Final Report: Overuse Injuries - A growing trend?

Biotechnology in Sports Medicine is becoming increasing relevant to young athletes. Throughout our blog, we have explored preventative techniques and treatment options for three main injuries associated with baseball, basketball, and rowing. We have noticed a growing trend in early specialization in specific sports, and there seems to be mounting pressure on today’s youth to perform at a higher level compared to previous generations. Additionally, because of the competitive nature of college admissions, people now see sports as a ticket to highly selective universities. This added focus on one sport has increased the prevalence of sports-related injuries, three of which we focused our research on: rotator cuff tears, ACL injury, and lumbar disc herniations.

Rotator cuff tears sustained playing baseball are most often caused by overuse due to the repetitive throwing motion. These are complicated injuries because not only do they sideline athletes, but they strongly impair daily life. A friend, a former varsity athlete, just sustained a full thickness rotator cuff tear and is in extensive physical therapy to even be able to hold her child in the future. Rotator cuffs are most often repaired surgically and technology has improved recovery rates and surgical outcomes. The Opus Knot Fixation System is an example of a new biotechnology used in the surgical treatment of shoulder injuries, and may become more widely available in the future. On the flip side, because of the effectiveness of surgery, younger and younger patients are opting for surgery instead of more conservative treatments. Our blog also investigated the conservative treatment alternatives for these injuries. Conservative approaches include activity modifications, and oral non-steroidal anti-inflammatory medications – these treatments have been proven effective in the treatment of shoulder injuries.

Many elite Basketball players have sustained or will sustain an ACL injury. ACL injuries have become so prevalent that The American Academy of Orthopaedic Surgeons and the National Athletic Trainers' Association has taken a proactive stance through public service announcements to make athletes aware of the importance of preventing these injuries. ACL tears are more commonly found in girls both because of their gender, and because they are genetically pre-disposed (the COL5A1 gene) to the injury. There are a variety of techniques being developed both to improve and change surgical techniques. An example of this is the use of bone marrow stimulation to regenerate growth of the torn ACL – one day this technique may be able to replace ACL reconstruction.

Overuse injuries in rowing most commonly manifest themselves in the lumbar region. The rowing stroke includes a significant amount of lumbar flexion, which increases with fatigue. Over time this leads to back injuries, including lumbar disc herniation. Our group was particularly interested in these injuries, as two of our bloggers are NCAA rowers, and have experienced overuse injuries. On the extreme end, one rower had a transforaminal epidural steroid injection, and a medial nerve block to treat a lumbar disc herniation. As an example of a more conservative treatment another rower underwent bone stimulation, a new technology that has been used to treat stress fractures (commonly found in the ribs of rowers). With respect to conservative treatments and prevention – the volume of training required for rowing makes prevention of overuse injuries difficult. Usually prevention focuses on improving core strength and flexibility, which may decrease the probability of an injury occurring.

Exercise is an integral component of personal health. Given these issues with overuse, it is becoming necessary to find alternative forms of training. An athlete’s training schedule should include exercise which allows the body to rest from the repetitive nature of certain sports, and which increases the strength of a diverse group of muscles (some of which they would not exercise during regular training.)

Overall our blog sought to focus on the development of biotechnologies and prevention methods to alleviate sports-related injuries. We hope that both coaches and athletes will continue to investigate new solutions, such as those discussed in our blog, to improve the overall health of athletes, as well as to decrease the incidence of sports-related injuries.

A Less Invasive Treatment for Disc Related Lower Back Pain? (SpineCATH IDET)

Chronic back pain is commonly caused by fissures in the intevertebral discs of the spine. This injury has been followed by this blog, as it is commonly found in rowers, due to the stress they experience on their lower backs. Surgery to correct this problem comes with risks, long recovery periods, and other hurdles, and is not the only available option. The articles linked to below examine a non-surgical technology developed called Intradiscal Electrothermal Therapy (SpineCATH IDET). The article linked here comes from Science Daily, and discusses the technology, which started being widely available to patients around 2001.

http://www.sciencedaily.com/releases/2001/01/010124074916.htm

How does this procedure work? It is a simple treatment done under only a local anesthesia or mild sedation. A needle guided by x-ray is inserted into the afflicted disc, and then a catheter is passed through it and into position. The catheter is then heated, applying heat to the disc. This triggers a significant reaction in the disc causing the disc wall to heat up, and the fissures to contract and close. Along with this, the nerve endings may be desensitized, and/or the bulge of disk material can be reduced.

Chronic lower back pain is not exclusively found in athletes, in fact Science Daily reports in the article that one in five Americans suffer from back pain, and that non-surgical treatments are actually the most common. Technology like this is important because it offers athletes, and countless other people who experience disc-related back pain, a treatment option that is minimally invasive, and that also differs from more traditional non-surgical methods such as physical therapy and pain medications. It is great to see technology being applied not only to surgical procedures, but also to methods that are less invasive, and thus often carry fewer risks.

While there is still a recovery time required for the disk to heal (stated at 12-16 weeks), in the article below Dr. Amundson explains how a typical patient might be sent home after the procedure “with a Band-Aid over the needle insertion site.” That sounds a whole lot better than a large surgical incision.

For a discussion of the SpineCATH IDET procedure, possible side effects, and criteria for treatment look at the following article for a question and answer session with Dr. Glenn M. Amundson, an Orthopedic Surgeon about IDET:

http://www.spineuniverse.com/displayarticle.php/article217.html

Advances in Biotechnology

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Advances in Biotechnology Improve Clinical Outcomes for Spinal Decompression

Many people suffer from back pains. Rowers in particular suffer from lumbar disc herniations, an uncomfortable spinal condition. A common solution is spinal decompression, but the procedure has many drawbacks. The purpose of the study by Gionis et al. was to determine the efficacy of recent advances in biotechnology used for spinal decompression. The DRX9000, a novel piece of equiptment recently approved by the FDA, was used in this study. Patients received twenty treatments of spinal decompression over a six-week course of therapy. Results showed that treatment was successful in 86% of the 219 subjects. These patients reported near complete resolution of pain, lumbar range of motion, and recovery of any sensory or motor loss.

Progress is the field of biotechnology is constantly under-valued; many people don't understand the science and judge based off of limited information. I feel it is important to pursue biotechnological solutions to common problems. If we don't we would miss out on such devices as the DRX9000 which led to very positive results as a treatment for disc herniation. Biotechnological advances in this area could further improve the results of treatments.

Click for Article Here!

A Study on Strategies for Noncontained Lumbar Disc Herniations

The rowing stroke places a lot of stress on the lower back, thus leaving many competitive rowers dealing with lower back injuries. Although many young rowers present with bulging discs, annular tears, and inflamed joints, these problems often do not become surgical until later in life. A recent article in The Journal of Korean Neurosurgical Society discusses many implications of biotechnology in revolutionizing lumbar disc herniation surgery. Entitled “Strategies for Noncontained Lumbar Disc Herniation by Endoscopic Approach: Transforaminal Suprapedicular Approach, Semi-Rigid Flexible Curved Probe, and 3-Dimensional Reconstruction CT with Discogram”, Dr. Chae et al discuss the combination of imaging and surgical technology to increase the success rate and the ease of this particular surgery.

When a patient is diagnosed with a noncontained disc hernation, there is a distinct probability that the inside of the disc has fragmented and possibly moved around in the spine. With these types of herniations, the typical surgical methods are not always effective because of the placement of the disc fragments. Dr. Chae et al explain that they used 3D reconstruction CT images to determine the severity of the disc herniation and whether or not the fragments were contained. This allowed them to see whether or not the use of a semi-rigid flexible curved probe, made by RZ Medizin Technik GmBH in Germany, would help to extract the disc material so that the endoscope could reach the material and remove it from the body. The use of this type of probe allows the surgery to remain endoscopic (an incision of only 1 cm) even when the disc fragment has migrated into a place where it cannot be reached by the endoscope alone. In this study, 94.77% of the 145 patients had satisfactory results, and within that group, 99 patients reported excellent results.

Because of the variation in types of disc herniations, it is often difficult for doctors to determine what type of approach will be necessary to remove the disc fragment. This can make surgeries more difficult and possibly increase recovery time. Yet, according to this study, the use of 3D reconstruction CT allows surgeons to see exactly where the disc herniation has occurred and can determine what type of surgical technique and instrumentation will be necessary. Surgical tools like the semi-rigid flexibly curved probe can help mediate problems like disc fragment migration and also keep the surgery as simple as possible for the patient. These types of innovations can help to decrease the likelihood of needing revision surgery in the future by making sure that all of the disc fragments were successfully removed the first time around. Most athletes, especially rowers who place a lot of strain on their lower back, and commonly suffer from herniated discs, would welcome innovative techniques like this.

http://www.jkns.or.kr/htm/fulltext.asp?no=0042009141

Rowing Injuries: Possible Effects of Lumbar Flexion and Back Muscle Activity

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Low back pain is one of the most common injuries seen in rowers. Within the rowing stroke, although the legs are the main component of power, the back extensor muscles are pivotal in the regulation of flexion and extension of the lumbar spine. It has been suggested that the range of lumbar flexion over the course of the stroke may contribute to injury. In accordance with this, prior studies have shown that bending increases as people come near the top of their range in lumbar flexion, this consequently increases stress on spinal structures.

The study, “The Effects of Repetitive Motion on Lumbar Flexion and Erector Spinae Muscle Activity in Rowers” investigated the changes in lumbar flexion and back muscle activity throughout the course of a rowing trial on an ergometer. It was published in Clinical Biomechanics in May of 2003 and is available online. The study involved 16 young adult rowers with an equal sex ratio, of whom none had any medical history of lower back pain.

The study measured lumbar flexion and muscle activity at two parts in the rowing stroke and at three separate times during the trial (at 20%, 60%, and 95%). Motion analysis was used to record lumbar flexion and was then compared to each individual’s initial total range of lumbar motion. EMG recordings were used to record muscle activity in the multifidus, ilicostalis lumborum, and longissimus thoracis; they were then compared to each individual’s initial maximum voluntary isometric contraction readings.

The study concluded that rowers have an initial high level of lumbar flexion that continues to increase over the duration of a rowing trial. The changes in EMG recordings provided indirect evidence of fatigue in the back extensor muscles, which may also contribute to the increase in lumbar flexion. They found no significant difference between genders.

Although the study has flaws in it’s design, the article was very effective in showing the importance of conducting further research in the area and how beneficial it could be to injury prevention in rowing. Study weaknesses included the small sample size as well as the possibility of crosstalk in EMG recordings. As a rower, I found this article to be very interesting. A few things I thought worth noting, which the article failed to discuss when it compared the ergometer to actual rowing, were the possible difference in the fluidity of the stroke when moving on water and the perceived weight of the handle during the drive.

See the Article Here!

Olympic Rower Undergoes Micro-Discectomy

In September 2008 Australian triple Olympic gold medalist rower Drew Ginn underwent micro-discectomy spinal surgery to repair a lower back problem caused by rowing. After winning the gold medal in the summer 2008 Beijing Olympics, Ginn needed to get surgery. He almost had to drop out of the Beijing Olympics due to a ruptured disc. He was experiencing nerve pain and ultimately discovered he had ruptured his disc, and that a fragment had broken off and been lodged in the cavity behind the disc. He pushed through the 2008 Olympics with the pain, but once it was over had a micro-discectomy to repair the ruptured disc in the L4/L5 region of his lower back. The pain had become so overbearing that surgery was Ginn’s only option. The pain in his lower back was moving down to the sciatic nerve in his leg. Micro-discectomoy’s are performed for herniated lumbar discs and effectively treat leg pain or radiculopathy. The recovery time for this procedure is about 6 weeks; Ginn had to stay in bed, only walking when movement was necessary. This is a significant amount of a time for an athlete in particular to have to remain inactive.

There are some risks associated with micro-discectomy’s such as dural tear, nerve root damage, infection, and bladder incontinence. Ginn experienced some nerve damage and deactivation of muscles around his hip, back, and right leg. The damage could be permanent but it takes about 6 months to determine that. Complications for micro-discectomy's are rare.

Ginn has had a long history of back injuries during his rowing career. He missed the Sydney Olympics due to a back injury and went through a rehabilitation process in 2000. This article provides a great case study of the dangers and severity of injuries associated with rowing athletes.

http://www.foxsports.com.au/story/0,,24298013-23210,00.html

Check out this video of a Basketball player tearing their ACL

http://www.youtube.com/watch?v=84OUUz3u7Lc&feature=player_embedded#at=16

Collagen-Platelet Composites Found to be Effective in ACL Repair

In 2006, an article in Science Daily reported on a promising technique that could one day replace ACL surgery. The technique described in the article involved injecting collagen gel, enriched with blood platelets from the patient, into the area where the ACL tear had occurred. This collagen would then it was theorized, act as a bridging material for the torn ligaments to fill. Meanwhile, the platelets would supply growth factors that would support this bridging. This technique had only been explored in animal models at the time, but nonetheless was exciting. Dr. Martha Murray, who led the team conducting the study, hoped that the technique would provide a less-invasive, more effective form of ACL repair, and that the collagen gel could eventually be used to regenerate cells damaged by osteoarthritis.

Building on this information, this past March 2009 researchers published an article in the American Journal of Sports Medicine that shows further promise for the utility of collagen-platelet composites. The study, titled “Collagen-Platelet Composites Improve the Biomechanical Properties of Healing Anterior Cruciate Ligament Grafts in a Porcine Model,” compared surgical outcomes in porcine subjects. The pigs were either given a traditional ACL repair, or an ACL repair with a collagen-platelet composite (CPC) around the graft site. Results are very promising. The CPC was well tolerated, as it was pre-treated with a pepsin product to help reduce rejection. Animals who received this treatment showed a stronger recovery from their ACL repair. Those who received the CPC had no observed necrosis in the graft, and had a lower level of knee laxity (instability) post-op.

The results of this study are exciting, and reinforce the thought that collagen support in ACL repair could hold promise as a future treatment in human patients. There are however a few caveats, since the grafts were used in animals they were not sterilized prior to grafting. There is no way of knowing whether the sterilization process that would be necessary to put an allograft into a human would reduce the efficacy of the treatment. Additionally, there remains the chance that the process of wound recovery, and the physiological differences between the porcine model and that of a human, contain variation that could influence the extent to which the treatment is effective. Moreover, the technique has not yet been tested in a human.

The results of the study still show that although the enhanced surgical graft was effective, that there is no substitute for a healthy, injury-free ACL. Thus, even with such exciting technologies beginning to emerge, prevention should still remain a focus as medicine moves forward.

The articles discussed in this post can be found at:

http://www.sciencedaily.com/releases/2006/03/060327214156.htm

http://ajs.sagepub.com/content/37/8/1554

Study Shows a Potential Future Alternative to ACL Reconstruction

Source

One of the most commonly treated knee injuries is an anterior cruciate ligament tear. It has been documented in the past that the ACL has a very limited ability to heal itself; this has made reconstructive surgery the standard treatment for ACL tears. In reconstructive surgery, the torn ACL is removed and replaced with a tissue graft often from the hamstring or patellar tendon. Another surgical option is primary repair, in which, the injured ACL is sutured back onto the residual ACL. This technique is not commonly used because it has been shown to result in continual laxity and instability of the knee.

The study, “Primary Repair Combined With Bone Marrow Stimulation in Acute Anterior Cruciate Ligament Lesions” hypothesized that primary ACL repair with additional bone marrow stimulation could successfully restore stability and function in the knees of athletes with partial tears. It was published in March of 2009 in the American Journal of Sports Medicine and can be found online on their website. The study consisted of 26 athletes, with a mean age of 26.6 years, all of whom were able to undergo surgery within 4 weeks. All participants in the study had athroscopically confirmed partial ACL tears and underwent a primary repair surgery in which there was also bone marrow stimulation of the ACL femoral attachment area. They also had to undergo a specific rehabilitation program post-op. After surgery and rehabilitation, only 19% of the patients did not return to the same initial level of sports activity, in more than half of these patients the determining reason was personal and not due to physical impairment.

The study’s use of bone marrow stimulation builds upon the notion that the use of stem cells in medicine may be at large in the near future. The stimulated cells were mesenchymal stem cells, which have healing capabilities because of their ability to differentiate into specific tissue.

The study concluded that primary repair of an acute ACL tear paired with bone marrow stimulation can successfully restore the knee’s function and stability. Unfortunately the small group size, strict experimental criteria, and lack of a control group/randomization make the study statistically insignificant. Instead, by revealing the possible use of natural healing in ACL injuries, the study serves as a window into what may eventually replace ACL reconstruction in the future.

Although this study has many flaws, it effectively promotes the benefit that may come out of further research into alternative ACL surgery. If successful, this surgery would be a great alternative to total ACL reconstruction. It would theoretically eliminate the decreased proprioception that ACL-reconstructed knees often suffer from as well as harvest site morbidity and harvested tendon weakness.

See the Online Article Here!

Patellar Tendon Versus Hamstring Tendon Autografts for Reconstructing the ACL

ACL (anterior cruciate ligament) injuries are very common among athletes and non-athletes alike, but sports like basketball tend to have a very high incidence rate of ACL tears. Jumping and twisting both put unnatural strain on the knee ligaments, and if a basketball player lands incorrectly, he/she can be out for the season and will be faced with a series of complicated decisions. Some ACL tears do not require surgery, but in order to return to athletics, it is usually necessary to surgically reconstruct the ACL. ACL reconstruction surgery is done using one of three types of grafts to replace the torn ligament: a piece of the patient’s patellar tendon, a piece of the patient’s hamstring tendon, or an allograft (usually a cadaveric Achilles tendon). Autografts have become the go-to surgical option for numerous reasons, but there has been a longstanding discrepancy between the use of patellar and hamstring autografts.

In August of 2009, The American Journal of Sports Medicine published a meta-analysis on individual patient data entitled “Patellar Tendon Versus Hamstring Tendon Autografts for Reconstructing the Anterior Cruciate Ligament”. This study looked at data from 6 previously published clinical trials and used two different knee stability tests to analyze the effectiveness of both grafts. Dr. Blau et al used the positive pivot-shift test to characterize knee instability and the positive Lachman test for instability on a post-ACL reconstruction knee. The bone-patellar-tendon bone autograft had significantly fewer positive pivot-shift tests, even when adjusted for age and gender. Because there are so many factors contributing to how individual knees recover and perform, some surgical options work better for some, but this study determined that, despite differences, pattelar tendon autografts are superior to hamstring grafts.

Orthopedic surgeons advise their patients based on a variety of factors, but as research on graft superiority becomes more definitive, the reconstruction procedure should become more standardized. For athletes like basketball players in which these injuries are so common and for whom stability plays an important role in their sport, bone-patellar-bone tendon autografts may be the answer for ACL reconstruction.

http://ajs.sagepub.com/content/early/2009/08/18/0363546509333006.long

A Genetic Link - Why females have a higher risk of tearing their ACL

http://ghr.nlm.nih.gov/dynamicImages/chromomap/col5a1.jpeg

The COL5A1 Gene is Associated with Increased Risk of Anterior Cruciate Ligament Ruptures in Female Participants

ACL injuries generally require a long recovery time. As a result, many studies have been done to identify risk factors and preventative measures that can be taken. It is commonly recognized that women have a higher probability of tearing their ACL than men, but it is not fully understood exactly why that is; women have up to 4.6 times greater risk of ALC rupture than men. A study titled “The COL5A1 Gene Is Associated with Increased Risk of Anterior Cruciate Ligament Rupture in Female Participants” explored this relationship. This study was published August 4, 2009. It can be found in the American Journal of Sports Medicine.

This study found that the female participants with a CC genotype in the COL5A1 gene had a decreased risk of ACL ruptures. This has never been shown before. The COL5A1 gene encodes for the alpha-1 chain in type V collagen, which is an important structural constituent of both ligaments and tendons. Thus it would make sense that women who were effective at producing type V collagen would have a decreased risk of tearing their ACL. Although the CC genotype was underrepresented in females with ACL ruptures, this link was not found in men, indicating that lacking the CC genotype is a gender-specific risk factor. The researchers in this study also found that female, but not male participants within the ACL group reported a significantly higher family history of ligament injury. This second finding is supported by data from another study. This again supports the idea of a genetic risk factor associated with family history, specifically in women.

It is important to identify these risk factors because avoiding an extremely painful injury with a long recovery process is important. The CC genotype of the COL5A1 gene might be a candidate for genetic testing. If you are a woman and you knew you did not have the CC genotype would you still participate in sports that involved jumping, such as basketball? Would you be more disciplined in learning preventative behavior, such as safe landing practices? These are things to consider as we move into a new era of science where it is possible to investigate your individual genetic code.

The COL5A1 Gene Is Associated With Increased Risk of Anterior Cruciate Ligament Rupture in Female Participants

Basketball Players Commonly Experience Anterior Cruciate Ligament Tears

ACL tears are a common injury among basketball players. The article, "Differences in Selected Predictors of Anterior Cruciate Ligament Tears Between Male and Female NCAA Division I Collegiate Basketball Players" not only mentions the prevalence of ACL tears in basketball players, but also focuses on the difference gender plays in the occurrence of ACL injuries. This article was published in the June 1998 publication of The Journal of Athletic Training and is a study looking at the increased risk female athletes’ experience towards ACL tears. According to recent NCAA injury statistics, women basketball players were 6 times more likely to incur an ACL tear than males. This study looked at gender differences in strength, Q-angle, and pronation as predictors of ACL injuries in college basketball players. The author hoped that by identifying specific gender differences, preventive measures could be taken to minimize injury among females.

Results from the study showed that there were some significant differences between male and female muscle strength affecting the tendency to experience ACL injuries. Results showed eccentric hamstrings strength relative to eccentric quadriceps strength and Q-angle measured at 30 degrees of flexion were quite different among males and females. Hamstrings act as protagonists to the ACL in controlling tibial movement. A deficit in eccentric hamstrings strength relative to eccentric quadriceps strength could predispose an athlete to ACL injury.

The study concluded that further research investigating landing mechanics and possible strengthening techniques to address eccentric hamstrings deficits is necessary. This is very important because having identified certain risk factors that make women predominately more susceptible to ACL injuries, researchers can tailor preventative meausures to decraese female risk.

This article was published over ten years ago, and since then, a growing concern and increase of knowledge about athletes and ACL injuries has emerged. ACL Prevention Programs have emerged to reduce modifiable risk factors in woman such as proper landing techniques, strength-training lower extremeities, and proprioceptive-balance training. In March of 2009, The American Academy of Orthopaedic Surgeons and the National Athletic Trainers’ Association debuted a public service announcement targeting athletes, coaches, parents, health care professionals and media on the prevention and treatment of ACL injuries. The organizations developed specific recommendations to help female athletes lower the incidence of these types of injuries.

Article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1320397/?page=1

ESPN Interviews Dr. Frank Jobe - pioneer of Tommy John Surgery

Check out this interview with Dr. Frank Jobe at the link below.

Dr. Frank Jobe was the first person to complete an ulnar collateral ligament reconstruction (named Tommy John surgery for the pitcher he performed it on) in 1974. Jobe has since become a prominent surgeon, and has worked extensively with baseball players, including with the Los Angeles Dodgers.

Jobe discusses the mechanics of Tommy John surgery, other potential injuries to the arm that occur in baseball players, prevention strategies, and lends his insight into what he thinks the future of medicine in this area might look like.

http://www.sciencedaily.com/releases/2001/01/010124074916.htm

Advances in Labrum Repair Surgery?

Shoulder surgery in baseball has come great lengths thanks to improved surgical techniques, and rehabilitation models; however, overshadowing the progress made in rotator cuff and elbow surgery is a new injury emerging in the shoulders of athletes, the torn labrum. Will Carroll’s May 2004 article written for Slate online does not make light of this injury. Carroll is well versed in Baseball, he is the author of the Baseball Prospectus, an online guide to everything dedicated to news in the sport. His article (link posted below) explains the threat of labrum tears in baseball pitchers using the following analogy, “if pitchers with torn labrums were horses, they’d be destroyed.”

The labrum is the collagen connection between the head of the humerus (upper arm bone) and the glenoid fossa (where the humerus connects). It works to absorb shock and as connective tissue in the shoulder. As the article points out, a major-league baseball player’s arm moves at the speed of 23 rotations per second! Now think about the role the labrum plays in the mechanics of every pitch, it acts as a decelerator for all of that force. Prevention of this injury is very hard. The labrum cannot be strengthened, and the best way to prevent it is to stop a player from pitching when tired – a very subjective and difficult measure to gauge.

It seems technology may have fallen short so far in treating this injury. The labrum is in a difficult spot (between two bones) in the body to visualize, even with MRI technology. Carroll reports that one major league team shows an MRI scan to five doctors to determine a diagnosis, and that furthermore the only way to know for sure that a tear is present is to perform exploratory surgery. In April 2004, Carroll wrote a humorous article for the April Fool’s Day issue of the Baseball Prospectus discussing a fictional emerging technology, the “soy-lentil matrix,” that could be used to successfully replace the collagen connection of the labrum in the shoulder. It seems that so far all science can offer Baseball players with a torn labrum is an unsure diagnosis, and the hope of a future discovery.

While many Baseball fans may not recognize the names of many of the injured players that Carroll speaks of, Roger Clemens is a name synonymous with the sport. Clemens had rotator cuff surgery and then went on to win the coveted Cy Young Award six times. Hopefully, technology will soon advance to the point where a torn labrum will be a treatable injury, and there will be many successful recoveries for fans to look forward to in the future.

The articles discussed in this post can be found at:

http://www.baseballprospectus.com/article.php?articleid=2728&mode=print&nocache=1257798644

http://www.slate.com/id/2100895

Clinical Outcomes of Double-Row Versus Single-Row Rotator Cuff Repairs

The rotator cuff is a major group of connective muscles and tendons in the shoulder. Many baseball players tear their rotator cuffs in either the pitching or sliding motion and surgery is the only way to reconnect the frayed muscles to the humerus and the scapula. In the past years, rotator cuff surgery has become a routine orthopedic procedure and can now be performed entirely arthroscopically. The tendon is reattached to the bone and can be done using either the single- or double-row technique. Single-row repairs are most common, but recent literature has begun looking into the benefits of double-row arthroscopy. Dr. Wall et al in their November, 2009 systematic review, “Clinical Outcomes of Double-Row Versus Single-Row Rotator Cuff Repairs”, attempt to answer this question. Published in Arthroscopy: The Journal of Arthroscopic and Related Surgery, this study looks at data from both types of repairs.

Although both single-row and double-row repairs successfully repair the rotator cuff, there is question as to whether or not the double-row repair improves biomechanics of the shoulder in the long run. This study concludes that there is no short-term difference, but further studies are necessary to look into the long-term effects. These doctors suggest that MRI and CT be used to assess the initial size of the tear and thereby determine if it is big enough for double-row techniques to have a positive impact. Double-row techniques require more fixation, and thereby more anchors and sutures into the shoulder, which promotes better re-growth, but makes the surgery more expensive, technically more difficult, and much longer. Because of the advanced technology in fixation devices and anchors, it is possible to attach the rotator cuff more forcefully to the bone and have a better outcome (double-row technique), but it has yet to be determined if this in fact is the case. The dependency on tear size of the success of these techniques complicates the nature of the study and requires more data to determine if double-row fixation is, in fact, superior to single-row rotator cuff repair.

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WB8-4XM6C0H-W&_user=489286&_rdoc=1&_fmt=&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000022678&_version=1&_urlVersion=0&_userid=489286&md5=a3baf0b1ce5bd9a949aaf608192ae7a6

Examining Arthroscopic Rotator Cuff Repair Techniques: the AutoCuff

Arthroscopic Photographs of a Rotator Cuff

Left: rotator cuff tear Right: final repair

Source

Rotator cuff tear is a common cause of shoulder pain and disability. Although it is not limited to the area and may occur elsewhere, the majority of rotator cuff tears are located in the supraspinatus muscle. One surgical repair option is arthroscopic repair; within this category there is a huge range in the reported failure rate. The relationship between repair technique and surgery failure is also quite controversial among surgeons.

The study, “Arthroscopic Rotator Cuff Repair Using the Opus Knotless Suture Anchor Fixation System” was published in March of 2009 in The American Journal of Sports Medicine. The article is available online through their website. The study’s main focus was to evaluate the post-op functionality of arthroscopic knotless fixation using the Opus AutoCuff device in rotator cuff repair surgeries. The study was a case series and evaluated 48 patients who underwent rotator cuff surgery using the Opus AutoCuff device. The advantages of knotless fixation are a reduction of suture materials and the subsequent reduction in operative time. The Opus AutoCuff device also allows a gradual adjustment of suture tension while decreasing the steps for suture passage. At this time the main disadvantage of the system is cost but with further research the device could eventually be covered by health insurance and potentially lower procedure costs by minimizing surgery time.

There was a significant improvement of the status of the shoulder as well as pain levels when post and pre-operative scores were compared. Functionality of the shoulder also greatly increased for a given list of daily occurring activities.

This is the first published study that examines arthroscopic rotator cuff surgery using a knotless suture anchor system, in this case the Opus AutoCuff device. Certain flaws in the study are the retrospective design, specific criteria for determining patients, lack of postoperative imaging, and the short follow-up period.

The study found that arthroscopic knotless suture fixation using the Opus AutoCuff device produces high quality results that are at least equivalent to techniques that employ conventional suture anchors. Although the study had many limitations in applying its results to the medical field, it is still effective in documenting the equivalence of the Opus AutoCuff device to other surgery techniques.

See the Online Article Here!

Torn Rotator Cuff: Conservative Treatments vs. Surgery

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The efficacy of conservative treatment in patients with full-thickness rotator cuff tears

Rotator cuff injuries are common, often resulting in chronic shoulder pain, weakness, and limited movement. Surgery tends to be the common solution. People are starting to investigate alternative treatments. A study titled “The efficacy of conservative treatment in patients with full-thickness rotator cuff tears,” explored the effectiveness of exercise supplemented with anti-inflammatory medication. The study was published on September 24, 2008 and is available through PubMed. Twenty patients with full-thickness rotator cuff tears were evaluated after six months of treatment. This study was the first to use an isokinetic devise to look at an objective measure of muscle strength in patients. Subjective measures were also used; after 6 months, 11 patients (55%) said that they were “much better” and 9 patients (45%) said that they were “better.” This study found that conservative treatment proved effective. There is some controversy, however. Other studies have found only slight improvement in shoulder function and comfort with conservative treatment, especially when looking at long-term results.

Previously, most clinicians advocated surgical treatment for torn rotator cuffs. Now, however, many people are starting to turn to conservative approaches, such as the one used in this study (oral non-steroidal anti-inflammatory medications paired with a three phase exercise program). Studies have shown that many people currently suffer from slightly torn rotator cuffs and do not even realize it. This would indicate that maybe surgery is not necessary. Just like any other operation, rotator cuff surgery is associated with many risks including infection, injury to nerves and blood vessels, stiffness of the joint, pain, the need for more surgeries, arrhythmias, and more. Also, even if you have rotator cuff surgery you may have to avoid sports or activities that require a throwing movement of your arm, such as baseball. Surgery can also be extremely expensive. Thus, a conservative alternative would allow people to save hundreds of thousands of dollars in medical bills. The positive results of this study compounded by the risks and cost of surgery suggest that conservative treatments should be a first line of defense in the treatment of full-thickness rotator cuff tears.

http://www.springerlink.com/content/n6ul921r2122u236/

Shoulder Injuries In The Throwing Athlete

http://www.ejbjs.org/cgi/content/full/91/4/966

I found this article in The Journal of Bone and Joint Surgery, which was published in April 2009. This article provides a thorough overview and introduction to the types of shoulder injuries associated with throwing athletes. This is an interesting article that establishes the connection between throwing athletes and specific sports injuries. It discusses the kinematics of throwing and how that can cause injury over time.

The article states that these athletes are prone to shoulder injuries as a result of the high forces placed on the shoulder during the throwing motion. Specifically articular-sided partial rotator cuff tears and superior labral tears are common injuries with these athletes. Laxity, impingement, and glenohumeral internal rotation deficit are also mentioned.

Our group will focus on articles discussing biotechnological advances to treat rotator cuff tears in future blog posts. This article states that the majority of shoulder injuries should be treated initially with nonoperative methods like physical therapy and rehabilitation. However, it also discusses that operative treatments can be extremely successful for certain traumatic injuries. The importance placed on physical therapy may have something to do with the fact that one of the authors is a physical therapist.