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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“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

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


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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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Health Care in High School Athletics

Written by admin on February 15, 2013 – 2:02 pm -

Within high school athletics there is an inherent risk for injury. On some days parents may be present, but on many occasions coaches are tasked with injury management and coaching simultaneously. To relieve some of the stress of this dual responsibility, and ensure proper medical care for high school athletes many schools employee Certified Athletic Trainers.

Certified Athletic Trainers are not to be confused with strength and conditioning coaches, or personal trainers, but are health care professionals. While working under the direction of a physician they are trained in the prevention, diagnosis, immediate care, and rehabilitation of many injuries and medical conditions.

Certified Athletic Trainers also may work in industrial settings, physician’s offices, physical therapy centers, hospitals, colleges/ universities, professional sports, performing arts, wellness centers/ gyms, the military, or other public service organizations such as fire/ police departments.

So whether it is a fracture, a sprain, tendonitis, muscle cramps/ spasms, a contusion, or even asthma, diabetes, or heat illness (etc), “Every Body Needs An Athletic Trainer”.

Mary Sult is a certified and licensed (NC) athletic trainer at Orthopaedic Specialists of North Carolina (OSNC). 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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Dr. Galland Releases Podcast on Double Bundle ACL Reconstruction Procedure

Written by admin on August 28, 2012 – 8:55 am -

Dr. Mark Galland has released a podcast discussing the double bundle, or anatomic, ACL reconstruction procedure. In the podcast, Galland discusses what the procedure entails, what types of injuries require the surgery, candidates for the surgery and the proper patient treatment after the procedure.

To listen to the podcast, click here: Double Bundle ACL Reconstruction


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Take Five To Stretch

Written by admin on April 6, 2012 – 7:29 am -

This post can also be found on the Association Executives of North Carolina’s Success By Association blog.

The core of my practice is sports medicine. But it isn’t just athletes that get injured. As we rely more heavily on technology and the average person uses a desktop computer, a smartphone, and an Ipad in a given day, chronic overuse injuries are only going to increase. Ailments like epicondylitis (tennis elbow), carpal tunnel, and tendinitis are generally caused by repetitive use of the forearm, wrist, and hand muscles. These problems are degenerative in nature and can be extremely uncomfortable and activity limiting. Ergonomics, the study of efficiency in the workplace, can offer many solutions and adjustments for reducing the severity and frequency of these problems. Here I’d like to offer my own advice- Take 5 to stretch.
5 minutes in the mid-morning and 5 minutes in the afternoon to do these 3 simple stretches will go a long way to keeping your arms limber and pain free, hopefully for years.

1. Epicondylitis Stretch- Epicondyle is the medical term for the bony area of your elbow where your wrist and forearm muscles attach. You have a medial epicondyle for the muscles that flex your wrist and enable you to pronate (turn your palm toward the floor). You also have a lateral epicondyle for the muscles that extend your wrist and allow you to supinate (turn your palm up). In order to stretch these muscles, you should reach your arm out in front of you with your elbow straight and use your opposite arm to bend the wrist into flexion. Hold 20 seconds. Then, keeping your elbow straight, pull your wrist into extension. Hold 20 seconds. Repeat each way one more time.

2. Wrist Rotation- Keeping your wrist poised while typing all day can cause stiffness, pain, and contribute to carpal tunnel. To give your wrist a break, make a loose fist and rotate your wrists in circles for about 20 seconds. Go on to stretch your hands (exercise 3) then repeat for 20 more seconds.

3. Hand/Finger Stretch- Give your hands a break from typing, emailing, texting, tweeting, blogging, and data entering. For this stretch, you want to spread your hands and fingers out as wide as you can and then make a tight fist. Open your hand and widen your fingers then pull it back into a fist. Repeat about 10 times.

Three exercises. Five minutes. Make it part of your daily routine until it becomes a habit- just like brushing your teeth. I would be happy to see you in the office for any problem any time, but if I can help keep you healthy, that’s even better.


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