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Osteoarthritis is the loss of the cartilage on the end of the bone. It's not the accumulation of debris necessarily, although that can be a secondary thing, but it's the loss of the smooth surface on the end of the bone. Well, that's again a loaded question in that regards because we really don't know (who is at risk for developing osteoarthritis). People who have a genetic predisposition, maybe a family history. People that are overweight. People that overuse and are overweight, so it's kind of a combination of multifactorial things. People that have had a prior injury to their knee, whether it be an ACL injury in high school.

Some people wonder if this is an age related problem. The answer is yes and no. It's not unheard of for us to see someone in their seventies or eighties who have no arthritis in any of their joints, so in that case, it's not. We can see fifty year olds who have advanced arthritis. Now the understanding is that as we age, we use our bodies more and if we have a predisposition of getting the problem in the first place, age probably plays a factor at that point.

While it's not hereditary in the sense of Mendelian genetics, it probably does run in families, and there probably is a genetic predisposition. It goes back to the age related question. Why are there some fifty year olds who have arthritis and others who don't? Well, there has to be something in their genetic makeup that gave them a predisposition to develop this at an early age. Right now, I don't think we have a clear handle on that, but there's research being done at centers all over the world that are trying to pinpoint this in the hope that if we can develop a way to assess for a genetic marker, we might be able to pick those patients out earlier and maybe either counsel them on dos and don'ts as they get older or maybe, and this would be really super cool, be able to manipulate it with medication of some sort.

Big toe arthritis or hallux rigidus, as doctors like to call it, is when a patient loses the cartilage on both sides of their joint that's at the base of their big toe. That can lead to pain, swelling, loss of function, inability to perform activities like running, jumping, things like that. It also causes difficulty with shoewear, especially in females who want to wear a higher heel shoe. This can lead to debilitation from the pain and swelling Common symptoms of big toe arthritis are pain and swelling. The first thing the patient usually notices is that it hurts when they roll over onto their big toe, as the toe flexes upward. That's where patients tend to get the first part of the arthritis, is at the top of the joint. When they lean into the joint, that's when they seem to notice the symptoms the worst. The pain might be associated with swelling right away. It's usually not associated with redness, like you'd see with gout and those other conditions, but the pain and swelling are usually fairly significant.

Hallux rigidus has traditionally been treated by, first off, conservative measures using anti-inflammatory medications, sometimes stiffening up the bottom of the shoe by placing a carbon fiber plate or some type of a steel shank in the shoe so that you don't bend as much into the joint, so you don't get the pain when you bend. Typically, those only last for a certain period of time until the patient requires something else more invasive, such as an interarticular injection of corticosteroid medication. Once things like that start to fail, then we start to have decisions being made about possible surgical methods of repair. Typically, patients start out having just the top portion of the joint removed because that's where the arthritis typically starts. That procedure's called a dorsal cheilectomy.

Once the patient reaches a point in their arthritic condition where it has involved the entire joint and they have pain with any range of motion attempts at all, then we typically will go ahead and perform a joint fusion, also called an arthrodesis, where we actually remove the joint altogether. We use plates and screws to hold it together until the bones heal across to each other. The joint is completely taken out at that point and your pain is removed because the joint is no longer there.

It's a very good pain relief operation for patients. However, it does take away the motion in the joint and patients do not like that. They want to be able to run and jump and do other activities.

A total shoulder replacement is when you take the normal ball and socket joint within the shoulder and you replace those with metal and plastic parts.

The recovery from a total shoulder is totally dependent on the patient and their willingness to listen to the postoperative instructions, participate actively in the physical therapy and their ability to ask relevant intelligent questions that can help us avoid any of the pit falls postoperatively.

It's on a daily basis that I'll meet a patient and the family member says, "You know, my shoulder's been killing me for six months. What should I do?" Those are the type of people we say, "Hey, ask the right questions. Come in and see us and we'll get a true evaluation and figure out what our options are in terms of treatment.

If you have pain in your shoulder, inability to raise your shoulder over head, cracking or grinding in your shoulder when you attempt to use it, inability to participate in overhead activities. Those would be times to go in and see an orthopedic surgeon and ask some questions. Although, the need for shoulder replacement is often dependent on a combination of symptoms and X-ray findings. Both of those things would require an evaluation by an orthopedic surgeon who could get appropriate X-rays and talk to you about your symptoms.

There are several reasons someone would consider a total shoulder replacement. Osteoarthritis of the shoulder joint, fractures within the shoulder joint, and/or rotator cuff tears or deficiency, or a combination of any of those three conditions.

People at a higher risk for the need for a shoulder replacement would include manual laborers, people who work with their hands and arms regularly, particularly in occupations where they're doing a lot of overhead work. Sometimes, people at risk for the need for a total shoulder replacement is just bad luck. They fell and broke their humerus, they fell and tore their rotator cuff and it was not a fixable tear. Or sometimes, they're just predisposed to arthritis within their shoulder and it has nothing to do with their occupation or lifestyle.

The meniscus is torn or injured in a variety of ways. Most commonly an impact or rotational injury through the knee. Twisting, deep knee bending, those are activities that put us at risk for a meniscal tear.

Young athletes typically get a meniscal tear during a traumatic knee injury. The most common types of meniscal tears we see are actually in a middle age to elderly population and represent degenerative tearing where the tissue has gotten weaker and the injury may not be so significant that they know when it happened, whereas in a young athlete, it's typically a different scenario. "My knee felt normal until I did this on the soccer field, and now something isn't right. It's clicking, catching, popping. I've got swelling and pain in the knee. 

Young athletes represent a distinctly different entity where there's usually a very definitive mechanism, usually related to athletics or participation in sport, whereas middle age to elderly people don't tend to have that same mechanism of injury. Oftentimes they don't even know when it occurred. They just know the knee has started to hurt them over the course of several months. Same injury, but representative of two different subtypes of that injury.

Sports where you'd be more prone to a meniscal tear, particularly in a young population, are sports that involved heavy landing, twisting, and pivoting. Sports where we most commonly see it would be soccer, football, basketball. The types of sports where we're landing and twisting simultaneously are the ones where you have a much higher likelihood of a meniscal tear.

The ways you can reduce the risk of a meniscal injury, particularly in a young athlete are being healthy about your participation in sport. In other words, participating in the same sport for extensive lengths of time, every day, seven days a week, 365 days a year, puts you at a high likelihood for a serious injury, possibly a meniscal tear. Keeping your body healthy and fit outside of your sport, eating well, exercising regularly not in your sport, in other words cross training, doing a variety of different activities at lower levels that allow you to stay strong globally instead of just strong from the perspective of your individual sport can help prevent serious injuries in a young athlete. 

Treatment for a young athlete with a meniscal tear once again can have several different levels of complexity to it. We always exhaust our nonoperative measures first. Time, rest, anti-inflammatories, ice, physical therapy. Oftentimes those nonoperative measures are enough to make this meniscal tear asymptomatic. If those don't work, then oftentimes we're talking about operative treatment in the form of knee arthroscopy, where we use small instruments through tiny incisions to go in and find the meniscal tear, and typically do one of two things. 

Either, if it's a small, relatively innocent meniscal tear, we can trim out the torn portion of the meniscus. If it's something bigger or more serious and involved in a young athlete where we're trying to get them back into sport and maintain their knee for many years to come, then oftentimes we're talking about actually repairing the meniscal tissue in that scenario.

Delayed onset muscle soreness is actually a very common problem where athletes or people that are involved in physical activities will end up with pain where the body is sore after any type of what we call eccentric exercise, where any time you're lengthening the muscle and putting a force on that muscle will cause the muscle strain. That will lead to delayed onset muscle soreness. Typically, delayed onset muscle soreness occurs about 24 to 48 hours after the physical activity and usually lasts around three to five days.

Reducing the risk of delayed onset muscle soreness ... really the only thing that you can do is not work out, and I don't advise that. Everybody is going to get sore at some point when they pick up a new routine, pick up a new activity. It's just how significant the muscle soreness is. There are definitely times when the soreness and the pain can actually be quite detrimental in the activity. As long as you can still do your normal activities after you work out, then it's okay. We actually don't discourage that.

There are a few signs where we do tell folks that it's concerning when their muscle soreness doesn't go away. Typically, those include swelling of the muscles or the extremity, pain in the joints, or if they actually urinate and their urine is dark brown. That is a sign that the muscles are actually broken down past the point of healing on their own. That's when we advise that folks come in and have us take a look at them.

It's minimally invasive and it doesn't burn a bridge. It's done in an outpatient setting. It's a small incision where we inject a toothpaste-type material into the bone marrow lesion using x-ray guidance, so we can get it right in the spot. It hardens up and over a year or two, becomes your bone. The nice thing about it is, this is an artificial bone grafting material that eventually forms into your bone.

The best candidate for this procedure is somebody who has pain in their knee, consistent with a diagnosis of arthritis, who has a bone marrow lesion on MRI consistent with the diagnosis, who's active and is trying to avoid a more invasive knee replacement procedure.

A lot of people are asking whether this is going to replace joint replacement surgery, and I just don't think that's going to be the case, because we said earlier, we're looking at joint preservation options to try to keep people's parts in them as long as we can. Now, is this going to be forever or two or three years? I think the jury is still out on that.

There's still 25% of patients who, within a year, have had a knee replacement. So, I don't think it's going to replace it.  I think it's going to give people another alternative prior to that, short of just physical therapy, cortisone injections, medications.

I think our outcomes have been consistent with the literature, 80% reduction in baseline discomfort in 80% of our patients, and so far, we have not seen a patient back who's asking for more additional treatment.

Stem cell therapy is a type of regenerative injection where we use the body's own stem cells and the capabilities that they have as far as natural healing and regenerative ability to heal your body's injured structures.

In orthopedic care, for anyone with arthritis, chronic tendon injuries, ligament injuries, muscle tears, we use the stem cells as an injection into those injured areas to use the body's natural healing ability to heal the injured areas.

Stem cell therapy is definitely an alternative treatment to joint replacement or for anyone who isn't interested in surgical options and it definitely has the potential to at least delay if not reduce the need for joint replacement.

There are a lot of people who could be good candidates for stem cell therapy. The number one reason we tend to do stem cell therapies is people with degenerative arthritis conditions where there is worn away portions of cartilage of the joint. But it can also be beneficial in people with chronic ligament, tendon, or muscle injuries as well.

Stem cell therapy absolutely has the potential to deliver long lasting benefit. Really, because of the different make-up of the joint, the degree of arthritis or chronic tendon or ligament damage, it really depends on the response of the individual person and their activity level, how long that response lasts.

The Benefits of Endurance Training

Endurance training is exercise focused on improving stamina, or the athlete's ability to do something for a longer period of time. For most athletes, this is looking at aerobic fitness or cardiovascular fitness. And this is the body's ability to get oxygen to the body and to the muscles that are using it during exercise. For the general population, and for athletes, these can include exercises such as walking, running, biking or swimming.

So all athletes need some type of endurance training. In the general population of adults, the American Heart Association recommends 150 minutes of cardiovascular exercise each week. Even athletes in sports that aren't focused on endurance should look at getting some amount of cardiovascular exercise to try to meet this minimum recommendation.

For athletes in endurance sports such as biking and cycling as well as running, they should focus on higher levels of endurance training to improve their ability to be competitive in these sports. Even our athletes in power sports, such as football and volleyball, should focus on strength endurance training to allow them to participate at a higher level.

How to Get Started

The need for a personal trainer for endurance training is really an individual question. Some athletes will benefit from a personal trainer, but many athletes are already equipped to start endurance training on their own. For our high school athletes, a lot of our coaches in the area are very well equipped to train our athletes. We have great coaches that have already formed great training programs that focus on endurance for our young athletes.

For an accomplished athlete endurance training can take them to the next level by allowing them to participate at a high level of activity for a longer period of time. This consistency and availability are important qualities in an athlete, and endurance training can improve both of these characteristics for an athlete.

There are different types of endurance training. The most common type of endurance training is aerobic exercise focused on cardiovascular fitness. And this is going to focus on building lean muscle. While athletes may not see a hypertrophy or enlargement in the muscles, their muscles are going to be getting stronger. For strength endurance athletes, they may some hypertrophy or increased mass in their muscle through that training.

Be Smart About Endurance Training

Endurance training can protect an athlete by improving their ability to keep their form and biomechanics throughout the activity. When athletes get tired or fatigued, their biomechanics and form can change, which places new stresses on their body. This can be seen in a distance runner late in a race, or in a pitcher late in a ballgame. As their form breaks down, it places new stresses on their tendons, ligaments, muscles and bones which can lead to overuse and stress injuries.

For any sporting activity, there are some risks of injury. And endurance training is no different. In endurance training, the most common type of injury we see is an overuse injury such as a stress fracture, a strain or tendonitis. For athletes getting into a new activity like endurance training the key to staying healthy is being patient and having a good plan and appropriate guidance.

Most injuries occur when athletes try to increase the intensity of volume of their training too quickly. With an appropriate plan, this risk can be decreased. The potential long term benefits of endurance training far outweigh the risks as endurance training and cardiovascular fitness can decrease the risk of chronic disease and the need for medications.

Learn About Overuse Injuries

Overuse injuries are extremely common in baseball and they're due to the repetitive nature of the game. Especially in throwers, we see a lot of overuse injuries to the shoulder and the elbow. 

Muscle strains are partial tears or stretch injuries to the muscles. They're graded one, two, or three based on the severity of the strain. Grade one is usually just a stretching injury of the muscle. Grade two is a partial tear. Grade three is a complete tear of the muscle and those are less common, fortunately.

Baseball with the repetitive activity and the high stress that we place on certain muscle groups puts an athlete at risk for those types of injuries.

A labral tear is a disruption or a stretching or some type of an injury to the structure surrounding the socket part of the shoulder called the glenoid. The labrum acts to impact stability to the shoulder. When that's disrupted or torn it can lead to instability symptoms in the shoulder.

Dead arm syndrome is a constellation of symptoms and it can be due to multiple injuries or multiple issues in the shoulder.

Most commonly we see it in throwing athletes or overhead athletes and it's due to an injury such as impingement or a labral tear or a rotator cuff tear in the shoulder. Usually, it presents as decreased control or accuracy in a throwing athlete or decreased velocity. Some of our pitchers that have dead arm syndrome can't throw as fast as they used to or they're not as accurate as they used to be when they have these symptoms.

Thrower's elbow is also known as medial epicondylitis. It's characterized by pain on the inside part of a thrower's elbow, the medial epicondyle. Sometimes, enough discomfort is present that it actually affects the throwing motion. It is due usually to overuse or it can also be due to increased activity all of a sudden and it can also be due to incorrect throwing technique.

UCL elbow strain is similar to medial epicondylitis or thrower's elbow but specifically with a UCL strain, the ulnar collateral ligament or the ligament on the inside part of the elbow is stretched or partially torn. Usually, this occurs over time but can occur suddenly or traumatically. Throwers usually notice it as pain on the inside of their elbow, but it can also lead to decreased velocity and decreased control as well.

Reducing Overuse Risk

I think it's very important when an athlete is going to perform in a game or even in a practice session to warm up before that game or practice session. Stretching is very important and some athletes like to even apply ice to the shoulder and perform other stretching activities before competing in the game. Likewise, a cool down is very important after the game to allow the muscles to recover.

Resting after a game is also very important. Particularly in overhead athletes and throwers, we like to have most of our throwers rest for several days after performing in a game where they throw multiple pitches, 50, 60, 70 pitches. In our younger athletes we like to have them rest for several days.

Some studies have shown that cross training and varying the activity that an athlete, especially a young athlete, performs is very helpful to overall efficiency and overall excellence in a certain type of sport.

We don't want our athletes playing competitive baseball year round. They do need some time off. They do need rest. They do need variability in their activity to perform at their top level during the season.

Pitch counts are very important in reducing injury and they vary by age. We want our younger athletes and throwers to be throwing less than our older athletes.

Generally speaking, we look at seven and eight year olds as having a maximum pitch count per game of about 50 pitches. When you're 9 or 10 years old, 75 pitches is acceptable. Between the ages 11 and 12, 85 pitches are acceptable. When you're in the age range from 13 to 16, 95 pitches are considered the maximum. Then, from 17 to 18, 105 pitches per game is considered to be the maximum.

Having the maximum pitch counts is important because we know that pitching beyond those numbers can lead to overuse injuries, which can limit the amount of time that the athlete actually is able to participate in a season. Permanent or semi-permanent damage to the elbow or shoulder can occur if pitch counts are not followed appropriately.

In addition, it's important to keep in mind the types of pitches that athletes throw. We really don't like our younger athletes to be throwing certain types of pitches like curveballs and screwballs. We like to wait until the bones are a little bit more mature, until growth is a little bit more complete before they're throwing those types of pitches.