Wednesday, December 5, 2012

St. Joseph's Health Center's Musculoskeletal Minute

Welcome back to St. Joseph's Health Center's Musculoskeletal Minute! This video blog features doctors from St. Joseph's Hospital Health Center in Syracuse, NY, speaking on orthopedic topics of interest. You will see a new video blog out every few weeks.

In this edition, Dr. Michael Vella, orthopedic surgeon at St. Joseph's Hospital Health Center, speaks on hip pain, hip replacement surgery and hip resurfacing.

Dr. Michael Vella is board certified in orthopedic surgery.

Education: MD, SUNY Health Science Center, BS, Siena College

Internship: SUNY Upstate Medical Center

Residency: Rhode Island Hospital

Fellowship: Brigham and Women's Hospital

Areas of Expertise: Arthroscopy, Patellofemoral Problems, Sports Medicine and Total Joint Replacement

Tuesday, November 6, 2012

St. Joseph's Health Center's Musculoskeletal Minute

Welcome back to St. Joseph's Health Center's Musculoskeletal Minute! This video blog features doctors from St. Joseph's Hospital Health Center in Syracuse, NY, speaking on orthopedic topics of interest. You will see a new video blog out every few weeks.

In this edition, Dr. Ryan Smart, sports medicine specialist at St. Joseph's Hospital Health Center, discusses shoulder injuries.

Dr. Ryan Smart is board certified in orthopedic surgery.

Education: MD, University of Michigan, BA, Cornell University

Residency: Yale University

Fellowship: Baptist Hospital, Boston

Areas of Expertise: Adult and pediatric sport injuries; fracture care; surgical repair of injuries of the shoulder, hip, knee, including arthoscopic shoulder and knee surgery; total shoulder and knee replacement, arthoscopic management of hip disorders, including labral tears and hip impingment.

Wednesday, September 26, 2012

St. Joseph's Hospital Health Center's Musculoskeletal Minute

Monday, September 10, 2012

St. Joseph's Hospital Health Center's Musculoskeletal Minute

Welcome back to St. Joseph's Hospital Health Center's Musculoskeletal Minute! This video blog features doctors from St. Joseph's Hospital Health Center in Syracuse, NY, speaking on orthopedic topics of interest. You will see a new video blog out every few weeks.

In this edition, Dr. Todd Battaglia, orthopedic surgeon at St. Joseph's Hospital Health Center, speaks on ACL injuries, including how they occur and the healing process.

Dr. Todd Battaglia is certified by the American Board of Orthopaedic Surgery.

Education:
MD - SUNY Buffalo School of Medicine
BS - Amherst College

Residency:
University of Virginia

Graduate Research Fellow:
University of Virginia - Surgery

Fellowship:
New England Baptist - Sports Medicine and Arthroscopic Surgery

Traveling Fellowship:
Arthroscopy Association of North America

Areas of Expertise:
ACL and Knee Ligament Reconstruction
Arthroscopic & Reconstructive Surgery of the Knee & Shoulder
Clavicle and AC Joint Injuries
Cartilage Regeneration/Restoration
Meniscus Surgery
Rotator Cuff Injuries
Shoulder Arthritis
Shoulder Instability/Dislocations
Sports Medicine

Friday, August 31, 2012

St. Joseph's Hospital Health Center's Musculoskeletal Minute

Thursday, August 16, 2012

St. Joseph's Health Center's Musculoskeletal Minute

Dr. Perry Cooke is certified by American Board of Orthopaedic Surgery.

Education:
MD - SUNY Health Science Center
BS - Amherst College

Internship:
Tufts Medical Center

Residency:
SUNY Upstate Medical Center

Areas of Expertise:
ACL and knee ligament reconstruction
Arthroscopic & reconstructive surgery of the knee & shoulder
Meniscus surgery
Rotator cuff injuries
Shoulder arthritis
Shoulder instability/dislocations
Sports Medicine

Tuesday, July 31, 2012

St. Joseph's Health Center's Musculoskeletal Minute

Welcome back to St. Joseph's Health Center's Musculoskeletal Minute! This video blog features doctors from The Center for Orthopedic & Spine Care at St. Joseph's Hospital Health Center in Syracuse, NY, speaking on orthopedic topics of interest. You will see a new video blog out every few weeks.

In this edition, Dr. Frederick Lemley, orthopedic surgeon at St. Joseph's Hospital Health Center, speaks on posterior tibial tendon problems.

Dr. Frederick Lemley is American Board of Orthopedic Surgery, Eligible.

Education:
M.D., SUNY Upstate Medical University
B.A., Dartmouth College

Residency:
West Virginia University

Fellowship:
University of Pittsburgh Medical Center

Areas of Expertise:
Foot & Ankle Surgery

Monday, July 16, 2012

St. Joseph's Health Musculoskeletal Minute

Welcome back to St. Joseph's Health Center's Musculoskeletal Minute! This video blog features doctors from St. Joseph's Hospital Health Center in Syracuse, NY, speaking on orthopedic topics of interest. You will see a new video blog out every few weeks.

Dr. Brett Greenky, orthopedic surgeon at St. Joseph's Hospital Health Center, speaks on obesity and its effects on orthopedic health.

Board Certified in Orthopedic Surgery and Assistant Clinical Professor

Education:
MD - Upstate Medical University
MS - Biology, Long Island University
BA, Biology, Northwestern University

Residency:
Upstate Medical University

Fellowship:
New England Baptist Hospital

Areas of Expertise:
Total hip, knee and shoulder, replacement, hip resurfacing, revision total joint surgery

Monday, July 2, 2012

St. Joseph's Health Musculoskeletal Minute

Welcome back to St. Joseph's Health Center's Musculoskeletal Minute! This video blog features doctors from St. Joseph's Hospital Health Center in Syracuse, NY, speaking on orthopedic topics of interest. You will see a new video blog out every few weeks.

In this edition, Dr. Warren Wulff, orthopedic surgeon at St. Joseph's Hospital Health Center, speaks on acute low back pain.

Dr. Wulff is certified by the American Board of Orthopaedic Surgery.

Education:
MD - University of Vermont College of Medicine
BA - Cornell University, College of Arts & Sciences
BS - Mechanical Engineering

Internship:
Upstate Medical University

Residency:
Upstate Medical University

Fellowship:
New England Baptist Hospital
Spine Fellowship, 2001

Areas of Expertise:
Cervical and Lumbar Spine Surgery

Monday, June 18, 2012

St. Joseph's Health Musculoskeletal Minute

Welcome back to St. Joseph's Health Center's Musculoskeletal Minute! This video blog features doctors from St. Joseph's Hospital Health Center in Syracuse, NY, speaking on orthopedic topics of interest. You will see a new video blog out every few weeks.

In this edition, Dr. Ryan Smart, sports medicine specialist at St. Joseph's Hospital Health Center, discusses sports knee injuries.

Dr. Ryan Smart is board certified in orthopedic surgery.

Education: MD, University of Michigan, BA, Cornell University
Residency: Yale University
Fellowship: Baptist Hospital, Boston
Areas of Expertise: Adult and pediatric sport injuries; fracture care; surgical repair of injuries of the shoulder, hip, knee, including arthoscopic shoulder and knee surgery; total shoulder and knee replacement, arthoscopic management of hip disorders, including labral tears and hip impingment.

Tuesday, June 12, 2012

Operation Walk Syracuse: Preparing for Panama

Operation Walk Syracuse is a group of orthopedic specialists (surgeons, medical doctors, nurses, anesthesiologists, and physical therapists) who travel to countries that lack ample access to desperately needed hip and knee replacement surgeries. The surgeries are performed at no cost and patients receive the same state of the art services that our patients receive here at home. This post highlights the “pre-trip” the group made to Panama recently, preparing for their longer trip in November 2012. Last year the group traveled to Nepal, performing more than 75 hip and knee replacements.

Thousands of miles closer, a fraction of the travel time, one hour difference in time, and the luxury of clean, running water, ample electricity, and sound building structures--this is Panama City, Panama. We joked casually as we were chauffeured from the airport in Panama City to the modest hotel that would serve as home base during our pre-trip visit to St. Tomas Hospital. We were preparing for our upcoming annual Operation Walk trip in November, 2012. We (Dr. Brett Greenky, Mike O’Hara, and I) discussed the stark contrast of Panama City in comparison to Kathmandu, Nepal our 2011 Operation Walk Syracuse destination. We speculated about the hospital, the working conditions, the medical staff, equipment challenges, and our potential patients. A literal world of difference from the far away and exotic land of Nepal, this mission should be a virtual walk in the park from a comparative standpoint.

Our small “scouting” team was warmly greeted by the Panamanians and hospital staff, and eagerly embraced and integrated into the Operation Walk Team visiting Panama City for their annual trip. Operation Walk Denver, a long time established Operation Walk group, had graciously permitted us to coordinate our “pretrip” visit with their scheduled mission trip to enable us to draw from their vast experience as an established team, as well as to permit them to show us the lay of the land at St. Tomas Hospital.

True to our beliefs, the differences were vast—a modern city with a fairly well equipped hospital rivaling many in the US in terms of the structure and facility features. Lacking, however, was the capacity to provide the people of

Panama

with life altering joint replacement surgery primarily due to the supply and demand. There simply aren’t enough joint replacement surgeons in Panama to meet the surgical needs of their people. It is for this very reason that Operation Walk teams are warmly embraced and welcomed into this country. The surgery missions are viewed by both government and hospital officials as a conduit for meeting the needs of their people; in essence, a salvation for them.

Our “perceived” differences between Kathmandu and Panama City rapidly dissipated as we filed into the patient screening clinic that had been assembled in anticipation of our arrival accompanying the Operation Walk Denver team. As we wound our way through the waiting room crowded with potential patients and their families, applause erupted and cheers echoed from the walls from the hundreds of people crowding the room. The American team offering the promise to relieve the pain and suffering for some, and restoring the ability to walk for others, had arrived.

The next six hours flew by in what seemed like mere minutes. Grateful patients and their families were ushered into screening rooms and evaluated by teams comprised of surgeons, medical doctors, anesthesiologists, and nurses. We encountered elderly people crippled from pain who had limbs misaligned by the long term effects of osteoarthritis. We met young people, eyes filled with hope for a better future, who had fused hips and/or knees with little or no mobility due to advanced rheumatoid arthritis that had been left untreated due to the lack of availability of disease modifying medications which are readily accessible in the US but not available in this country.

The potential patients were all impeccably dressed in Sunday best for their appointments with the Operation Walk team, wanting to demonstrate respect and admiration for the Americans who had come to offer them hope and relief. We quickly learned from the Denver team and from the Panama physicians that their lifestyle reality is actually dramatically different from the way they presented to us. Many live in condition of complete squalor and poverty, but their pride and respect for Operation Walk inspires them to present themselves immaculately coiffed and wearing what might be their only untattered garment.

Most of the patients were candidates for bilateral hip or knee replacements, and whenever medically feasible, procedures on both sides would be performed. For those patients only able to tolerate a single procedure, they were offered the hope of having the second surgery done when we, Operation Walk Syracuse, returns in November. The same held true for those patients who had medical conditions such as heart disease or diabetes that had to be brought under control prior to undergoing a surgical procedure. These patients were all considered to be in our “bullpen” and in the queue for surgery in November upon our return.

So, back to the differences—Nepal versus Panama City—the city, the hospital, the environment couldn’t not have been more in contrast, but the differences end there. Glance into the eyes of the people, old or young, patient or family member, and we were witness to the same basic need and hope for relief from suffering. It transcends several continents and many thousands of miles. Once again as we embark on this new journey to Panama City, we are forever humbled by the honor and privilege of caring for those less fortunate brothers and sisters in our world.

A patient in Panama, who will receive total knee replacement surgery.

Monday, June 4, 2012

St. Joseph's Health Musculoskeletal Minute

Education:
M.D., Yale University School of Medicine
B.A., University of Rochester

Residency:
New York Weill Cornell Medical Center

Fellowship:
Kerlan Jobe Orthopaedic

Areas of Expertise:
Arthroscopic & reconstructive surgery (shoulder, knee, elbow, hip & ankle)
Sports Injuries

Tuesday, May 22, 2012

St. Joseph's Health Musculoskeletal Minute

Welcome to the first edition of St. Joseph's Health Center's Musculoskeletal Minute! This video blog features doctors from St. Joseph's Hospital Health Center in Syracuse, NY, speaking on orthopedic topics of interest. You will see a new video blog out every few weeks.

In this first edition, Dr. Seth Greenky, chairman of Orthopedic Surgery at St. Joseph's Hospital Health Center in Syracuse, NY, speaks on partial knee replacements - specifically, patellofemoral knee replacement.

Dr. Greenky is Board Certified in Orthopedic Surgery and is an Assistant Clinical Professor.
Education: MD, Upstate Medical University, BA, Biology, Northwestern University
Residency: Upstate Medical University
Fellowship: Cleveland Clinic Foundation
Areas of Expertise: Total hip, knee and shoulder replacement, hip resurfacing, revision total joint surgery

Monday, April 23, 2012

Patellofemoral Pain

Dr. Michael Vella

Your knees carry the weight burden of your body and are subject to the rigors associated with that responsibility. When combined with the stress of high impact activities such as running, jumping, skiing, and other strenuous activities, a condition referred to as patellofemoral pain syndrome (Runner’s Knee) can develop. This condition is characterized by pain in the front of the knee which is caused by the irritation of the cartilage (flexible connective tissue connecting bones to bones) located on the back of the kneecap (patella).

Causes

Although a number of factors can contribute to this condition, the exact cause is unknown. Most typically it is caused by:

· Overuse from high impact activities that cause improper tracking of the patella on the femur (thigh bone)

· Injury or dislocation (displacement or misalignment) of the kneecap

· Thigh muscles that are too weak or too tight; inadequate stretching

· Flat feet

· Wearing down, roughening or softening of the cartilage under the kneecap

· Misalignment of the kneecap which can be caused by vigorous activities causing excessive wear and tear on the kneecap cartilage. The resultant softening and breakdown of the patellar cartilage irritates the joint lining which causes pain.

Symptoms

· Most common: a dull aching pain under and around the kneecap where it connects to the femur

· Pain most frequently occurs when climbing up or down stairs, kneeling, squatting, and sitting for prolonged periods of time with the knee in a flexed position

· The knee might also “catch”, grind, or pop

Prevention

· Maintain a healthy weight and stay in good shape

· Stretch and sufficiently warm up before participating in any exercise or activity (especially running)

· Gradually increase your work out or training program over time. Avoid sudden and intense increases in the intensity of exercise

· Wear proper running gear and footwear with sufficient shock absorption features and of quality design and materials. Footwear should fit properly and be changed out frequently when worn

· Shoe inserts may be necessary if you have flat feet

· Use proper form when exercising and running. Running surfaces should be smooth, even, and somewhat resilient. Avoid running down a steep hill (slow the pace to a brisk walk or use a serpentine pattern when descending)

Diagnosis

· History – your physician will explore your symptoms, exercise/sports participation patterns, and any recent injuries

· Physical Exam – your physician will want to assess your knee’s strength, motility, and alignment by watching you stand, walk, jump, squat, and will also put your knee and leg through a series of maneuvers to assess the alignment and stability of your lower leg and kneecap

· Imaging – your physician may order diagnostic imaging studies such as x-ray, MRI, or CT based on the findings of the history and physical exam

Treatment

Depends on the underlying cause of the knee pain but is generally nonsurgical

First Aid Treatment:

· Immediately cease any activity that causes the knee pain (running or jumping)

· RICE

o Rest – avoid putting weight on the painful knee; change to non-weight bearing exercise such as swimming or stationary biking

o Ice – apply cold packs for 20 minutes several times each day

o Compression – wrap the area or cover the area with an elastic bandage or elastic knee sleeve that fits snuggly

o Elevation – keep the knee raised at a level higher than your heart when at rest

· Medications such as nonsteroidal anti-inflammatory drugs to relieve pain

· Consult your physician if the knee pain does not subside or improve with RICE

o Runner’s knee generally improves with early treatment

Nonsurgical Treatment

Once the knee pain and swelling has subsided, reconditioning is often needed to restore the full range of motion, strength, and agility present prior to the condition’s onset. Your physician and physical therapist can assist with prescribing an exercise program that will assist with this. Occasionally interventions such as taping the knee, wearing a brace, or using specialized shoe lifts might be used to relieve the discomfort.

Surgical Treatment

Not frequently necessary except in severe cases but might include

· Arthroscopy – surgery made through a small incision in which the surgeon removes small fragments of the damaged kneecap through a small tube-like instrument called an arthroscope

· Realignment – there are many realignment procedures to relieve pain. Some involve small releases, patellofemoral ligament reconstruction or bony procedures to improve tracking of the patellofemoral joint. Lastly, in older individuals or most severe cases, there is a limited patellofemoral joint replacement.

Dr. Michael Vella specializes in adult reconstruction of hips and knees, sports medicine including arthroscopy of the knee, shoulder, and ankle, fracture care, and general orthopedics. He attended medical school at Upstate Health Science Center, completed two years of general surgery residency at Brown University, and fellowship trained at Harvard. Dr. Vella has been practicing here since 1989 and participates in the care of many high school, collegiate, and minor professional athletes. He is a member of several medical societies and is president of Midstate IPA, serving over 1200 health care providers.

Monday, April 9, 2012

Shoulder Injuries in Athletes

Bradley S. Raphael M.D.

RSM Medical Associates

As spring sports start up (lacrosse, baseball, tennis) so to can shoulder pain. Shoulder injuries are common in overhead athletes (swimming, tennis, baseball, football), but can also occur in overhead workers. This is especially true with heavy laborers or jobs which require repetitive overhead activities at work.

Different shoulder problems from overuse:

-Impingement

-Rotator cuff tears

-Rotator cuff tendinitis

-Labral tears

-Instability/dislocation

Anatomy:

-The shoulder is essentially a ball in socket with less restriction than any other joint in the body. This allows the shoulder to be the most mobile joint in the body.

-Rotator cuff is a series of 4 muscles that center the ball on socket during shoulder motion, maximizing the efficiency of shoulder movement. These can be inflamed with repetitive motion and can make overhead activity painful.

-The rotator cuff can also become inflamed as it rubs under the color bone and shoulder blade (often described as a “bone spur”)

-The labrum is made of a thick tissue that rings the shoulder socket and is susceptible to injury with trauma to the shoulder joint. When a patient sustains a shoulder injury, it is possible for the labrum to tear. Some symptoms are an achy sensation to the shoulder joint, catching of the shoulder with movement and pain with specific activities

Treatment:

-These injuries are often treated with physical therapy, strengthening, stretching, (especially baseball players and other overhead athletes)

-It’s important to do appropriate warm up before long pitching outings, lacrosse games, tennis matches and overhead work activity in order to prevent injuries.

-If physical therapy fails, may need an injection to help decrease pain (steroid).

- These injuries usually respond to conservative measures, but sometimes it can become refractory and may need arthroscopic procedure to clean out bursitis, remove bone spurs or repair the tendons or labrum.

Prevention:

-Important to follow little league pitching guidelines at young age (littleleague.org)

-Pre-game, pre-work, and pre-activity stretching

-Hip and core strengthening to alleviate stress on shoulder with your local therapist or athletic trainer.

-See your doctor as soon as you start having soreness that doesn’t go right away, because it could be the sign of something more serious

Bradley S. Raphael M.D. completed his sports medicine training in Los Angeles at the Kerlan Jobe Orthopedic Clinic and is in practice at RSM Medical Associates where he specializes in Shoulder and Knee problems. He is also a team physician for Syracuse University Athletics. For appointments or questions: 315-701-4024 or on the web at raphaelmd.com

Sunday, April 1, 2012

Rotator Cuff Tears

By Ryan Smart, MD

Syracuse Orthopedic Specialists

Intro

Rotator cuff tears are among the most commonly encountered disorders of the shoulder. They can be debilitating and difficult to treat. Chronic rotator cuff tears are common and with the aging population the incidence of new tears continues to rise. More than 50% of individuals older than 60 years have at least a partial rotator cuff tear and full thickness tears are found in almost half of individuals older than 80 years. (1) Approximately two-thirds of all rotator cuff tears in the general population are asymptomatic and factors found to be associated with symptoms when one has a rotator cuff tear are a positive impingement sign, weakness in external rotation, and presence of a tear in the dominant arm. (2) Procedures done to treat rotator cuff disease are among the most common of all orthopaedic surgeries.

Anatomy

The glenohumeral joint has very little bony support. The rotator cuff, which is made up of four muscles (subscapularis, supraspinatus, infraspinatus, and teres minor), plays a major role in both the mobility and stability of the shoulder. Of these two roles, stability appears to be the larger function. To maintain a ball-and-socket articulation during motion, the humeral head is compressed into the glenoid socket by the rotator cuff. Without such compression, the humeral head can undergo excessive translation within the socket which disrupts shoulder kinematics. EMG studies have shown that the rotator cuff muscles fire prior to and then concurrently with the deltoid and pectoralis major muscles.(3) This preceding and concurrent activation of the rotator cuff muscles maintains the shoulder joint for dynamic stability during larger muscle contractions.

History

Pain is the most frequent complaint. It can at times radiate down the arm to the level of the elbow. Many patients will complain of nighttime pain. Typically, the pain will be worse with certain motions such a forward elevation or abduction. As the tear progresses, weakness will become a more prevalent symptom. Rotator cuff pain does not typically radiate down the arm to the level of the wrist or hand. If such symptoms are present one should suspect the cervical spine as the pain generator. A history of a trauma or fall will sometimes be present but many times patients cannot recall a specific inciting event.

Physical Exam

A thorough physical exam significantly aids in the diagnosis and management of rotator cuff tears. A complete shoulder exam should be performed starting with inspection and palpation. Range of motion is then assessed both passively and actively. If both passive and active motion is limited one should consider an alternative diagnosis such as adhesive capsulitis (ie frozen shoulder). Patients with rotator cuff pathology will typically have mid-arc pain. A positive Neer and Hawkins maneuver is common. Strength testing is performed for each rotator cuff muscle. The empty can and drop arm maneuvers test the supraspinatus. The lift-off, belly press and bear hug all test the subscapularis and external rotation strength tests the infraspinatus and teres minor. The combination of a positive drop-arm sign, painful arc sign, and infraspinatus muscle strength test was most predictive for full thickness rotator cuff tears.(4)

Treatment

Conservative

Nonsurgical management is typically the first line of treatment for most rotator cuff pathology. The natural history of rotator cuff tears is thought to be that of tear progression. (5) It is believed that tear size progression is a factor in the development of symptoms. Physical therapy and shoulder rehabilitation should focus on restoration of motion, flexibility and strength. (6) Nonsurgical management may also include pain medication and anti-inflammatory drugs and subacromial cortisone injections. Although injections are common a recent systematic review suggests that long-term benefits are limited. (7) Multiple cortisone injection should be avoided in patients who may be best served with surgical intervention. Successful non-operative management has been correlated with symptom duration of less than 3 months. Factors that have been found to predict failure of conservative treatment are: 1) full-thickness tear greater than 1cm x 1cm, symptoms present for more than 1 year, and functional impairment and weakness. (8) Nonsurgical treatment is often attempted for a minimum of 6 to 12 weeks before surgery is considered.

Surgical

When patients fail conservative treatment surgery is usually indicated. Tears can be repaired either arthroscopically or by open means. The clinical results reported with arthroscopic repairs are equivalent to those reported for both open and mini-open. (9,10) However, the deltoid muscle is undisturbed with arthroscopic repairs thus making it the favored approach by many. The goal of surgery is to anatomically repair the rotator cuff securely to bone with as little tension as possible. Reported healing rates, based on ultrasound and MRI, range from 91% in small tears to 10% in massive tears. (11) With larger tears, the best clinical results are achieved in patients who experience tendon healing postoperatively. (12)

Rehab

The ideal rehabilitation program allows for tendon to bone healing and prevents stiffness. Most agree the best clinical results occur when the rotator cuff heals to bone in its entirety. Since the rotator cuff heals very slowly (~5% per week) most have adopted fairly conservative rehab protocols limiting motion the first 6 weeks.

Dr. L. Ryan Smart specializes in sports medicine, arthroscopic surgery, and shoulder surgery. He completed his fellowship in sports medicine at the New England Baptist Hospital in Boston, MA and completed his orthopaedic surgery residency at Yale in New Haven, CT. After completing his undergraduate studies at Cornell University, he went on to the University of Michigan for medical school. He is the team physician for the Christian Brothers Academy football team, Cornell Men’s Ice Hockey, Syracuse Silver Nights soccer club and Fayetteville-Manlius High School. He played 4 years of varsity ice hockey at Cornell and was drafted by the New Jersey Devils in the 1994 NHL entry draft. His professional memberships include Arthroscopy Association of North America and the American Orthopaedic Society for Sports Medicine.

Monday, March 19, 2012

Anterior Cruciate Ligament (ACL) Injuries: What You Need To Know

By Todd C. Battaglia, MD, MS

Tears of the anterior cruciate ligament (ACL) are among the most common knee injuries, particularly in high demand sports like soccer, football, and basketball. In fact, more than 200,000 ACL injuries occur each year in the United States alone and affect individuals of all levels, from recreational athletes to professionals. In recent years, numerous well-known athletes, including Tom Brady, Ricky Rubio, and Tiger Woods, have suffered well-publicized ACL tears.

THE BASICS

Ligaments are strong bands of tissue that connect one bone to another. The ACL, one of two ligaments that cross in the middle of the knee, connects your thighbone (femur) to your shinbone (tibia) and helps stabilize your knee joint. It prevents the tibia from sliding forward in front of the femur, as well as provides rotational stability to the knee. The ACL can withstand approximately 500 lbs. of pressure, but only a 25% stretch, before failing.

Injured ligaments are considered "sprains" and are graded on a severity scale from a mild stretch (Grade 1) to a complete tear (Grade 3). Partial tears of the ACL are relatively rare; most ACL injuries are complete or near-complete tears. About half of all injuries to the ACL also involve damage to other structures in the knee, such as articular (joint) cartilage, meniscus, or other ligaments. Nearly 80% of ACL tears are the result of non-contact injury (cutting, jumping, sudden stops); this is much more common than direct contact or collision ACL tears. Female athletes have a much higher incidence of ACL injury than male athletes (between 2-7 times more common). It is thought that this is due to differences in leg alignment, muscular strength, and neuromuscular control. It is also believed that hormone differences play a role, as estrogen may weaken ligaments.

SYMPTOMS

When you injure your ACL, you may hear a "popping" noise and you may feel your knee give out from under you. Most ACL tears are associated with moderate to severe pain. The knee will usually swell (often severe) within 4-8 hours of injury. Other symptoms may include loss of motion, tenderness along the joint line, and discomfort while walking.

The pain and disability associated with an ACL injury usually prompts most people to seek medical attention. Continued athletic activity on a knee with a torn or malfunctioning ACL can have devastating consequences, resulting in severe cartilage damage and increased risks of arthritis.

DIAGNOSIS

Diagnosis of an ACL tear primarily relies on the physical examination performed by your doctor. Through movement and manipulation of your knee, the physician can usually diagnose an ACL tear without use of any special tests. X-rays may be taken to rule out a bone fracture. But X-rays cannot visualize soft tissues such as ligaments and tendons, so an MRI, which can, is often used to confirm the diagnosis and to evaluate for torn cartilage or other injuries often associated with ACL tears.

TREATMENT

Initially, treatment for an ACL injury aims to reduce pain and swelling, regain normal knee movement, and strengthen the muscles around your knee. Ultimate treatment, however, will depend on several factors, such as the severity of the injury, presence of associated injuries, and most importantly, the patient’s individual needs. If the overall stability of the knee is intact, your doctor may recommend simple, non-surgical options. This might include physical therapy to strengthen the leg or use of a brace during certain activities.

A completely torn ACL will not heal without surgery, and the lack of a functioning ACL greatly increases the risk of other knee injuries, such as a torn meniscus, so sports with cutting and twisting motions are strongly discouraged. For younger patients and those who frequently participate in such sports, surgery will most likely be required to safely return to those activities. But non-surgical treatment may be effective for patients who are elderly or have a very low activity level.

If surgery is chosen, a torn ACL cannot simply be sewn back together. During surgery the ACL is not repaired; instead, it is reconstructed - your doctor will replace your torn ligament with a tissue graft. This graft acts as a scaffold on which a new ligament will grow.

Grafts can be obtained from several sources. Some are taken from the patient’s own body (autografts) and include the hamstring tendons or patellar (kneecap) ligament. Alternatively, various cadaver grafts (allografts) can be used. There are different advantages and disadvantages with each graft option; factors to be considered are graft strength, healing time, re-tear rates, and infection risks. Your surgeon should discuss graft choices thoroughly with you prior to surgery to help determine which option is best for you.

Nearly all ACL surgeries today are performed with an arthroscopic camera, using small, minimally invasive incisions. Although arthroscopic reconstruction has been performed for more than two decades, over the last five years, ACL surgery has undergone a major revolution. New strategies and techniques, particularly with regard to placement sites of the new graft, have shifted dramatically. We have learned, unfortunately, that the techniques used 10 or 20 years ago did not do a good job of placing the new graft in the same location as the patient’s original ACL. Our newer techniques have resulted in greatly increased stability, and although not yet proven, we suspect will also reduce the likelihood of subsequent arthritis in these knees.

After surgery, crutches and a brace are typically used for a period of time, usually 2-6 weeks. The rehabilitation process is a very important part of the surgery. There is a long and rigorous course of physical therapy required, first focusing on returning motion to the joint and surrounding muscles. This is followed by a strengthening program designed to protect the new ligament. This strengthening gradually increases the stress across the ligament. The final phase of rehabilitation is aimed at a functional return tailored for the athlete's sport. Because the biologic healing and re-growth process take time, it may be 6 months or longer before an athlete can return to sports after surgery. A surgeon who promises a faster return to sports is doing the patient no favors – early return to sport before appropriate healing has occurred is associated with much higher rates of re-injury to the ACL.

The most common risks of ACL surgery include infection, persistent instability or pain, and stiffness. The good news is that better than 90% of patients have no complications with ACL surgery. Most patients are able to return to their previous level of athletic activity; however, for very high-level athletes, this is not always the case. For instance, only 50-60% of professional football players return to the NFL after ACL surgery.

PREVENTION

Some studies have shown that rates of ACL injury can be reduced anywhere from 20% to 80% by engaging in specific training designed to enhance balance, proper movement patterns, and muscle strength. Not all physicians agree with this, however, and other studies show much less, if any, benefit from these “ACL prevention programs.” In addition, although many sports medicine doctors frequently prescribe knee braces, there is no scientific evidence to date that braces significantly prevent ACL tears.

Dr. Battaglia is a board-certified, fellowship-trained orthopedic surgeon at Syracuse Orthopedic Specialists, PC. He specializes in sports medicine and reconstructive surgery of the shoulder and knee, and has a particular interest in ACL injuries and revision surgery for failed ACL repairs.