Dr. Nicholas Cappello

Some 70%-80% of men (and nearly as many women) have endured a bout of moderate to severe back pain. And the problem goes well beyond pain and inconvenience; the annual cost of medical care and lost productivity is more than $50 billion. It would be encouraging to report that this investment of time and money results in recovery, but in most cases back pain will resolve as quickly without medical attention as it will with a doctor’s care, according to Harvard Men’s Health Watch.

If you have garden-variety back pain, you can probably take care of it yourself. The trick is to know what to do and to recognize those symptoms that really do call for prompt medical tests and treatments..

In the vast majority of cases, back pain is caused by a mechanical problem that can’t be pinpointed exactly. But occasional cases result from some other, more serious causes. The possibilities include infections, vascular disease, and tumors, among other things. That’s why it’s important to know the “red flag” warning signs that suggest serious problems. Among these are recent major injury, radiation of pain down a leg, pain that is constant, pain in the upper back or chest, unexplained fever or weight loss, and pain that increases at night.

About 90% of people with ordinary mechanical low back pain get over it without special therapy. But it takes time to recover. About 30% of patients are substantially improved in just a week, but another 60% take up to eight weeks to get better.

I came across a great review of Rotator Cuff Problems

Whether you’ve been relatively inactive or fairly athletic, age is the enemy of one of the most important sets of muscles in the body: the group of four known as the rotator cuff that surround the ball of the shoulder joint.

About 54% of adults older than 60 have a completely or partially torn rotator cuff, compared with just 4% of those between 40 and 60. But tears are most frequently caused by degeneration of the tendon due to age, rather than injury from sports or trauma. Studies show that tears can be managed without surgery in half of patients, mainly through physical therapy, pain medications, and avoiding activities that cause pain.

But one’s strength tends not to improve without surgery to reattach tendons to the ball of the shoulder joint. So, the question for many patients who want to have full use of their shoulder is less whether to have surgery than when and how. In a recent review in the Annals of Internal Medicine, researchers noted that patients and doctors struggle with when to stop nonoperative treatment in favor of surgery, but that repairing a tear earlier rather than later may result in better patient outcomes, earlier return to work and lower costs.

The Price of Delay

“Many patients who have a tear figure they can take six months and live with it, but left alone the tear will progress and you can get to the point where it is irreparable,” says David Altchek, a surgeon at New York’s Hospital for Special Surgery. Dr. Altchek says repairing torn rotator cuffs earlier with a new technique that uses a double row of sutures to fix tendons to bone, rather than a single row, is improving healing rates in his studies.

While some tears may never worsen or need surgery, says Ken Yamaguchi, an orthopedic surgeon at the Washington University School of Medicine in St. Louis, “the older somebody is when they get a repair, the less likely it is for the repair to heal.”

The good news is that surgery results in reduced pain and improved function in 80% to 95% of patients. And open surgery with big incisions is being replaced by new, less-invasive techniques known as mini-open and arthroscopic repair, which involve less pain and blood loss, shorter hospital stays and a generally easier rehabilitation period, according to the American Academy of Orthopedic Surgeons.

Ask Your Doctor

The academy, which recently updated its guidelines for rotator-cuff repair, doesn’t recommend for or against a specific technique for surgery. Dr. Yamaguchi, vice chairman of a working group that developed the guidelines, says there isn’t enough high-quality evidence to recommend any specific technique, a conclusion also reached by the Annals of Internal Medicine researchers. He advises that patients confer with surgeons about their options.

The most common procedure is mini-open repair, which uses a smaller incision than traditional open repair. To remove any bone spurs, a surgeon uses arthroscopic, pencil-size instruments to magnify and illuminate the structures inside the joint. Once that is completed, the surgeon repairs the rotator cuff through the small incision. But some surgeons are now performing the entire operation using the small camera-guided instruments, in what’s known as an all-arthroscopic procedure.

There are possible complications with all surgical procedures, of course. An Academy of Orthopedic Surgeons review of about 40 published studies showed that as many as 2% of patients have nerve injuries, while 1% may get an infection at the surgical site. About 6% may have a tendon re-tear, though that doesn’t mean a repeat surgery will be needed or that pain and poor function will result.

Lengthy Recovery

And as with any surgery, postoperative recovery depends largely on how well patients adhere to their physical-therapy regimens. Initially, that means being extra careful: A repair needs to be protected until the tendon heals strongly to the bone. Patients may be advised to use a sling for the first four to six weeks after surgery and to limit active use of the arm. Therapy usually starts with passive-motion exercises, then range-of-motion exercises continue during the next six to 12 weeks. It can take as long as six months after surgery to return to a functional range of motion and adequate strength.

Eric Taylor, a 62-year-old documentary filmmaker who plays sports like tennis with his right arm, says he was surprised when he began developing pain in his left shoulder. He tried to ease it by doing yoga, but after six months with no relief, he scheduled an MRI. It confirmed that a bone spur digging into a tendon had caused a tear in the left rotator cuff.

He scheduled surgery with Dr. Altchek at the Hospital for Special Surgery last June, but wishes he had acted sooner. Because he waited so long, he says, his surgery required three incisions instead of one. He was surprised at how much work was involved in rehabilitation but has been diligent about his recovery and physical therapy.

Back to playing tennis now, Mr. Taylor says, “When it comes to our own bodies, as baby boomers we’ve always been active, and we are going to stay active any way we can.”

Knee patients need patience: injuries to these joints take weeks to heal. Fraunhofer researchers have now developed a system that documents the healing process in detail. This motivates patients and at the same time helps doctors to fine-tune the course of treatment.

There’s nothing like the sheer delight of sun and snow on a skiing trip. But a momentary lapse of concentration can have nasty consequences. Taking a tumble on the slopes often causes injuries most commonly to the knee. Weeks can go by before knees regain their full function, and patients are obliged to re-learn how to walk. The time it takes for the knee to heal is directly related to how well it reacts to the chosen treatment. But how is an orthopedic doctor to evaluate the healing process? And how are patients to know what progress they are making? Currently, doctors can only perform limited function tests, whilst patients are obliged to rely on their own subjective feelings. Now researchers from the Fraunhofer Institute for Manufacturing Engineering and Automation IPA in Stuttgart have developed a system for gathering exact data on knee mobility. It shows patients as well as medical staff how the joint is doing. “It not only lets sufferers see how their healing process is coming along; it also means doctors can tell straight away whether they need to adapt the treatment,” says Dipl.-Ing. Bernhard Kleiner of Fraunhofer IPA. “This can give patients a psychological boost.” They might not feel they are getting any better, but the system highlights every little improvement in knee mobility. “And that’s very motivating,” says Kleiner.

This is how the novel approach for monitoring the treatment works: Special sensors are placed in a kind of bracket that is integrated into the bandage. These register the knee’s range of movement over a period of time to determine exactly how patients are moving their knee. A new piece of software evaluates these data and presents them in an easy-to-understand format. It sounds pretty simple but it was a tough challenge for the engineers, because such angular measurement systems have only ever been used in industry up to now. The central question was how to place the sensors onto the human body without inconveniencing the patient. The answer, researchers found, lay in using lightweight materials and miniaturizing the sensors, which fall into two categories: angular measurement systems that are based on magnetic principles; and acceleration and rate-of-rotation sensors.

Depending on the injury and treatment, the system not only records the joint’s range of movement but can also determine to what degree it rotates and what forces are acting upon it. The sensors observe movements and store data non-stop. This allows doctors to observe how the knee’s range of movement changes over time, so they can recognize trends and, where necessary, adjust the treatment. What is more, the various fittings for the sensor systems have been designed by the researchers not to restrict freedom of movement in any way, meaning patients do not even notice that their joint is being monitored.

“We would like to apply the measurement of human kinematics to other parts of the body in future,” says Kleiner, and the Fraunhofer researchers have already set their sights on the shoulder and the hips. However, these joints are even more demanding because the system will have to measure their movement about all three axes. To achieve this, engineers are coupling 3-D sensor systems with appropriate software. Visitors to the MEDTEC Europe trade show (March 22-24, 2011, Hall 6, Booth 6211) will have a chance to see the experts demonstrating how mobile joint monitoring works.

All joints have a smooth coverage coverage ,called cartilage. A good analogy is to compare your skin to this cartilage. As we age our skin looses water and starts to wrinkle, and becomes rough and this also occurs in our joint cartilage.

When the cartilage is damaged, as in osteoarthritis, rheumatoid arthritis, and other types of arthritis, the cartilage loses some of its ground substance and eventually loses fibrils and becomes thin. The surfaces of damaged cartilage become pitted and irregular and no longer allow for the smooth, gliding motion of a normal joint. For this reason, when a joint with structurally damaged cartilage moves, the patient may feel a clicking, grating, or grinding sensation. The grating or grinding, known as crepitus (creaking), can be felt when the physician is examining such a joint. Sometimes patients perceive these sensations as painful.

The cervical spine, which is the part of the spine in the neck, is a very complicated structure with two types of joints, ligaments, several muscle groups, the spinal cord within the spinal canal, the nerve roots emanating from the spinal cord, and a rich supply of blood vessels. The disc joints are between the vertebral bodies (the bones of the spine), while the facet joints are between bony structures extending to the side of the vertebral bodies. The spinal ligaments are strong tissues, made up mostly of collagen, that hold the bones and joints together.

In osteoarthritis, pressure on the nerve roots by bony spurs (osteophytes) is more common than pressure on the spinal cord. At times, however, osteophytes may form inside the spinal canal and press on the spinal cord. A disc herniation may also cause spinal cord compression.

Symptoms of spinal cord compression are neurological: pain in the base of the head, numbness, tingling, jerking motions of the extremities, and even paralysis that, at worst, could affect all four extremities (quadriplegia

Several studies have found that ankle injuries sustained in basketball are not only among the most common, they can also be the most severe, so preventing them is key to ensuring a safe and healthy season. Of critical importance is recognizing and addressing the fact that high school- and college-age men and women have entirely different risk factors for first-time ankle ligament injuries — a finding resulting from a Vermont-based study of 901 young athletes conducted by Bruce Beynnon, Ph.D., associate professor and director of research in orthopaedics and rehabilitation, and colleagues at the University of Vermont.

“Prior to conducting our study, we understood that previous ankle injury was a strong risk factor for a repeated ankle injury,” said Beynnon. “Our goal was to study the risk factors that predispose an athlete to suffering their first injury with the hope that we could use this information to develop programs that prevent athletes from ever experiencing an ankle injury in the first place.”

Ankle sprains are typically considered one of the most common injuries among athletes. To analyze ankle ligament injury risk factors, Beynnon and colleagues measured factors in 901 Vermont high school and collegiate athletes who logged a total of 50,680 “person-days” of exposure to soccer, basketball, lacrosse or field hockey over four years. In order to clearly isolate which factors put athletes at the most risk for a first ankle injury, the study did not include athletes who suffered prior ankle trauma. Only 43 (4.5 percent) athletes suffered their first ankle sprain during the study period. Risk of ankle injury was highest among female basketball athletes who are at significantly greater risk than male basketball athletes.

The research team found that the women in the study were at increased risk of suffering their first ankle injury when there is a strength imbalance in the muscles that control the side-to-side movement of the ankle. They also identified several non-modifiable risk factors, including alignment of the muscles in the front of the leg with the knee; loose ankles, which are suggestive of weak ligaments or structural problems; and equally dominate legs.

Men in the study who had undergone one or more prior surgeries to their legs were at increased risk of suffering their first injury, as were men who had decreased dorsi-flexion – the ability to point the toe toward the head – and weak muscle strength for motion when the ankle rolls away from the body. Beynnon and colleagues hypothesize that risk of injuries after surgery may be indicative of incomplete healing or a more aggressive physical style.

“Ankle trauma is not the result of bad luck,” said Beynnon. “It occurs, not randomly, but in patterns that reflect the operation of underlying causes. Our research determined the underlying causes for this debilitating injury and revealed that combinations of risk factors, which are different for men in comparison to women, are responsible for predisposing an athlete to injury. Based on our findings, we now know that separate programs – in areas such as intervention, screening and injury prevention – must be developed for males and females and this will be the focus of our future .

Sprained ankles can be avoided by those at high risk through a weekly balance training program, according to new research released today at the 2006 Annual Meeting of the American Orthopaedic Society for Sports Medicine at the HERSHEY(R) Lodge and Convention Center.

“Our previous research showed that high school football players who are overweight and have had a previous ankle injury are at increased risk of sustaining a subsequent ankle sprain,” says lead author Malachy McHugh, PhD, director of research at the Nicholas Institute of Sports Medicine and Athletic Trauma at Lenox Hill Hospital in New York City. “We have now demonstrated that these injuries can be avoided by having players do balance training on a foam pad for five minutes on each leg several times a week.” Dr. McHugh says that ankle sprain is the most common sports injury.

Some researchers have theorized that the compounding effect of a previous ankle sprain and a high body mass index on ankle sprain is due to weakened ankle stability and the lack of dynamic movement control caused by large body mass.

Dr. McHugh and colleagues followed 175 high school varsity football players for three years to determine if balance training could reduce risk of ankle sprain. Those at risk of ankle sprain due to body mass and/or history of previous ankle sprain balanced on each leg for five minutes, five days a week for four weeks in preseason and twice weekly during football season. Injury incidences included games and practices.

The researchers found that 18 percent of the players at increased risk sustained a non-contact ankle sprain compared with 3 percent following the balance training intervention. Prior to intervention, overall injury incidence for those at risk of ankle injury was 2.2 per 1,000 exposures, which was reduced to 0.5 following intervention.

Dr. McHugh and colleagues conclude that stability pad training was inexpensive and easily implemented. It reduced ankle sprains by 77 percent, effectively eliminating the increased risk associated with high body mass and previous sprain.

The American Orthopaedic Society for Sports Medicine (AOSSM) is a national organization of orthopaedic sports medicine specialists. See http://www.sportsmed.org .

The American Academy of Orthopaedic Surgeons (AAOS) Board of Directors approved and released a clinical practice guideline for treating rotator cuff tears. The rotator cuff is a group of muscles and their associated tendons which holds the humerus (upper arm bone) stable in the shoulder joint, allowing the arm to rotate and elevate. Rotator cuff tears are a common cause of pain and disability among adults, occurring often as a consequence of aging, because of tendon degeneration. Tears can also occur following injury from sports or acute trauma.

Clinical practice guidelines, based on the highest quality evidence-based research available, are an educational and learning tool for Academy members, can assist orthopaedic surgeons and patients in potential treatment recommendations, and also serve to improve the design of future clinical studies. In this case, an arduous review of the literature up through 2008 identified 74 studies to be included in the guideline. Robert Pedowitz, MD, chair, and Ken Yamaguchi, MD, co-chair, of the Academy work group developing this guideline, state that although a large number of lower evidence studies exist, they were surprised at the absence of more high quality prospective studies to support many commonly used interventions.

“Although there is a tremendous amount of research on the rotator cuff, much of it does not reach the quality levels necessary to be considered definitive,” says Yamaguchi. “Thus, we cannot say that there were recommendations that could be unequivocally supported.”

That said, Yamaguchi points out that the AAOS work group has recommended 14 interventions for treating rotator cuff tears. There is a consensus opinion among the work group for the following recommendation:

- In the absence of reliable evidence, it is the opinion of the work group that surgery not be performed for asymptomatic full thickness rotator cuff tears. By “asymptomatic,” the work group refers to a patient without symptoms. The primary indication for rotator cuff repair is significant pain or dysfunction affecting the quality of life.

Rotator cuff repair is an option to treat both symptomatic acute and chronic tears. There was no Level 1 evidence, however, to demonstrate a difference in outcome from one type of surgical approach to another.

Dr. Yamaguchi mentioned that many of the common practices for repairing acute tears or chronic tears that have failed conservative management are considered viable options today. The work group found no evidence to refute most of these common treatment practices. It is entirely probable, they believe, that future, good evidence will substantiate current opinion.

“In our opinion, the guideline process taken by the Academy is a valuable exercise that has focused our awareness on what precisely are the modern standards for good evidence,” says Yamaguchi. “This process clearly demonstrates the need for higher quality research and should hasten the progression toward more sophisticated studies in the future.”

Disclaimer: This Clinical Practice Guideline is not intended to be a fixed protocol, as some patients may require more or less treatment or different means of diagnosis. Clinical patients may not necessarily be the same as those found in a clinical trial. Patient care and treatment should always be based on a clinician’s independent medical judgment, given the individual patient’s clinical circumstances.

Note: A physician volunteer work group developed this clinical practice guideline, based upon a systematic review of the current scientific and clinical information and accepted approaches to treatment and/or diagnosis. The entire process included a review panel consisting of internal and external committees, pubic commentaries, and final approval by the AAOS Board of Directors.

A group of Canadian researchers led by Prof. Jean-Pierre Pelletier, Head of the Osteoarthritis Research Unit at the University of Montreal Hospital Research Centre, published a clinical trial in which they confirm, for the first time using quantitative Magnetic Resonance Imaging (qMRI), the disease modifying effects of chondroitin sulphate, a symptomatic slow acting drug for osteoarthritis (SYSADOA).

This clinical trial, published in Annals of the Rheumatic Diseases (impact factor 8.111), explored the effect of chondroitin sulphate (CS) treatment on cartilage volume loss, subchondral bone marrow lesions (BML) and synovitis in patients with knee osteoarthritis (OA). “This study focused on quantifying over time by MRI the main structural changes observed in the cartilage, bone and synovial membrane”, Prof. Pelletier said.

The investigator states that after only six months of treatment with CS, patients show a significant decrease in loss of articular cartilage as compared to the placebo group, and for the first time, a significant reduction in the progression of BMLs by 12 months.

According to Prof. Pelletier, these data highlight not only the importance of the interrelationship between cartilage and subchondral bone in OA, but also its potential role in the disease process and response to treatment with SYSADOAs.

Prof. Pelletier concluded that, “CS is a safe drug with an overall positive effect on OA, significantly reducing the volume of cartilage loss in knee OA, and providing for the first time new information on its positive effect in vivo on other structural changes observed in this disease”.

Professor Pelletier commented that the clinical trial results prove that CS is able to slow the progression of OA, however this does not mean it is able to cure. “The cure involves the regression of all lesions related to OA,” he says, “and that’s not the case. Chondroitin sulphate slows the progression of the disease. This is an important finding as a decrease in the rate of progression of cartilage loss in knee OA patients, as seen by MRI, could potentially reduce the need for total knee replacement a phenomenon that has been observed in other MRI clinical studies”.

Confirming previous studies

The clinical trial by Prof. Pelletier definitively supports the findings of previous studies describing the positive effects of CS on the pathogenic mechanisms of action of OA (Kwan S et al 2007; Monfort J et al 2005; Bassleer et al 1998; Ronca de 1998, etc), and supports the ability of CS to modify the natural history of the disease, as previously demonstrated by Kahan (2009), Michel (2005), and Uebelhart (1998 and 2004), and the two meta-analyses by Hochberg (2008 and 2010).

Similarly, Prof. Pelletier said that these findings refute the conclusions reached by S. Wandel et al. in a meta-analysis published in the British Medical Journal (BMJ) in 2010 to the effect that SYSADOAs do not offer benefits in the treatment of patients with OA.

In this regard, Prof. Pelletier says, “the methodology used by Wandel et al. is questionable based on the opinion of several experts in the field of OA, as reflected by the several letters to the editor posted on the BMJ website, some of which have also been published in the official Journal. The results of the Wandel et al. meta-analysis are in contrast to many other meta-analyses performed by expert scientists dealing with the same issue, which have shown that CS is an effective symptomatic treatment for OA and that it can slow disease progression”.

“In line with my previous comments, following the publication of this meta-analysis, one of the editors from BMJ issued an official statement in the BMJ website questioning some of the assumptions made in the article and also mentioning a possible conflict of interest of the BMJ senior statistics editor, thus seriously questioning the validity and reliability of this meta-analysis”, Prof. Pelletier specified.

Future goals

The expert says the results of this pilot MRI study are very positive and encouraging. Given the evidenced efficacy and safety of the product, it definitely represents a most valuable option for OA patients. Though he notes, “it is important that patients are provided with highly purified pharmaceutical grade CS, the one used in this study, as this is the only one that can guarantee such efficacy and specifically, safety results”.

Jean-Pierre Pelletier, MD, Professor of Medicine, Head Arthritis Division, Director of Osteoarthritis Research Unit, University of Montreal Hospital Research Centre (CRCHUM)

For years, studies have offered conflicting opinions on whether exercise is good for knees. A new report released today by the American College of Sports Medicine (ACSM) provides strong evidence that exercise is, in fact, good for the knees.

The report, titled “What is the Effect of Physical Activity on the Knee Joint? A Systematic Review,” was published this month in Medicine & Science in Sports & Exercise®, ACSM’s official scientific journal. A research study led by Donna Urquhart, Ph.D., and Flavia Cicuttini, Ph.D., examined the effects of physical activity on individual parts of the knee.

“Several studies have already examined the impact of physical activity on the knee as a whole, but none have looked at the effect of physical activity on individual parts of the knee,” said Dr. Cicuttini, head of the musculoskeletal unit in the School of Public Health and Preventive Medicine at Monash University in Australia. “As it turns out, exercise affects each part of the knee differently, which helps explain why there have been conflicting reports for so long.”

According to the team’s findings, while exercise was linked to osteophytes, or bony spurs, there were no detrimental changes to joint space, the place where cartilage is housed. There were beneficial effects on cartilage integrity, with evidence of greater volumes and fewer defects.

“These findings are significant, as they suggest that osteophytes, in the absence of cartilage damage, may just be a functional adaptation to mechanical stimuli,” said Dr. Urquhart.