Our Birth Story

I meant to get this posted near her birth! But the 4th trimester has been wild! … more on that another day. Alas, here we are, and it is finally time for a catch up! If you had been following along you know pregnancy was going well. (And I’ll share my 3rd trimester update eventually…) Due to my age we were candidates for induction at 39 weeks. My doctor and I had made this the tentative plan. I wasn’t super into a ‘birth plan’ per se, but I am type A and like to have some semblance of a strategy in place! But baby girl evidently did not feel this was a good plan… we discovered she was breech, and for a first pregnancy this would mean you cannot have a vaginal delivery due to safety reasons.  If she did not flip to the appropriate direction (ie: head down versus up), I would need a caesarean.  Spoiler alert: she stayed breech. Google “spinning babies” if you want a laugh thinking of me laying upside down while very, very pregnant in a feeble attempt to turn this strong-willed little lady.  We also tried an external cephalic version (ECV) where my doctor attempted to rotate by pushing on my belly.  Yes, it looks as barbaric as it sounds.  It was tolerable pain (nothing compared to what was to come…) but, sadly not successful. Baby girl was showing her stubborn streak. I blame her dad.

Speaking of the hubs… he had a work trip leaving 4 days before our planned induction/now possible c-section. The day before his departure his parents were flying in to stay with me while he was away and help once baby arrived. They were somewhere mid-flight when I went in for one last OB visit before he heads out of town. You know, just in case…

At the doctor I reported the standard late pregnancy symptoms of feeling tired and uncomfortable but overall, feeling well. I had been having mild intermittent belly tightening, and a few episodes of tightening that were more intense but random and rare, nothing too crazy to me or that would signify labor was near. My doctor checked me, and we found out those pains were actually contractions! I was dilated in early labor. The best laid plans, am I right? Since baby girl was breech, suddenly time was not on our side. If we waited I could further into labor and need an emergency c-section. Not ideal. Instead, we opted for a more controlled urgent one. This meant… we were having our baby that day. What! We left the doctor’s office at 10 am. Drove home. Francis got a potty break (of course) and I grabbed my hospital bag. (I almost took it to the doctor appointment that day but was thinking what a rookie move that would be… go figure!) We were back at the hospital and in the operating room by noon. We attempted one last ECV after my spinal (numbing me from the waist down for surgery) … but again she wasn’t willing to flip. 

There was such a mix of emotions this day. I felt like I had done everything the best I could during pregnancy and still ended up having a c-section which I really did not want. I was scared. I know too much medical stuff. But not enough at the same time, if that makes sense? The nurse with me saw my fear. While wheeling me back to the operating room she paused the bed and told me a story about my baby girl. She gave me breathing techniques and promised to stay with me throughout. And then we were on our way again. At this point it all happened so fast. There was a mirror overhead and I watched my doctor working. I remember squeezing my husband’s hand in pulses to focus on something other than the fear. I watched as baby girl arrived and heard her little cries. My fear now mixed with a whirlwind of other emotions. It was one of the most overwhelming moments in my life. As they brought her over and placed her on my chest, I knew nothing would ever be the same.  Welcome to the world Everette Hazel. You represent the hope and dream of your parents. And we can’t wait to get to know you.

Photo: Stephanie Honikel Photography

All you need to know: Cortisone.

In orthopedic offices cortisone shots are offered to patients every day. What exactly is a cortisone shot and who needs it? What are the risks and benefits? 

Let’s start at the beginning.  Cortisone is the name used to describe a group of steroid medications we inject into the body. In orthopedics a cortisone shot is given into your knee, shoulder, finger etc… basically any joint space or area. Other names you may hear are methylprednisolone (Depo-Medrol), Triamcinolone (Kenalog) and betamethasone (Celestone). 

I describe these injections to my patients as strong anti-inflammatory medications that are injected into (as one example) your knee.  They work similar to anti-inflammatory medicines you take by mouth (like Advil or ibuprofen) by decreasing inflammation.  However, the mechanism of how it works is different. Also, since we are directly injecting them into the area sometimes they are more effective. 

What does the cortisone actually do? I want to make this super clear- a cortisone injection does one thing only- decrease pain. Cortisone does not fix the injury, repair the joint it is injected into, grow back cartilage or any other magic. Just pain relief. 

How is the shot usually given? Most often cortisone is mixed with a standard numbing medication and injected using a syringe and needle. The numbing medication helps short-term with the pain (just like going to the dentist and getting numb before they pull a tooth) and it also helps distribute the cortisone evenly. My standard recipe is 40 mg of Kenalog and 4 mL of 1% lidocaine in the knee.  Another doctor’s recipes may differ based on their preferences and experience. 

When are cortisone shots needed? That is a difficult question without knowing the specifics of your injury or problem.  That said, the most common thing injected with cortisone are the things that cause us pain. Makes sense, right?  But also keep in mind all things that cause pain do not get a cortisone shot.  One very common use for cortisone is in the treatment of osteoarthritis. Osteoarthritis is the degenerative breakdown of cartilage (a whole topic we will discuss another day) but simply put it is wear and tear on a joint surface.   When someone has pain from osteoarthritis cortisone is often the first go-to for relief. Cortisone also can help with pain associated with meniscal tears, labral tears, bursitis, and several other conditions. Be mindful that there are certain areas of the body, such as tendons, ligaments or soft tissues spaces that either should not have cortisone injected at all or it is at best questionable to do so. 

Who needs one? That is a great discussion for you to have with your doctor!  I would ask the following: What are the goals of the injection? How can I optimize the pain relief to make it better long term?  What are the risks, side effects or alternatives? Remember although very well tolerated any medication we give isn’t a free pass and has risks and side effects. You need to know these ahead of time.  

Here are some of the ways I answer the above. First, how to optimize the pain relief?  I optimize the pain relief after giving a cortisone shot by focusing on the overall function of the body.  If you have a shoulder problem, I want your shoulder to be functioning as close to a normal shoulder as possible.  This is often hard to do! Your shoulder moves differently when you have pain.  Without guidance it is nearly impossible to fix.  Also, with a shoulder problem you are limited in your ability to use that arm normally which can affect other body parts.  This is called compensation.  It can include how you hold your arm, the alignment of your neck or back, and even how you move the other arm. We need to break this cycle for your pain to go away for good!  Cortisone can help with the pain but if the movement pattern is not improved it isn’t a long-term solution. Why? Your body has gotten accustomed to moving the injured way.  If you get cortisone and are having less pain, this is a great time to try to optimize the shoulder movement to keep the pain away. I often recommend physical therapy for this.  Also please note- physical therapy can be fantastic even without a cortisone shot. 

Next, what are the risks? Every medication has risk. I always remind patients every needle stick has a risk of bleeding and infection. The skin is your safety barrier and sticking a hole in it means breaking that barrier.  When sticking a needle into the skin there are structures below the surface.  Depending on where the needle is headed (more for certain injections than others) we need to be aware of blood vessels to avoid bleeding.  These are both very small risks but depending on the person getting the injection.  Another important risk I always discuss applies to patients with diabetes.  We know cortisone injections can transiently increase blood sugar for about two weeks after the injection.  If you are a well-controlled diabetic you can likely still have the injection, but your physician should have you monitor your sugars closely and report any issues. Unfortunately, if your sugars are out of control before the injection it may not be safe to proceed.

How long does the pain relief last?  That is highly variable.  I tell my patients the medication effect lasts a few months. That is how long the medication itself is altering the insides of joint.  However, if you do more (refer back to the above about PT and shoulder pain), then it may last much longer.   Another possible and important ‘risk’ to be clear on is sometimes cortisone does not provide any pain relief at all. 

What if I need to get several cortisone injections to maintain pain relief? This again is variable but could be a concern.  Let’s revisit the knee example for osteoarthritis.  You as my patient have had one the injection every few years and otherwise have done well!  You are able maintain your exercise program, stay at a healthy weight and are maintaining cardiovascular fitness… to me, this is great! Those benefits clearly outweigh the occasional injection.  However, if you notice that you are having repeat injections and the time between them is getting shorter to maintain pain control this may not be the best solution any longer.  There is some data that suggests repeated cortisone injections may advance breakdown of the tissue faster than normal.  So, we must proceed with caution.  

Overall injections of cortisone are safe and well-tolerated in many and can be extremely helpful in alleviating pain. If you have questions about cortisone or whether you are a candidate for one it may be time for an educated discussion with your orthopedic physician.

Ski Season.

The cold winter air on your face, fresh powder under your feet, stillness of the wilderness… Whether you tackle the slope on skis or a snowboard nothing quite compares to the feeling of that first run of the day. But as with all sports, injuries can ruin what started as the perfect alpine morning.  Read on to learn about the most common issues snow seekers face and what can be done to stay as safe as possible. 

Common Injuries

For winter sports enthusiasts of the skiing type, the most prevalent injury is in the knee.  With the feet and ankles locked in a hard sided ski boot, the force is directed to the knees means when you fall on the slope.  This force can cause a variety of knee issues, one of the most feared is the ACL Tear (which I wrote about in depth here… LINK), but you can also injure other areas including ligaments such as the MCL or LCL, the menisci, or even the bones (femur/tibia) as they join at the knee.  

For snowboarders, knee injuries can also occur. However, given the orientation of the board on the slope and the single-sled positioning (feet both fixed to the same board), the most common area injured is the wrist. When a snowboarder starts to fall, they instinctively reach for the ground causing injuries ranging from minor sprains to fractures of the wrist bones. 

For all alpine lovers, injuries to the shoulder can also occur.  During a fall you can easily land on your shoulder or outstretched arm causing injuries to the tendons, muscles, or ligamentous structures in and around the shoulder. Shoulders can stretch out of place (subluxate), dislocate, or break with this mechanism. 

Other areas of the body are also prone to injury from a fall on the slope including the hips, spine, and chest wall. 

The most traumatic snow sport related injuries are those to the head or neck. For experienced and novice skiers alike, barreling down a slippery slope can be hazardous. Conditions that make this worse are crowded areas and other obstacles like trees or rocks.  Hitting another person or a tree can have devastating consequences as can your head on the hard packed snow.  Injuries can range in severity from concussion  to bleeding or fractures to severe traumatic brain or spinal cord injuries.

How to stay safe

Staying safe on the slopes makes for a much better day then ending a run with an injury.  

My recommendations: 

1- know your limits and the trail maps

2- train before you ski

3- save the alcohol for the après

4- wear a helmet, always

1. Know your limits

Staying safe on the slopes requires a level of understanding of what you are getting yourself into as well as a knowledge your ability. If you are a beginner or novice, look at the trail map ahead of time and stick with the runs appropriate for your skill level. You are not competing for a spot on the Olympic team… Even if you are more advanced, remember to avoid putting yourself in a position where you feel out of control.  The number one reason I see patients in the office with an injury is getting themselves into an uncomfortable position.  If you end up in this scenario, it is best to stop and ask for help. Ski patrol is always available to keep you safe.  They would much rather help you down the slope than find you injured. 

Another great tip is to take a lesson. No matter how advanced of a skier you are, lessons can be extremely helpful! During my last ski trip, I took a lesson, and it was worth every penny. The instructor was a true gem, helping me (more novice) and my husband (more intermediate) at the same time by challenging each one of our levels safely.  He was so great that when he ran into us the next day while skiing with his daughter, he skied with us for a bit for follow up tips.  These instructors live for skiing, know the terrain, and know how to teach you to be better. Everyone can learn!

2. Train before you go

If you were going to run a half marathon you wouldn’t just show up race day and expect to finish without problems.  Same goes for snow sports. Even if you are in great physical shape at baseline, some activity specific training can be beneficial.  Skiing and snowboarding are physically demanding sports. You need strong legs, great control of your upper and lower body, and stamina to survive the day.  I can’t count the number of patients who describe their injury as something like, “I was tired, out of control and crashed but can’t remember what actually happened.” Don’t be that person. 

3. Save the Après

Ah yes, the time-honored tradition of that first amazing post-ski après beverage at the lodge. It may be my favorite part of the ski day.  However, studies have shown that alcohol increases the risk of injury for both skiers and snowboarders. (As does any illicit/mind-altering substance use). Save the après festivities for after you are done skiing for the day. 

4. Wear a helmet, always

This one cannot be stressed enough. Head injury can be a devastating outcome of a crash on the slopes. No matter how well you ski, a fall can still happen. It is sort of like driving, even if you drive perfectly, someone else can hit you or cause you to crash. So, we were seatbelts, right? Wear a helmet every time you ski or snowboard. Protect your skull and brain and decrease your risk of tragic outcomes. 

If an injury occurs

Ski patrol is always available for injured skiers. They are all over the mountain and at the base, and most resorts employ trained medical staff. Some even have physicians available. Every ski town I have been to has a local urgent care as well with a team that is used to seeing slope related injuries. If you need follow up after a day on the slopes for a bone, muscle or joint problem seek out your local sports medicine orthopedist. It is always helpful to bring any images (Xray’s, MRI’s, etc…) that were taken on the slopes or after.

And of course, enjoy the snow!

Orthopaedic Injuries of Pregnancy

It is no secret that pregnancy comes with a host of changes for your body. These changes allow you to accommodate making a new life but also can put you at risk for musculoskeletal issues along the way.  This is often because of some combination of loosening of ligaments due to hormones, changes in the center of gravity due to your new “bump”, added weight in general, and increases in overall body stress.

Most common Issues I see in practice:

#1 Injuries from a Fall:

As a specialist, I usually see a patient when they hurt something that needs further investigation.  Injuries happen to even the healthiest of pregnant patients.  One of the most common I see is an ankle sprain (see my full post here on all things ankle sprains) Pregnant patients often feel unbalanced.  A movement as simple as stepping off a curb awkwardly can lead to an ankle injury. The great news is the treatment for ankle sprains during pregnancy is very similar to the average patient, and most do very well without long term issues. 

Another common injury from a fall is a broken kneecap (patella).  Again, these tend to happen because of being a little off balance.  With a slip or fall, you can land directly on the knee causing the patella to break. This is painful! The injury is not usually subtle and makes it difficult to stand or walk.  X-rays will show us the problem, and sometimes the problem needs to have surgery to fix, but often you can get better with a period of resting your leg in a straight position. Though keeping your leg fully straight for weeks is not easy while pregnant… something I appreciate even more now that I am pregnant! But my patients have made it through, and you will too! 

Other broken bones can also happen during pregnancy from falls. The second most common fracture in my practice is a broken wrist. When you start to fall you naturally reach for the ground to brace yourself. Unfortunately with this motion, you can land on your outstretched hand break a bone in your wrist called the distal radius. Again, sometimes these need to be fixed with surgery. The ones that do not are treated in a cast for several weeks. Being in a wrist cast while pregnant also seems absolutely no fun, but it is achievable and safe.  Keep in mind these things can happen in pregnancy (just like outside of it), and orthopedic doctors are trained to do what is best to make sure your bones heal well, and your pregnancy stays safe. It is key to let your OB know if you have had a fall or are seeking care with another doctor. This allows us to all work together to be sure we are optimally treating you and keeping everything as pregnancy safe as possible.

#2 Aches and Pains

Ah yes, the joys of pregnancy…  Sometimes if feels like everything hurts whether you move or sit still! Joint pains, achy muscles, and stiffness all over are very common.  Muscle imbalance mixed with a growing belly often leads to a very common complaint, back pain.  It is estimated that 50-80% of patients experience back pain during pregnancy (2). Other super common areas of pain are the hips/pelvic girdle, knee, and neck. Most of this can again be attributed to the normal changes that occur during pregnancy, and keeping active throughout is the absolute best way to keep these issues at bay.  

#3 Wrist and Hand issues

Again attributed to the changes of pregnancy, wrist and hand pain is also very common. One specific condition that plagues pregnant patients is carpal tunnel syndrome.  This condition usually experienced as hand numbness and tingling in the thumb, index and middle fingers and has been estimated to occur in up to 62% of women who are pregnant (1). Great news, this most often resolves on its own after delivery. Until then, stretches and braces for the wrist usually help relieve the symptoms. 

How to stay safe:

First and foremost, listen to your body! The changes of pregnancy alter so much about your function and physiology. You should avoid risky activities where falling could occur, be careful on wet ground and ice, and always be extra vigilant of where you are walking. Stepping off a curb requires attention as does hurrying across a street or walking on a dirt road/path. Be careful! 

Another great tool is a daily body “check in” to see how you are feeling. Is your back tighter today? How do those hips feel? If you can catch an ache or pain early before it becomes severe, you can likely fix it faster. Add in stretches or targeted exercises for your problem areas, and keep moving throughout pregnancy.  Another tip is to remember to take a break if you are sitting for a prolonged period. This helps keep your body from becoming stiff.  It is important to avoid heavy lifting, and be sure you are using proper techniques to lift with your legs (not your back) to stave off further back pains and injuries.  Avoid reaching far away from your body as much as possible to keep your center of gravity stable.  Sadly, since your balance is a little off, retiring your high heels short term is the safest thing to do. 

As always on this website I preach an overall healthy, active lifestyle. In pregnancy this doesn’t change! If anything, it means more focus on these techniques to keep you fit as everything changes. Daily stretching, strengthening, and cardiovascular exercise help keep your body healthy and strong all pregnancy long. This helps you avoid injuries, keeps a better mind-body connection to avoid falls, and keeps aches and pains away.

Finally, what to do if you have pain or get hurt:

First, think about the severity (how bad is it?). If on your daily body check you noticed some general soreness and aches and pains, start with easy-to-do changes at home. Sit in a more proper position while working, remember to take standing breaks, and be sure you are getting proper exercise and stretching.  Always keep in mind your daily routine and that you may need to change something if your body is aggravated by these activities. Also, as always, talk to your OB! Bring up these concerns at appointments or even before if you feel they are significant.  Many small aches and pains are common and not a big deal, but you should always discuss with your doctor to be sure something further doesn’t need to be evaluated. Also know that even for general aches and pains, sometimes braces or other supports can be used to ease the discomfort.  Sometimes your doctor may recommend a pregnancy-safe medication such as Tylenol or even refer you to physical therapy to aid in your recovery.

If you have a larger amount of pain related muscle or joints or if you have had a sudden injury, an urgent/emergency evaluation is the way to go. You should also absolutely reach out to your OB as they can work with your orthopedic team to be sure you are optimally treated as a whole by coordinating specific recommendations based on pregnancy. If you need an X-ray, don’t panic. You can use a shield, and the doctor will do everything possible to keep you safe by only taking x-rays that are necessary to treat you properly. Trust your doctor, and ask questions along the way. I never feel bad when a pregnant patient asks about the necessity of a test or treatment. 

Sources:

1. https://pubmed.ncbi.nlm.nih.gov/19753825/

2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3306025/

3. https://www.cedars-sinai.org/health-library/diseases-and-conditions/b/back-pain-during-pregnancy.html

Need to know: Ankle Sprain

The ankle sprain… One of the most common reasons patients see me in the office. Here is all the information you need to know if this happens to you.  It will be just like if you were visiting me in the office!

An ankle sprain occurs when your foot rolls in or out putting extra stress on the ligaments.  This causes the ligaments to stretch/tear, which is by definition an ankle sprain. If your ankle rolls where sole is facing in, it is called an inversion injury (most common). If your ankle rolls where with your sole facing out, it is an eversion injury. These injuries can happen during sports, basketball and volleyball are common, or in any setting when athletes can land awkwardly from any jump or step. Sometimes though for the unlucky patient the injury can occur during day-to-day activities, something as simple as stepping off a curb wrong at the grocery store.  I have seen all of the above (and more) in my office!

During the sprain, the ligaments are stretched/torn which causes pain and swelling. The great news is these ligaments are not typically the type we need to fix with surgery, and most people heal quickly without long-term problems.  However, more complex types of sprains do exist that take longer to heal or may need more intervention.  For example, a “high ankle” sprain results from a more forceful twist that injures the ligaments above the ankle between the lower leg bones in an area called the syndesmosis. With other high energy injuries, you can also injure ligaments lower down in the foot or even break the bones.  If you are a kid and still growing, your growth plates are weaker than the ligaments.  Because of this when you twist your ankle, the bones may be more likely to break than for a ligament to tear.  This is a commonly missed injury by non-orthopedic physicians, can take longer to heal, and needs a correct diagnosis to be treated properly.

 Today we focus on the essential adult ankle sprain, the inversion (sole of foot turning in) injury that tears ligaments mainly on the outside part of the ankle. The most common injured ligament is called the ATFL, or anterior talofibular ligament.  If you look at your right foot it is that approximately at the 2 o’clock position on the top of your foot about 1 cm from the ankle joint. 

The injury causes a tear/stretch of this ligament resulting in pain, swelling, and bruising. 

 Treatment is usually very straightforward. I recommend starting with ice for the first 24-48 hours with rest (doing as little as possible) and elevation (at or above the level of the heart) for swelling. You should only do light activities that do not increase pain. If you have a more significant injury and you cannot walk normally, sometimes I recommend using a brace or other support device like a medical grade boot short term.

The timeline for recovery is variable and depends on how bad the injury is and what your goals for return to activity are. If you have a small injury and are doing low impact movements (sitting/walking) a full recovery is quicker than if you have a larger injury and play sports that require cutting, jumping, or pivoting. 

The biggest risk with an ankle sprain is repeat injury. Once the ligaments are injured, your ankle is more unstable and weaker.  You are more likely to sprain it again or injure it further if you have not fully regained all your strength, balance, and coordination lost with the initial injury.  Your body normally controls ankle stability (balance and strength) with proprioception. Proprioception is a protective sensation where your brain sends a signal to a joint and the joint responds with position updates.  Think of it like you brain asking your ankle, “Hey, how’s it going down there, which way are you pointing, how stable is that ground?” And your ankle responds, “I am okay, pointing straight ahead, ground stable no cause for concern.”  This happens constantly and nearly instantaneously with movement.  Consider this – don’t you always know where your ankle is without even having to think about it?  When you have an injury that feedback communication does not work as well.  The ankle’s response can be slowed and inaccurate.  This causes an increased risk of a second injury.

We can improve the ankle’s ability to communicate via proprioception, as well as its strength and our balance with physical therapy. A physical therapist can assess how the ankle is moving and what needs to happen to retrain it to be pain free and moving well. In my office I see people with the initial injury and then depending on the degree of injury will either send them straight to physical therapy or will send after a period of rest. It takes several weeks to get the ankle back to moving normally, but most often after doing so people do very well.  

One common question I get is why the swelling lasts so long after the injury, even if they are progressing well otherwise. This is usually not cause for concern. In addition to injuring the ankle ligaments the other soft tissues around the ankle were injured.  Because of this, swelling can persist for many months even after your ankle feels better.  Another common question is why the ankle feels stiff or not quite like the other ankle.  The stiffness is from the lack of movement in the early recovery and from scar tissue that forms during healing. The great news as that the stiffness dramatically with time and work with physical therapy. 

My goal with treating an ankle sprain is to get patients safely back to all the activities they love as soon as possible.  At my initial evaluation we make a plan for what one should expect in the next few days to week and schedule a follow up to assess progress.  Having two visits helps me understand your trajectory for healing – two data points helps me see the line of how quickly you are progressing much better than single point.  Once physical therapy is started, I continue to monitor progress and help determine when one can return to sport activities. 

A final word on return to sport.  I return most people cautiously.  As I mentioned, recurrent injuries happen.  I unfortunately see patients that have long term chronic ankle pain or instability due to having multiple sprains.  This is a harder problem to fix and may even require surgery.  Getting the physical therapy right from the first injury can help prevent this problem.  For those with recurrent sprains, optimizing a physical therapy program and integrating ankle rehab into your exercise will absolutely be helpful and may also prevent the above. 

Any questions about ankle sprains? Let me know!  Share this with anyone you know that may find this useful. 

The ACL Tear.

As we approach the end of football season, there is one injury that we have heard of several times throughout the year (and past years as well). The ACL tear.  Most sports fans have seen this listed on the injury report and heard the announcers talk about concerns for this when a player goes down on the field, but what is it? Why is it a big deal, how does it happen, and what is typically done about it?  

First, knowing a little anatomy of the knee is important. The ACL – or anterior cruciate ligament – is an important structure inside your knee joint.  We have 4 ligaments in and around that area, named for where they are located. Anterior (front) and posterior (back) cruciate ligaments, and medial (inside) and lateral (outside) collateral ligaments.  Today we focus on the ACL because it is usually the most ‘tragic’ when injured in sports. By tragic, I mean the one that is the most worrisome for an athlete because of the long treatment and recovery process that often alters one’s career short and long term. 

The ACL connects the bottom bone in the knee (tibia) to the top bone of the knee (femur) from front to back.  It plays a key role in stabilizing the knee. In medicine we would say it “resists anterior translation of the tibia on the femur.”  Stick with me here… this means in regular language that it stops the bottom bone of the knee from sliding forward in relation to the top bone during normal movement, aka inside the knee joint where it bends.  This bending is what allows us normal knee motion needed for walking, running, jumping, playing.  But we need something to help keep the bones attached to one another or else the knee may feel unstable (jelly-like) when we put stress on it.  [Think of the knee as a door hinge where the ACL is the pin that connects the two pieces of the “hinge”; without this the door can swing open and closed gently, but if it’s pushed too hard the hinge may not line up properly and may become damaged].  Not an ideal situation if one is interested in getting back to doing higher impact activities like playing football. 

If the ACL is torn the knee becomes unstable because the bottom bone can shift away from the top bone.  The cool thing the human body is that there are often redundant systems.  For the most part (although not always for every person) normal walking and low-impact day-to-day life can still be achieved without the ACL because the other ligaments and muscles around the knee can pick up the slack to provide stability.  This means even without an ACL, for daily life activities, many people move about fine.  The problem is with any sudden or shifty movements, such as cutting in sports or in high-impact jobs like law-enforcement or firefighting where folks are required to do movements that aren’t straight forward or backwards. These types of movements are more complex and require more stabilization, so without an ACL the knee can feel unstable and even give out.  For football and other sport athletes, one also would not get the control or explosive power she or he needs to play.   

An ACL tear most likely occurs when the leg is forced in a way that stretches the ligament too far.  Remember, the ACL blocks forward movement of the bottom part of the knee.  Consider a  a football player whose foot is planted to the ground when his knee gets pushed backwards, pushing the top bone away from the bottom bone. Pop!  The ACL is overstretched and gives way.  This is just one example, and there are of course other ways this happens.  Sometimes it involves a collision with another player (as described above) and sometimes it involves getting the leg in an awkward position when a person is running or jumping with the knee buckling inwards/backwards due to the force of the jump or a bad landing.  In this case, it is simply the lack of control and force of the jump landing or cut that causes the tear.  We tend to think of these “non-contact” tears occurring most frequently in young female athletes (maybe a teenage basketball player) that hasn’t developed full hip/knee control. 

The tearing of an ACL is an abrupt injury and not usually subtle.  Sometimes people hear a pop (but not always), feel a pop, have sudden onset of significant pain, and usually fall to the ground.  Most of the time the injured can’t walk easily (if at all) and don’t usually keep playing the game after.  The knee swells up from the inside due to the trauma (effusion).  I usually ask patients if it swelled up like a water balloon as an analogy.  A former mentor of mine taught me when I was learning about knee injuries that a young person running or cutting during sports with a sudden burst of pain with a pop in the knee and large swelling is an ACL injury until you prove otherwise.  This still rings true for my patients today.  #mentor

To diagnose the ACL tear we first talk about what happened when the injury occurred in great detail.  Then, we do an office examination of the knee, as well as the hips and lower legs.   Looking at the other nearby joints is important! Just because it seems that it might be an ACL tear it doesn’t always mean that is our answer.  We complete a few special maneuvers that help clue us in to what possible problem could be happening inside your knee. These maneuvers are helpful to distinguish other injuries that present in the office like an ACL tear.  This exam also helps us determine what next steps to take or if there is concern for other associated injuries (ACL tears often occur with other injures such as MCL tears, meniscus problems, and bone or cartilage injuries).

So you tore your ACL, what now?  Since it is such a crucial ligament for knee stability, most highly active people or athletes should discuss surgery to repair or reconstruct the ligament in the knee.  It does not grow back. It does not scar into place or heal. That said, it is important to note that older patients or people who are less involved in side-to-side/cutting sports or activities may not need surgery.  Be sure you have a discussion with your doctor about what the benefits of surgery are for you, the associated risks of the procedure, as well as the expected long term outcomes.  We practice medicine using the guide of high quality research, and if the studies show that you may do just as well without surgery, that may be the best way to treat your specific injury. Most important is to have these discussions with an orthopedic sports trained surgeon.  They will discuss options, the optimal timing to have surgery if it is thought to be best for you, and also very importantly your rehabilitation and expectations for recovery.  

Whether one has surgery or is treated without operation, he or she will need extensive physical therapy/rehab.  It takes many months for one to get back on the field!  One has to be patient.  For professional athletes that have dedicated athletic trainers and rehab specialists, these are season ending injuries. Often with great rehab, they can return in 6 months (at the earliest) though it can take 1 or more years to reach the prior level of sport.  But these are gifted individuals with many many resources.  For the average injury, it will be at least 1 year before one may feel 100%. And keep in mind, once a person has had an injury, and then had surgery, it is quite possible the knee will never feel 100%.  [Stay tuned for my article discussing preventing injuries like ACL tears.]

Stay healthy-

The ICU is not what you see on TV.

Sunrise over our local hospital.

But you don’t want to find this out first hand.

I saw a picture of a group of physicians and nurses in the “COVID ICU” on social media today. It was the same intensive care unit I worked in for years as a medical trainee. I recognized it right away with its beige tiled floor, clear glass rooms, and that awful yellowish paneled wood work area. Suddenly a flood of emotions passed over me. Memories unrolling one after another. And I realized something…

After all these years I still feel deeply the pang of the long hours in that ICU spending hour after hour with the sickest of the sick. I still hear the alarm beeps. I smell the cleaner in the air and feel the cold as the temperature drops in the wee hours of the morning only rectified by the overly starched heated hospital blankets. And I still remember the patients.

I can see the cancer patient getting treatment with medications making them so sick they could no longer breath on their own. In the corner I see the young cystic fibrosis patient praying for a miracle transplant. I remember standing in a pool of blood putting giant tubes down throats for patients with massive stomach bleeds on the brink of death. And I will never forget the numerous patients so sick with infections in their blood all their organs were failing them, one after another. I hear the ‘code blue’ alarm ringing and nurses yelling for help. I can feel my stomach drop and my heart race a bit as I run towards the room for CPR. 

Sometimes I was there with you alone at 3am, doing everything possible to save you. And other times your family was at your bedside when the ultimate tragedy struck. Tears could not be stopped on either side of our exchange as they said goodbye.

Seeing that picture I remembered everything so vividly my heart felt heavy in my chest. I realized suddenly very few people know this experience. Very few ever have the emotional experiences attached to seeing that ICU. Most Americans (luckily) have never personally witnessed the wrath an ICU on the delicate human body. Most have not had a loved one suffer through countless procedures or treatments, with lines and tubes sticking in and out of every body part possible. They haven’t seen their beloved spend day after day hooked up to breathing machines and machines mimicking kidneys when their bodies basic systems start to fail. They haven’t seen the trees of pumps with IV medications surging into large veins in the neck and groin, while their loved ones lay paralyzed and asleep in a bed growing more and more swollen from the fluids trying to sustain life. This isn’t the television version of the ICU you have been shown before. It isn’t glamorous. At all. People don’t always survive and there is nothing TV viewable about the actual ICU experience.

I know one thing for certain. Be happy you haven’t been there and don’t know that experience. But more importantly just because you haven’t seen it doesn’t mean it isn’t real. It is real. It is the most tragic existence you’ll never be able to imagine.

Wear a mask. Stay home. Stay distanced when you must go out. Please avoid groups. And keep yourself safe. You don’t want to learn what the ICU is really like, trust me.

Don’t delay routine medical care, even during a pandemic!

Given the ongoing COVID-19 pandemic it is easy not to feel safe leaving our own homes, especially if our destination is a place we feel at higher risk.

One of the settings where you may feel more at risk is your doctors office. The reassuring news is since the pandemics onset hospitals and medical offices have instituted many protocols and policies which make it safer to visit. Protocals that you may notice include temperature checks upon arrival, questionnaires about possible COVID-19 symptoms and exposure, limited capacity waiting rooms, visitor regulations and mask requirements (I reviewed those in this post). These changes make coming to your appointment safer, but it is clear that patients are still avoiding the doctor. From the CDC, as of June it was estimated that 32% of Americans had delayed routine care due to COVID-19. (1)

Continuing to seek out routine medical care, preventative health screenings and other medical care is vital even during an event such as a global pandemic to prevent long term increases in morbidity and mortality for all medical conditions.  

The reason why we have routine medical screenings and preventive health appointments is exactly what it sounds like- these visits prevent future problems.  Unfortunately delaying these visits can delay diagnosis and treatment of conditions not only now, but also in your future. Delays in diagnosis means the disease can make you more sick, or worse, cause earlier death.

For the average adult there are a few routine maintenance visits to consider.  First, a visit with your primary care physician can get you on the right track.  These visits are a great way to evaluate any health changes you may have had in the last year, as well as check for early signs of issues to come. Getting your blood pressure checked and discussing what you may need for your age/lifestyle/risk factors may seem simple, but it is these parameters that give your doctor insight into your current and future health needs.  Some of these needs may include lab tests to evaluate your cholesterol levels, blood sugar, or referrals to other specialists for more specific care.  These routine visits, although seemingly simple for most people are very important.  

Another screening needed if you are female may be seeing your OB/GYN for a women’s health exam.  Depending on your age, marital status and sexual history this may include a pap smear and pelvic exam, lab screening and again further referrals if needed.  Both males and females need to consider seeing a dermatologist to evaluate for any skin concerns, and let’s not forget about routine visits with the eye doctor and dentist. 

Another area to consider in addition to these routine visits are those that are dedicated to prevention.  The main appointments focus on preventive health for age-related screenings for malignancies (cancer).  Your primary care doctor is a great start to determine if you need one of these type of visits based on your age, risks factors and family history.  For women, mammograms are an extremely important and we know that early detection of breast cancer is vital to survival. For men, you may consider an evaluation of your prostate health and have any appropriate screenings required. For both males and females of appropriate age, you need a colonoscopy.  There is great evidence that routine colonoscopy screening is vital to early detection and treatment.  Unfortunately if these screenings are missed or delayed due to the pandemic the delay could precipitate short and long term consequences.

The final area to focus on for routine medical care is vaccinations. Vaccines are becoming more of a hot topic with the push for pandemic mitigation and recent data release for the COVID-19 vaccinations awaiting emergent FDA approval for use. However, there are other vaccines that both children and adults need regularly. When you go for a visit, ask if there are any additional vaccinations that you need. This year more than ever the influenza vaccine is at the top of the list. (And I’ve had mine!) The concern here is this year’s flu season could be even more challenging given the current pandemic.  The fear of doubling the sick population (with flu patients on top of our already stretched hospital system trying to provide care for covid patients) could be insurmountable.

And since I try my best to practice what I preach in all areas of medicine and health… if you follow me on Instagram (@sportsdrmorgan) today you will see my experience at my doctor visit!

  1. Czeisler MÉ, Marynak K, Clarke KE, et al. Delay or Avoidance of Medical Care Because of COVID-19–Related Concerns — United States, June 2020. MMWR Morb Mortal Wkly Rep 2020;69:1250–1257. DOI: http://dx.doi.org/10.15585/mmwr.mm6936a4