Back Pain in Triathletes, Herniated Discs, Spondylolisthesis

Support comes in many packages, some sane, some.......

Low Back Pain

Anatomy

Description

Cause

Symptoms

Tests and Diagnosis

Treatment

Prevention

Almost everyone will experience low back pain at some point in their lives. This pain can vary from mild to severe. It can be short-lived or long-lasting. However it happens, low back pain can make many everyday activities difficult to do.

Anatomy

Understanding your spine and how it works can help you understand why you have low back pain.

Your spine is made up of small bones, called vertebrae, which are stacked on top of one another. Muscles, ligaments, nerves, and intervertebral disks are additional parts of your spine.

Vertebrae

Parts of the lumbar spine.

These bones connect to create a canal that protects the spinal cord. The spinal column is made up of three sections that create three natural curves in your back: the curves of the neck area (cervical), chest area (thoracic), and lower back (lumbar). The lower section of your spine (sacrum and coccyx) is made up of vertebrae that are fused together.

Five lumbar vertebrae connect the upper spine to the pelvis.

Spinal Cord and Nerves

These "electrical cables" travel through the spinal canal carrying messages between your brain and muscles. Nerves branch out from the spinal cord through openings in the vertebrae.

Muscles and Ligaments

These provide support and stability for your spine and upper body. Strong ligaments connect your vertebrae and help keep the spinal column in position.

Facet Joints

Between vertebrae are small joints that help your spine move.

Intervertebral Disks

Intervertebral disks sit in between the vertebrae.

When you walk or run, the disks act as shock absorbers and prevent the vertebrae from bumping against one another. They work with your facet joints to help your spine move, twist, and bend.
Intervertebral disks are flat and round, and about a half inch thick. They are made up of two components.
Annulus fibrosus. This is the tough, flexible outer ring of the disk. It helps connect to the vertebrae.
Nucleus pulposus. This is the soft, jelly-like center of the annulus fibrosus. It gives the disk its shock-absorbing capabilities.

Healthy intervertebral disk (cross-section view).

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Description

Back pain is different from one person to the next. The pain can have a slow onset or come on suddenly. The pain may be intermittent or constant. In most cases, back pain resolves on its own within a few weeks.

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Cause

Lumbar ligament tear.

There are many causes of low back pain. It sometimes occurs after a specific movement such as lifting or bending. Just getting older also plays a role in many back conditions.

As we age, our spines age with us. Aging causes degenerative changes in the spine. These changes can start in our 30s — or even younger — and can make us prone to back pain, especially if we overdo our activities.

These aging changes, however, do not keep most people from leading productive, and generally, pain-free lives. We have all seen the 70-year-old marathon runner who, without a doubt, has degenerative changes in her back!

Over-activity

One of the more common causes of low back pain is muscle soreness from over-activity. Muscles and ligament fibers can be overstretched or injured.

This is often brought about by that first softball or golf game of the season, or too much yard work or snow shoveling in one day. We are all familiar with this "stiffness" and soreness in the low back — and other areas of the body — that usually goes away within a few days.

Disk Injury

Some people develop low back pain that does not go away within days. This may mean there is an injury to a disk.

Disk tear. Small tears to the outer part of the disk (annulus) sometimes occur with aging. Some people with disk tears have no pain at all. Others can have pain that lasts for weeks, months, or even longer. A small number of people may develop constant pain that lasts for years and is quite disabling. Why some people have pain and others do not is not well understood.
Disk herniation. Another common type of disk injury is a "slipped" or herniated disc.

Herniated disk.

A disk herniates when its jelly-like center (nucleus) pushes against its outer ring (annulus). If the disk is very worn or injured, the nucleus may squeeze all the way through. When the herniated disk bulges out toward the spinal canal, it puts pressure on the sensitive spinal nerves, causing pain.
Because a herniated disk in the low back often puts pressure on the nerve root leading to the leg and foot, pain often occurs in the buttock and down the leg. This is sciatica.
A herniated disk often occurs with lifting, pulling, bending, or twisting movements.

Disk degeneration.

Disk Degeneration

With age, intevertebral disks begin to wear away and shrink. In some cases, they may collapse completely and cause the facet joints in the vertebrae to rub against one another. Pain and stiffness result.

This "wear and tear" on the facet joints is referred to as osteoarthritis. It can lead to further back problems, including spinal stenosis.

Spondylolisthesis.

Degenerative Spondylolisthesis

(Spon-dee-low-lis-THEE-sis). Changes from aging and general wear and tear make it hard for your joints and ligaments to keep your spine in the proper position. The vertebrae move more than they should, and one vertebra can slide forward on top of another. If too much slippage occurs, the bones may begin to press on the spinal nerves.

Spinal Stenosis

Spinal stenosis occurs when the space around the spinal cord narrows and puts pressure on the cord and spinal nerves.

Spinal stenosis.

When intervertebral disks collapse and osteoarthritis develops, your body may respond by growing new bone in your facet joints to help support the vertebrae. Over time, this bone overgrowth - called spurs - can lead to a narrowing of the spinal canal. Osteoarthritis can also cause the ligaments that connect vertebrae to thicken, which can narrow the spinal canal.

Scoliosis

This is an abnormal curve of the spine that may develop in children, most often during their teenage years. It also may develop in older patients who have arthritis. This spinal deformity may cause back pain and possibly leg symptoms, if pressure on the nerves is involved.

Additional Causes

There are other causes of back pain, some of which can be serious. If you have vascular or arterial disease, a history of cancer, or pain that is always there despite your activity level or position, you should consult your primary care doctor.

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Symptoms

Back pain varies. It may be sharp or stabbing. It can be dull, achy, or feel like a "charley horse" type cramp. The type of pain you have will depend on the underlying cause of your back pain.

Most people find that reclining or lying down will improve low back pain, no matter the underlying cause.

People with low back pain may experience some of the following:

• Back pain may be worse with bending and lifting.
• Sitting may worsen pain.
• Standing and walking may worsen pain
• Back pain comes and goes, and often follows an up and down course with good days and bad days.
• Pain may extend from the back into the buttock or outer hip area, but not down the leg.
• Sciatica is common with a herniated disk. This includes buttock and leg pain, and even numbness, tingling or weakness that goes down to the foot. It is possible to have sciatica without back pain.

Regardless of your age or symptoms, if your back pain does not get better within a few weeks, or is associated with fever, chills, or unexpected weight loss, you should call your doctor.

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Tests and Diagnosis

Medical History and Physical Examination

After discussing your symptoms and medical history, your doctor will examine your back. This will include looking at your back and pushing on different areas to see if it hurts. Your doctor may have you bend forward, backward, and side to side to look for limitations or pain.

Your doctor may measure the nerve function in your legs. This includes checking your reflexes at your knees and ankles, as well as strength testing and sensation testing. This might tell your doctor if the nerves are seriously affected.

Imaging Tests

Other tests which may help your doctor confirm your diagnosis include:

X-rays. Although they only visualize bones, simple X-rays can help determine if you have the most obvious causes of back pain. It will show broken bones, aging changes, curves, or deformities. X-rays do not show disks, muscles, or nerves.
Magnetic resonance imaging (MRI). This study can create better images of soft tissues, such as muscles, nerves, and spinal disks. Conditions such as a herniated disk or an infection are more visible in an MRI scan.
Computerized axial tomography (CAT) scans. If your doctor suspects a bone problem, he or she may suggest a CAT scan. This study is like a three-dimensional X-ray and focuses on the bones.
Bone scan. A bone scan may be suggested if your doctor needs more information to evaluate your pain and to make sure that the pain is not from a rare problem like cancer or infection.
Bone density test. If osteoporosis is a concern, your doctor may order a bone density test. Osteoporosis weakens bone and makes it more likely to break. Osteoporosis by itself should not cause back pain, but spinal fractures due to osteoporosis can.

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Treatment

In general, treatment for low back pain falls into one of three categories: medications, physical medicine, and surgery.

Nonsurgical Treatment

Medications. Several medications may be used to help relieve your pain.

• Aspirin or acetaminophen can relieve pain with few side effects.
• Non-steroidal anti-inflammatory medicines like ibuprofen and naproxen reduce pain and swelling.
• Narcotic pain medications, such as codeine or morphine, may help.
• Steroids, taken either orally or injected into your spine, deliver a high dose of anti-inflammatory medicine.

Physical medicine. Low back pain can be disabling. Medications and therapeutic treatments combined often relieve pain enough for you to do all the things you want to do.

• Physical therapy can include passive modalities such as heat, ice, massage, ultrasound, and electrical stimulation. Active therapy consists of stretching, weight lifting, and cardiovascular exercises. Exercising to restore motion and strength to your lower back can be very helpful in relieving pain.
• Braces are often used. The most common brace is a corset-type that can be wrapped around the back and stomach. Braces are not always helpful, but some people report feeling more comfortable and stable while wearing them.
• Chiropractic or manipulation therapy is provided in many different forms. Some patients have relief from low back pain with these treatments.
• Traction is often used, but without scientific evidence for effectiveness.
• Other exercise-based programs, such as Pilates or yoga are helpful for some patients.

Surgical Treatment

Surgery for low back pain should only be considered when nonsurgical treatment options have been tried and have failed. It is best to try nonsurgical options for 6 months to a year before considering surgery.

In addition, surgery should only be considered if you doctor can pinpoint the source of your pain.
Surgery is not a last resort treatment option "when all else fails." Some patients are not candidates for surgery, even though they have significant pain and other treatments have not worked. Some types of chronic low back pain simply can not be treated with surgery.
Spinal Fusion. This is essentially a "welding" process. The basic idea is to fuse together the painful vertebrae so that they heal into a single, solid bone.
Spinal fusion eliminates motion between vertebral segments. It is an option when motion is the source of pain. For example, your doctor may recommend spinal fusion if you have spinal instability, a bad curvature (scoliosis), or severe degeneration of one or more of your disks. The theory is if the painful spine segments do not move, they should not hurt.
Fusion of the vertebrae in the lower back has been performed for decades. A variety of surgical techniques have evolved. In most cases, a bone graft is used to fuse the vertebrae. Screws, rods, or a "cage" are used to keep your spine stable while the bone graft heals.
The surgery can be done through your abdomen, your side, your back, or a combination of these. There is even a procedure that is done through a small opening next to your tailbone. No one procedure has been proven better than another.
The results of spinal fusion for low back pain vary. It can be very effective at eliminating pain, not work at all, and everything in between. Full recovery can take more than a year.
Disc Replacement. This procedure involves removing the disk and replacing it with artificial parts, similar to replacements of the hip or knee.
The goal of disk replacement is to allow the spinal segment to keep some flexibility and maintain more normal motion.
The surgery is done through your abdomen, usually on the lower two disks of the spine.

Thanks to AAOS for this piece.

Tsunami Hits Kona 2011, 1 Year Later

March 11th marks the one year anniversary of the Tohuku, Japan magnitude 9.0 Earthquake.  According to Wikipedia, the World Bank labeled it the most expensive natural disaster in history with damage estimates approaching 250 billion dollars lost.  Currently,there are islands of debris floating in the Pacific headed east, some as large as 70 miles.  The photo below made it's way around the Internet as the tsunami hit Hawaii.  The photo is of normally tranquil Kailua Bay, and we should be able to see the Kailua- Kona pier to the right.  The pier serves many functions during the race as the transition area, location of the medical tent, etc.  However, the bay now filled with water, has submerged the entire structure save the light poles and green tents.  Looks like they were lucky to get all the boats somewhere else.  Compare this to the following pair of pictures I took during race week showing what's supposed to be seen near the green tents.

The piping in the photo above will eventually have all 1800 blue swim to bike bags (remember, blue bike red run?)  The view at the right is from the opposite side of the pier from the original water filled image after bike inspection and check in on Friday evening before the race.

There was considerable water damage to the bay front stores and the Ironman Headquarters Hotel,  King Kamehameha's Kona Beach Hotel. But, in the 7 subsequent months...and a significant financial outlay I'm sure, everything looked terrific for the race.  When walking through the lobby of the hotel, the Ironman Store and Race office, all appeared fresh, clean and attractive.

The point of this report is to remind us that race participation is a privilege, not a right.  This is a time of year where we are all planning our racing season and just because we put it on our calendar, there may be a host of reasons why we may never toe the start line come race date.  Yes, including tsunamis.

Just make sure that a preventable injury isn't one of them.


                                                          

Clavicle Fractures, Injections For Carpal Tunnel Syndrome

"Running as fast as they can, Ironman lives again."

                                                                                                    Black Sabbath

A certain Mr. L. Armstrong following surgical repair of his clavicle fracture.

Clavicle Fractures

How frequently, while watching a televised bike race and a big crash occurs, do we hear the announcer observe one or more of those who've gone down as "Holding his arm in the broken collarbone position?"  Many names quickly come to mind in addition to Armstrong.  Frank Schleck, brother of 2010 Tour de France Winner Andy Schleck, Bradley Wiggins, and Tyler Hamilton just to name a few.
When interviewed, former national caliber swimmer (and budding triathlete) Phd candidate Cortney Crane noted how common these injuries and subsequent repair are. "We've known for years that the collarbone was the most commonly fractured bone in children but I was initially surprised to learn that statistic includes young adults."  Crane's main doctorate research emphasis is corrosion, critical to the orthopedic world given the various metals we implant for joint replacement, fracture fixation, etc.  Imagine the consequence if the total hip replacement in your mom began to rust! 

For many years, the non-operative approach to clavicle fractures was nearly always taken as the research base was lacking in designing satisfactory fixation methods and appropriate plate selection.  This led to some less than satisfactory outcomes, disability and dissatisfied patients.  Currently working in research applicable to naval vessel design, one of corrosion expert Crane's favorite quotes comes from B.F. Brown, "Successful prolonged corrosion-free service of stainless steel in seawater requires sophisticated corrosion engineering, or enormous good fortune."  "The same is true for the human body," adds Crane.

Let's get into some specifics.

Anatomy

The collarbone (clavicle) is located between the ribcage (sternum) and the shoulder blade (scapula), and it connects the arm to the body.
The clavicle lies above several important nerves and blood vessels. However, these vital structures are rarely injured when the clavicle breaks, even though the bone ends can shift when they are fractured.

The clavicle is part of your shoulder and connects your ribcage to your arm.

Reproduced from The Body Almanac. (c) American Academy of Orthopaedic Surgeons, 2003.

Description

The clavicle is a long bone and most breaks occur in the middle of it. Occasionally, the bone will break where it attaches at the ribcage or shoulder blade.

In this drawing, the fracture is closer to where the clavicle attaches to the shoulder blade.

(Reproduced from Nuber GW, Bowen MK: Acromioclavicular joint injuries and distal clavicle fractures. J Am Acad Orthop Surg 1997;5: 11-18.)

Cause

Clavicle fractures are often caused by a direct blow to the shoulder. This can happen during a fall onto the shoulder or a car collision. A fall onto an outstretched arm can also cause a clavicle fracture. In babies, these fractures can occur during the passage through the birth canal.

Symptoms

Clavicle fractures can be very painful and may make it hard to move your arm. Additional symptoms include:

• Sagging shoulder (down and forward)
• Inability to lift the arm because of pain
• A grinding sensation if an attempt is made to raise the arm
• A deformity or "bump" over the break
• Bruising, swelling, and/or tenderness over the collarbone

Doctor Examination

During the evaluation, your doctor will ask questions about the injury and how it occurred. After discussing the injury and your symptoms, your doctor will examine your shoulder.
There is usually an obvious deformity, or "bump," at the fracture site. Gentle pressure over the break will bring about pain. Although a fragment of bone rarely breaks through the skin, it may push the skin into a "tent" formation.
Your doctor will carefully examine your shoulder to make sure that no nerves or blood vessels were damaged.
In order to pinpoint the location and severity of the break, your doctor will order an x-ray. X-rays of the entire shoulder will often be done to check for additional injuries. If other bones are broken, your doctor may order a computed tomography (CT or CAT) scan to see the fractures in better detail.

This x-ray shows a fracture in the middle of the clavicle. Note how far out of place the broken ends are.

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Nonsurgical Treatment

If the broken ends of the bones have not shifted out of place and line up correctly, you may not need surgery. Broken collarbones can heal without surgery.

Arm Support

A simple arm sling or figure-of-eight wrap is usually used for comfort immediately after the break. These are worn to support your arm and help keep it in position while it heals.

Medication

Pain medication, including acetaminophen, can help relieve pain as the fracture heals.

Physical Therapy

While you are wearing the sling, you will likely lose muscle strength in your shoulder. Once your bone begins to heal, the pain will decrease and your doctor may start gentle shoulder and elbow exercises. These exercises will help prevent stiffness and weakness. More strenuous exercises can gradually be started once the fracture is completely healed.

Doctor Follow-Up

You will need to see your doctor regularly until your fracture heals. He or she will examine you and take x-rays to make sure the bone is healing in good position. After the bone has healed, you will be able to gradually return to your normal activities.

Complications

The fracture can move out of place before it heals. It is important to follow up with your doctor as scheduled to make sure the bone stays in position.

If the fracture fragments do move out of place and the bones heal in that position, it is called a "malunion." Treatment for this is determined by how far out of place the bones are and how much this affects your arm movement.
A large bump over the fracture site may develop as the fracture heals. This usually gets smaller over time, but a small bump may remain permanently.

Surgical Treatment

If your bones are out of place (displaced), your doctor may recommend surgery. Surgery can align the bones exactly and hold them in good position while they heal. This can improve shoulder strength when you have recovered.

Plates and Screws

During this operation, the bone fragments are first repositioned into their normal alignment, and then held in place with special screws and/or by attaching metal plates to the outer surface of the bone.

After surgery, you may notice a small patch of numb skin below the incision. This numbness will become less noticeable with time. Because there is not a lot of fat over the collarbone, you may be able to feel the plate through your skin.
Plates and screws are usually not removed after the bone has healed, unless they are causing discomfort. Problems with the hardware are not common, but sometimes, seatbelts and backpacks can irritate the collarbone area. If this happens, the hardware can be removed after the fracture has healed.

(A) The clavicle is broken in more than one place and the fragments are severely out of alignment. (B) The fractured pieces are held in place by a combination of plates and screws.

Reproduced with permission from Bahk MS, Kuhn JE, Galatz LM, Connor PM, Williams GR: Acromioclavicular and sternoclavicular injuries and clavicular, glenoid, and scapular fractures. Instructional Course Lectures, Vol. 59. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010, p 215.

Pins

Pins are also used to hold the fracture in good position after the bone ends have been put back in place. The incisions for pin placement are usually smaller than those used for plates. Pins often irritate the skin where they have been inserted and are usually removed once the fracture has healed.

Rehabilitation

Specific exercises will help restore movement and strengthen your shoulder. Your doctor may provide you with a home therapy plan or suggest that you work with a physical therapist.

Therapy programs typically start with gentle motion exercises. Your doctor will gradually add strengthening exercises to your program as your fracture heals.
Although it is a slow process, following your physical therapy plan is an important factor in returning to all the activities you enjoy.

Surgical Complications

People who use any kind of tobacco product, have diabetes, or are elderly are at a higher risk for complications during and after surgery. They are also more likely to have problems with wound and bone healing. Be sure to talk with your doctor about the risks and benefits of surgery for your clavicle fracture.

There are risks associated with any surgery, including:

• Infection
• Bleeding
• Pain
• Blood clots in your leg
• Damage to blood vessels or nerves
• Nausea

The risks specific to surgery for collarbone fractures include:

• Difficulty with bone healing
• Lung injury
• Hardware irritation

Outcome

Whether your treatment involves surgery or not, it can take several months for your collarbone to heal. It may take longer in diabetics or people who smoke or chew tobacco.
Most people return to regular activities within 3 months of their injury. Your doctor will tell you when your injury is stable enough to do so. Returning to regular activities or lifting with your arm before your doctor advises may cause your fracture fragments to move or your hardware to break. This may require you to start your treatment from the beginning.
Once your fracture has completely healed, you can safely return to sports activities.

Courtesy AAOS, Ortho info
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Injections for Carpal Tunnel

An interesting article in HAND discussed the potential for using cortico-steroid injections ("cortisone") to treat the very common diagnosis of Carpal Tunnel syndrome.  Triathletes very commonly complain of numbness in their hands during and, for a short time following. bike rides.  As long as the duration of symptoms is short, invasive treatment is probably not indicated.  But, according to Paul Jenkins, MD, when the diagnosis of CTS is made and testing is positive, "steroid injection is an appropriate treatment in carefully selected patients."  The highest relapse was seen in females, diabetics and those with neurophysiological confirmation of the diagnosis.

I have injected many patients with carpal tunnel and it's nice to have this as back up.

Distracted Driving, Cyclist Killed, Pass It On

 "The best car safety device is a rear-view mirror with a cop in it."   Dudley Moore

You never really learn to swear until you learn to drive.  ~Author Unknown

Distracted Driving

I wrote a while back about a local cyclist who was killed by a motor vehicle.  The gent's family had a vacation home at a local ski resort called Wintergreen.  As you might imagine, it's quite mountainous and provides not only great climbs for local riders but is the home of the state hill climb championship every Spring.  It seems that this cyclist was going on a pleasure ride to one of our local colleges to surprise his son.  Sadly, he didn't even make it half way before being struck by a youthful driver. He wasn't identified for quite some time.  The newspaper article below tells the sad tale in it's entirety:

Bicyclist Killed By Car ID'd Posted 2009-08-27

Father Of JMU Frosh Was On Way To Surprise Son

By Pete DeLea and Jeremy Hunt

HARRISONBURG - Joseph V. Mirenda left Wintergreen on his bicycle Tuesday morning bound for Harrisonburg.

He was going to stop by and surprise his son, a freshman at James Madison University, but Mirenda didn't make it to the end of the 50-mile trek.

On Wednesday, police identified Mirenda, 49, of Virginia Beach, as the victim in Tuesday's fatal crash in Rockingham County.

Around 10:30 a.m. Tuesday, emergency personnel were dispatched to Port Republic Road, about a mile east of Cross Keys Road, where they found the cyclist lying in the ditch.

Mirenda was riding west on Port Republic Road when he was struck by a westbound 2000 Ford Taurus driven by Jessica Chandler, according to the Virginia State Police.

No charges were filed as of press time Wednesday, but investigators obtained a search warrant for the driver's cell phone records. (She would eventually be charged with reckless driving.)

First Sgt. Bryan Hutcheson with the state police said investigators will be looking into whether Chandler, 22, of Port Republic, was talking on her cell phone or texting in the moments before the crash occurred.

"We don't want to leave any stones unturned," Hutcheson said.

Although the Daily-News Record has confirmed a search warrant was issued in the case, the document remains sealed by court order at the Rockingham County Circuit Court.

Meanwhile, investigators are still trying to piece together exactly how the crash happened.

They had spent Tuesday and most of Wednesday trying to determine the name of the cyclist, who had no identification on him.

State police caught a break in the investigation Wednesday afternoon when they received a call from the Wintergreen Police Department.

A Virginia Beach woman contacted the department and said she couldn't reach her husband, who was staying at the family's home in Wintergreen, Hutcheson explained.

The wife mentioned he may have gone on a bicycle ride.

Wintergreen officers recalled seeing a man riding a bicycle there Tuesday morning, and he matched the description of the then-unidentified cyclist killed in Tuesday's crash.

The state police and Wintergreen officers then confirmed the man's identity based on an inscription on a wedding band he was wearing.

It said "Frauke & Joe" with the date 9-24-88 on it.

Contact Pete DeLea at 574-6278 or pdelea@dnronline.com
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Fitness expert Lauren Record (below) teaches regularly on issues of safety. "You can't do the work out if you don't get to the work out."  Cycling is dangerous business as you well know.  And if you don't know, you should.  In our bike group alone, while riding a couple weeks ago, Superbowl Sunday, we remembered a Superbowl 4 years go where two of us collided resulting in a crash, head to the asphalt and loss of consciousness for one rider!

About ten years ago, while mountain biking on SB Sunday, one of us crashed and broke his neck! Fortunately there was no neurologic component and he was part of today's mountain bike ride.  

Even with this history, some of us still flaunt danger by riding two abreast making cars go around them (professionals both), some of us ride with no hands adjusting who knows what on their clothing even with cars behind the group (Lawyer and respected HS FB Coach), you know what I'm talking about.  Maybe you can be the good example and convince others to follow your lead. Maybe we should all put mirrors on our bikes and put a cop in them.

Photo #2, Nick Strocchia

Knee Replacements (Athletes, Too) Becoming More Frequent

"Not having a goal is more to be feared than not reaching one"
                                                  Chinese Proverb

Is this any truer than in triathlon where an entire year's work is frequently pointed at a single event.
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"Sure, I know several triathletes besides me who've had their knees replaced."    Chuck Graziano, Training Bible Triathlon Coach

4.5 Million Americans Living with Total Knee Replacements

TKR surgeries have more than doubled over past decade

San Francisco, CA

New research presented at the 2012 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS) found that more than 4.5 million Americans are living with a total knee replacement (TKR), as the number of TKR surgeries has more than doubled over the past decade, with the sharpest rise among younger patients. Osteoarthritis continues to be the primary reason for TKR.

Investigators used a computer model; U.S. Census data; information from the National Health Interview Survey, the Multicenter Osteoarthritis Study and the Osteoarthritis Initiative; and other national data and literature to determine the number of Americans living with TKR.

The study, funded by the U.S. National Institutes of Health’s National Institute of Arthritis and Musculoskeletal and Skin Diseases, found that more than 4.5 million Americans are currently living with at least one TKR. This represents 4.7 percent of the population age 50 years or older – higher than the national rates for congestive heart failure and rheumatoid arthritis. In addition:

• The prevalence of osteoarthritis is higher in women and so is TKR: 5.3 percent, compared to 4.1 percent in men.
• 
  
• Among persons age 60 to 69, 4.1 percent of men and 4.8 percent of women have a TKR; among those ages 70 to 79, 7.1 percent of men and 8.2 percent of women have had at least one knee replaced.

• Ten percent of Americans age 80 and older are living with a TKR.

“The number of total knee replacements is growing drastically,” said Elena Losina, PhD, lead investigator and co-director of Orthopedic and Arthritis Center for Outcomes Research at Brigham and Women’s Hospital in Boston, Mass. “We now have a lot of people living with TKR,” which may lead to substantial increases in the likelihood of revisions and complications, especially in younger patients.

Stephen Arata, PhD, at the University of Virginia preaches patience. "There are many with osteoarthritis of the knees that can put off something as complex as joint replacement if they simply step back for a moment and look at what they can do, not what they can't."  He thinks more would delay having the surgery if they could simply look at the picture both today and well into the future.  "Many of the long term questions have yet to be answered." One definition of patience is "the capacity to endure waiting, or provocation without becoming angry or upset."  Arata's teaching are spot on for 2012.

The findings above may aide in anticipating the future challenges related to TKR, including capacity for follow-up care, health care costs, and treatment access.  Hopefully, you can delay a procedure such as this.

The first triathlete I met with a total knee in place was during the marathon portion of the 1982 Ironman.  (In those days it was the Bud Light Ironman Triathlon World Championship.  There were 969 competitors in the race program, Scott Tinley wearing #1.  Guess what they served at the aid stations.)  Not knowing any better, I was run/walking from 13 miles on in, with two other equally spent athletes. If you've never done it, there's more time than you realize to talk about anything and everything.  For some reason, the subject of Vietnam came up and one of my walking mates admitted to a gun shot wound to the knee with subsequent replacement.  I was flabbergasted.  I'd been taught that joint replacement was for the bocci set at the nursing home and here's this guy next to me with one...who's probably going to beat me!  Well, maybe.

Dr. Arata carrying  the final rock in local cross country "mud race."

Your Medical Help At The Races, The Medical Tent

"The road is long, with many a winding turn."  The Hollies

The Medical Tent - what would we do without it?

Shorter Warm-Ups  It wasn't that long ago, especially for running work outs, that prior to hitting the asphalt, a good bit of stretching, static stretching, was the norm.  Also, in races like the time trial day of a multi day stage race, extended time on the trainer would  precede the event.  I can remember HS Cross Country races where the warm-up/course check was almost the same distance as the race. 

I've seen several pieces in the past couple years, including famed running coach Bobby McGee where the old hurdler's stretch and others like it may not only not be necessary but may indeed inhibit progress rather than help.  Donna Krupa of the American Physiological Society writes that while the benefits of warming up, increasing muscle temperature, accelerating oxygen uptake, etc. will enhance performance, that researchers at the Human Performance Lab in Calgary, Alberta have found that "less is more."  The researchers go on to point out that "If warm-up results in fatigue of an athlete....what impact would it have on (multiple) performances required on the same day?"  They imply a negative impact.

I know that we've adopted McGee's techniques and would strongly suggest that you at least look at this 3 minute video from D3 Multisport.  http://www.d3multisport.com/video.php?video=Run-warmup-drills .  I'm told that McGee has a video out that compliments this and if you've seen it, a comment below would be helpful to other readers.

Unplanned "Finish Line" for some in Kona, 2011

Race Day Medicine

We frequently oversimplify the role of the medical staff into caring for dehydration issues. In point of fact they have to be prepared for almost any medical or trauma situation, both expected and unexpected.  This is not always appreciated by the occasional volunteer who's there for the t-shirt.  Enter the bike crash victim with half a dozen broken ribs and a pneumothorax (collapsed lung), short of breath and bleeding, and a sense of reality returns.  Or the athlete with a closed head injury in need of help - stat!  The medical team that works the tent is much like the Emergency Department back home at you local hospital.  From heart attacks and hip fractures, to sunburn and over exertion, they are able to provide care.  Resolving the episode may not be possible on this level but making an accurate field diagnosis and stabilizing the patient for potential transfer to the local medical center are key.  This takes a group of individuals who work at a fast pace, can get a great deal of meaning from a limited amount of information, and even in pressure filled situations where life and death are on the line, maintain their composure, remembering who's the patient.  

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Local distance runner Nadia Badr reminds us that it wasn't that long ago that not only the sick or injured were seen in the med tent.  So were the impatient (not to be confused with inpatient, like in the hospital.) She has friends, who, upon crossing the finish line in an endurance race, would saunter over to the medical area, not that they were in any particular distress, to have an IV stuck in their arm for instant re hydration.  "It's time for my IV," they'd calmly say. This is to be contrasted with the triathlete who, like so many others, has a GI system that's just shut down, will accept no more fluids, but is in desperate need of that IV bag full of fluid and electrolytes simply to maintain blood pressure. Thankfully, screening for med tent entry has changed  significantly and those other folks are encouraged to "Keep drinking." (I've been to a few post-race parties where none of us needed to be told to keep drinking! Hooyah!)

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Dislocated Shoulders, Muscle Mass

“American triathletes work way too hard on easy days ….and way too easy on hard days.”  American Olympian Ryan Bolton


The images below come from a study published in the Physician and Sports Medicine that took detailed measurements of 40 masters athletes between the ages of 40 and 81, and found a surprising lack of age-related muscle loss. These are MRI cross sectional views of the thigh of three different people.  The dark shade represents muscle, the light shade fat.

This study contradicts the common observation that muscle mass and strength decline as a function of aging alone. Instead, these declines may signal the effect of chronic disuse rather than muscle aging.

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On the lighter side

When asked if triathlon cut into his family time, a friend noted that when he started training for Ironman, “The hardest thing was teaching my wife how to mow the grass!”

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Dislocated Shoulders

Image from Snowsphere removed here!

You know the image.  After a particularly vicious tackle, a football player emerges from the pile of humanity cradling his arm like it no longer belongs to him.  On the sidelines when the pads are removed, if he’s thin, the deformity is pretty obvious.  So is the diagnosis.  If the decision is made to attempt an on-field reduction, the athlete will have limited choices for anesthesia.  In short, there won’t be any.

Remember, a dislocated shoulder is talking about the ball and socket, the glenohumeral joint, where the term separated shoulder refers to the joint at the lateral end of the collar bone, the A/C joint.  In the athletic world, the cause is frequently a fall or forceful blow to the shoulder….like falling off of a bike or slipping on wet or snowy pavement while running.  There can be sudden, intense pain with a visible deformity.  It can be accompanied by nerve involvement in the arm, manifested by weakness or numbness in the hand, arm, or shoulder.  Occasionally some athletes will report a weak or “dead arm.” 


When the ball and socket become dislocated, the ball moves out of the socket.  This is most commonly out the front and “immediate” attention is desired.  The first question to answer is whether to try an on-field relocation or proceed with a diagnostic work up first.  Occasionally, despite presence of an experienced operator, conscious sedation or even General Anesthesia is required to accomplish this relocation.  Post reduction x-rays, immobilization and position are individualized.  Recurrence is more common at a young age and in those who are physiologically lax.  Even with a rapid replacement of the ball back into place, it can frequently go on to surgery.   Scientist Roger Reynolds reminds us that dislocations are often not simple injuries but are accompanied by a fracture of the humerus, the socket (or both) and careful examination for nerve involvement pays dividends.
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Other joints will dislocate as many of you are aware. Fingers, toes, etc. where the level of injury is not terribly great.  But should you dislocate your hip, ankle, mid-foot (Matt Schaub of the Houston Texans) etc., these can be a much more serious issue requiring surgical reconstruction.  Achieving full recovery can be challenging.

Reynolds, center, guts it out to the finish line.

Image #2, Google Images, snowsphere