irritated in patients with medial epicondylitis, ulnar collateral ligament injuries, ulnar nerve entrapment, elbow fractures/ dislocations, or in some cases people have been known to experience a subluxation of the nerve.

Mary Sult (LAT, ATC) is a Certified Athletic Trainer at Orthopaedic Specialists of North Carolina. Mary regularly provides outreach services to Bunn High School (Bunn, NC). OSNC’s Sports Medicine staff also works with other schools and sports organizations in Franklin, Granville, Wake, and Vance counties. For more information please visit www.orthonc.com.


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Athletic Trainers on the Sidelines & in the Clinic/ Office…

Written by admin on March 6, 2013 – 4:00 pm -

Traditionally physician’s offices have been staffed by receptionists, medical assistants, nurses, physician assistants, x-ray technicians, and maybe even an intern or student. However, in recent years, athletic trainers (AT) have become important additions to many clinics, especially in orthopedic practices.

Athletic trainers have been recognized as allied healthcare professionals, by the American Medical Association, since 1990 (AMA, p. 1). An entry-level position within the profession requires a bachelor’s degree from an accredited academic program, a passing score on a three part (national) exam administered by the Board of Certification TM, state licensure or certification (required by 48 states within the U.S), and adherence to professional standards and a code of ethics. Once certified, an AT must also complete continuing education programs, and maintain CPR/ AED credentialing (Rogers).

The traditional role of an AT on the sidelines and within an athletic program, has expanded to the medical clinic as a physician extender. For some, formal post-graduate work may be completed in the form of a residency or fellowship, but even without such additional training, most ATs are well-prepared to function as physician extenders in orthopaedics. This ability is borne from the undergraduate curriculum which is an intense focus on prevention, diagnosis, and intervention techniques for emergency, acute, and chronic musculoskeletal maladies.

As a physician extender, athletic trainers are often responsible for recording patient histories, performing physical assessments, and presenting the findings to the physician. Additional duties include preparing injections, teaching home exercise/ rehabilitation programs, applying/ removing casts, fitting crutches/ braces, removing sutures/ staples, completing therapy/ lab/ medication orders, and answering patient questions about insurance claims, disability forms, injuries, treatment options, and procedures. With additional training, an AT may even administer patient injections and assist the surgeon in the operating room.

In 2009, Orthopedics Today reported that clinics utilizing athletic trainers, as physician extenders, “saw an 18% average increase in productivity,” without any apparent deterioration in quality of care. Recent literature suggests there is “no difference in the patient’s perception of care comparing an orthopedic resident and athletic trainer” (Pecha), and in fact, “trends are a little bit higher for the athletic trainer in patient satisfaction scores” (Pecha). Modern medicine, by its very nature is characterized by unprecedented uncertainty and volatility. There is little doubt that Athletic trainers are well-positioned to provide much needed support to their supervising physicians and to their patients.

Caitlin Davis, LAT, ATC is a post graduate fellow at GOSM. For more information, visit us at www.atcfellowship.com

Mary Sult (LAT, ATC) is a certified and licensed (NC) athletic trainer at Orthopaedic Specialists of North Carolina. Mary regularly provides outreach services to Bunn High School (Bunn, NC). OSNC’s Sports Medicine staff also works with other schools and sports organizations in Franklin, Granville, Wake, and Vance counties. For more information please visit www.orthonc.com.

References

American Medical Association. Therapy and Rehabilitation. Retrieved from

https://www.ama-assn.org/ama1/pub/upload/mm/40/ah03-athletic-trainer.pdf

Pecha, Forrest (2013, January). The Growing Role of Athletic Trainers in Orthopaedics. Retrieved from http://wwworthopreneurpub.com/component/content/article/332-the-growing-role-of-athletic-trainers-in-orhopaedics?…

Rogers, C. (2008, October). Physician extenders: Pa’s, np’s, and…athletic trainers?. Retrieved from http://www.aaos.org/news/aaosnow/oct08/managing4.asp

Today, O. (2009, July). Athletic trainers can move from the playing field into the office as physician extenders. Retrieved from http://www.healio.com/orthopedics/business-of-orthopedics/news/print/orthopedics-today/{8CC880B5-E523-4092-A54B-009EBB665D38}/Athletic-trainers-can-move-from-the-playing-field-into-the-office-asphysician-extenders


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Anterior Cruciate Ligament Injuries in the Skeletally Immature Athlete…: Journal of AAOS(February 2013)

Written by admin on March 4, 2013 – 6:19 am -

Anterior Cruciate Ligament Injuries in the Skeletally Immature Athlete: Diagnosis and Management

Jeremy S. Frank, MD and Peter L. Gambacorta, DO

Abstract

Intrasubstance anterior cruciate ligament (ACL) injuries in children and adolescents were once considered rare occurrences, with tibial eminence avulsion fractures generally regarded as the pediatric ACL injury equivalent. However, with increased single-sport focus, less free play, and year-round training at younger ages, intrasubstance ACL injuries in children and adolescents are being diagnosed with increased frequency. As in the adult, a knee devoid of ligamentous stability predisposes the pediatric patient to meniscal and chondral injuries and early degenerative changes.

Management of ACL injuries in skeletally immature patients includes physeal-sparing, partial transphyseal, and complete transphyseal ACL reconstruction. Complications include iatrogenic growth disturbance resulting from physeal violation.

In the past 20 years, sports injuries in pediatric and adolescent athletes have dramatically increased. Approximately 38 million young athletes participate in organized sports annually in the United States. Of these, nearly 2 million high school students and almost twice as many athletes aged <14 years are treated for a sports-related injury each year. This new epidemic of sports-related injuries can be partially attributed to the dramatic surge in the number of participants since the passage of Title IX, along with increased emphasis on year-round competition, single-sport concentration, and more intense training.

Summary

ACL ruptures in skeletally immature patients are becoming more common with increased single-sport concentration, year-round participation, and less time spent in free play. It is the role of pediatric sports medicine providers to properly diagnose and manage these injuries. Nonsurgical management, including activity modification, bracing, and physical therapy, is best used for patients with partial tears involving <50% of the ACL diameter. In patients with complete ruptures, chronologic, physiologic, and skeletal maturity must be assessed to appropriately address the injury. Treatment options are predicated on assessment of the patient’s maturity and include physeal-sparing, partial and complete transphyseal, and adult-type anatomic ACL reconstruction. Postoperative management includes weight-bearing and activity modifications, bracing, and a progressive physical therapy protocol emphasizing ROM, closed-chain strengthening, and a gradual and measured return to sport-specific maneuvers. Surgical complications are rare.

Journal AAOS © 2013 (February)


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Posted in Arthroscopy, Knee, Sports Medicine | No Comments »

“Bad Romance” with the Hip

Written by admin on March 1, 2013 – 8:22 am -

Musician and song writer Lady Gaga recently underwent hip surgery to repair a torn labrum. Many fans were concerned and dismayed as she canceled the rest of her current tour. Fans should not be overly disappointed. Hip arthroscopy has a relatively quick recovery and return to a high level of activity is a realistic goal.

Many are unaware that the hip joint has a labrum. As with the shoulder joint, the labrum of the hip is a type of cartilage that provides stability while allowing a high degree of flexibility, and motion of the hip. While labral injuries are much more common in the shoulder, they are being diagnosed with increasing frequency in the hip. A tear in the labrum can be degenerative– which occurs as a result of over-use, or traumatic–due to a sports injury, fall, or accident.

A tear in the labrum of the hip can be difficult to diagnose as it may not be evident on magnetic resonance imaging (MRI). Additionally, many symptoms characteristic of a labral tear of the hip, such as groin pain, clicking, snapping, and decreased range of motion, are also common in other hip conditions including groin strains or sports hernias. To further confound matters, even if an MRI demonstrates a labral tear, it is not necessarily an indication that the tear is the source of the symptoms. Confused yet? Never fear, at the conclusion of a methodical workup and rehabilitation program, the answer is usually clearly obvious. Conservative management of labral injuries is thus, not only an option, but often a necessary part of the diagnostic process. Failure of conservative management, physical therapy or steroid injection, may ultimately lead to surgical repair.

Arthroscopy of the hip involves small incisions and use of a tiny camera to locate the damaged labrum and either repair or remove the damaged tissue. Full recovery after arthroscopic intervention may take 12 weeks or longer depending on both the individual and the extent of the damage.
Recovery can be accelerated with skilled rehabilitation from properly trained individuals such as physical therapists and/or athletic trainers.

Fans of Lady Gaga should remain optimistic that she will return to the stage and “Just Dance” her way to “The Edge of Glory.” Many professional athletes have received similar surgeries, including Alex Rodriguez, Mario Lemieux, and Kurt Warner. Warner, a Super Champion, NFL quarterback, was able to return to full workouts two months after his hip arthroscopy.

Matt Rongstad is an Certified Athletic Trainer, Licensed in the state of NC. Matt is currently training in the GOSM Fellowship.

Dr. Galland is a Board Certified Orthopaedic Surgeon specializing in sports medicine practicing in Raleigh, NC. He serves as the team physician and orthopaedic consultant to the Carolina Mudcats, Cleveland Indians Single-A affiliate as well as many other local high schools and colleges.


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