Mark Ingram’s injury on Tuesday was likely a meniscus tear.  I have no inside knowledge of the procedure performed or diagnostic studies and am not involved in his care. However, I can guess what the injury is based on the formal statements made describing the injury as:

-mild

-one that is better taken care of now than risk it affecting him later in the season

-treated arthroscopically

A small meniscus tear that is not repairable can be treated with simple debridement by knee arthroscopy. The typical recovery would be no athletics 2 days, low impact exercise for 5 days, and then progress to aggressive strengthening in second week when incisions are fully healed. He could conceivably be full speed by 14 days post-op assuming all goes smoothly.
Almost any other diagnosis in the knee takes much longer. For example if it turns out to be a bigger meniscus tear that requires repair, he will be out a minimum of 6-8 weeks. An ACL and most cartilage injuries take even longer to recover. I don’t think the physicians or coaches expect this based on what they saw on MRI, or they would not have called it a minor injury.

Ask any of the BayBears what the key to becoming a pro athlete is, and most will say “staying healthy”. At the pro level, enormous amounts of time, resources and research is spent developing and implementing stretching, strengthening, and practice regimens.

At the little league and high school level, focus on injury prevention is even more critical for several reasons. Up to the age of about 15, young athletes have active growth plates in their bones. These growth plates are made of soft cartilage-like material that is far more susceptible to injury than mature bone. Additionally, rapid changes in weight, height, strength, and flexibility result in constantly changing body-mechanics. If care is not taken, the changing mechanics can quickly result in injury to tendons, joints and growth plates.

Too many times, parents and coaches, encourage excessive repetition to develop skills ignoring the physiologic weaknesses in the young athlete and injury results. In tragic cases, a child “with promise” may have to give up baseball all-together due to avoidable injury.

Here are some simple guidelines:

1. Do not play year-round baseball & never pitch two leagues at once

2. Follow age-appropriate pitch count and type guidelines

3. Warm-up and stretch regularly

4. Do not ignore or “play through” pain

5. Focus on good mechanics and fundamentals rather than speed/stats

Be informed. Check the website below for more information:

www.littleleague.org

A shoulder separation is often confused with a shoulder dislocation.

A shoulder separation is technically an injury to the acromioclavicular joint. This joint is located at the top of the shoulder just under the skin and is often a visible bump in thin individuals. A shoulder separation or AC injury occurs as a result of a direct blow to the top of the shoulder such as might be experienced by an athlete during a shoulder tackle in football or a fall onto the top of the shoulder. The ligaments that support the AC joint may be sprained or completely torn resulting in varying degrees of pain and disability. While the AC joint only moves about 10 degrees with complete motion of the shoulder, when injured it can cause a tremendous amount of pain. The athlete will have tenderness over the point of the shoulder. Because the joint is just under the skin, if all supporting ligaments are torn the end of the clavicle may actually tent up the skin making the diagnosis obvious. Lower grades of AC injury may require only a short period of rest followed by progressive return to activity. Higher grade injuries may require arthroscopic surgery to stabilize the joint and prevent chronic pain.

A shoulder dislocation usually refers to a dislocation of the glenohumeral or ball and socket joint of the shoulder. This injury results from the arm being bent or pulled back beyond the limits of the ligaments that stabilize it. Once the ball slips out of the socket, it may not go back in on its own and a closed reduction may be required by a trained professional. Once back in place, an MRI will be required to assess the damage. A Bankart injury to the ligaments and labrum of the shoulder is often found which requires surgical repair in younger individuals. Some older individuals and those with ligamentous laxity (“double-jointed”) may be treated without surgery at least initially.

This football season, I saw a fair number of shoulder separations in my office. It was clear in talking to my patients, that many were not sure exactly what this injury is. Therefore, I think this explanation of the injury and prognosis may be helpful to my patients as well as anyone who has had a shoulder injury from a direct blow.

A shoulder separation is distinctly different than a shoulder dislocation. A shoulder dislocation usually occurs when the arm is hyperextended and the ball of the shoulder pops forward out of the cup, tearing ligaments and the labrum in the process. This is a dislocation of the glenohumeral joint. A shoulder separation, on the other hand, is a dislocation of the acromioclavicular joint or AC joint located on the point of the shoulder. The AC joint is the junction between the clavicle and the acromion which only moves 5-8˚ with full 180˚ motion of the glenohumeral joint. A shoulder separation occurs when one suffers a direct blow to the top of the shoulder. This type of injury can occur during a shoulder tackle in football or more classically in a running back who dives over a pile only to hit the ground directly on the point of the shoulder.

There are several ligaments in the AC joint, and the severity of the injury is determined by which ones are torn and which direction the clavicle dislocates. In low grade injuries, the ligaments are stretched such that there is still sufficient stability of the AC joint. These injuries heal very well with simple rest, compression, anti-inflammatories and progressive range of motion. In more severe injuries, the clavicle completely dislocates and may result in an obvious prominence or bump on the top of the shoulder where the clavicle “tents” the skin. These more severe injuries are more likely to need surgical stabilization. Fortunately, the surgical techniques in sports medicine have evolved such that this injury can usually be treated arthroscopically which is much less invasive than even 10 years ago.

Whether or not surgery is required, the prognosis is very good for isolated shoulder separations. Taken on the whole, an AC separation is a far less significant injury than a shoulder dislocation, therefore I think it’s important to distinguish the two. If this explanation doesn’t clarify the issue, or if you have questions about other orthopedic injuries, try checking my educational “Bonebreak” videos at www.alortho.com.

When parents read stories of childhood “prodigies” such as Tiger Woods learning a sport as young as 3 years old, it is natural for us to wonder what sports are best for our child and at what age they should start. While there are no sure answers as to when a particular child is ready for a sport, there are well-studied developmental patterns that can guide us.

Infants and toddlers, for example, gain gross and fine motor skills along a predetermined path, and any attempts to speed this up with training will fail. That being said, there are windows of opportunity in which a toddler learns certain movements more readily and should not be missed. So, the best course in this age-group is to expose the child to a wide variety of interactive games so that they can have the tools to progress at their own pace. Mom and Dad can create a variety of activities with a ball and things around the house or get some ideas at the local toddler gym.

In preschool a child can follow simple instructions and has basic postural control and balance to allow sports participation. Soccer is a great activity at this level because it can be played by following one simple instruction; “kick this ball in that goal!” Preschoolers do not have the ability to engage in rapid decision-making to account for unexpected events. So, they all stick with the one thing they do get—kick the ball! The result is the “swarm” phenomena we see in all soccer games at this level. This is normal behavior and should not be a source of frustration to parents—and oh, by the way, kids this age cannot distinguish multiple instructions coming from the crowd, so you can save your breath!

A classic study has shown that by elementary school, 6 out of 10 children can throw, kick, run, jump, catch, strike, hop and skip. This opens the door to a wide variety of sports. However, children this age also become aware of their status among their peers and their own inadequacies (they know who is “cool”, who is “athletic”, etc.). Keep in mind that children of the same age and grade may be at very different developmental stages, so comparing them to their peers is misguided. For these reasons, confidence-enhancing activities for all children are important. Parents should choose at least one noncompetitive activity and always emphasize socialization and sportsmanship more than physical performance. Additionally, contact sports are not ideal because coordination is not fully developed and children have little ability to consider future consequences of current behavior. For example, they cannot think through the consequences of spear-tackling. Weight-training with light weights under strict supervision can begin as early as 8 years of age. Strength gains can be achieved in pre-pubescent children, but no gains in muscle size will occur until the hormones kick in at puberty.

As a child transitions to adolescence, their growth dramatically increases. Bones grow faster than tendons which can result in loss of flexibility and “growing pains”. This is a crucial time for skills development, and most are ready for organized sports of all types. However, precautions, such as pitch counts and cross-training, must be taken to avoid overuse injuries to the growth plates. This is the most appropriate time to begin weight-training. There is no evidence that a proper weight-training program during adolescence stunts growth. However, to avoid injury, explosive exercises such as clean-and jerk should not be done until skeletal maturity (15-16 years old).

In summary, children are not just “little adults”. They react to physical and emotional stress at different developmental stages in different ways. Moderation should always rule, and as my grandmother used to say about raising children, “the best that we can hope for is to not mess ‘em up.”

Here in South Alabama athletes have the advantage of being able to train outdoors year-round thanks to our subtropical climate. The downside of that is that in mid to late summer the heat and humidity can combine to put athletes at risk of heat-stroke, a deadly condition responsible for the deaths of 37 football players between the years of 1980 and 2001. While a sports medicine orthopedist’s primary job is to evaluate and treat orthopedic injuries, one of the most common issues I run into on the sideline is heat-illness.

There are three categories of heat-illness in order of increasing severity: heat cramps, heat exhaustion, and heat stroke. Heat cramps presents as cramps in the arms and legs during exertion. The athlete’s skin will be pale and wet with sweat. The athlete should be moved to the shade and hydration with cold sports drinks initiated.

Heat exhaustion, the next step on the ladder, is characterized by headaches, weakness, and “feeling faint”. The skin is still pale, but sweat volume decreases. The skin can be described as “cold and clammy” (moist to the touch). Again the athlete should be moved to the shade, but more aggressive cooling should begin such as ice bags in the armpits and groin. The athlete should lie down and remove their clothes (particularly heavy gear such as football pads).

The first sign of heat- stroke, the final stage of heat-illness, is confusion. This may be accompanied by nausea and vomiting. The skin will be red and hot. The athlete may still be sweating, but as the severity increases, sweating may stop. The core body temperature will rise to greater than 104˚F. This is an emergency. IV fluid hydration must be begun urgently and the athlete transported to the nearest hospital. During transport, the cooling methods mentioned above such as ice bags and ice water immersion should be performed if possible.

Heat illness, once it begins, is hard to reverse without discontinuing play. Therefore, coaches, trainers and athletes should place adequate emphasis on prevention to avoid not only the risks of heat-illness but also the inconvenience of having to stop a workout or withdraw from competition. Regarding weather, the temperature and the humidity are important. For example, while it may be safe to compete in 90˚ weather when the humidity is 40%, it is recommended by sports medicine organizations that play or practice be cancelled if the temperature is 90˚ and the humidity 80%. Now this is not always realistic here in South Alabama as we probably could not get through a season if that guideline was followed strictly. However, measures can be taken such as scheduling work-outs and games in early morning or late evening in the hottest months and moving to the air-conditioned weight-room or gymnasium to work-out when exceedingly hot and humid. A single layer of light-colored clothing is preferred when heat is an issue to promote evaporation of sweat and protect from UV rays. Also changing out of a sweat-soaked garment during exertion is helpful when possible.

Another means of prevention is paying close attention to athlete hydration. While body types and metabolism will vary the required amounts of fluid, a good rule of thumb is to drink 20 ounces 2 hours before exercise. Drink another 10 ounces 20 minutes before exercise and then 10 ounces every 20 minutes during exercise. Sports drinks are superior to water if exercise lasts greater than 1 hour. A good way of monitoring this is pre- and post-practice weigh-ins. If the athlete loses greater 3% body weight during exercise, they are not adequately hydrating.

Taking these precautions will help prevent heat-illness will likely improve performance.

Forearm fractures are the most common long bone fracture in children. They usually result from a simple fall onto an outstretched hand while running or playing sports. When this injury occurs, it is arguably more traumatic to the parents than it is to the injured child! Here are some basic first aid techniques and things to expect to help parents be prepared in case the unexpected happens.

When your child takes a fall, first look for signs of head trauma, such as a cut, a loss of consciousness, or nausea and vomiting. With regard to forearm fractures, look for obvious deformity. If detected, gentle straightening of the deformity by pulling on the fingers may be helpful in reducing pain and damage to the nerves and vessels. If there is any resistance, do not forcibly try to straighten the arm. At this time, also take note of any lacerations so you can point them out to the doctor.

Next, try to calm your child and reassure him or her that it will hurt less if they can relax. Then, find something to immobilize the arm. There are many effective ways to do this. Taping the arm to a clip board works well. In the woods, using multiple sticks wrapped with strips of a T-shirt can work. On the athletic field, the EMT or coaching staff will have arm boards or other prefabricated splints that can be wrapped with an ACE bandage before transport. If nothing else, a makeshift sling made from a towel or from pinning the child’s T-shirt over the arm can provide some support.

In addition to the makeshift splint, applying bags of ice will help control pain and swelling. The child should not be allowed to eat or drink until a physician tells you otherwise. If any anesthesia is required, there are increased risks if the child has taken anything by mouth in the last eight hours.

Upon arrival to the emergency room, the ER doctor will check for good circulation and nerve function. The doctor will also check to see if there are any cuts, which could indicate an open or “compound” fracture. X-rays will then be taken, and a splint will be applied. At this point, the ER doctor will decide whether the injury can be effectively splinted and referred to an orthopedist’s office for follow-up or whether an immediate consultation with the orthopedist is required. Examples of when the orthopedist will be called urgently are gross deformity, open (compound) fractures, circulation or nerve problems. You may request your own doctor or accept the orthopedist who is on call in the ER that day.

Unlike adults, forearm fractures in children can often be effectively treated nonoperatively with a long arm (above the elbow) cast. Healing time varies from six to 12 weeks, depending on age and the type of fracture. In some cases, surgery is required, which can involve pins, intramedullary rods, or plates and screws.

The good news is that if you as the parent can survive the anxiety surrounding your child’s injury, the prognosis is good in almost all cases. Your orthopedist will be on the lookout for things such as growth plate disturbances and late displacement, so good follow-up is paramount.

The Achilles tendon is the strongest tendon in the human body and owes its name to the great, invulnerable warrior of Homer’s Iliad. Invulnerable, that is except at his heel. Greek mythology has it that, Thetis, Achilles’ mother dipped him in the Styx River making him invincible at all points on his body but the heel by which she grasped him as he was being immersed. This proved to be his undoing when Paris, the brother of Hector, shot him in the heel with a poisoned arrow.

The Achilles tendon is located just behind the ankle and is the only connection between the calf musculature and the calcaneus or heel bone. It allows us to toe-off providing much of the energy during jumping and running and has a specialized twist in it giving it additional elastic recoil during these activities.

Anyone who has torn their Achilles tendon will tell you that it is quite fitting that a great warrior was brought down by this injury. In sports the tear occurs most often when pushing off with the foot while the knee is in full extension. This movement is common during sprint starts and in jumping sports such as basketball. The athlete feels a sharp pop in the back of the leg that has been compared to being shot in the heel! In fact, the athlete will sometimes swear that someone hit them on the back of the leg or stepped on the back of their heel even though no contact truly occurred.

After injury, the athlete will report being unable to bear weight on the affected side. Bruising and swelling can occur. A physician can often palpate and feel the defect in the tendon to confirm the diagnosis. Also on examination, when the calf is squeezed the foot will go down or plantarflex in a normal foot but may not move at all if the tendon is ruptured. MRI and ultrasound have both been used to confirm the diagnosis.

Treatment is largely surgical in the young athlete. Studies have shown that there is a lower rate of rerupture, and increased strength with surgical repair verses casting. However, the differences are small and casting avoids all of the inherent risks of a surgical procedure. Therefore, consideration to casting should be given to the “weekend warrior” and nonathlete. Casting must be started within 48 hours of injury and surgical repair can be done up to 2 weeks after injury.

“Shin splints” is a waste-basket term to describe any pain that occurs in the leg during exercise. Shin splints is not a diagnosis as there are many causes of leg pain in the athlete, some of which require more urgent treatment than others.

Posterior tibial syndrome or “PTS” is one common cause of leg pain. The pain is located at the proximal medial cortex (upper inner edge) of the tibia or shin bone. It begins as the athlete begins to run, feels better as he warms up, and then comes back with a vengeance after exercise. It is most common in beginning runners or experienced runners who begin training too aggressively after an off-season. Changes in running surface, shoe wear or intensity of training all may contribute. My opinion is that this is most often due to periostitis or inflammation where the posterior compartment (calf) muscles attach to bone. Therefore, treatment involves anti-inflammatory medications and rest, stretching, progressive strengthening with cross-training.

Another condition that may be confused with PTS is exertional compartment syndrome. There are four groups of muscles in the legs called compartments. These compartments are enveloped in a thick fascia that can be thought of as a bag. This bag does not stretch and is important in containing the muscles as they expand with contraction. However, if the muscles swell significantly during exercise, this inability to stretch results in excessive pressure in one compartment. If this pressure becomes too high, the nerves and blood vessels begin to be compressed causing severe pain and eventually numbness and discoloration of the foot. The athlete complains of pain that gets progressively worse as they exercise and then goes away with rest. In some cases this condition requires surgery to relieve the pressure.

Stress fractures are another cause for leg pain in the athlete that should not go unrecognized. Our bones have a remarkable ability to adapt to stress. The bones bend with weight-bearing activity causing microfractures. The bone senses the location of bending or stress, and reacts by building more bone in that area. The trouble comes when an athlete increases her training intensity too rapidly. The muscles become fatigued and stop providing shock-absorption. This results in increased stress on the bone. The remodeling or building of bone cannot keep pace with the microfractures that begin to occur. If this goes on too long, a crack in the bone results. This crack causes pain with every step whether exercising or not. If the athlete continues to push through the pain, a complete fracture can occur. Treatment, depending on the severity, ranges from cross-training to casting and complete non-weightbearing.

What else can cause leg pain in the athlete? : Effort-induced DVT, popliteal artery entrapment, tennis leg, and nerve entrapment to name a few. I won’t go into detail with the rest of these, but the point I’m trying to make is that there are many causes of leg pain in the athlete and the term shin splints is an oversimplification that may lead to inappropriate treatment and prolonged inability to compete.

Tears of the meniscus in the knee are one of the most common causes of knee pain in active individuals. In fact, six out of ten people over the age of 65 years old have a meniscal tear. It is a mistake however to assume that all meniscus tears are the same.

The tears that occur in older individuals are often what is called degenerative. That means they occur as the meniscus wears out. To explain why this happens I will have to explain some basic anatomy. The primary function of the meniscus is to share the load of our body weight during activity. The meniscus can be thought of as a wedge shaped gasket that allows the curved surface of the femur (thigh bone) to articulate with the relatively flat surface of the tibia (shin bone). A good analogy would be sitting in a hard, straight-backed wooden chair verses sitting in a contoured cushioned easy chair. We quickly develop sore points when sitting in a chair that does not conform to the curves of our back.

Similarly, the meniscus helps the tibia ‘conform’ to the shape of the femur preventing pressure points. In doing that, the meniscus bears one half of our body weight when standing. Over the years, one can see that supporting half the body weight will eventually lead to wear of the meniscus. That is a degenerative tear. These tears cause a constant aching pain on one side of the knee. They usually get better with anti-inflammatory medication (i.e. Aleve) and physical therapy. Sometimes they require arthroscopic surgery to remove the torn fragments. However, there is no rush to do surgery, because the surgical treatment for a degenerative tear is the same regardless of how long it has hurt.

An acute tear of the meniscus is a very different animal. This type of tear is much less common and usually occurs in young athletes. It often results from a single twisting type injury while the knee is flexed and loaded, but the mechanism can vary greatly. This type of tear causes pain on one side of the knee, but it often is also associated with swelling and popping of the knee or even locking. The clock is ticking after this type of injury as there are certain types of tears that require surgical repair. Studies have shown that there is a higher success rate when a repair is done within two months of injury.

Another characteristic of degenerative tears is that, because the tissue is weaker, the tear sometimes grinds itself down until it doesn’t catch in the joint and cause pain. In a younger patient with a meniscal tear, each additional pull on the meniscus during activity can rip it more and convert a repairable meniscus to an irreparable one. Often, a trainer will counsel an athlete with knee pain to try rest, ice, compression and elevation followed by a progressive return to sport. This is sometimes a reasonable approach, but keep tabs on when the injury occurred and see an orthopedic surgeon if the pain persists more than a couple weeks or is associated with popping or locking.