Saturday, December 31, 2016

Food Swaps to Help That New Year's Diet Resolution

Many foods can be swapped out for healthier choices without sacrificing taste. See great examples HERE to help jump start that New Year's diet

Friday, December 30, 2016

Make Smoking Cessation Your New Year's Resolution: This App May Help

If your New Year's resolution is to stop smoking that is fantastic. It can be incredibly challenging to accomplish. The National Cancer Institute has developed a free App to help with the struggle. Find details HERE

Wednesday, December 28, 2016

Saturday, December 24, 2016

What Holiday Foods to Avoid and Healthy Alternatives

While we all would like to indulge without concern about health some foods are healthier than others around the holidays.  Read about some foods to avoid and healthy alternatives  HERE

Friday, December 23, 2016

Worrying About Your Health Can Make You Sick

Studies have demonstrated that worrying about getting can actually increase your chances of becoming ill. Try not to worry as you read the details HERE in this interesting Time Magazine article

Thursday, December 22, 2016

Exercise Combats Work Stress

Holiday stress combined with work stress getting you down. Exercise is the best antidote. Read the details HERE in this Time Magazine article

Tuesday, December 20, 2016

Does Exercise Negate Sitting All Day?

We all know exercise is an important part of healthy living, but does it negate the effects of a 14 hour day of sitting. Find out HERE in this NY Times article

Monday, December 19, 2016

Take a Deep Breath--- and Improve Your Memory

At this time of year it never hurts to stop and take a deep breath. Interestingly it may improve your memory. Read details HERE

Sunday, December 18, 2016

Adrian Peterson Returns From Meniscus Repair: What is the Likelihood of Success?

Adrian Peterson, the outstanding running back for the Vikings is returning from what was apparently a meniscus repair.
While many people think they undergo meniscus repair the most common treatment for meniscus injuries is to trim out the torn portion. Only in ~10% can you actually stitch the meniscus together. We have researched meniscus repair results extensively in my Sports Medicine practice and have found that when indicated the results can be excellent. In our minimum 5 year results for all inside arthroscopic meniscus repair we found that 88% were still intact at 5 years when meniscus repair was the only procedure. If combined with an ACL reconstruction the results were slightly worse with a success of 82% at 5 years. To read more detail find the study HERE

 Torn meniscus requiring trimming on the left and a meniscus undergoing all-inside arthroscopic repair on the right

Thursday, December 8, 2016

Worried About Holiday Weight Gain?

If you are worried about holiday weight gain this article won't lift your spirits, but will help you approach it more realistically. Read details HERE

Tuesday, December 6, 2016

Thursday, December 1, 2016

What Exercise is Best at Decreasing the Risk of Death

It is well known that exercise in general is healthy, but does it help lower the risk of death over time. If it does lower death risk which sports and activities are the best. Read some surprising study results HERE

Wednesday, November 30, 2016

Hints to Lose That Holiday Weight Gain

The average person gains 1 pound between Thanksgiving and New Years Day. Read some helpful hints on how to avoid the gain or lose it once it arrives HERE

Thursday, November 24, 2016

Is Turkey Healthy for You?

Feeling guilty about the amount of turkey you ate today. Actually, most nutritionists feel its benefits live up to its healthy reputation. Read the details HERE

Wednesday, November 23, 2016

A Prescription for Exercise

Very soon your physician may be prescribing exercise. It is already being adopted around the country as recommended treatment. Read details HERE

Tuesday, November 22, 2016

Monday, November 21, 2016

YOYO Weight Loss/Weight Gain May Be More Stressful Than Previously Thought

Cyclical weight gain and loss of 10 lbs may be worse than previously thought. This may especially be true for women. Read details of the study HERE

Thursday, November 17, 2016

That Stressful Job May Be Healthy

Feeling stress at the workplace. The angst actually may be healthy. Good news in the midst all that is going on in our world. Read about the study HERE

Sunday, November 6, 2016

Compete to Motivate Yourself to Exercise

In a study detailed HERE it was shown that in groups of exercisers that were fun social groups they were less likely to attend as many workout sessions as people in groups deemed competitive. Time to bring a little competition to your workouts!

Wednesday, November 2, 2016

Want a Better Start to the Day

Nothing gets the day going better than a healthy breakfast. Take the 21 day better breakfast challenge. For details and ideas look HERE

Tuesday, November 1, 2016

Some High Fat Foods Can Actually Be Healthy

Not all fatty foods are necessarily the enemy. Low fat with high sugar may be worse. Read these hints to find the right fatty foods HERE

Monday, October 31, 2016

Diet Hints to Combat That Sit Down Job

Sitting all day at work is not healthy, but many of us find ourselves with jobs in the sedentary category. Some foods and snacks can help fight this with their anti-inflammatory characteristics. Read more detail HERE

Saturday, October 29, 2016

Maybe You Don't Have to Order That Egg White Only Omelette

For years we have been told eating high cholesterol foods resulted in increased cholesterol levels. Thus, egg yolks received plenty of bad press. Probably unfairly. Read this review which may surprise you. Egg yolks have plenty of good nutrients and don't necessarily increase cholesterol levels. Read the details HERE

Friday, October 28, 2016

Thursday, October 27, 2016

Not all Foods are as Healthy as They Appear

Several foods that many of us believe to be nutritious may not be as healthy as they appear. Read this article to learn foods no nutritionist will eat. Find it HERE

Tuesday, October 25, 2016

ACL Reconstruction Graft Choice in Young Athletes

Anterior cruciate ligament (ACL) injuries currently require a reconstruction for active individuals desiring to return to activities that involve planting, cutting, turning, twisting or jumping. A reconstruction simply means a replacement of the ACL since repair currently does not work (see this link for exciting news regarding ACL repair). As part of the reconstruction a graft must be chosen and used. There are several options available, but young athletes and their families need to be careful in their graft decision process. Certain graft choices may not be the best for younger patients.

Broadly, there are two categories of graft: 1.) allograft (cadaver) and 2.) autograft (patient’s own tissue). There are advantages and disadvantages for both types. Allograft offers the advantage of no need to obtain a graft from the patient which may mean less pain and a quicker recovery. Unfortunately, the disadvantages include risk of disease transmission (HIV and Hepatitis 1/1,000,000), slower graft incorporation and a higher rerupture/failure rate. In an important study by the Multi-center Orthopaedic Outcomes Network (MOON) Group that we participated in at Washington University as an original MOON Group site cadaver grafts were noted to have a 4 times higher failure rate vs. autografts for patients of the same age and activity level. For example a 16 year old female high school team sport athlete has an ~5% ACL autograft failure rate in the first 2 years after surgery and ~20% failure rate over the same time period for an allograft. Read the study here: ( Obviously, that is a rate of failure unacceptable for young athletes. Conversely, in a patient over the age of 40 the failure rate remains 4 times higher, but at 2% vs. 0.5% the relative risk is very close and allograft may be a reasonable choice for an older adult patient.
This has been confirmed also in the revision (redo) ACL reconstruction setting with a 2.78 times higher failure rate for allografts noted by a study performed by the Washington University coordinated MARS Group. Read the study here: ( )

There are 2 types of autografts commonly used: hamstring or patellar tendon. Both have advantages
 and disadvantages. Hamstring grafts have a lower risk of kneeling pain, but less strong initial fixation and typically are ~1mm looser once healing is complete. Patellar tendon grafts have stronger initial fixation, heal a little tighter, but have a higher risk of kneeling pain. Data from Europe suggest the hamstring grafts may have a slightly higher (0.5—1.0%) risk of rupture, but this has not been duplicated in the US in similar studies. I typically recommend patients let their surgeons use the graft with which they are most comfortable. The small differences in the grafts typically do not matter clinically.

The Effects of Stopping Exercising

The effects of stopping your workout program accumulate quickly. Read the sad review of the multiple effects HERE.

Monday, October 24, 2016

The Concussion Protocol

It is not uncommon to read in the sports pages that an NHL or NFL player sustained a concussion and is undergoing the concussion protocol. What is the concussion protocol? There are significant similarities and I will try to explain the big picture of what the protocol means without becoming too technical.

Once a player sustains trauma to the head in either league that is worrisome or suspicious for a concussion the player is removed from the game and taken to a quiet place for evaluation. This will include formal testing of the player and determining any symptoms the player may have. Testing will include cognition, memory and physical tests of balance.

If the player is determined to have sustained a concussion or if there is suspicion of a possible concussion the player is removed from the rest of the game and monitored.

At this point the player may need additional testing or close monitoring. Following the game and the next day the player’s symptoms are monitored. The player is encouraged to avoid activities that might exacerbate symptoms including video games, TV, computer and smart phone activities. As symptoms improve the next steps are taken to determine recovery. When the player’s symptoms have resolved then physical activity can be attempted which typically is a short exercise session of light stationary cycling, jogging or another aerobic activity. If symptoms return then the activity is stopped. If the player tolerates the increase in heart rate without symptoms then in following days the player will continue to slowly increase the activity level and will repeat the neuropsychological testing done previously ---before the season began.

If the neuropsychological testing has returned to baseline and the player has remained without symptoms then they will be allowed to return to practice and increase activity as tolerated. Once their functional skills and conditioning has returned to a level consistent with returning to game action they are released to play. All of this is contingent upon remaining asymptomatic during the progression of activities. As can be seen it can involve several days to protect the health of the player and avoid worsening symptoms or returning them to play prior to resolution of any concussion symptoms.

Frequently associated with concussion can be cervical spine musculature aggravation due to the trauma to the head. Local modalities, stretching and massage can sometimes relieve these symptoms which can be confused with concussion symptoms. Addressing these can help speed recovery and eliminate confusing symptoms.

Saturday, October 22, 2016

How to Manage Hydration and Exercise

Previously we discussed proper nutrition for exercise. Hydration is just as critical. Look HEREfor suggestions

Friday, October 21, 2016

Proper Nutrition Before and After Exercise/Run

It's the Fall and many people are training for and participating in marathons and half marathons. That type of training and event requires proper nutrition before and after exercise. Read Time Magazine's helpful hints HERE

Monday, October 17, 2016

Knee Bone Bruise: Their Affect on Athletes and the 2016 Baseball Playoffs

The Blue Jay's playoff hopes were hurt when Devon Travis was diagnosed with a bone bruise.
He underwent a cortisone injection, but has not improved enough to play. These injuries which are increasingly diagnosed require a traumatic loading of the knee. In the isolated situation there is no structural damage. The knee will be swollen and painful with activity. Bone bruises are also frequently noted with ACL tears (80%) when the tibia (leg bone) subluxes and strikes the femur (thigh bone). Diagnosis can be suspected based on clinical exam and history, but requires an MRI for confirmation. That is why they were not known to exist before the mid 1980s. 

In the common isolated situation there is little that can be done to speed recovery. Most physicians have felt that the recovery to full activities is 6 weeks, but in this study I published in 2000 we demonstrated different results. This was the first ever report of a series of isolated bone bruises. In this study published in the American Journal of Sports medicine it was shown that the average time to recovery and full normal activities was 3.1 months. This was much longer than health care professionals had previously thought it took for recovery. This has ended up as very helpful information in advising athletes, coaches and general managers as to the timeframe for their recovery from these injuries. You can read the entire study HERE

Saturday, October 15, 2016

Why You May Not Want to Overload on Protein to Lose Weight

A recent Washington University study demonstrated that in weight loss patients a diet with increased protein compared to balanced calorie restriction resulted in equal weight loss. The concern arose regarding insulin sensitivity where the higher protein diet did not result in an improvement. Read details of the study and the diets in the Time magazine study HERE

Wednesday, October 5, 2016

Meniscal and Chondral Predictors of ACL Revision Reconstruction Outcomes

Revision ACL reconstruction is known to result in worse outcomes. Meniscus and cartilage damage may contribute to these worse outcomes. With the MARS (Multi-center ACL Revision Study) Group we looked 1215 revision ACL reconstructions to analyze the impact of meniscus and articular cartilage damage on patient results We found that a previous lateral meniscectomy and femoral groove/trochlear groove cartilage damage most strongly contributed to worse patient outcomes. Read further details HERE

Tuesday, October 4, 2016

Exercise in the Elderly

There are multiple beneficial effects for the elderly from exercise. These include mental and physical effects. Physicl effects include not only improved balance and injury prevention but also injury recovery. Read the full story HERE

Monday, October 3, 2016

Patient Expectations Regarding Meniscus Injuries and Treatments

In a recently published study we anlyzed patient expectations and knowledge regarding meniscus injuries and treatments. Patients that had previously undergone meniscus treatment were much more knowledgable regarding meniscus issues. Only 28% of patients understood that meniscus resection is actually more common than repair. The most common concern regarding meniscus treatment was the risk of arthritis. You can read further details HERE

Thursday, September 29, 2016

Exercise Benefits Brain Function

Continuing evidence that exercise exerts a positive impact on brain blood flow and probably likewise function. Read the NY Times article HERE

Saturday, September 24, 2016

Tips to Jazz Up Your Healthy Diet

Tips from an accomplished chef to add interest and variety to your diet while remaining healthy. Read the article from TIME HERE.

Monday, September 19, 2016

Frequently MRI Not Needed for Diagnosing Knee Conditions

In this study performed at Washington University we found that screening x-rays frequently prevented the need for ordering the more expensive MRI. When patients showed up with MRIs already obtained they frequently did not add any needed information. This is especially true when arthritis was noted on the x-ray. Read a synopsis and further details HERE

Friday, September 9, 2016

7 Surprising Benefits from Exercise

If you are struggling to motivate yourself to exercise there are some surprising benefits from exercise. Read about them HERE

Thursday, September 8, 2016

Healthy Between Meal Snacks to Curb Hunger

Some days it is really hard to make it to the next meal without a snack. When those days occur reach for something filling and healthy. Great examples HERE

Tuesday, September 6, 2016

Late Night Workouts Need Fuel for the Next Day

Some people are night owls and truly enjoy late night workouts. No problems there, but if you are one of those people you need to replenish and provide fuel for the next day with a late night snack. Look for great examples and ideas HERE

Wednesday, August 31, 2016

Great Questions to ask Your Doctor

Great questions to ask your doctor about options and outcomes before you begin a treatment can be found HERE.

Monday, August 22, 2016

Shoulder Separations

It is football season with hockey not too far behind so we are beginning to see shoulder separation injuries showing up at the Washington University Orthopedic Injury Clinic. Patients always are confused as is the media on the difference between a shoulder separation and a shoulder dislocation. A Shoulder Disloction and its Treatment as previously reviewed on this blog refers to the humeral head (ball) sliding off the glenoid (socket). This frequently needs to be put back in place and frequently requires surgery to prevent future episodes.

A shoulder separation on the other hand is typically treated conservatively and rarely requires surgical reconstruction except in severe circumstances such as the injury Sam Bradford sustained while playing for Oklahoma. The injuries most commonly occur in contact sports but are also frequently seen in cycling injuries when riders fly over the handle bars and land on their shoulder. It is typically a blow to the point of the shoulder that drives the shoulder blade down and stretches or tears the ligaments that connect the collar bone (clavicle). These ligaments are called the coracoclavicular
ligaments and are 2 tough bands running from the collar bone to the coracoid -- a bony prominence projecting from the scapula. It also occurs frequently in hockey when players are checked into the boards or fall and hit the ice. Typically it causes local pain in the shoulder area with limited range of motion and weakness. Initially it is treated with a sling ice. A plain x-ray showing the depressed shoulder blade and ruling out a fracture is all that is necessary. An MRI is not required.
Physical Therapy is begun soon after the injury with a focus on motion and strength. Once the pai n is tolerable and full motion and strength is regained the athlete can return to sports with no long term sequelae except some prominence of the clavicle in that area.

 There are 6 grades of injury with most falling into Grades 1,2 and 3. Grades 1 and 2 are always treated conservativeley. Grade 3 with worse ligament damage and more deformity is still usually handled without surgery. Occasionally throwers or other overhead repetitive workers require repair/reconstruction of the ligaments. Fortunately, despite several injuries of the Type 3 severity with the St. Louis Blues we have never had to perform a surgical reconstruction. Grade 1 injuries typically require 1-2 weeks for recovery, Grade 2 2-4 weeks of recovery and Grade 3 treated without surgery are 6 week injuries.

Saturday, August 13, 2016

Cupping? Why Michael Phelps and others are doing it. Read about it here.

If you are wondering why Michael Phelps and other swimmer and athletes have those purplish circles over their body it's called cupping and aimed at improving recovery following workouts or competition. Read more details HERE

Want to eat like an Olympian? Look at these examples

The amount of food it takes to fuel an Olympian is unbelievable. See examples HERE

Tuesday, August 9, 2016

Oblique Muscle Strains

Once again this season baseball players have been affected by oblique muscle strains. Most recently it impacted the St. Louis Cardinals when their All Star infielder Matt Carpenter sustained the injury missing a month of games including the All Star Game. Why are these such significant injuries for some sports and playing positions while you never hear about them in other sports?

The oblique muscles reside on both sides of the abdomen and chest running from the pelvis to the chest and ribs in the front and chest and spine in the back. There are 2 muscle groups on each side--- the internal and external obliques. Rather than running straight vertically or horizontally they run “obliquely” across the body and thus their name is derived.

These muscles are critical for rotational activities and that is why they are more impactful for certain sports. While challenging for any athlete an oblique muscle strain is the worst for those athletes that repetitively rotate. Thus baseball pitchers and hitters are highly affected. Hockey players are also bothered by it while shooting especially during slap shots.
We have had several with the St. Louis Blues over the years that resulted in several man games lost. It much less frequently affects sports that are more linear such as track, swimming, football or basketball. It is an infrequent injury even for quarterbacks and I can’t remember a significant oblique injury with loss of time for any of the Rams quarterbacks.

Treatment is similar to other muscle strains and involves conservative management with ice, NSAIDs and rehabilitation including stretching and strengthening. Nothing seems to shorten
the recovery which for baseball position players is typically a month. If anything more than a minor strain for a pitcher it can cost 6-8 weeks. Cortisone injections can be utilized, but still time is the best ally and cortisone is relatively a quick fix. These muscle strains typically are diffuse over a relatively large area and thus difficult to pinpoint for an injection. Likewise there is no scientific evidence that platelet rich plasma (PRP) or stem cell injections will speed recovery. That is why these are difficult injuries for the athletes and the fans that follow them. It is hard to be patient.

Sunday, August 7, 2016

Exercise Improves Memory

Exercise can improve skill and fact retention. I wish I had known that in Medical School! Read the details HERE

Saturday, August 6, 2016

Pectoralis Muscle Injuries

It is the start of football training camps across the country and already there have been reports of pectoralis muscle injuries leading to lost time and frequently surgery. Manny Lawson the Buffalo Bills outside linebacker expects to miss time with a partial tear. The Bengals' first round draft pick William Jackson III a cornerback will have surgery shortly for a complete tear as did Desmond Bryant a defensive lineman for the Browns. Previously, we discussed rotator cuff injuries, but this represents a different type of shoulder muscle injury.

The pectoral musccle is in the front of the chest and is active in use of the arm extended away from the body or in pushing objects away from the chest. It has 4 parts with the major portion attaching to the humerus (arm bone) as a thick tendon.

Many are muscle strains that represent a partial tear of the muscle much like a hamstring strain. These do not require surgery and will recover with ice and rest followed by physical therapy including stretching and strengthening. A complete pectoral tear involves the tendon pulling off the bone. This typically requires reattachment to the bone to restore function in healthy active individuals.

Frequently the injuries occur while weight lifting especially bench press. Also specific football acts that increase the risk is using the arms in extended fashion away from the body as offensive lineman do frequently.

Diagnosis is made by a loss of contour of the chest in the front, pain, weakness and significant bruising. An MRI can help determine the severity of a partial tear, but may not be necessary for a complete tear diagnosis.

Commonly this is a 3-6 month recovery for most athletes with 6 weeks of minimal activity followed by 6 weeks of intensive rehabilitation. At this point more functional rehabilitation and training can occur, but it is difficult to return to true sports before 4-6 months. Thus, it is frequently a season ending injury especially for offensive linemen.

Friday, August 5, 2016

Thursday, August 4, 2016

Is remaining unfit as risky as smoking?

Physically unfit lifestyles with little aerobic capacity may be as bad or worse than smoking. Read details in this NY Times Review HERE

Tuesday, August 2, 2016

Ankle Sprains Can Be More Than They Appear

Ankle sprains represent one of the most common reasons people present to Emergency Rooms for musculoskeletal complaints. While nearly everyone has sustained a sprain in their lives if ignored they can present significant disability. Ankle sprains as depicted in this picture are tears of the ligaments around the ankle. The most common type is depicted here as an inversion sprain with the ankle rolling in on itself.
Typically significant swelling is noted and there may be dramatic bruising.

Frequently when seen in the Emergency Room patients are given crutches, instructed to ice and elevate and little else is done. In reality all ankle sprains severe enough to go to the ER should undergo physical therapy for range of motion, strengthening and balance training. Additionally, the patient may need to braces during recovery.
Upon returning to sports it may be a good idea to wear a functional brace which may be as effective or more effective than taping.

A significant ankle sprain may continue to ache with activity for several weeks. Read HERE for several more facts regarding ankle sprains. Always take these seriously.

Monday, August 1, 2016

Fall Sports Heat Acclimation Recommendations from the NATA

Consensus statement from the National Athletic trainers Association regarding heat acclimation for sports. Recommendations are for a 14 day period of acclimation with the following recommendations:

  1. 1. Days 1 through 5 of the heat-acclimatization period consist of the first 5 days of formal practice. During this time, athletes may not participate in more than 1 practice per day.
  2. 2. If a practice is interrupted by inclement weather or heat restrictions, the practice should recommence once conditions are deemed safe. Total practice time should not exceed 3 hours in any 1 day.
  3. 3. A 1-hour maximum walk-through is permitted during days 1–5 of the heat-acclimatization period. However, a 3-hour recovery period should be inserted between the practice and walk-through (or vice versa).
  4. 4. During days 1–2 of the heat-acclimatization period, in sports requiring helmets or shoulder pads, a helmet should be the only protective equipment permitted (goalies, as in the case of field hockey and related sports, should not wear full protective gear or perform activities that would require protective equipment). During days 3–5, only helmets and shoulder pads should be worn. Beginning on day 6, all protective equipment may be worn and full contact may begin.
  5. A. Football only: On days 3–5, contact with blocking sleds and tackling dummies may be initiated.
  6. B. Full-contact sports: 100% live contact drills should begin no earlier than day 6.5. Beginning no earlier than day 6 and continuing through day 14, double-practice days must be followed by a single-practice day. On single-practice days, 1 walk-through is permitted, separated from the practice by at least 3 hours of continuous rest. When a double-practice day is followed by a rest day, another double-practice day is permitted after the rest day.6. On a double-practice day, neither practice should exceed 3 hours in duration, and student-athletes should not participate in more than 5 total hours of practice. Warm-up, stretching, cool-down, walk-through, conditioning, and weight-room activities are included as part of the practice time. The 2 practices should be separated by at least 3 continuous hours in a cool environment.7. Because the risk of exertional heat illnesses during the preseason heat-acclimatization period is high, we strongly recommend that an athletic trainer be on site before, during, and after all practices.

  1.  Read the full article HERE

Wednesday, July 27, 2016

57 science backed tips for weight loss

57 tips scientifically researched that will help with achieving and maintaining weight loss. Read the details HERE

Wednesday, July 20, 2016

Monday, July 18, 2016

Exercise for a Purpose

Researchers in this Time magazine article describe improved healthy habits if people see a purpose behind the behavior. Read the article HERE

Thursday, July 14, 2016

Not sleeping well? Some easy tricks in this Time magazine report

Sleep can be critical to good health. A review of some surprising results of enough or too little sleep and tips on improving HERE

Friday, July 8, 2016

Exercise can make you wealthier?

We know exercise makes us healthier, but may also make us wealthier. Read the statistics from Time and Money magazine HERE

Wednesday, June 29, 2016

Monday, June 27, 2016

ACL Reconstruction Rehabilitation Part 3

Postoperative rehabilitation remains critical to the outcome for the patient undergoing ACL reconstruction. If the physical therapy following surgery does not go well then it does not matter how well the surgery was performed. When the
MOON group began enrolling ACL reconstruction patients we decided to develop a standardized physical therapy protocol to use for our patients and to have consistency for our patients’ recovery. I was tasked with developing an evidence based review of ACL reconstruction rehabilitation and then using it in conjunction with our physical therapists to develop a practical protocol. Ultimately, we developed what has been a very popular protocol that is more milestone based than time based and has been easy to implement across our several sites. We have subsequently published the protocol in the AOSSM journal Sports Health so that others can utilize it also. You can read the description and find the protocol HERE.

We based the protocol on a series of Systematic Reviews we performed to establish the evidence for best practice ACL rehabilitation. Previously we discussed the first 2 reviews. Here we will review the findings in our 3rd review which was an update of the original 2. It can be found HERE. In this study we discussed an additional study evaluating the use of Continuous Passive Motion machines which once again showed no advantage. Several additional studies had been published evaluating bracing and none demonstrated any advantage in the postoperative rehabilitation period. Additional studies evaluated early ROM and quad strengthening without any increase in laxity. Eccentric strengthening was safe and showed improved strength gains compared to concentric strengthening when initiated at 3 weeks and continuing for 12 weeks. Accelerated rehab shortening to 5 months the recovery did not result in worse outcomes  or safety issues. Additional electrical stimulation studies showed safety, but no significant efficacy in ACL rehabilitation.

Most additional studies performed since our last review reiterated our additional findings. I will be presenting specific findings for revision ACL reconstruction rehabilitation at the July 2016 American Orthopaedic Society for Sports Medicine and we will blog those results when available next week.

Tuesday, June 7, 2016

Tuesday, May 24, 2016

Additional Evidence from Time Magazine on Interval Training

Additional evidence that short interval training may be as effective as longer continuous exercise. Read Time Magazine's take on the discussion HERE

Monday, May 23, 2016

ACL Reconstruction Rehabilitation Part 2

Postoperative rehabilitation remains critical to the outcome for the patient undergoing ACL reconstruction. If the physical therapy following surgery does not go well then it does not matter how well the surgery was performed. When the
MOON group began enrolling ACL reconstruction patients we decided to develop a standardized physical therapy protocol to use for our patients and to have consistency for our patients’ recovery. I was tasked with developing an evidence based review of ACL reconstruction rehabilitation and then using it in conjunction with our physical therapists to develop a practical protocol. Ultimately, we developed what has been a very popular protocol that is more milestone based than time based and has been easy to implement across our several sites. We have subsequently published the protocol in the AOSSM journal Sports Health so that others can utilize it also. You can read the description and find the protocol HERE.

We published the systematic review evidence we based the protocol on in 3 separate studies. in Part 1 I reviewed the findings in our first publication. The second publication can be found HERE. Findings in this study included a review of open (isokinetic) vs. closed chain exercises. Closed chain exercises occur when the foot is planted on the floor or on a firm surface such as a leg press machine. These type of exercises may be more protective for the healing ACL graft,  but it appears open chain exercises are safe 6 weeks after ACL reconstruction.

Neuromuscular stimulation has been extensively studied utilizing a variety of parameters and has not been shown to be critically important. It is safe and can be utilized at the therapist's discretion most commonly when the patient is struggling to recruit the quadriceps muscle for strengthening.

Accelerated rehabilitation has gained much attention, but there remains little evidence that it can be truly lowered below the 4 month time frame safely. One randomized study looked at 8 vs. 5 months and found no problems with this length of rehabilitation, but to many of us this doesn't represent significant acceleration. Future research will be necessary to address this further.

Water exercise may decrease swelling and appears to be safe. Slide board exercises can be incorporated at 6 weeks without harm. Stair climber is as safe as stationary cycling at 4 weeks.

Additional principles will be reviewed in Part 3 reviewing our 3rd study evaluating ACL rehab PT

Saturday, May 21, 2016

Wednesday, May 18, 2016

Allegations of Russian Athletes Use of Performance Enhancing Drugs May Impact Summer Olympics

The Justice Department has opened an investigation of allegations of Russian athletes state sponsored use of performance enhancing drugs in the Sochi Olympics. This may impact Russian athlete's ability to participate in this summer's Rio Olympics. Read the New York Times story HERE

Tuesday, May 17, 2016

Sunday, May 15, 2016

Nutrition Gaining Importance Even For High School Athletes

Nutrition is critical for maximizing athletic performance at all levels including the high school athlete. Read the New York Times article on this HERE

Thursday, May 12, 2016

ACL Reconstruction Rehabilitation Part 1

Postoperative rehabilitation remains critical to the outcome for the patient undergoing ACL reconstruction. If the physical therapy following surgery does not go well then it does not matter how well the surgery was performed. When the
MOON group began enrolling ACL reconstruction patients we decided to develop a standardized physical therapy protocol to use for our patients and to have consistency for our patients’ recovery. I was tasked with developing an evidence based review of ACL reconstruction rehabilitation and then using it in conjunction with our physical therapists to develop a practical protocol. Ultimately, we developed what has been a very popular protocol that is more milestone based than time based and has been easy to implement across our several sites. We have subsequently published the protocol in the AOSSM journal Sports Health so that others can utilize it also. You can read the description and find the protocol HERE.

We published the principles that it was based upon in a series of evidence based systematic reviews. The study can be found HERE  I will summarize our findings in this and subsequent blogs. Continuous passive motion CPM has been anecdotally advocated as a way to improve range of motion (ROM) following ACL reconstruction. It has become increasingly difficult to get insurance to pay for this and fortunately 6 randomized controlled trials demonstrated no advantage for the use of CPM. Based on this we did not utilize or advocate for its use in our protocol.

Immediate weight bearing and early ROM has been shown to improve outcome with less patellofemoral pain postoperatively. More than 15 randomized trials have evaluated using braces during the recovery phase following ACL reconstruction. No study demonstrated an advantage for safety, swelling, graft function or ROM with the use of the brace. Given the cost and inconvenience of braces we do not require or advocate bracing after ACL reconstruction.

Home based vs. outpatient rehabilitation has been evaluated in several studies. In the motivated patient appropriate outcomes can be achieved with minimal outpatient therapist guidance. This should be individualized for each patient.

Read future blogs for a review of further studies guiding our protocol’s development.

Wednesday, May 11, 2016

Can man run a sub 2 hour marathon? This scientist believes it's possible

Yannis Pitsiladis, a scientist, believes man can run a marathon in less than two hours --- lowering the record by more than 2 minutes. Read his ideas  HERE

Wednesday, May 4, 2016

The 7 most common Sports Injuries

Sports Injuries are common every day occurrences in the general population. Follow this link to read a review of the 7 most common.
The 7 most common Sports Injuries

Saturday, April 30, 2016

Meniscus Repair 2

The role of the meniscus in cushioning the joint and protecting the articular cartilage makes preserving them a key part of knee health. For a meniscus tear unfortunately meniscectomy (removing the torn portion) is the appropriate treatment 90% of the time. This is because in most situations a repair will not be successful. The reasons repair is not attempted is due to the lack of blood supply in 1/3-1/2 of the meniscus that precludes healing of a repair. Additionally, if the configuration of the tear is not appropriate then repair is not possible. In the 10% of situations when repair is possible it is typically highly successful in the short term with > 90% success without reoperation within the first 2 years. Our ability to predict ahead of time whether or not repair will be possible has been evaluated. In a study performed in conjunction with my partners and published in  the American Journal of Sports medicine we found we were able to predict the chance to repair a meniscus 74% of the time. This makes it easier to tell patients what to expect after surgery regarding recovery and rehabilitation. Read the Abstract HERE.

We evaluated the MOON meniscus repair results at 2 years in a study published in the American Journal of Sports Medicine and found that in 82 tears of which we were able to obtain follow up on 77 (94%) there was a success rate of 96% with no further surgery required for the meniscus within the first 2 years following repair in 74 of the 77 repairs. Read the full study HERE. In future blogs I will discuss the longer results we have noted at 5 years or more following meniscus repair.

Friday, April 29, 2016

1 Minute of All-Out Exercise May Have Benefits of 45 Minutes of Moderate Exertion

  A New York Times article reviewing studies that suggest high intensity short length interval training may give the same benefits as longer episodes of lighter exercise. Read the article HERE

Saturday, April 23, 2016

PRP for Osteoarthritis

The search for ways to improve osteoarthritis pain continues. I believe eventually we may figure out the proper use of Platelet Rich Plasma (PRP) injections to decrease pain. HERE  is a study evaluating different kinds of PRP preparations. It appears PRP containing fewer white blood cells works better when injected into joints than injections with higher concentrations of white blood cells.

Wednesday, April 20, 2016

Revision ACL Reconstruction Graft Choice Part 2

Revision ACL reconstruction Graft choice is an important Issue that impacts patient outcome.  In the AOSSM O'Donoghue award winning study published in American Journal of Sports medicine the MARS group analyzed the impact of allograft versus autograft choice on patient reported outcomes, reoperation and return to sports.Read the full study HERE In this study of 1205 patients that underwent revision anterior cruciate ligament reconstruction at 52 sites by 83 different surgeons 58% were male, median age was 26.  48% underwent autograft reconstruction and 49% underwent allograft reconstruction.  3% had a combination.  We obtained followup on 989 with questionnaires (82%) and an additional 10% phone followup for a total of 92% followup At 2 years. The IKDC Sports score improved with the use of autograft with an odds ratio of 1.33. The Knee Osteoarthritis
Outcome Score subscales sports and recreation and quality of life improved with autograft use with an odds ratio of 1.33.  37/1112 (3.3%) patients sustained a graft rerupture. Use of an autograft resulted in a 2.78 times less risk for graft rerupture.  Graft irradiation versus nonirradiated grafts did not affect the allograft failure rate.  More grafts had not undergone a radiation that ultimately failed.  Many people previously had believed that if the graft had not undergone irradiation then the results were equal to autograft. Reoperation risk was not affected by allograft versus autograft use.

Based on these findings many people now recommend if at all possible using an autograft for revision anterior cruciate ligament reconstruction.  This can involve the quadriceps, patellar tendon or hamstring grafts.  Frequently I will use a graft from the opposite knee if no other autograft options remain. 

Tuesday, April 19, 2016

Revision ACL Reconstruction Graft Choice Part 1

Revision ACL reconstruction requires careful thought about the appropriate graft to utilize.  In the revision (redo) situation a previous graft has already been used and failed.  This can force surgeons to potentially use a graft that is not their first choice.  As the basis for the MARS (Multicenter ACL Revision Study) we allowed surgeons to choose their graft that they felt most appropriate in the clinical situation.  Many surgeons believed that graft choice was a fait accompli and that they had no real choice in the matter.  They were forced to many times use a graft not of their choice based on other factors including patient's age, patient’s sport, previous graft utilized, gender etc. In a propensity study the MARS Group performed (Accepted for publication in The Journal of Knee Surgery) we analyzed a variety of factors that impacted revision ACL graft choice. Below you can see the factors analyzed and their impact on what graft the patient eventually received.

As can be seen despite a variety of factors that impact graft choice the most important factor was the particular surgeon that treated you.  Thus, a surgeon that wants to use an allograft (cadaver) for the reconstruction can do that.  Likewise, a surgeon that wants to utilize an autograft has the ability to control that decision most of the time.  The top 5 choices are expanded below and as can be seen in this table ---in fact the particular surgeon involved was 5 times higher impact on graft choice than anything else analyzed including the previous graft the patient had utilized for the primary ACL reconstruction.

Following this study we knew that if we could improve what type of graft gave the best results we could then recommend to surgeons to use that graft and impact patient outcomes.  In Part 2 I will discuss the follow-up study that analyzed outcomes depending on the patient's graft utilized in the MARS study.

Thursday, April 14, 2016

Tuesday, April 12, 2016

Meniscus Repair

The meniscus is critical for protecting and cushioning the joint. When the meniscus is torn and unable to be repaired then a meniscectomy is performed. Meniscectomy means removal of the torn tissue. When this occurs it increases the risk of arthritis. Even when performed arthroscopically the risk of developing arthritis in the future remains high. 50-75% of people that lose a moderate portion of their meniscus will develop symptomatic arthritis over the next 15 years. Since the meniscus helps protect the knee from wear and tear, surgeons try to repair the meniscus whenever possible. However, most meniscus tears are not considered repairable. Approximately only 10% are reapairable. The meniscus has a limited blood supply, and tears in areas of little or no blood flow have a high risk of not healing. The pattern of the tear is also important. It is not always possible to predict whether a meniscus tear is repairable prior to surgery.

If a meniscus tear is considered appropriate for an attempt at repair, a number of techniques can be used. The surgery is primarily arthroscopic (minimally invasive). It can involve small devices that utilize a technique completely inside the knee or small incisions, or cuts, may be necessary to perform the repair. A variety of devices or sutures can be used to perform a repair. If a patient has an ACL reconstruction at the same time as the repair of the meniscus, there is more blood present in the knee joint. Other methods can be used to improve the blood supply to a meniscus repair, for example using a portion of the patient’s own blood with a technique called platelet rich plasma (PRP).

The physical therapy following meniscal repair varies depending on a number of factors. Most patients can put weight on the knee soon after surgery, although a brace may be used. Running is usually delayed until 3-4 months after surgery while a full return to sports and squatting typically occurs after 4-6 months. The results are good following repair. In future blogs we will delve into some of the research we have performed at Washington University regarding meniscus repair, but in general 90% of repairs last a minimum of 2 years and 75-90% will last 5 years without retear.