May the Course Be With You

As your feet pound the pavement, you become keenly aware of the hard reality of training for a 5K, or 3.1-mile, road race. While training for a 5K is challenging, it can also be fun and beneficial. Before you begin a training program, however, you will need to plan accordingly. First, particularly if you are over the age of 40, you should schedule a physical exam with your doctor to make sure you are healthy enough to train for and participate in this type of event. Next, to be sure you get the most out of your training, you will want to put a nutrition and hydration program into place. You can then establish a realistic timeline and sound strategy for training.


Nutrition for optimal performance and recovery

As you train for an athletic event, it can be easy to focus too narrowly on the physical aspects of training, but it is just as important to train nutritionally. If you do not fuel or hydrate adequately, your endurance and overall performance can be compromised. A comprehensive nutrition plan for training should include carbohydrates, protein, and healthy fats. You should also drink plenty of water (Fig.).

   Fuel: Carbohydrates, proteins, and fat

Carbohydrates are a crucial dietary element as they supply the energy you need to run and work out. Ideally, calories from carbohydrates should make up at least 60% of your total calorie in-take. Some great carbohydrate choices are vegetables, fruits, whole grain breads, and pasta. Protein in appropriate portions constitutes another important component of your diet. Calories from protein should make up 20 to 25% of your total intake. Chicken, fish, eggs, beans, yogurt, low-fat cheese, and nuts are good, readily available sources of protein. Overall, eating protein along with energy-dense carbohydrates throughout endurance training has been shown to improve a runner’s performance; it has also been shown to decrease recovery time, probably because protein helps repair muscle tissue. Fats also contribute to a runner’s general good health, but because of the stigma associated with eating fat, figuring out which types are healthy to consume can be confusing. Your best bet is to choose the unsaturated, healthy fats found in avocados, almonds, cashews, and fatty fish, such as salmon or tuna, and to avoid saturated fats such as those found in lard and butter. Calories from fat should account for no more than 15 to 20% of daily calorie intake for the runner.


Hydration is another key element of an optimal nutrition program for training and racing. Simply put, without adequate hydration, your body cannot function properly. It is therefore important to hydrate well by drinking plenty of water—in staggered amounts so as not to feel too full—before, during, and after training and events. You may even want to carry a water bottle with you while training or, alternatively, choose running routes in places, such as a park, where you can pass by a water fountain. In the hours following a run or race, drink as much water as you can to rehydrate. When you are completely rehydrated, your urine will be a light yellow color. You can also use sports drinks to help replenish electrolytes—salts and minerals, such as sodium chloride and potassium, that control fluid balance and muscle contraction—but these should not replace water. The Summer 2016 issue (vol. 28, no. 3) of the Hughston Health Alert covers proper hydration for athletes in greater detail.


Training: how much, how often

Once you have adopted an appropriate nutrition and hydration program, you can establish a training timeline and strategy. If you have not participated in any type of physical activity before, a realistic timeline for training to complete a 5K race would be 7 to 8 weeks. To allow both your cardiovascular and musculoskeletal systems to adjust to the new workload, you should train in a steady progression. For the first couple of weeks, mix walking and running, beginning with 15-minute training sessions, 3 days per week with at least 1 rest day in-between. Always adjust your running pace to be within your current fitness level. As you move, you should have the breath to carry on a conversation; if not, you are trying to go too fast. In the coming weeks, as you become more comfortable with your routine, you can gradually increase the amount of running versus walking. You should also be able to increase your overall training time in 5-minute increments or your overall mileage in half-mile increments each week. However, always listen to your body, and if you become sore or fatigued, back off. As muscles actually grow stronger during rest and not during training, lack of rest can lead to fatigue and even injury. You may also want to stretch your muscles before and after running. This will help keep them flexible and may prevent injury. The Fall 2008 issue (vol. 20, no. 4) covers stretching techniques in greater detail.


The benefits of training

Running has been proven by research to improve your mood and reduce mental stress. As you exercise, your body releases chemicals called endorphins to the receptors in your brain, producing a sensation of overall well being. Moreover, regular running can help you lose weight because your body not only burns calories while you run, but also continues to burn extra calories afterward, a phenomenon known as excess post-exercise oxygen consumption (EPOC). Furthermore, running has been shown to strengthen your knees, keep you mentally sharp as you age, and to decrease your risk of developing diabetes mellitus, certain types of cancers, and cardiovascular disease, as well as increase the number of years you have to live.  


Race day

As race day approaches, remember to adhere to the principles of fueling and hydrating well, particularly the day before. Continue to hydrate the morning of the race, but eat lightly or not at all, as running forces the blood away from the stomach to the working muscles. During the race, run at a pace that feels comfortable and smooth. If you need to drink water on the course, slow up slightly to grab a cup at one of the water stations and sip. If you want to push yourself, wait until you are well past the second-mile marker and don’t sprint until you are past the third-mile marker. Once you are over the finish line, get the recovery process going by drinking plenty of water. As a rule of thumb, it will take your body a day for every mile raced—in this case, just over 3 days—to fully recover.


May the course stay with you

Training for a 5K race is an amazing journey that begins with planning and preparation. Success is based on a realistic timeline and sound training strategy along with a good nutrition and hydration program. Following these principles can lead you not only to the finish line, but also to improved physical and mental well being. Whether or not you plan to participate in other events, by making running part of your everyday routine, you can continue to reap the benefits.


Author: Kamal Leak, MS, LAT, ATC, and Morgan Carr, MS, LAT, ATC | Columbus, GA

Reprinted with permission from the Hughston Health Alert, Volume 28,Number 4, Fall 2016.



Impetigo: A Concern for Athletes


If you are an athlete, you have a greater risk than most people of contracting impetigo, a highly contagious skin infection that affects about 2% of the global population annually. The term impetigo comes from the Latin verb impetere, meaning to attack, and refers to the breakouts or skin eruptions that characterize the disease. Impetigo has 2 forms: nonbullous and bullous. The nonbullous form is more common, accounting for 70% of all cases, and appears on the skin as a pustule or golden crusty sore surrounded by red infection. This form is usually caused by the Streptococcus pyogenes (strep) bacterium, but can sometimes be caused by the Staphyloccocus aureus (staph) bacterium. By contrast, the bullous form of impetigo manifests as a macule or red rash that resembles a burn mark. It is caused only by staph bacteria which release epidermolytic toxins or poisonous substances that cause the lesions to form blisters (bulla is Latin for “blister”) or fluid-filled sacs called vesicles. Such vesicles tend to be thin roofed and easily ruptured, revealing a moist red infected layer beneath. After a few days, a golden crust will form over the blisters. Impetigo lesions can erupt anywhere on your body, but the most common sites are the nose and mouth, followed by the arms or legs. While the lesions of either type of impetigo can be itchy, they are not usually painful. The bacteria are transmitted through skin to skin contact or through direct contact with contaminated objects. It usually takes 1 to 3 days after contact with strep, and 4 to 10 days after contact with staph, for the symptoms of impetigo to appear.


Who is at risk?
You are more likely to contract impetigo if you live in hot, humid climates. Additionally, poor hygiene and poor nutrition, as well as having diabetes or a compromised immune system, can make you susceptible to the infection. The condition occurs most frequently in pre-school and school-age children; in fact, 90% of all impetigo cases occur in children under the age of 2. Impetigo is the most common bacterial skin infection in children and is therefore sometimes referred to as “school sores.” Impetigo also occurs more frequently in athletes who play sports involving a high degree of physical contact than in the general population. For example, if you are a wrestler, boxer, swimmer, gymnast, or football player, your risk of contracting impetigo is high, due to direct skin contact with other players, gym mats, and the showers in the locker rooms. You can also transmit or contract the disease if you share personal items with people such as clothing, towels, and bedding. If you or a fellow athlete has a skin irritation from eczema, poison ivy, insect bites, cuts, or scrapes, it could easily become infected and develop into impetigo. For instance, one day you might notice that you have insect bites on your lower legs. You continue playing sports and doing your normal activities while waiting for these to clear up, but a couple of days later you find that the bites have now developed into crusty pustules. To avoid spreading the infection to your fellow athletes, you should abstain from playing and see your doctor.


How is impetigo diagnosed?
Your doctor can usually diagnose impetigo by taking a personal history and examining the appearance of your skin. However, as the skin patches associated with impetigo can resemble those seen in a host of other skin diseases such as eczema, psoriasis, poison ivy, lupus, or shingles, there is a chance that the condition could be misdiagnosed. To determine the particular type of bacteria causing your infection, and prescribe the best antibiotic, your doctor may take a culture using a swab.


How is impetigo treated?
While impetigo may clear up on its own within 2 to 3 weeks, primary treatment consists of topical antibiotic ointments; more severe cases will also require oral antibiotics. Since impetigo is highly contagious, you should avoid close contact with anyone until 24 hours after starting the medication. After this, you may return to your normal activities, but be aware that your impetigo sores will take at least a week to heal completely. As an athlete, you should not be allowed to participate in sporting events until you have completed a 72-hour course of antibiotic treatment, have no moist or crusty wounds, and have had no new lesions for at least 48 hours. Lesions should not be covered as a way to allow you to participate.


What are the possible complications?
Left untreated, impetigo can develop into a more serious form of the disease called ecthyma. This condition occurs when the disease invades the second layer of skin, causing painful fluid or pus-filled sores that turn into deep ulcers and may leave scars. If you develop ecthyma, you may also have swollen lymph nodes. Other complications of impetigo can include cellulitis, another serious infection that affects the underlying skin. Even more rarely, you could suffer kidney damage from the bacteria that cause impetigo.


How can you prevent impetigo?
To prevent impetigo, avoid contact with infected individuals. If you touch an open wound, wash your hands immediately with soap and warm water. You should also make sure to wash any surfaces, objects, clothing, towels, or bedding that may have come in contact with the infection with soap and hot water. If you have an open wound or a fresh abrasion, avoid scratching as this could allow the bacteria from the impetigo to enter and cause an infection; better yet, cover all open wounds and insect bites. If you do contract impetigo, avoid spreading the infection to other people and to other parts of your body by not scratching and applying antibiotic ointment and proper dressings to affected areas.


Know the facts, then act
Impetigo is a highly contagious bacterial infection of the skin that can sometimes have serious complications. It is spread through direct skin contact, which means everyone is at risk, but athletes, particularly wrestlers, are at increased risk for contracting the disease. If you even suspect that you have impetigo, avoid contact with others until you know for sure you are not infected or you have been on medication for at least 72 hours. Knowing the facts and taking measures to prevent contracting or spreading impetigo will benefit not only you, but also your fellow athletes.



Author: Heather Martin, MS, LAT, ATC and Ashley Wojnowski, LAT, ATC | Columbus, GA

Reprinted with permission from the Hughston Health Alert, Volume 28,Number 4, Fall 2016.

Getting the Facts on Fragility Fractures

If you are over the age of 50, especially if you are also female, you may be at risk for a fragility fracture. The American Academy of Orthopaedic Surgeons defines fragility fractures as fractures that result from a fall from a standing height or that occur in the absence of obvious trauma (Fig. 1). These types of fractures affect up to 50% of all women and 25 to 33% of all men over 50 and are often associated with low bone-mineral density. The hip, spine, and wrist are the most common sites where you could sustain a fragility fracture.

What causes fragility fractures?
Low-energy fragility fractures usually occur as a result of not just general low bone density, but the presence of osteoporosis. Osteoporosis is a bone disease characterized by the structural deterioration of both the inner and outer bone tissue, resulting in porous bones (Fig. 2). These changes lead to overall low bone mass, compromised bone strength, and an increased risk for fractures. If you do have osteoporosis, you are not alone: the National Osteoporosis Foundation estimates that 10 million people in the United States suffer from osteoporosis while another 34 million are at an increased risk of bone fracture due to osteopenia or low bone mass. One of the most serious injuries you can suffer as a result of osteoporosis is a hip fracture; 50% of those who suffer a hip fracture will lose the ability to live independently.


Additional risk factors
Once you have suffered a fragility fracture, you have a greater risk of sustaining another. Apart from age, gender, and a previous fracture, risk factors include a family history of fragility fractures, frailty, poor health, dementia, Caucasian or Asian race, calcium and vitamin D deficiencies, smoking, and excessive alcohol consumption. Moreover, certain diseases, such as rheumatoid arthritis, diabetes mellitus, and renal disease, as well as any kind of prolonged immobilization, can increase your risk of generalized osteoporosis and fractures. Furthermore, taking certain types of drugs, such as glucocorticoids, immunosuppressants, anticonvulsants, and testosterone antagonists, constitutes a risk factor for the disease. It is best to try to identify all of your risk factors before a fracture occurs.


Since an orthopaedic surgeon is the first, and often the only, physician you may see if you break a bone, it is important that he or she have you evaluated for osteoporosis. Your evaluation should include a medical history, physical examination, laboratory tests, bone mineral density tests, and possibly x-rays. Although your orthopaedic surgeon will typically initiate this evaluation while overseeing the care of your fracture, you may be referred to your primary care physician or a bone health clinic to treat the underlying causes of the disorder to prevent future fractures.


As a fragility fracture patient, optimal care will involve not only treating your injury, but also identifying and treating the underlying cause. If it is determined that you have osteoporosis, your treatment will begin with counseling about diet, exercise, and fall prevention. You may be encouraged to perform regular weight-bearing exercises, such as walking, and to get sufficient amounts of calcium (1,200 mg/day) and vitamin D (800 IU/day) through your diet, dietary supplements, and exposure to sunlight. Your treatment plan may also include pharmacologic agents to prevent bone loss, such as bisphosphonates, or various hormone therapies such as selective estrogen receptor modulators, parathyroid hormone, and calcitonin.


Fracture care
When it comes to fragility fractures, both nonsurgical and surgical management have proven highly successful, depending on the particular fracture. As with other types of fractures, the basic principle for the management of fragility fractures is to first reduce the fracture (manipulate the broken bone back into its proper position); next hold the fracture in this position (non-surgically with a splint or cast, or surgically with plates, screws, or rods); and, finally, to rehabilitate the patient through exercise and physical therapy. Sometimes, in order to provide extra support for weak bone, special techniques can be applied surgically to create a more robust fixation construct. An example of this is the use of special locking screws. Additionally, after surgery you may be instructed to avoid weight bearing on the affected extremity for an extended period of time in order to help it heal.


You can both reduce your risk level and enhance outcomes for fragility fractures if you and your physician assume an active role in managing your osteoporosis and preventing additional fractures. While it is best to start a preventative program early (around age 30), it’s never too late to take care of your bones and improve your odds.

Author: Aaron D. Schrayer, MD | Lewisville, TX

Reprinted with permission from the Hughston Health Alert, Volume 28,Number 4, Fall 2016.

What’s New in Knee Replacement Surgery?


As an orthopaedic surgeon who performs joint arthroplasty (replacement surgery), I am often asked about what’s new in regards to the surgery. Total knee replacement has been performed for many decades, and in short, over the years, many things have changed for the better.


Robotic technology

The first big change is the use of technology in the operating room. Robotic assisted joint replacement surgery was FDA approved in 2009. I was the first in the state of Tennessee to adopt this technology in surgery in 2011. Initially, it was only available for partial knee replacements and in 2014 I began using it for total hip replacements. In 2017, it was available for total knee replacement.

Robotic assisted surgery begins with a three-dimensional computer model of the actual knee of the patient. Using this model, I can precisely place the knee replacement components on the patient’s knee using their own anatomy. This allows for a more accurate placement of the implant which is matched to the patient’s anatomy. The end result is a more natural feeling knee while removing the lease amount of bone possible. During the procedure, I obtain real time information regarding the alignment of the limb and balance of the joint. A well-aligned joint will last longer than a knee replacement a few degrees out of alignment. I no longer need to place cutting blocks in a knee to perform the procedure, so there is less surgical dissection and exposure. This leads to a quicker recovery. The end result is a better positioned, well-aligned knee, less time in the operating room, and a faster rate of healing for the patient.


Anesthesia protocols

Great advances have been made in anesthesia techniques and postoperative pain control. Previously, joint replacements were performed under general anesthesia; however today, we use regional anesthesia techniques. Using nerve blocks and spinal anesthetics, we now perform joint replacement without general anesthesia. When using regional anesthesia techniques, patients begin to walk as early as 1 to 2 hours after surgery. This leads to less risk of blood clots and better postoperative pain control. Additionally, I use long acting numbing agents and oral medications to prevent postoperative pain. This has lead to higher patient satisfaction with the surgery as well as a quicker return to daily activities.


Rehab protocols

Finally, rehabilitation after knee replacement has had significant changes over the last several years. Previously, patients would begin their rehabilitation after the surgical procedure and often need to stay in rehabilitation facilities following surgery. Now we begin rehabilitation as soon as the decision for surgery is made. Physical therapy begins prior to surgery now and continues with immediate mobilization after surgery. Often, when patients receive preoperative therapy they are more physically ready for the surgery, which results in shorter hospital stays and faster return to activities.

With all the great strides made in surgical care, this is an exciting time for the patient and their orthopaedic surgeon. We are providing better outcomes with less pain and recovery time for our patients. However, each patient is unique, and their recovery is specially tailored to them. If you would like to discuss your knee and the pain you have been experiencing, I would be happy to talk with you.


Author: Jonathan P. Cornelius, MD | Hughston Clinic Orthopaedics, Lebanon, Tennessee

ACL Tears in Teens

With more and more young athletes participating in sports each year, injuries to the anterior cruciate ligament (ACL) of the knee have become quite common. Youngsters, particularly during the period of rapid growth—generally around age 12 for girls and 14 for boys—are at increased risk for ACL tears. For various reasons, adolescent girls may be 3 to 8 times more likely than their male counterparts to tear their ACL. Fortunately, new injury prevention programs have emerged that can help at risk athletes, particularly adolescent females, to avoid ACL tears.



Knee anatomy and the ACL
The knee is a complex joint made up of 3 bones: the femur (thighbone) and the tibia (shinbone) meet to form a hinge that allows for flexion (bending) and extension (straightening) with a minor degree of rotation while the patella (kneecap) covers its front and helps extension. These bones are held together by 4 ligaments: the 2 collateral ligaments and the 2 cruciate ligaments (Fig.1). The collateral ligaments run along either side of the knee, limiting side-to-side motion and providing stability. The outside ligament is known as the lateral collateral ligament and the inside as the medial collateral ligament. Inside the knee joint are the 2 cruciate ligaments, so called because they criss-cross, forming an X. The posterior cruciate ligament or PCL is in the back while the often-injured anterior cruciate ligament or ACL is in the front. The ACL slides within the intercondylar notch, or the space between the 2 rounded ends of the femur. Its primary function is to prevent the tibia from either moving too far forward or from rotating too far inward underneath the femur.


Risk factors for ACL tears in teens
While participation in demanding sports such as football, basketball, and soccer has been linked to a greater likelihood of ACL tears (Fig. 2), further investigation into risk factors has divided ACL tears into nonmodifiable and modifiable categories.1 Nonmodifiable risk factors include issues with knee structure, hip-knee alignment, hormone function, neuromuscular maturation, and reduced muscular strength. Modifiable risk factors include various neuromuscular imbalances and deficiencies. Both types of risk factors are more closely associated with being female.


A narrow intercondylar notch of the femur or notch stenosis (narrowing) as well as variations in tibial plateau (the upper surface of the tibia within the knee joint) anatomy, such as an increased slope, can lead to pinching of the ACL by the femur and possible rupture. Also, by adolescence, females have a wider pelvis than males and thus a greater Q-angle or angle of hip-knee alignment, concentrating more force on the ACL and increasing the likelihood of a tear. Moreover, during their developmental phase, females exhibit less neuromuscular maturation along with greater inner knee rotation and valgus (knock-knee). They also have a greater ground reaction force—the force exerted on the body when landing a jump. Furthermore, young female athletes have less strength in proportion to bone size in the muscles that stabilize the knee than male athletes, yet experience the same twisting and loading forces on this joint. Lastly, hormone fluctuations may cause the collateral ligaments to become looser at certain points during the menstrual cycle and so unable to absorb the stresses placed on them, putting the ACL at risk of injury.


Modifiable risk factors for ACL tears include neuromuscular imbalances and deficiencies. Traditionally, boys have participated in sports, such as soccer, that involve twisting movements at an earlier age than girls. By adolescence, they may have developed the muscle coordination and reflexes needed to protect the knee while girls may have neuromuscular imbalances and deficiencies—such as knee ligament, muscle, or overall leg dominance, as well as various muscular weaknesses—that can make them more prone to ACL injuries.


Ligament dominance is a condition that results in decreased medial-lateral (side-to-side) neuromuscular control of the knee joint. This neuromuscular deficiency can lead to valgus collapse, or medial displacement, of the knee and possibly to an ACL tear. Quadriceps dominance—a condition where the quadriceps muscles in the front of the thigh overpower the hamstrings in the back of the thigh—can cause excessive anterior translation, or forward slippage, of the tibia and strain the ACL.1 Leg dominance, which predisposes the nondominant leg towards valgus collapse, can also be a factor in sustaining ACL injuries.


Muscular weakness
Weaknesses in the gluteal (buttocks), hamstring (back of the thigh), and gastroc soleus (back of the calf) muscles can lead to a valgus collapse and consequent ACL strain, especially during a jump landing.2 Moreover, weak core (abdominal and mid and lower back) muscles mean an unstable pelvis, resulting in too much lateral trunk motion and pronation (inward rolling of the feet), and thus increased risk of an ACL injury.


Prevention programs
Prevention programs have been created to train athletes to resist injury. Prevention programs for ACL tears focus on neuromuscular imbalances and deficiencies. While each program has its own specific regimen that combines plyometrics (jump training that makes the leg muscles exert maximal force in a brief amount of time in order to increase speed and power) with conditioning and strengthening exercises,1 all of them concentrate on developing more appropriate landing techniques along with better balance and stability in the lower extremity. For teens, the most effective regimens are those that implement neuromuscular training and emphasize plyometrics and strengthening both preseason and in season.

While not all studies have shown a reduction in ACL injury for their particular study group,3 the bulk of evidence indicates that these programs can work.1, 4 One study reviewing several prevention programs saw a 52% risk reduction for ACL tears in females, and for males the rate was even higher at 85%.4 Two programs that have been shown to significantly reduce ACL injuries in females are Sportsmetrics and Prevent Injury and Enhance Performance (PEP).5, 6 With all prevention programs, it should be noted that success depends largely on the athlete’s degree of compliance.1 As prevention is still the most efficient and cost-effective method to avoid ACL injuries, screening for at-risk athletes has been considered.


ACL surgery
Over the past 30 years, ACL reconstructive surgery to stabilize the knee and lessen further damage has advanced considerably. While such progress has led to improved outcomes that potentially allow the athlete to return to play, it has also heightened expectations. Affected athletes must realize that they may still have limitations after ACL reconstruction. In their study, Ardern et al. showed that among athletes with ACL injuries, 82% returned to sport, but only 63% to their pre-injury sport, and just 44% at a competitive level. Furthermore, the knee with the ACL tear has been shown to be more likely than the uninjured knee to develop arthritis.7


The best cure
An ACL tear can be a significant life-altering injury for a young athlete, and teens, particularly girls who participate in sports, are at increased risk. While more research is needed, appropriate ACL injury prevention programs have been shown to reduce the overall number of ACL tears. As with all types of injuries, prevention is the best cure. Such programs should therefore be seriously considered before a young athlete suffers an ACL tear.


Author: David A. Lalli, DO | Niceville, Florida

Reprinted with permission from the Hughston Health Alert, Volume 28,Number 4, Fall 2016.


1. Hewett TE, Torg JS, Boden BP. Video analysis of trunk and knee motion during non-contact anterior cruciate ligament injury in female athletes: lateral trunk and knee abduction motion are combined components of the injury mechanism. British Journal of Sports Medicine. 2009;43(6):417-22.
2. Hewett TE, Lindenfeld TN, Riccobene JV, Joyes FR. The effect of
neuromuscular training on the incidence of knee injury in female athletes:
A prospective study. American Journal Sports Medicine. 1999;27(6):699-706.
3. Sadoghi P, von Keudell A, Vavken P. Effectiveness of anterior cruciate ligament injury prevention training programs. Journal Bone and Joint Surgery, American. 2012;94(9):769-76.
4. Ardern CL, Webster KE, Taylor NF, Feller JA. Return to sport following anterior cruciate ligament reconstruction surgery: a systematic review and
meta-analysis of the state of play. British Journal Sports Medicine. 2011;45(7):596-606.
5. Mandelbaum BR, Silvers HJ, Watanabe DS, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: a 2-year follow-up. American Journal of Sports Medicine 2005;33(7):1003-10.
6. Pfeiffer RP, Shea KG, Roberts D, et al. Lack of effect of a knee ligament injury prevention program on the incidence of noncontact anterior cruciate
ligament injury. Journal of Bone and Joint Surgery, American. 2006;88(8):1769-74.
7. Mather RC 3rd, Koenig L, Kocher MS, Dall TM, et al. Societal and economic impact of anterior cruciate ligament tears. Journal of Bone and Joint Surgery, American. 2013;95(19)1751-9.

Don’t “Just Do It” – Do It Right


In 1988, an upstart advertising firm in Portland, Oregon was approached by Buck Knight to help with his company’s print and television campaign. Interestingly, while developing the campaign,  Dan Weiden found inspiration in the last words spoken by Gary Gilmore—a convicted murder who was executed by firing squad in 1977. Just before his life ended, Gilmore shouted “Let’s do it.”  Born out of Gilmore’s final words, Weiden’s famous slogan “Just Do It” is considered one of the top 5 slogans of the 20th century. Weiden described his slogan as “a tough, take no prisoners, intensely personal” ad campaign targeted at all Americans, regardless of their level of physical fitness. After the “Just Do It” campaign, Nike’s athletic shoes market-share went from 18% to 43% in the United States. In recognition of the impact of Dan Weiden, Nike and its slogan are enshrined in the Americana exhibit at the Smithsonian National Museum.


Caring for orthopaedic patients and their injuries is not easy work. The doctor must quickly assimilate the information given by you, and put together a comprehensive plan for recovery. Teamwork is the key to successful outcomes in orthopaedic care. The team will always include at least two participants, known as the doctor-patient relationship team. The doctor uses his or her years of training and experience to create the game plan and you, the patient, uses your understanding, efforts, and biofeedback to execute that plan. Not only is it time to “Just Do It,” it’s time to “Do It Right.” Your health and recovery take focused and consistent effort. Although other team members, such as physical therapists may get involved in the patient-care episode, there is only one person ultimately responsible—YOU.


All too often, I see a patient and prescribe a comprehensive treatment plan, only to find out that this plan wasn’t properly executed, or wasn’t attempted at all. The patient returns with continued complaints, and seeks more options. Effort, energy, and ownership of your health and well-being are your option.  Don’t “Just Do It,”—Do It Right. You might not be enshrined in the Smithsonian, but your reward will be equally gratifying.


Author: Marc A. Tressler, DO | Hughston Clinic Orthopaedics, Hendersonville, TN

Bone Grafting: An Essential Guide


Bone grafting is a surgical procedure in which an orthopaedic surgeon transplants bone tissue. Bone grafts are used to repair fractures that are complex or have failed to heal, to replace missing bone following trauma or tumor removal, and to correct deformities. They are also used in spinal surgery to help fuse vertebrae. Bone grafts work because, given sufficient space and proper scaffolding, bone tissue has a remarkable ability to regenerate.



Osseous, or bone, tissue consists of protein fibers called collagen embedded in a matrix of intercellular liquid hardened by deposits of calcium and phosphate salts. Within and around the matrix, 3 types of bone cells build, maintain, and remodel bone. These include osteoblasts, or immature bone cells, which produce the bone matrix; osteocytes, or mature bone cells, which serve to maintain the matrix; and osteoclasts which break down and remove bone tissue (Fig. 1).


Bone grafts

A bone graft grows and repairs a defect according to 3 different processes. The first is osteogenesis, or the formation of new bone by living cells within the graft such as osteoblasts. The second, osteoinduction, is a chemical process in which protein molecules within the graft recruit and stimulate the patient’s undifferentiated cells to become osteoblasts. Lastly, osteoconduction is the process by which the matrix of the graft serves as a scaffold to maintain space so the recipient’s cells can generate new bone tissue. Bone grafts thus provide a structure for bone to grow, but then slowly dissolve, leaving behind only the new bone.



An autograft, or bone obtained from a patient’s own body, is considered the gold standard in bone grafting procedures largely because native bone is osteogenic as well as osteoinductive and osteoconductive. It is also non-immunogenic, which means it is compatible with the patient’s own tissues and the body will not attack or reject it. As all bone requires an adequate blood supply, depending on the graft size and transplant site, a section of the periosteum (the thin layer of connective tissue that covers the bone) and its accompanying blood vessels may be included with the autograft and reattached at the site to ensure its blood supply.

There are additionally 2 types of bone that can be used for an autograft: cancellous or soft bone and cortical or hard bone. Compared to cortical bone, cancellous bone has greater surface area and is much more porous, allowing cells to infiltrate and blood vessels to form. It thus has more bone-forming potential than cortical bone, but cortical bone, being harder, can provide immediate structural support for new bone. Common sources of cancellous autograft bone are the iliac crest (upper portion of each side of the pelvis), upper tibia (shinbone), and the radius (wrist). Cortical autografts can be harvested from the diaphysis, or shaft, of the fibula (outer bone of the lower leg) and used to reinforce reconstructions, such as for spinal injuries or to replace segments where bone has been lost due to a trauma or tumor removal.

While autografts are the preferred material, harvesting bone from the patient’s own body necessitates additional surgical time and blood loss, and the amount of bone that can be harvested is always limited. The chief drawbacks to an autograft, however, are potential complications at the harvest site, such as infection and possible nerve injury.


Allografts and synthetic materials

A graft obtained from donor (cadaveric) bone is called an allograft. After being harvested, the bone tissue is tested for disease, cleansed, frozen, and stored in tissue banks. Allografts are not osteogenic, but they are able to stimulate cells to become osteoblasts and to provide a scaffold for bone growth. Unlike autografts, they do not require the patient to undergo an additional surgery; this reduces the risk of infection and precludes pain and loss of function at a second surgical incision site.

A variety of natural and synthetic replacement materials can also serve as substitutes for natural bone or can be mixed with either allograft or autograft tissue as bone extenders. These include ceramics like calcium phosphates, bioglass, and calcium sulphate. All of these materials are biologically active to some degree. For example, allograft bone that has been treated with a strong acid to remove the inorganic mineral deposits, known as demineralized bone matrix, possesses some osteoinductive properties. Additionally, coral, which has a biochemical and physical structure similar to bone, can act as a scaffold for new bone. Natural substances, such as bone morphogenetic proteins (BMPs), which contain growth factors, can be added to these synthetic materials to enhance their biological activity.

Allografts, either alone or mixed with extenders or enhancers, are often used in pelvic, knee, and femur (thighbone) reconstructions, but, ultimately, the type of bone graft used depends on the site and the exact nature of the injury being repaired. Since allograft tissue is not the patient’s own, the bone quality may vary. Moreover, the graft may take longer to incorporate with the patient’s native bone than an autograft. There is also a greater risk of reabsorption of the graft as well as the possibility of immune response complications, though taking anti-rejection drugs helps diminish this. Likewise, advanced testing and cleansing methods have greatly reduced the risk of transferring a disease along with an allograft.


Bone grafting procedures

During a bone grafting procedure, the orthopaedic surgeon will either place the graft material directly into the bone defect or lay it across to bridge the area to be fused. In some instances, the bone graft is held in place with pins, plates, or screws. When additional stability or protection is needed during the healing process, a splint, cast, or brace can be applied.

Recovery from a bone grafting procedure can take from 2 weeks to more than a year, depending on the size of the defect and the condition of the surrounding bone at the time of the surgery. More severe cases take longer and can require follow-up surgery.



Certain behaviors and conditions can affect the outcome of a graft. For instance, smoking can diminish outcomes because the carbon monoxide in cigarettes reduces local blood flow, decreasing osteoblast formation and bone metabolism at the graft site. Diabetes mellitus, which can cause peripheral nerve and vascular problems, may negatively impact fracture healing and bone grafting. Deficiencies in dietary calcium and vitamin D impair bone metabolism while metabolic conditions, such as thyroid problems and low growth hormone levels, have been associated with high rates of nonunions (fractures that fail to heal). Additionally, some drugs, such as nonsteroidal anti-inflammatory medications and corticosteroids, can interfere with bone healing. By inhibiting osteoclasts, bisphosphonates used to treat osteoporosis (low bone density) can decrease the rate of bone remodeling. Overall, bone grafting is highly successful in patients who do not smoke and follow their surgeon’s instructions when it comes to medications and activity modification.


Author: Thomas N. Bernard, Jr., MD | Columbus, GA

Reprinted with permission from the Hughston Health Alert, Volume 29,Number 1, Winter 2017.

Atrial Fibrillation in Athletes

Atrial Fibrillation is the most common cardiac arrhythmia (heart rhythm) affecting over 5 million people in the United States with projections up to 20 million people by 2030.1 Physicians define atrial fibrillation as rapid, chaotic electrical impulses in the upper heart chambers known as the atria that result in irregular heartbeats. In the early phases of the disease, abnormal impulses from pulmonary veins—which carry oxygenated blood and connect directly to the left atrium of the heart—trigger the arrhythmia. As the disease progresses, the normal cellular architecture of the atria changes as thicker scar tissue replaces healthy muscle, which in turn causes the atrial fibrillation to worsen. Based on the patient’s symptoms, treatment can include medications or catheter ablation (a minimally invasive procedure) to disrupt the faulty signals.



Risk factors

Other than rare genetic disorders, atrial fibrillation is an acquired condition. It often presents in the sixth and seventh decades of life, with a lifetime risk of 25% for people who are over 40 years of age. Typical risk factors for atrial fibrillation include age, heart failure, valvular (heart valve) disease, obesity, sleep apnea, hypertension, diabetes mellitus, and alcohol consumption.1 In addition to causing cardiovascular symptoms, it increases stroke risk 5-fold and can lead to heart failure. To determine stroke risks, physicians use the CHADS-VASC score (Table). Based on a score of 2 or more risk factors, anticoagulants (blood thinning medications) are used to reduce the chance of stroke.



Endurance athletes

Cardiovascular exercise is generally beneficial for patients with atrial fibrillation; however, there are some scenarios where exercise can increase the episodes. Endurance exercise including marathon running, triathlons, and similar long-duration exercise can increase the risk of developing the condition. One study of endurance athletes showed a 2- to 10-fold increase of occurrence compared to sedentary individuals.2 In endurance athletes, the left atrium is often enlarged and there is usually some degree of cardiac muscle stiffening. A leading theory for increased atrial fibrillation in endurance athletes includes increased vagal tone. When the vagus nerve controls the heart rate through the parasympathetic nervous system, nerve fibers slow the heart rate—this is called vagal tone. Prolonged episodes of heightened vagal tone, necessary for endurance activities but possibly arrhythmia provoking, is the most established theory. In this scenario, increased vagal tone leads to increased heart rate variability and ectopy (a rhythm disturbance) thereby triggering atrial fibrillation. The phenomenon appears to be more common in men and in those under the age of 60. Additionally, theories involving athletes include increased physical stress on the heart, inflammation, prolonged electrolyte imbalance, remodeling of the heart muscle, and increase in pulmonary vein trigger firing.3



Most patients with exercise-induced atrial fibrillation usually have the mildest form, which doctors define as episodes lasting less than 1 week. To assess the contribution of heavy exertion, physicians often advise their patients to stop endurance training for 3 months. Exercise-induced atrial fibrillation is different from that seen in the general population, although the treatment strategies for the condition remain similar. For those with 2 or more risk factors for stroke, physicians often prescribe anticoagulants. Medical treatment of atrial fibrillation in athletes can be challenging since most medications can slow the resting and exertional heart rate thereby limiting the ability to exercise. Physicians often prescribe anti-arrhythmic medications specifically designed to treat the disease; however, these tend to have other types of unwanted side effects. Catheter ablation in the endurance athlete has become a more favorable option since it provides freedom from the condition and can eliminate the need for long-term medications.


How much is too much?

Despite findings of increased atrial fibrillation in endurance athletes, physicians do not recommend stopping exercise as a means to reduce the risk. Recommendations for weekly cardiovascular exercise regimens totaling 150 minutes remain part of standard practice. In fact, one study reported that a monitored diet and exercise program for 3 months after an ablation procedure greatly reduced the rate of recurrence; therefore, exercise plays a beneficial role in care.4 However, researchers need to determine the ideal balance before the risk of atrial fibrillation increases. Strength training, such as moderate weight lifting does not increase or decrease the risks. For athletes taking supplements and consuming energy drinks, there is little information to provide any guidance; however, many of these products contain caffeine and other stimulants that have shown to trigger atrial fibrillation events. The question of “how much is too much” in exertional activities remains unclear.


Don’t overdo it

Atrial fibrillation is a common cardiac arrhythmia that has significant health implications including increased risks of heart failure and stroke. Medications and ablation procedures are often effective along with lifestyle modifications in preventing progression of the condition. Cardiovascular fitness is important in reducing episodes; however, extreme training and endurance events can increase the risks. Moderate exercise training regimens are likely the best strategy to reduce the incidence of atrial fibrillation in athletes.


Author: Michael L. Bernard, MD, PhD | New Orleans, LA

Reprinted with permission from the Hughston Health Alert, Volume 30,Number 4, Fall 2018.



  1. Morin DP, Bernard ML, Madias C, Rogers PA, Thihalolipavan S, Estes NA 3rd. The State of the Art: Atrial Fibrillation Epidemiology, Prevention, and Treatment. Mayo Clinic Proceedings. 2016 Dec; 91(12):1778-1810.
  2. Estes NA 3rd, Madias C. Atrial Fibrillation in Athletes: A Lesson in the Virtue of Moderation. JACC: Clinical Electrophysiology. 2017 Sep;3(9) 921-8.
  3. Sanchis-Gomar F, Lucia A. Pathophysiology of atrial fibrillation in endurance athletes: an overview of recent findings. Canadian Medical Association Journal. 2016 Dec;188(17-18):E433-35.
  4. Pathak RK, Middeldorp ME, Meredith M, et al. Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort. A Long-Term Follow-Up Study (LEGACY). Journal of the American College of Cardiology. 2015 May;65(20):2159–69.

“Dr. Google” Misses the Mark Most of the Time


In the age of the Internet, all too often we seek the medical opinion of “Dr. Google” prior to obtaining a medical evaluation and treatment recommendations. Sometimes, “Dr. Google” can accurately predict the cause of your problem; but more often than not, its algorithm formula misses the mark. In fact, the Pew Research Center’s Internet and American Life Project found that 39% of all Internet searches are related to medical topics or conditions. Of those searches, 82% of the medical information was gathered from either Google, Bing, or Yahoo, whereas only 13% of the medical information was gathered from an actual medical website like the Hughston Health Alert or WebMD. Furthermore, the Pew Research Center found that only 46% of all people who decided that they had a medical problem actually sought the opinion of a medical professional. Meanwhile, another 38% of respondents initially self-diagnosed and self-administered the treatment “Dr. Google” suggested. Of the 46% of people who ended up going to the doctor’s office for evaluation, only 41% of them found that their Internet diagnosis was correct.


With this information in mind, how can the doctor-patient visit be optimized? Upon intake (with the doctor’s assistant) for your appointment, reveal to the assistant your beliefs about what your Internet research has concluded. It’s your doctor’s job to listen. Once you have revealed your beliefs…sit back, relax, and learn what your doctor’s years of medical training and experience can teach you. The reality is almost all medical conditions are “cause and effect” scenarios. Diagnosing the “effect,” or confirming the reason you are here is the easy part. Determining the “cause” of why you acquired this “effect” is what you really want to know. This breadth of knowledge is power.


It helps if you can get answers and take ownership of these questions:

What is it?

What’s the source?

Why did it happen?

What should I do now?

Why would I decide for or against surgical treatment?


All this information undoubtedly will be a lot to take in. It is also a lot for the doctor to get through. As such, inquire if there are summary handouts for you to review. Lastly, ask your doctor which websites he or she feels are the most reliable sources to learn more about your medical condition. Talk to your doctor because “Dr. Google” gets it wrong most of the time.


Author: Marc A. Tressler, DO | Hughston Clinic Orthopaedics, Hendersonville, TN

Brachial Plexus: Traumatic Nerve Injuries

The brachial plexus are nerves that conduct signals to the shoulder, elbow, and hand muscles and provide feeling in the arm. If these nerves become injured you can lose function, sensation, and experience pain. Some injuries to the brachial plexus are minor and brief, while others are severe and can cause permanent disability. These injuries often occur after a traumatic event, such as a sports injury, an automobile accident, or from complications at birth.

Brachial plexus injuries involve the C5, C6, C7, C8, and T1 nerves that originate from the spinal cord in the neck. As these nerves leave the neck, they form the brachial plexus, which weaves together then branches as they pass under the clavicle (collarbone) toward the shoulder. Depending on the extent of the injury and which nerve is damaged, brachial plexus injuries are sometimes called Erb’s palsy, Klumpke palsy, Parsonage-Turner syndrome (brachial plexus neuritis), and burners and stingers. Most brachial plexus injuries are minor and you will recover within a few weeks with limited treatment; however, other injuries can require rehabilitation or surgery and take longer to heal.


Often, brachial plexus injuries occur during high-speed automobile accidents, blunt trauma from a fall, or from the violence of a stab or gunshot wound. Difficult births are a major cause of brachial plexus nerve injuries in newborns. The nerve injuries can also result from medical conditions such as inflammation, compression from a growth or tumor, and nerve disease.

The damage occurs when 1 or more nerves are pulled, stretched, compressed, or torn. The nerve injury can be an avulsion (pulled away from the spinal cord), a stretch (pulled but not torn), or a rupture (stretched with a partial or complete tear). Often, the nerves closer to the neck are damaged when the shoulder is forced down and the nerves closer to the armpit are more likely damaged when your arm is forced upward or above your head. In addition, athletes in contact sports can sustain transient brachial plexus injuries known as “burners and stingers” after sustaining a blow to the neck and shoulder girdle region. The injury occurs when the arm is forcibly pulled or stretched downward and the head is pushed to the opposite side. Interestingly, brachial plexus insult can also occur in an idiopathic (unknown cause) fashion after inflammation of the nerves.


For most brachial plexus injuries, only one side is usually affected and depending on the severity and location, the signs and symptoms vary. For example, the minor damage caused by a burner or stinger can produce an electric shock or burning sensation shooting down the arm and numbness and weakness in the limb. The symptoms can last a few seconds or they can last for days. Traumatic brachial plexus injuries can present with partial or complete motor and sensory paralysis of the arm, shooting pains in the affected arm and an inability to use all or selected muscles on the affected side. These injuries can be transient and slowly resolve over time or can persist for longer periods leading to permanent damage. If you experience a serious injury, such as an avulsion, you may become unable to use certain muscles in your shoulder, arm, or hand. You may experience severe pain or lose feeling and the ability to move the limb. Acute injuries to the brachial plexus often warrant close follow-up with a medical professional.

You should seek medical advice and treatment if a brachial plexus injury is suspected, especially when symptoms persist without improvement. Additionally, you should see a doctor if you have recurrent burners and stingers, weakness in your hand or arm, or experience neck pain.

Screening and diagnosis

A thorough health history and physical exam are of paramount importance in screening patients for potential brachial plexus injuries. Your physician may first order chest, spine, or shoulder x-rays to rule out a fracture or dislocation that can cause entrapment (compression of the nerve) of the brachial plexus. Performing a computerized tomography with myelography (a CT scan using dye) a few weeks after the initial injury is the current gold standard to identify the nerve injury level. Other imaging modalities that can be useful include magnetic resonance imaging (MRI), electromyography (EMG), nerve conduction velocity (NCV), and other nerve studies based on the discretion of the healthcare provider. If your physician suspects an infectious cause, he or she will include laboratory work in the screening process.


The mainstay treatment for brachial plexus injuries remains nonsurgical management with close observation for symptom resolution. The physician conducts frequent and thorough exams over the first 3 to 6 months and performs additional testing as needed to evaluate the recovery. Partial brachial plexus injuries with a halt in neurologic resolution can require surgery. If your physician suspects an inflammatory process, a course of pain control, physical therapy, and oral corticosteroids may be necessary.

Patients with open injuries, progressive neurologic deficits, and penetrating injuries such as gunshot wounds, often require immediate surgical treatment. For patients with a total plexus injury, surgery will likely take place around 4 to 6 weeks after the initial injury. New advances in nerve surgery are helping to restore movement and function in the shoulder, elbow, and hand, which once was impossible. There are many surgical techniques available depending on the specific injury encountered. Some of these include direct nerve repair, nerve grafting, nerve transfers, muscle or tendon (tissue connecting muscle to bone) transfers, osteotomies (bone surgery), and arthrodesis (fusion of a joint). Reconstruction procedures can take up to 3 years before full recovery occurs, especially since nerve regeneration occurs at a slow rate of approximately 1 mm/day. When comparing injuries of the upper (C5, C6) and lower (C8, T1) brachial plexus, the upper plexus tend to have better outcomes as hand function remains preserved.

Be patient

Nerves heal and regenerate slowly, so you must be patient. Your doctor may prescribe a rehabilitation program to follow to keep your muscles strong and healthy while the nerve heals. Outcomes after sustaining brachial plexus injuries are dependent on the extent and level of your injury. However, given enough time, many brachial plexus injuries heal without lasting damage.

Author: Devin W. Collins, DO

Reprinted with permission from the Hughston Health Alert, Volume 30, Number 4, Fall 2018.