When Play Hurts
Local Physicians Raise the Bar in Treating Sports Injuries
It happens nearly seven million times each year across the country. One second an athlete is racing up the court or down the field, fueled by the thrill of chasing the ball, making the play and winning the game. The next second, that same athlete is on the ground, clutching an injured joint or a pounding head, gasping with pain and wondering how it all suddenly went so wrong.
As Americans turn to sports for fitness and recreation, more of them end up in medical clinics and emergency rooms with serious sports-related injuries, according to the Centers for Disease Control. Fortunately, sports medicine practitioners are rising to the challenge, coming up with new techniques to repair injuries and new protocols to prevent them.
For example, baseball pitchers from Little League to the major leagues will soon know when to step off the mound before they damage their shoulders, thanks to orthopedic surgeon Dr. Pietro Tonino, director of sports medicine at Loyola University Medical Center in Maywood. Tonino is collaborating with a team of Italian orthopedic surgeons to develop the XBus Kit, a computerized tracking system that detects signs of fatigue in working pitchers before they become visible to coaches’ eyes. A recent study of the portable system using Chicago-area college pitchers proved its effectiveness at reducing injury risk.
“Baseball pitchers are the ‘poster child’ of preventable shoulder injuries,” says Tonino. “When a pitcher gets tired, his scapular-humeral (shoulder blade-upper arm) rhythm is disrupted, which puts strain on the shoulder, elbow and wrist. Coaches are looking to improve their pitchers’ performance through sheer repetition, but for some players that just disrupts their scapular-humeral rhythm faster and makes them more likely to sustain joint damage, usually at the shoulder.”
Until the XBus Kit hits the market — and becomes affordable for amateur leagues and schools — Tonino recommends that coaches pay careful attention to even slight changes in the way their pitchers’ arms and shoulders move while pitching, and not respond to complaints of pain by telling them to “work through it.” If a pitcher reports post-game pain bad enough to disrupt sleep, not being able to lift his pitching arm above his head, or soreness that lasts more than two days, it’s time for him to let his shoulder heal.
“These are life-lasting injuries that can affect people’s health,” Tonino says. “Even the best surgical procedures don’t restore young athletes to the status they had before their injuries. It’s much better to take preventive measures that avoid the injuries to begin with.”
When rest and physical therapy alone won’t restore lost function after an injury, sometimes patients must resort to surgery. Even then, new techniques and technology can give them more hope for an active life than they could have expected even five years ago. Dr. Vishal Mehta pioneered a cutting-edge cartilage regeneration procedure at Fox Valley Orthopedics’ Geneva clinic in 2014 that is now being performed on hundreds of patients throughout the world.
“The cartilage layers that cover the ends of the upper and lower leg bones are smoother than two ice cubes rubbed together,” the orthopedic surgeon explains. “When they get damaged, even just a small crack, they can wear each other down, causing more damage and knee pain.”
While surgeons can replace damaged cartilage layers with grafts from cadavers, the waiting list is long because the donor layers must exactly fit the recipients’ bone contours, Mehta says. So he worked with AlloSource, a nonprofit donor bank whose board he sits on, to develop an alternate treatment.
Cartilage regeneration works by replacing damaged sections of the patient’s existing cartilage with a mixture of live cartilage cells from cadavers and growth factors, such as vitamins and hormones, that stimulate the cells to reproduce. Small holes poked into the bone end underneath the cartilage let stem cells rise into the affected area to help fill in the gap, and a laser-etched fine mesh coated with fibrin — a human-produced protein that forms scabs over cuts and scrapes to promote healing — gives the new cells a scaffold to keep them aligned with neighboring cartilage cells.
“This is similar to the way coral grows,” Mehta says. “The mesh and fibrin give the grafted cells something to grow into, like new coral develops on dead coral branches.” It has worked so well over the past two-and-a-half years that surgeons are now using it to regenerate cartilage in the foot and ankle, and are studying how to apply it to hip cartilage injuries.
Unfortunately, most patients who request the procedure don’t qualify for it. “I spend more time talking people out of this surgery than I spend performing it,” says Mehta. “It’s only meant to treat focal cartilage lesions in otherwise healthy cartilage tissue. If you have arthritis in your knee, it’s not going to work and you’ll only be in more pain.” To benefit from cartilage regeneration, patients must be younger than 50, at or near normal weight, and have no abnormalities in their ligaments, he adds.
Sometimes children destroy their anterior cruciate ligaments so thoroughly that they can’t continue in their sport without surgery. In the past that usually meant waiting until their late teens, after their leg bones had finished growing and the growth plates had fused to the bones. Dr. Steven Chudik, though, has developed a surgical technique to replace torn ACLs that spares the growth plates so that children can get the knee stability they need to keep developing as athletes.
“I started developing this procedure over 10 years ago, and I’ve had lots of good success with it. The youngest patient I’ve replaced an ACL for was age eight,” says Chudik, an orthopedic surgeon with Hinsdale Orthopedics.
The technique works, Chudik says, because he tailors it to each patient’s physiology. “When I make a new ligament, I make sure I place it exactly where the old one used to be,” he explains. “I make tunnels in the bone and insert the ligament ends in them so that the bone heals around them. That keeps the ligaments in the proper alignment and protects the growth plates.”
Now Chudik is working on a way to attach the ligaments without tunneling into the bone. “Tunnels cause more pain and longer rehabilitation times, and they might complicate future surgeries,” he says. “Instead of 18-month recovery times, patients could recover in six months. That’s a big deal for young athletes, especially if they’re trying to get athletic scholarships.”
As more people of all ages opt for ACL replacement surgery, more of them are experiencing post-surgical arthrofibrosis, in which an excessive amount of scar tissue at the surgery site makes moving the joint painful and difficult.
“Arthrofibrosis is a fancy way of saying that someone has a stiff joint,” observes Dr. Vijay Thangamani, an orthopedic surgeon with DuPage Medical Group. “It’s relatively uncommon, but when it happens it can cause a lot of other problems if we don’t control it.” Without treatment, arthrofibrosis can weaken leg muscles, shorten the tendon that holds the kneecap in place and damage the kneecap itself, requiring more surgery to let the patient walk normally.
The first step in sparing patients the pain and disability of arthrofibrosis is teaching doctors and physical therapists how to recognize it. “The sooner we know that it’s there, the faster and better patients will recover from it,” Thangamani says. The American Association of Orthopedic Surgeons presented a seminar on arthrofibrosis at its May conference.
Patients at risk of developing arthrofibrosis after knee surgery should start physical therapy as soon as possible, Thangamani recommends. “We want to break up the scar tissue before it forms,” he explains. “We try to get patients into therapy the same day as their surgeries. An anesthesiologist gives them a nerve block that lasts 24 to 36 hours so they can start their therapy with little or no pain.”
One recently examined preventive measure to avoid injuries on the playing field flies in the face of what coaches and doctors have been telling athletes for decades.
“People hear all the time that when they’re exercising or playing a sport that they should drink lots of liquids so they don’t get dehydrated. But over-hydration is a much more dangerous situation than dehydration,” says Dr. James Winger, a Loyola sports medicine doctor who co-wrote the latest international sports hydration guidelines, recently published in the Clinical Journal of Sport Medicine.
Over-hydration dilutes the blood, which harms the body in two ways. First, it drops the average level of sodium in the blood to dangerously low levels. Symptoms of mild hyponatremia (abnormally low blood sodium) include dizziness, lightheadedness and nausea; the more advanced stages add vomiting, headaches, mental confusion, seizures and coma.
As the condition progresses, the excess water separates from the blood and leaks through the thin walls of small blood vessels. Once outside the circulatory system, the water floods permeable organs, particularly the brain and the lungs. Without emergency medical treatment, the soaked organs shut down, sometimes killing the athlete. At least 14 athletes have died of exercise-related hyponatremia in the recent past, according to Winger.
Competitors in endurance sports like rowing, marathons and football run the highest risk of hyponatremia, Winger’s studies show. But all athletes can protect themselves by following one simple rule.
“Drink only when you’re thirsty,” he advises. “If you don’t feel thirsty, don’t drink water or sports drinks just because you’re playing or training and you think you should. The medical risks of dehydration are very, very few for healthy athletes, and it’s easy to drink something and rehydrate. The medical risks of over-hydration can be fatal, hard to treat and hard to catch early. Unless you have a sodium meter in your pocket, you won’t realize you’re over-hydrating until you’re in trouble.”
On a bitterly cold January afternoon in 2016, 15-year-old “Geraldine” was walking home from her suburban high school when she slipped on the icy sidewalk and fell backward, hitting her head. While she thought she was fine at first, by the time she arrived at her evening volleyball practice, the club’s athletic trainer immediately recognized the early signs of concussion — dizziness, fatigue, slurred speech and acting dazed. He called her parents, who took her to the emergency room, where a doctor confirmed the diagnosis.
What that doctor couldn’t tell Geraldine or her family was how severe the concussion was or how long it would take for her brain to heal. “It’s hard to manage people’s expectations about their concussion or their children’s concussions because there’s no good way to tell at first how serious it is,” explains Dr. Larissa Pavone, a pediatric physiatrist at Marianjoy Rehabilitation Center in Wheaton. “There’s a lot of research now focusing on what concussion actually is and how best to treat it. We’re still trying to define what we’re seeing.”
Dr. Julio Gonzalez agrees. “Most doctors don’t grade concussions anymore,” says Gonzalez, a sports medicine physician with DuPage Medical Group. “From a clinical perspective, it’s not useful because it doesn’t accurately predict patient outcomes. Sometimes you see a kid take a hit and you think he’s not going to be conscious, but when you get to him, he’s fine. Other kids barely get bumped and they have horrendous symptoms that last for months.”
Once commonly described as a bruising of brain tissue, concussion is now defined as “a traumatic brain injury that affects your brain function,” according to the Mayo Clinic’s website. Some researchers postulate that sharp impacts to the skull sometimes break or damage nerve connections within the brain, rendering segments of the brain inaccessible until those connections are rebuilt. Whatever damage the brain sustains from a concussion, most treatment plans focus on giving the body enough time and rest to heal the brain itself. For years, that meant that patients were commonly restricted to lying in a dark room, sometimes for weeks, to avoid stressing the brain with visual images. Recent research, though, shows that helping patients ease back into school or work sooner helps speed their recovery, says Dr. Nathaniel Jones, director of Loyola University Medical Center’s new multidisciplinary concussion treatment program. “We try to get kids back to school earlier, even if they can’t fully participate yet, because it helps prevent psychological issues that interfere with healing,” he explains.
While Geraldine wasn’t ordered to bed for weeks, her recurring headaches and sensitivity to light kept her home from school for nearly a month. “She spent a lot of time in the basement ‘listening’ to TV with a blanket over her head,” reports her mother, “Marie.” When Geraldine’s doctors did approve her return to class, she was still not allowed to do homework or take tests because she was not symptom-free.
“Whether to send a child back to school is a very delicate balance,” maintains Pavone. “An early return is not necessarily a bad thing if the patient’s symptoms are properly managed. But sometimes that requires compromises, like letting a child attend class and be with friends without letting him or her use electronics like computers or phones.”
When Geraldine was still experiencing balance problems two months after her fall, her school’s athletics trainer recommended that she try vestibular therapy to restore the link between her eyes, inner ear and cerebellum. Disrupting that link interferes with the brain’s ability to sense how the body is oriented in its surrounding space, which in turn prevents proper balance.
At Marianjoy, vestibular therapy begins with an exam by a neuro-optometrist, says physiatrist Dr. Sara Padalik. “A blow to the back or the side of the head can weaken one or more of the ocular muscles [which control eyeball movement],” she explains. “Even a small change in how the eyes move can confuse the brain because the images it gets from the eyes aren’t quite right.”
In most cases, vestibular therapy retrains the brain to correctly interpret the visual and inner ear clues it needs to maintain balance. The process involves a series of orientation exercises and, sometimes, a new eyeglass prescription, Padalik says. Geraldine spent about six weeks in vestibular therapy before her balance was restored and she was allowed to fully resume her life.
By that time, the A student had only a few weeks to make up more than a semester’s worth of work in her honors STEM program. “She was making up her first semester finals just a few weeks before taking second semester finals. It was quite stressful,” Marie recalls. “We hired a math tutor, as her math teacher emphasized how important it was that she really learn the material and required Geraldine to make up every homework assignment, quiz and test. Fortunately, to give her extra time to catch up the therapist didn’t clear her for gym at all so she could go to a special study hall instead.”
Despite the challenges Geraldine’s recovery presented, she finished the school year with her A average intact and her place in the school’s competitive STEM program secure. And she didn’t even object to sitting out the rest of her volleyball club’s season — unlike many other high school athletes and their parent who resist giving up the chance to pursue a coveted college athletic scholarship.
“Before returning to sports, a child has to be asymptomatic,” Pavone asserts. “There may be a lot of pressure (from parents or coaches), but if a child can’t make it through the school day without symptoms, he or she doesn’t belong on the playing field.”
“We tell parents that the most important thing is to make sure their child’s brain is fully recovered before the child resumes participating in sports, and seeing how well the child handles school helps us gauge how his or her recovery is progressing,” Gonzalez adds. “A lot of emotional issues arise when a patient is cut off from sports and social activities, but we don’t know all the long-term effects of concussion yet. We’re talking about your brain and the rest of your life, so it makes sense to be cautious and go slowly.”Edit Module