Sunday, March 29, 2015
Athletes like to compete. Surgeons like to operate. When injury happens, their worlds collide. Ideally, the goals of the athlete and the surgeon align; return to full time playing status at the same level of function and expertise as before the injury. Athletes tend to be more blunt, wanting to get back into the game as soon as possible and sometimes have to be protected from themselves in doing more harm. Often, decisions have to do with timing.
A pro athlete’s career is relatively short and missing even one season may be professionally and emotionally devastating. Rushing to surgery to repair an injury may be preferable than committing to physical therapy for a few weeks in hopes of avoiding an operation and then still needing to be repaired. Yet surgery is not a sure thing. Kevin Durant of the Oklahoma City Thunder broke the 5th metatarsal bone in his foot, (a Jones fracture). Surgery is usually the first option and it should have taken 6-8 weeks to completely heal, but in pro athletes, there can be a significant non-union and refracture rate. Mr. Durant developed that complication and now need further surgery and a lost year of competition.
But just because surgeons like to operate, does not mean that they always advocate for that as the first option. The success of New Orleans Pelican’s Eric Gordon using conservative therapy (non-surgical)in treating his torn shoulder labrum, is testament that the opportunity to avoid an operation should be given to everybody if possible.
The shoulder is the most mobile and least stable joint in the body. A ball and socket arrangement allows for a wide variety of movements, but its design makes it prone to become damaged and unstable. The glenoid fossa of the scapula (shoulder blade) forms a very shallow socket where the humeral head fits. The bony socket is extended by the labrum, a sleeve of cartilage that helps stabilize the joint and keep it from dislocating. The muscles that surround the shoulder are also key in that stabilization. However, in overhead athletes, (for example basketball and volleyball players, swimmers, tennis players and baseball players, the shoulder can be subject to violent forces and the structures in and around it can fray and tear.
When a shoulder labrum tears, the inflammation causes swelling and pain and this can shut down the surrounding muscles, weakening them and decreasing range of motion. Surgery can repair the damage and physical therapy can help return those functions, but the recuperation and recovery time may be as long as a year. Physical therapy alone may be successful in returning the athlete to normal function and it is a big decision for an elite athlete to forgo first line surgery in hopes that rehab alone might work. Mr. Gordon elected that second option and has continued to play throughout the season.
Mr. Gordon also used clothing made by AlignMed, also being worn by his teammate Anthony Davis and Dwight Howard of the Houston Rockets, to help with his shoulder that was recommended as part of the healing process. The shirts with built in bands that help with posture and muscle alignment have the ability, according to research from the Kerlin Jobe Orthopedic Foundation, to stabilize and increase rotator cuff function (one of the muscle groups that helps stabilize the shoulder). In another study from that group, the clothing helped increase stability of the scapula and increased muscle strength. The Stedman Research Institute found that the shirt might help decrease the risk of impingement and pain.
Most sport clothing companies, from Under Armour to Nike, make compression clothing that uniformly squeezes parts of the body. Perhaps the next step has been taken with the AlignMed concept to make functional clothing to apply pressure and help muscles, tendons, bones and joints, align more physiologically. This might allow mere mortals the opportunity to catch up to their pro athlete counterparts. Most people cannot spend hours a day in the gym or physical therapist’s office rehabilitating an injury. Work and family time get in the way. Pro athletes, on the other hand, can devote an 8 or 10 hour work day to their therapy regimens. And wearing the shirt all day long at work, whether it is on the playing field or in the office may help prevent injuries caused by poor posture and muscle fatigue.
Every patient is different and the treatment options presented and chosen will depend upon their injury, their underlying medical status and how active they were and will want to be after recovery. That said, it will be interesting to watch what happens with the Pelican’s Mr. Davis and Mr. Gordon and how they recover from their injuries. And as the baseball season begins, will players who strain or damage their shoulders look to physical therapy and clothing as an alternative to surgery. Because as Kevin Durant can attest, surgery is not a sure thing.This entry was tagged AlignMed, Anthony Davis, conservative therapy, Dwight Howard, Eric Gordon, physical therapy, shoulder labrum, surgery
Monday, March 23, 2015
One of the joys of the college basketball post season is the potential for the unexpected. The small school underdog can celebrate a Cinderella win against a larger and stronger opponent, at least for one round. Upsets occur and those filling out their bracket bemoan the fact that what was expected did not occur. They play the games because nothing is guaranteed. Welcome to March Madness. That same lack of a guaranteed win also exists in the medical world, where things don’t always go according to plan, but it’s call a complication, not an upset.
Some complications are inconveniences. After surgery, there may be a little bleeding from a wound and nothing more than an extra bandage is needed. There may be an extra day of discomfort. Nausea can occur after taking a pain pill. Other complications, however, can be devastating. Death comes to mind as one particular example. The goal of modern medicine is to minimize complication rates by improving techniques and care, yet for the individual patient who experiences a complication, theirs happens 100 per cent of the time. For that reason, the patient and family need to pay special attention to the informed consent discussion that happens with every medical encounter.
Not so long ago, the relationship between doctor and patient was one sided and paternalistic. The science of medicine was progressing nicely by improving diagnostic skill, but there were few treatment options available to offer to a patient. It was easy for the doctor to dictate the terms of treatment. There was but one way to treat a specific problem. Over time, the medical world has evolved and alternative treatment approaches exist for many illnesses and injuries. Ear infections can be observed for a few days before jumping to write an antibiotic prescription. Some fractures do not need emergent surgery. Cancer therapy can offer a myriad of experimental options. But each option carries its own risks and rewards.
Not so long ago, a knee injury ended an athlete’s career, but with technical advances like arthroscopic surgery, it is almost routine to “fix” knees. The goal is to return elite athletes and weekend warriors alike to their previous level of activity. However, that routine surgery is anything but. Some type of complication may occur in almost 5% of arthroscopic knee surgeries, and the more complicated the knee repair, the higher the potential risk. Infections may affect 1% of patients, anesthetic problems occur in 1 out of 250 operations and a pulmonary embolus, or blood clot to the lung, occurs in 1 out of 1000. This last number is very tiny, but pulmonary embolus is one of the most common causes of sudden death.
The discovery of antibiotics changed the world for medicine and allowed infections, like pneumonia, that were once a death sentences to be treated and cured. Doctors liked antibiotics so much that their indiscriminate prescribing increased resistance rates, making some bacteria relatively immune to common drugs. Plus, docs felt that patients would be less than satisfied if they did not leave their appointment with a prescription in hand. Some complications were irritating. Patients who were prescribed amoxicillin for a presumptive sore throat and strep infection, would develop a whole body rash if their real diagnosis was infectious mononucleosis…but who wanted to bother with the time and expense of a doctor’s visit if a prescription could be called in over the phone instead. But even with the proper use of antibiotics, unintended consequences could occur. Clostridium difficile, C Diff, can cause significant diarrhea due to colitis, or inflammation of the colon, in some patients who have been treated with antibiotics. The drug wipes out the normally present colon bacteria and lets the C Diff run wild. This infection can be devastating and may take weeks to cure. Once thought only to be a hospital acquired infection, C Diff, now rears its ugly head, even in the outpatient world.
Every doctor patient interaction has the ability to have an unintended consequence or complication. Care and treatment plans have become a collaborative decision making process. Deciding to watch and wait may cause an illness or injury to worsen instead of improve. Being aggressive with a medication can lead to cure or complication. The same holds true for the timing and type of surgery that might be recommended. The doctor has the responsibility to explain the ups and downs of alternative treatments. The patient has the responsibility to listen and ask question so that an informed decision can be made.
And there is one certainty that holds true. There is never a sure thing in medicine or March Madness.This entry was tagged antibiotics, C diff, clostridium difficile, complications, decision making, infections, surgery
Dr. Wedro weighs in
“The difference between doctors who look after mere mortals and those who look after elite athletes may have to do with how many tests they can order, regardless of the cost.”