Joba Chamberlain, pitcher for the New York Yankees, suffered from a serious open ankle dislocation on Thursday and underwent surgery for the injury.  After recovering from Tommy John last June, this will be another big setback for this young pitcher.    

ANATOMY

The ankle is made up of three bones: the fibula (on the outer part of the ankle), the tibia (on the inner part of the ankle), and the talus (on the central part of the ankle).  Between the tibia and fibula, at the level of the ankle joint, is a ligament which holds these one together, called the syndesmosis.  

In an ankle dislocation, the talus comes out of the “socket”.  When coming out of the joint, the skin may or may not rip open.  If the skin opens, this is known as an open dislocation.  If the skin does not rip open, then it is known as a closed dislocation. 

When the ankle dislocates, any of the bony structures can fracture/break or the tendons around the ankle tear.  Finally, the ankle joint or the subtalar joint (the joint beneath the ankle that allows the foot to move in and out) can be damaged.

CAUSES

An ankle dislocation can occur whenever the ankle is twisted to its maximum point.  Rarely, can this happen with bad ankle sprains.  More often, the athlete turns or twists the ankle with a fall, motor vehicle accident, or jumping activity.

SYMPTOMS

Individuals who dislocate the ankle will have pain, swelling, loss of motion, and bruising.  A lump or bump will be seen around the ankle.  If the skin breaks open, the ankle bone may be seen.   

WHEN TO SEEK MEDICAL CARE

If you suspect that you are suffering from a dislocated ankle, you should seek medical attention immediately.  A physical exam and x-rays are usually performed. A CT or MRI scan at times may be needed.  The ankle will need to be placed back into the alignment. 

TREATMENT

Ankle dislocations that are closed can often times be put back in place, or reduced, without surgery.  If there is no associated break of a bone or tendon injury, the leg is kept in a cast for a few weeks to allow the soft tissue to scar in and stabilize.  Then a lot of physical therapy is needed to work on the range of motion and strength.

If an ankle fracture is open, the athlete must go to the operating room so that the wound can be washed out.  The joint is put back in place and any broken bones, if present are fixed.  Depending on how large the skin laceration is, infection is a serious and real risk.  Again, the leg is kept in a cast for a few weeks to allow the soft tissue to scar in and stabilize.  Any bones that may be broken will take 6-8 weeks to heal before the athlete can walk on the leg.  Once the cast is off, a lot of physical therapy is needed to work on the range of motion and strength.

OUTCOMES

Ankle dislocations can be career ending for an athlete, especially if there are associated injuries.  Pain, loss of motion, and loss of strength can be long term issues that do not allow the athlete to return to competitive sports.   

RETURN TO ACTIVITIES

From the current reports, it is unclear if Chamberlain has any associated injuries.  This is a serious injury.  If Chamberlain is able to return to the pitching mound, it will be late in the season this year. 

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.d

Red Sox pitcher, John Lackey, will undergo Tommy John surgery.  What is this and what does it mean for his career?

ANATOMY

The elbow is a hinged joint, with many structural supports on the inner and outer parts of the joint.  Three bones make up the elbow joint:  the humerus (upper arm bone), the ulna (a forearm bone), and the radius (another forearm bone).

On the inner aspect of the elbow, the medial or ulnar collateral ligament (UCL), gives stability to the elbow.  On the outer part of the elbow, the lateral or radial collateral ligament (RCL) and annular ligament provide stability for the elbow.  A lot of stress and force passes through these structures with certain activities.  The  UCL must withstand a lot of force with pitching.  The motion of pitching produces forces which try to separate the ulna  from the humerus.  The UCL prevents these bones from moving apart.

In addition to these ligaments, the muscles of the tendons that bend and flex the wrist attach to the humerus on the inner part of the elbow.  The muscle attachment to the bone can be stressed with repetitive, high energy motions and forces.

CAUSES

Injury to the elbow is common in pitchers.  The repetitive motions, stresses, and forces that go through the structures of the elbow place it at risk for injury.  The common injuries to the elbow that happens in the adult pitcher include a strain or tear of the UCL, inflammation and degeneration of the attachment site of the wrist flexors (medial epicondylitis), or an osteochondral defect (OCD) of the elbow joint surface. An OCD is where a chunk of bone and cartilage are divoted out of the joint, similar to a pothole in a road.

SYMPTOMS

Most pitchers with thrower's elbow will experience pain and swelling on the inner part of the elbow.  At times there is also loss of strength and pitching velocity.  There will be tenderness and pain over the UCL or the attachment site of the wrist flexors.  If the UCL is torn, these players will also feel instability in the elbow with throwing activities.  If there is an OCD, players may describe locking or catching of the elbow joint. 

TREATMENTS

Treatments are tailored the structure that is injured.  A pitch count is used in baseball to minimize fatigue and stress to these elbow structures.

UCL strain - These players can be treated with rest and anti-inflammatories. Changing the mechanics of throwing can minimize future injury to the UCL.  Physical therapy is used to strengthen and stretch the muscles on the inner side of the elbow.

UCL tear - These players will require what has become known as Tommy John Surgery.  This surgery is a reconstruction of the UCL.  This restores the stability of the elbow.

Medial epicondylitis - This can be treated initially with rest, anti-inflammatories, straps, and physical therapy.  At times, a steroid injection can help calm down the pain.  If an individual fails these conservative options, then surgery is needed to remove the painful tissues and reattach the tendon to the bone.

OCD - An OCD usually develops on the outer aspect of the elbow.  An elbow arthroscopy can be used to remove the loose cartilage and bone.  Since the human body is unable to regrow cartilage, the OCD lesion is cleaned and drilled to stimulate scar tissue to fill in the "pothole.".  

WHEN TO SEEK MEDICAL CARE

Pitchers who have persistent pain, swelling, or difficultly pitching should seek medical attention.

RETURN TO ACTIVITIES/OUTCOMES

Most athletes with a tear of the UCL will need surgery to have a chance at getting back to playing competitive sports.  Recovery will be prolonged and extensive requiring months of physical therapy.  Lackey will likely be throwing again 6 – 8 months after his surgery.  However, most athletes with this injury struggle to return to their pre-injury form.  He will likely miss the entire 2012 season.

VIDEO/ANIMATION

All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

Boston Red Sox designated hitter David Ortiz has been seen walking in a boot.  He is out of the line-up, being diagnosed with Achilles bursitis.  Most have heard about Achilles tendonitis, but what is the story of Achilles bursitis.

ANATOMY

The Achilles tendon is the longest, strongest, and largest tendon of the human body.  It runs from the back of the knee to the back of the heel bone.  It inserts into the heel bone (also known as the calcaneus).  The insertion is over an area estimated to be roughly 2cm x 3cm.  Between the Achilles tendon and the heel bone is a fluid filled sac known as the retrocalcaneal bursa.  This sac serves the purpose of cushioning the tendon against the bone and minimizing the irritation to the tendon and. providing some sensation feedback to the foot and ankle region.

CAUSES

A retrocalcaneal bursa can become inflamed for a number of reasons.  A tight Achilles tendon can rub on the bone and lead to inflammation of the bursa.  A bump in the back of the heel bone, known as a Halgund’s deformity or “pump bump” can irritate the bursa and the tendon and lead to bursitis as well.  If the tendonitis and bursitis have been present for a long period of time, the inner part of the Achilles tendon can degenerate and lead to “tendinosis.”  Furthermore, irritation of the tendon for a long period of time can cause calcium to be deposited into the tendon.

This entity is usually seen in females, over the age of 40, and obese.  However, it can be seen in any individual.

SYMPTOMS

Individuals usually experience pain in the back part of the heel.  Swelling may be present.  A bump in the Achilles insertion site may also be present.  The pain is usually worsened with shoes with a back on it, activities that require the ankle to be flexed upwards (such as when you walk up a hill), or movement of the ankle in any plane of motion.

WHEN TO SEEK MEDICAL CARE

If you suspect that you have an Achilles bursitis, you should seek medical attention within 1-2 weeks, particularly if the pain worsens or does not improve. A physical exam and x-rays will be initially used to assess your condition.  At times, and MRI may also be needed to look for any Achilles tendon involvement.

TREATMENT

Treatment is initially managed with non-surgical options.  These include the short term use of heel lifts, boots, anti-inflammatories (pills or topical creams), physical therapy to stretch the Achilles, night splints used to hold the Achilles stretched out at night.  Ultrasound, shock wave therapy, platelet rich protein, and laser therapy have had mixed results in the medical literature.  Steroid injections should be used with caution, as the steroid can  lead to the Achilles being torn.

If nonsurgical treatments fail for 3 to 6 months, surgical options are explored.  These include shaving the Haglund’s deformity, cleaning the Achilles tendon (if there is degeneration of the tendon), and tendon transfers (if the Achilles tendon is severely involved).  Depending on the severity of the condition, these surgeries can be performed endoscopically with two small incisions and a camera and tools, or with open surgery.

OUTCOMES

Most patients  with a retrocalcaneal bursitis do well with conservative care.  Those who require surgery will recover for up to 1 year and require a lot of physical therapy.

RETURN TO ACTIVITIES

Depending on the severity of the bursitis, Ortiz may be out of play for 1-4 weeks.

VIDEO/ANIMATIONS

A live surgical video can be seen at: 

PART 1: http://www.youtube.com/NCOCatDuke#p/u/13/S_1ur94eXTk

PART 2: http://www.youtube.com/NCOCatDuke#p/u/5/1quCnfbf6Po

 Animated video can be seen below:

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics

Stephen Drew of the Arizona Diamondbacks underwent ankle fracture surgery yesterday.  He had a plate placed.  What happens in this surgery?

ANATOMY

The ankle is made up of three bones: the fibula (on the outer part of the ankle), the tibia (on the inner part of the ankle), and the talus (on the central part of the ankle).  Between the tibia and fibula, at the level of the ankle joint, is a ligament which holds these one together, called the syndesmosis.  

Any of these structures can be injured in an ankle fracture/break.  Typically, the fibula is fractured.  At the same time, the tibia can be broken and/or the syndesmosis can be torn. 

CAUSES

The ankle can break with any type of trauma that causes excessive energy to go through the ankle.  The energy can break 1, 2, or more bones.  Typically, the ankle breaks with a twisting mechanism, when the ankle "rolls", or if one trips and falls.  Occasionally, a direct blow to the ankle or the heel can break the ankle.

SYMPTOMS

A person who breaks their ankle usually experiences immediate pain and swelling.  A pop or crack may be heard or felt.  The ankle will get black and blue.  Often times, the person will not be able to walk on the broken ankle.

WHEN TO SEEK MEDICAL CARE

If you suspect that you have an ankle fracture, you should seek medical attention within hours of the injury. A thorough physical exam and xrays will be needed to find out if you have an ankle fracture and the type of fracture you may have.

TREATMENT

Treatment varies depending on the severity of the ankle fracture.  If the fibula has broken, but has not shifted, a non-weight bearing cast may be worn for 8-10 weeks.  If the fibula is fractured and shifted out of place or the tibia is fractured or the syndesmosis is torn, then surgery may be necessary.  In the operating room, an orthopaedic surgeon will usually place a plate and screws in the fibula, screws or a plate in the medial malleolus part of the tibia, and/or screws or a similar device across the syndesmosis.  This allows for the broken bones and ligament to be held in place while the bones and/or ligament heals.  If the syndesmosis is torn, the patient is not allowed to put weight on the foot and ankle for 3 months.  If the syndesmosis is not torn, then the patient is not allowed to put weight on the foot and ankle for approximately 6-10 weeks.  

Below are representations of a type of ankle fracture where the fibula and the syndesmosis were torn and needed to be repaired.

OUTCOMES

Most patients with ankle fractures are able to return to their pre-injury activities with little or no difficulties.  However, there are some long-term implications of this injury.  First, about 30% of the time a "pot-hole" can develop in the ankle at the time of the injury.  This can lead to long-term pain.  Second, the cartilage is damaged at the time of injury.  This causes the development of post-traumatic arthritis in the ankle at a faster rate than an ankle that has never been broken.  Third, many patients will have stiffness and loss of motion following the injury.  Finally, extensive physical therapy is required to regain as much motion and strength in the ankle.

RETURN TO ACTIVITIES

Depending on the type of ankle fracture that Drew has, he will be out of baseball for at least 8 weeks.  If his syndesmosis is also torn, he will be out for 12 weeks. He will need significant rehabilitation before he gets back onto the field.

VIDEO/ANIMATIONS

Dr. P

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All material published through this blog/website is for informational and entertainment purposes only. Readers are encouraged to confirm the information contained herein with other sources. Patients and consumers should review the information carefully with their professional health care provider. The information is not intended to replace medical advice offered by physicians. Dr. Parekh and Duke University will not be liable for any direct, indirect, consequential, special, exemplary, or other damages arising from the discussions in this blog.   For more information on the North Carolina Orthopaedic Clinic, go to: http://www.ncorthoclinic.com/  For more information on Duke Orthopaedics, go to: http://www.dukehealth.org/orthopaedics