The $1000 bottle of Ibuprofen

After practicing for 32 years, I have finally had it. People complain all the time about how dysfunctional the health care system is. In many ways it is, with rules and regulations dictating choices caregivers have, and roadblocks for patients to obtain care.

I have a 53 year patient who has fairly significant arthritis of her knee. She injured her knee on the job, and her job requires her to be on her feet most of the day. She has had surgery twice over the past 10 years and needs a knee replacement, but she is too young. She has been able to continue working by using Ibuprofen when her pain increases.

She called about 3 months after her last visit asking for a refill for her Ibuprofen, which costs about $10-12. She did not feel a need to come in for an exam, as it would take time away from her work. She used it occasionally.

We have to submit a form to her Workers comp insurance company for approval rather than just calling in a refill, and the adjustor sent it to another doctor to be “reviewed for medical necessity”. This reviewing doctor denied our request. Said they had called the office twice to try to speak to me.

Our notes: “Mark with Mitchell UR called and said you can speak with Dr. Brooks, reviewing physician, if there is any other info you would like to add to the ibuprofen refill request. Mark said you do not necessarily have to call if there is nothing else to add. They already have the last report.”

So I appealed his decision, thinking this was a mistake. I sent our request to the next level appeal, to the “Independent Medical Review”, a board of reviewers the legislatures passed in 2009, set up as the final word. Kind of like God… you really don’t know what he/she looks like…There is no list of who is on the board, it is a secret, and after all the records were sent for review, to my surprise, it was denied again. The 4 page denial stated the according to the Chronic Pain Guidelines I needed to document that she had failed a trial of Tylenol. (She had Tylenol use documented, just not the statement that it had FAILED.) NSAIDS such as Motrin are not for long term use”… This was the first refill in 3 months. What- they want me to give her Percocet instead?

The problem is the law also states that we cannot ask for a review for 12 months. She will have to pay for it herself.

What did it cost to deny a $10 bottle of Ibuprofen?

Request for refill of Ibuprofen……….$NA
Cost to fill out Request for Authorization form 10 min……….$40
Phone call from physician reviewer to me (2 times)……….$60
UR Reviewer denial estimated fee……….$100
Administrative time to send initial 7 page denial est……….$50
My time to prepare appeal, talk to patient to explain denial……….$125
Filing costs to IMR……….$400
Estimated physician reviewer fee #2……….$100
Phone call to patient explaining denial #2……….$50
Total estimated cost to deny Motrin……….$925

Time away from actually treating patients……….priceless

So let’s see…what happened to common sense for a $10 medication? Why is this happening?

Several years ago, then Gov Schwarzenegger and a few key legislators (called the Gang of 5) put together a bill that required utilization review for all care patients receive in the workers compensation system. (SB 899). This was supposed to hold down the rising cost of premiums for employers, avoid unnecessary tests, surgeries, and use of narcotics. In the big picture, there was some abuse, and some of the tenants seemed reasonable.

Instead, an entire new industry was born- Utilization Review Companies, whose job it is to review requests for medications, crutches, a simple sling to surgery requests and every postoperative need the patient may have. Some of the companies deny as much care as possible to save money for the insurance company and have every request from a sling to Motrin reviewed. A few are reasonable and leave the decision to protocols for the adjustor. Many of the physicians are hired from out of state, are not required to practice here, just have a California license. Many are retired from actively practicing. I met one recently at an Orthopedic meeting who was at least 80 years old, and clearly was not practicing and had in fact denied an anti-inflammatory for one of my patients.

Has this system saved money for the employer and improved care for the injured worker? NO.

One recent study indicated that over 50% of the cost of care for the patient is in utilization review. If a bottle of Motrin can cost $1000, no wonder.

The people getting hurt here are hardworking blue collar workers, many of whom have never had an injury in their work life. Many do not have English as their primary language, and have limited recourse for denials. Or they hire a Workers compensation attorney, and this too can increase costs and complicate the case. As physicians, our main goal is to help heal the patient. 90% of the doctors caring for these patients are doing just that.

Only the legislature who passed this bill can make this better. Will I continue to treat injured workers? For the few companies that have reasonable review, yes. But my no-fly list is getting longer by the month. Maybe, only when access becomes a crisis will anything change.

Lesley J. Anderson, MD

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Should you take antibiotics after your total joint replacement?

Reprinted from

J Am Acad Orthop Surg 2013;21: 190-192 by David S. Jevsevar, MD, MBA

You have an orthopaedic implant (for example, joint arthroplasty, metal plates or rods) from a previous orthopaedic surgery. A potential complication of these implants is bacterial infection, which occurs in approximately 1% to 3% of patients. These infections require additional surgery as well as antibiotic usage for an extended period of time. Most infections occur around the time of the procedure (within 1 year), but some have occurred much later.

In theory, late implant infections are caused by the spread of the bacteria from the bloodstream to the implant. Unfortunately, there is no clear scientific evidence to support this theory. We know that many patients with orthopaedic implants frequently have bacteria in their blood that does not spread to their implants.

Dental procedures have long been considered a potential cause of implant infections even after the initial orthopaedic postoperative period. This is because dental procedures can introduce bacteria from the mouth into the bloodstream. However, this fact should be considered in the context that eating and performing oral hygiene at home may also introduce oral bacteria into the blood.

Traditionally, antibiotics have been provided before dental procedures in patients with orthopaedic implants to minimize the bacteria that get into the blood. Best evidence, however, does not show that antibiotics provided before oral care help prevent infections of orthopaedic implants. The routine use of antibiotics in this manner has potential side effects, such as increased bacterial resistance, allergic reactions, and diarrhea, and may even cause death.

Patients who have compromised immune systems might be at greater risk for implant infections. Diabetes, rheumatoid arthritis, cancer, chemotherapy, and chronic steroid use are examples that suggest the presence of immunosuppression.

Please discuss your potential for immunosuppression with your physician or dentist. Patients who are immune-compromised might wish to consider antibiotics before dental procedures because of their greater risk for infection. Decisions with regard to antibiotic premedication should be made by patients, dentists, and physicians in a context of open communication and informed consent. See Figure 1, the Doctor-Patient Shared Decision Making Tool.

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Over the last several years, a lot of exciting work has done in the use of concentrated platelets taken from the patient’s own blood, and putting in joints, tendons and inflamed areas. Platelets are the cells in our blood that assist in clotting and healing tissues that have been damaged. Platelets are full of growth factors that help tissues heal.

PRP is prepared from the patients’ own blood, and involves taking a small amount of blood, and separating the platelets from the red cells and concentrating the platelets in a centrifuge in a sterile manner, so they can be injected into the knee joint. This is done in the office and the injection is done at the same visit. This procedure has been done in Europe for several years, and in our office for the past 2-3 years in very select patients. If you have bone on bone arthritis, the usefulness of all of this options is limited.

As an introduction, for decades steroids (cortisone) has been used to treat the swelling and pain of osteoarthritis. Arthritis can be mild (Grade 1-2), with softening of the cartilage that covers the end of the bone, to moderate (Grade 2-3), to severe, when the cartilage is worn down to bone (Grade 4). Cortisone has been very successful in relieving swelling and offers short term improvement in pain, but long term relief is not as predictable. It is low cost, easy to administer during an office visit, and does not require lengthy authorization and paperwork from the insurance companies. However, repetitive use of steroid injections is not healthy for the articular cartilage in the knee, and is usually restricted to at most 2-3 a year in most cases. Many insurance companies now require a trial of a cortisone injection before use of hyaluronic acid (HA).

Because of the limitations of cortisone or steroid injections, hyaluronic acid injections were developed to try to replace some of the chemical imbalance seen in the knee in osteoarthritis. The claims that HA can regrow cartilage in some of the advertising media is just not true. It acts to relieve pain in 70% of patients for up to 6-8 months in many of the series published. It is quite expensive, and requires authorization from the insurers. The patient receives one to 5 injections a week apart, but most companies have 3 injections. (There are several companies that sell HA such as Synvisc, Eufflexa, Orthovisc, or Suppartz). The risks are small, from swelling after the injection, allergic reaction to the medication, and infection. Recent papers indicate that it’s effectiveness is not as strong as once thought.

There have been some important papers published in the past year comparing the benefits of injection of platelet rich plasma (PRP), hyaluronic acid (HA) and saline (placebo). These papers show statistically significant improvement in pain relief with platelet rich plasma over HA and saline. These findings offer an additional weapon in treating pain in patients with moderate osteoarthritis.

There are 4 excellent papers that have been published in the past 2-3 years that were done to the highest quality. This is called a double blind, randomized trial. This means the patients and doctors do not know whether they received the PRP or HA or saline. (Level 1).

In one study, PRP was compared to saline and the results indicated that 2 injections of PRP were not better than one, and that the PRP patients activity and pain scores in both groups were statistically better than those injected with saline. In fact, the group injected with saline (salt water) got worse over time. The results improved up to 6 months when the study ended. Other studies from Italy, have shown improvement of over a year.

A second study, also a Level 1 study compared PRP and HA. This study injected the knees 4 times with either HA or PRP, and compared them at 6 months. The PRP group showed a statistically significantly better outcomes than HA (p<.001).

The other 2 studies also indicate that at 6-12 months, patients undergoing PRP injections have less pain. The level of function was not significantly different. It seems to act by restricting the rate at which enzymes in the knee break down cartilage.

It should be noted that PRP is not covered by the insurers yet, so patients would have to pay for these out of pocket. The cost varies so it is important to check out your local options and pricing.

These papers are exciting because there is finally some hard science looking at the results of several options for injections in patients with osteoarthritis. We anxiously await more Level 1 studies, so hopefully, insurers will finally recognize this as a reasonable alternative to treatment.

Risks: The risk of complications is quite low. Infection, pain after the injection, swelling may occur.

You need to not use any aspirin or blood thinning medications such as Motrin, Alleve or other anti-inflammatories for 7 days before and after the injection, since these interfere with the platelet activity. Pain relief is not as quick as a cortisone injection and can take several weeks, and continue to improve over a few months. Occasionally, a second injection is needed.

If you have any questions, please do not hesitate to contact me. I look forward to being of service to you.

Lesley J Anderson MD

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Raised Toilet Seat

You hear all the time from patients, physicians and healthcare workers that the health system is broken.  This weekend was an example of how broken the Worker’s Compensation system is.  I fear that private insurance and Medicare are not far behind.

On Friday morning, my surgery scheduler called me and indicated that one of my female patients, who is almost 6 feet and weighs almost 250 pounds, was insisting on a raised toilet seat to use following her knee surgery that was coming up in 3 days, Monday.  She had a very small bathroom and I felt this was very reasonable since getting your knee bent far enough to get into a bathroom in the first couple of days is occasionally very difficult.

Normally, in the sane healthcare world, I would give the patient a prescription for a raised toilet seat, they would go to the local pharmacy, and purchase one for around $20.  Unfortunately, in the California Worker’s Compensation world, insurance companies feel that everything needs to be approved in advance for payment.  Of course we could put in the appropriate paperwork, we called the insurance company’s adjuster, got a voicemail, faxed over the request, and knew that there was no way that this raised toilet seat would be approved in time for the patient’s surgery.

We explained that to the patient who then went out and tried to procure one on her own.  She went to the local medical supply houses, since her local pharmacy did not carry them, and was told that the least expensive toilet seat would be about $100–120.  She obviously could not afford this, and called to indicate she would cancel her surgery on Monday unless she could get this approved.

It takes on average, 2-3 hours of work to schedule a surgery, getting all the appropriate authorizations, coordinating anesthesia and equipment, preoperative tests, and writing out all the paperwork that is involved.  The cost of changing this woman’s surgery date for a raised toilet sear seemed ridiculous.

So my surgery scheduler, Jessica, and I went online and googled raised toilet seats. Viola!  At least 20 raised toilet seats under $30 were easily found with just 2 clicks of the mouse.  So I went to Amazon on Friday afternoon, ordered a raised toilet seat that cost $15.99 and to have it delivered to my home the next day, cost an extra $3.99.  Well, a total cost of $21.99 including tax of course. Thanks you Amazon Prime!

It’s a beautiful Saturday afternoon in early fall, and I’m sitting in my office working on a power point presentation for a national meeting next week on complex ligament injuries.  I see the FedEx truck arrive at the top of my driveway, the dog started barking, and I find myself getting very excited and happy that the FedEx driver is bringing me the coveted raised toilet seat.  Not only will my patient pee in comfort postoperatively, but her surgery will go on time on Monday, and I have had enough laughter over this to account for the $21.99 that I will never get reimbursed from the worker’s comp carrier.  That doesn’t matter.

After 30 years of practicing orthopedic surgery, I am now relegated to a toilet seat delivery person.  No wonder physicians are leaving medicine in droves.

Hey! Where’s the water?

-Lesley Anderson, MD

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What is an MRI?

Sometimes we physicians get very accustomed to ordering a test and assume the patients understand what the test involves.  This blog will attempt to clarify what an MRI is and also a make your experience less scary and more understandable.

While an x-ray is still the mainstay in orthopedics since it looks at the bones for fractures, calcium deposits, loose bodies, and arthritis of the joints, an MRI (or magnetic resonance imaging) is a test that has revolutionized diagnosis and treatment of soft tissue, ligaments, and bone injuries. It has enhanced the diagnosis of many bone conditions in orthopedic surgery.  In the knee, an MRI can look at the tissues in great detail to determine if there are tears of the meniscus, tears of the tendons, and in a higher quality scan even degeneration of the articular cartilage in its early stages.

It is important to know that MRIs do not have any radiation.  Unlike an x-ray which has a very small dose of radiation or a CT scan which has a higher dose of radiation, an MRI has none, and for this reason it is extremely safe.  It is not used in patients that have pacemakers, metal clips, or metal fragments near vital structures.  For example, metal near the brain as in a sheet metal worker could be a contraindication to an MRI.  However, plates, screws, orthopedic hardware, and total joints are not affected by the magnets and MRIs can be safely done in these situations.  The center where the MRI is being ordered will ultimately determine if there are any reasons that your MRI needs to be rescheduled or canceled when you do your scheduling questionnaire.

The quality of the MRI is very important in order to get the best images possible. The strength of the magnet where the MRI is being done will determine the quality of the images that the radiologist and your orthopedic surgeon will see.  The higher the magnet strength, generally the better the pictures.  Some of the newer 3.0 Tesla magnets have incredible detail capabilities. Lower strength magnets such as 0.3 T and 1.0T are older magnets and may have much grainier and not as clear of images.

There are two types of MRIs.  The best quality MRI is a closed MRI, i.e. the patient goes into a tube and the quality of the images from these machines is much better.  An open MRI is often heavily marketed as being “easier, more comfortable”, but as a good consumer you should also know that many times the quality of the MRI in an open scanner can be poor and therefore the level of detail is often not as good. There has been no clinical advantage to a “standing MRI.”

I try to reassure my patients if they have concerns about claustrophobia. For example, if they are having a knee or ankle MRI, their head is not all the way in the tube and therefore it is much more comfortable.  A shoulder MRI, however, is a bit more difficult and less comfortable. Make sure if you are worried about being claustrophobic then consider some sedation first, or if you are sure you cannot tolerate a closed MRI, then an open one would be needed. I have no difficulties giving these patients a sedative such as Valium to make the examination much easier.

Many times the MRI center will have ear plugs or earphones that you can wear while you are having your examination as the machine can be quite loud and depending on your personality some can find the rhythmic sounds pleasing and  fall asleep, while others do get somewhat anxious. Ask for a sedative if your feel like you will be anxious, but just make sure someone drives you home after if you take a sedative.

The test itself takes about 45 minutes.  The cost of the MRIs do vary, so make sure your insurance is covering it. If not, ask your doctor if there is a place to have a “cash pay” for those patient’s that are paying out of pocket since they may work with you on pricing.

MRIs are probably one of the most important medical advances of the 2oth century, but as I always say, it is not the first test. The first “test” is to take a good history and physical exam. Your doctor should actually examine your injured joint. Most of the time that usually gives me the diagnosis, and the MRI is a test to help determine if surgery is necessary.


Lesley J. Anderson, M.D.

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ACL Treatment Options

My last blog discussed the diagnosis of ACL injuries.  I think the last blog was very timely, as this has been really quite a season for what seems to me, an increased number of patients coming in with ACL tears from the mountains.  The early abundant snow that we got in Tahoe, and now very icy condition with very little new snow may be one of the reasons for seeing more injuries.  In any event, this blog will discuss various approaches to treating an ACL tear.

Once the diagnosis of an ACL tear is made, focus should be on regaining range of motion, swelling reduction, and return of basic function of the knee, i.e., walking, standing, and rehabilitating the quadriceps.  The decision for surgery is really based on future goals in regards to sports, activities one likes to do, and current level of disability.  What I mean by that is, is the knee strong and feel stable, or does it feel unstable and insecure particularly stepping off a curb or going down a stair?  If the latter is true, I believe an ACL reconstruction is probably needed.  If your plans are to pursue sports that involve pivoting and twisting, or you are young and want to continue with a very active lifestyle, most surgeons are currently recommending reconstruction.  I was not to say that a very strong rehabilitation program focused on core strengthening, hamstring, and quadriceps balancing cannot allow one to get back to the same active lifestyle, provided they do not have significant looseness of their knee or laxity on examination.  There are many happy patients have been those who did not have reconstruction and had an isolated ACL tear who do primarily straight head activities such as hiking, running, biking.

We have tried to find the ideal tissue to replace a torn anterior cruciate ligament.  Repair does not work and long-term results are not good.  One can use their own tissues or cadaver tendon.  I remember when I did my fellowship in knee surgery, we even tried artificial ligaments such as Gore-Tex (yes, the same material that you wear) which initially did well, but all failed as they did not get a blood supply.  Some are trying to use pig tendons, although personally I do not see an advantage to using a graft from a different animal over an allograft since there are still potential infectious disease concerns for nonhuman grafts.

For those deciding on pursuing an ACL reconstruction, there are two main sources of graft material.  Basically, you can use your own tissues called autograft, and the most common tendons for these, are the patellar tendon or the hamstring tendons.  The other option is in allograft or cadaver tendon, which is obtained from a deceased person who has donated their tissues. The tissues are cleansed and sterilized. There are a number of different ways to do that. Most are irradiated with low dose radiation to kill bacteria and viruses. The risk of infectious disease transmitted from an allograft is estimated to be 1 in 1.5 million.

The most important thing to my mind, about choosing an allograft, is that your surgeon is aware of what bank they are getting the tissues from, and that the banks are all certified by the American Association of Tissue Banks which ensures the highest quality of screening and harvesting techniques from the donors.

An autograft, or a graft from yourself, obviously carries no risk of infectious disease transmission, such as hepatitis or AIDS, but does “rob Peter to pay Paul.”  The patellar tendon was very popular in the 1980, through the early part of 2000. Using the patellar tendon as a graft can leave patients with difficulty kneeling, with some softening of the cartilage under their kneecap, or trouble regaining full extension.  Many of these problems have been corrected in recent years.  Initially, it was felt that it had better fixation in the tunnels we drilled. More recent studies, however, show that there is no real advantage of patellar tendon over hamstrings, and that the results of using patellar tendon and hamstring autograft are nearly identical.  The hamstrings on the other hand, make an excellent graft material and do not carry the risks of pain with kneeling, chondromalacia, r kneecap pain.

On the other hand, once in a very long while, a patient will notice some decreased strength in the hamstring which was harvested, but I can tell you that in my 25+ years of practice I have only had one patient who really complained about this significantly.  Ultimately, the choice of which graft to use, I think really should be the preference of the surgeon (since you are really not shopping at Macy’s) with his or her own comfort level and expertise.

Postoperatively, most patients are back to walking with a fairly normal gait 4-6 weeks postoperatively or even sooner if they go into the surgery with really good quadriceps function and minimal swelling, and work very hard in the rehabilitation.  This is so much different than 25 years ago when patients were placed in a plaster cast for six weeks and I remember as a resident, being made to hold the leg of a 250-pound football player while the plaster was being rolled to see if I was strong enough to do it as the first woman in UCLA’s orthopedic residency. One of my various “tests”. That’s a different blog, though.

The results of ACL reconstruction are really very reproducible and really depend on whether there has been any other damage in the joint such as meniscus tears, fractures, or loss of articular cartilage.  The amount of arthritis one has at the time of injury, as well, will affect the outcome.

In regards to rehabilitation, there was an interesting paper that came out a few years ago that looked at patients that had intensive physical therapy, three times a week for approximately 8 weeks, compared to those that did a very focused home program and saw the therapist for 4 visits total and set up with a specific home exercise program. In fact, the outcomes were the same with a slight improvement in those that had a reduced physical therapy.

Motivation, consistency, and learning the popular rehabilitation is a very important factor in coming out with a good result.  Letting Mother Nature mature the graft over time is also critical to the success of the operation, and we do know that those under age of 25 are much more likely to have their ACL reconstructions fail (15%) if they have an allograft.  For that reason, I do not recommend using an allograft under the age of 25 unless there are some extenuating circumstances.

Complications from ACL surgery include infection (1 in 500), blood clot (1 in 400), stiffness, failure of the graft and recurrent instability (4-5%), anesthesia complications, scar tissue, bleeding, wound healing problems, numbness around the scars, and other rare complications such as pain, muscle weakness or arthritis. It is important to realize that the vast majority of patients do very well, and going into the operation as educated and committed to the rehab is one thing you can do to get the best result.


Lesley J. Anderson, M.D.

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When is it Best to Contact a San Francisco Knee Doctor, To Keep On Living Your Active Lifestyle?

Robert Purchase, M.D. - Top Shoulder Doctor in San Francisco, CA

Given all the health benefits of an active lifestyle and the beautiful outdoor spaces of our area, many San Francisco Bay Area residents participate in regular exercise. If you travel anywhere on the weekend, you will see that the area’s trails and roads are full of road cyclists, runners,hikers, and mountain bikers. This doesn’t even consider those who participate in indoor exercise activities such cross-fit, yoga,weights, etc.
When to see a San Francisco Knee Doctor
Unfortunately, a good number of regular exercisers will experience knee pain from time-to-time. If active people came to the knee doctor for every ache and pain, it would become a part-time job. So the question becomes what knee pain is worth getting checked; we are lucky in the San Francisco Bay Area to have many of the best knee doctors around.

As an orthopedic surgeon in San Francisco, I see and talk with many patients who want to maintain an active San Francisco lifestyle yet have knee problems. Here are my thoughts.

Common Types of Knee Injuries: Anterior Cruciate Ligament and Medial Collateral Ligament

Sometimes when a patient looks me up as his or her knee doctor, it’s obvious what the pain is when they come into my office. Any acute, traumatic injury should be evaluated especially if there is the immediate onset of pain and swelling. While fractures about the knee present in a way that makes the need for further evaluation obvious, some patients are able to convince themselves that they can “walk off” most ligament injuries.The two most common knee ligaments that are injured are the Anterior Cruciate Ligament (ACL) and the Medial Collateral Ligament (MCL). While most MCL’s heal with appropriate bracing, a good number of patients with ACL injuries will have ACL reconstruction to hasten their return to the prior level of activity and prevent secondary injuries,such as meniscus tears. Therefore, a patient who experiences the acute onset of pain and swelling associated with their knee giving out should seek an evaluation with an orthopedic surgeon to ensure that they are appropriately diagnosed and treated.

Most traumatic meniscus tears require surgery. The symptoms that they cause, locking and catching that causes pain and limits function, are a result of the mechanical consequence of the injury. The torn portion of meniscus acts similar to a pebble in one’s shoe. Unfortunately,most meniscus tears do not respond to non-operative treatments.Therefore, a patient who experiences the onset of episodic pain and the above mechanical symptoms after a twisting knee mechanism should be seen by an orthopedic surgeon.

There are a whole host of musculo-skeletal conditions that can cause the insidious onset of chronic knee pain such as patello-femoral syndrome (AKA chondromalacia of the patella) and iliotibial band syndrome (ITB syndrome). While an orthopedic surgeon can most accurately make a diagnosis and prescribe an initial non-operative treatment plan, most patients will respond to some basic, intuitive measures. Sometimes, the easiest thing to do is take a week off or cross-train. By changing the routine and allowing the injured part to rest, most people will experience symptom relief. Similarly ice and compression can provide relief. A well-rounded stretching and strengthening routine can not only address the root problem but can prevent these issues if followed routinely.

Reaching out to a San Francisco Knee Surgeon or Specialist

Unfortunately, some patient’s problems do not respond to this at-home approach. If that’s the case or if your symptoms are severe enough to cause a significant restriction of your activity, then an trip to the ortho office makes sense. Fortunately, San Francisco is a city not just with an active lifestyle but with many top orthopedic surgeons and specialists!

Clearly, this discussion only scratches the surface, but hopefully this provides some assistance in decision making. Of course, when in doubt, have it checked out.

~ Robert Purchase, M.D., March 3, 2013

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It Is All in Your Mind

There is strength within all of us. Whatever you want to call it: the power of the human spirit, will power, perseverance, determination. And it is on display all around us.

One morning I watched a video documenting one person’s transformation from an obese disabled vet who required a back brace, two knee braces, and crutches to walk into a fit middle-aged man who could run. I was so struck by it. I posted it on my Facebook page. Later, after my morning run, I read an article in the recent Journal of Bone and Joint Surgery entitled “Contribution of Kinesophobia and Catastrophic Thinking to Upper-Extremity-Specific Disability.” While not a great title, it showed that patients who were afraid to move their arm and had negative thoughts about their injury had more disability than those who viewed their injury in a more positive way.

As an orthopedic surgeon, I see examples of the triumph of the human spirit every day. Sometimes it is the total knee replacement patient that pushes through their rehab and gets the outcome that they want. Other times, it is the trauma patient that refuses to succumb to their injuries, both those on the x-rays and the other ones that you can’t capture on an image. Unfortunately, I have had patients who have not done as well.

We often forget that our responses to the world are just as important as the actual events. A friend of mine once explained that their idea of Karma was self-determined. In their mind, Karma came from the way that we choose to respond to the events that happen to us. I guess it is sort of like making lemonade out of lemons.

I am not sure how I started by reading such an imposing sounding article and ended by contemplating the meaning of Karma. Maybe I should stop reading orthopedic journals right after my morning run. But I do know that the way orthopedic patients respond to their injury/post-op rehab has a major impact on their outcome.

Robert J. Purchase, MD

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Tis the Season- for ACL tears

The 2 most common ligament injuries in skiing are the medial collateral ligament (MCL) and the anterior cruciate ligament (ACL). These injuries are not quite so common in snowboarding. Ligament injuries generally occur as a result of a high speed injury and do not occur with a simple pivot or twist. That is how a meniscus tear occurs.

The MCL is sprained or torn most commonly. It is a strap-like ligament on the inner side of the knee. The hallmark of an MCL tear is medial or pain on the inside of the knee, and generally the pain is worse the next day for milder sprains although for complete tears, sometimes there is very little pain because the ligament is no longer attached to the bone. Most medial collateral ligament tears are treated conservatively without surgery and take 6-12 weeks to completely heal.

The ACL is a main pivot to stabilize the knee and is in the center of the knee. It is needed for pivoting, twisting, and for most sports. 70% of the time a pop is heard at the time of injury. The history is very helpful in making the diagnosis.

At the time of the ski injury, in general, most patients with a ligament tear will feel some instability. If both ligaments are torn, when one gets up and tries to bear weight, the knee will buckle. If you are unable to ski down the slope, it is more likely than not that a ligament injury may have occurred. A rare patient with an isolated ACL tear will be able to ski down the mountain if they are very careful.

Immediate swelling of the knee generally means something has bled inside the joint and suggests a more serious injury and is not seen with an isolated MCL tear. This generally is seen with an ACL tear, fracture or kneecap dislocation. A pop is heard 70 % of the time in those having an ACL tear.

Initial treatment is RICE, rest, ice, compression and elevation and often some sort of immobilizer is placed. Crutches are generally needed. Weightbearing and walking on the leg should be minimal until you are cleared by an orthopedic surgeon. Range of motion and movement, as well as continuing to flex her quadriceps muscles, generally are safe.

If a visit to the emergency room is made, generally x-rays are done to rule out a fracture, and treatment will consist of a splint and crutches. Ask for a copy of your x-rays, since they can often be placed on a CD now, so they don’t have to be repeated. It is best to see an orthopedic surgeon if you heard a pop or are unable to bear weight within a few days. In the meantime, use Rice treatment. If you have an HMO and have to go through your primary care physician first, let them know that you want a referral to an orthopedic surgeon. In general, waiting a few days for the swelling to go down will not be harmful to your knee, unless the ligament injury is on the outside (lateral side) of the knee rather than the inside. The injuries to the lateral collateral ligament (LCL), can be much more complicated and may need more urgent attention if they are combined with either an ACL tear or PCL tear. So, significant swelling bruising or tenderness on the lateral or outside of your knee should be seen by an orthopedic surgeon fairly soon. And seeing an orthopedic surgeon with a subspecialty in knees would be ideal. These can be very tricky and complicated injuries.

Some patient’s call our office asking for an MRI before they are even seen. While in our high-speed Internet age, this may seem the most efficient thing to do, not all MRIs are of the same quality, and are very expensive. Insurance companies will not authorize them without an exam. Your orthopedic surgeon will know the best place to have it done. It has been shown in numerous studies, that an adequate physical examination and history by a trained knee surgeon is nearly as accurate as an MRI. I personally use the MRI to help me with preoperative planning and timing.

So, if you were skiing, fell, heard a pop, your knee swelled and you felt unstable when you got up, chances are you tore your ACL. It is a real bummer when the powder is fresh and it is your first day…

The next blog will cover the treatment options for ACL injuries. This is where the patient as a consumer can become overwhelmed with the multiple treatment approaches, graft choices and postoperative care. Hopefully, it will give you some direction. The main point is in treatment of ACL injuries, there is no urgency in the vast majority of cases, and if someone is urging you on to have surgery “today” and all you have is an ACL tear, get a second opinion.

-Lesley Anderson, MD

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The Emerging Problem of Atypical Femur Fractures in Patients with Osteoporosis

As an orthopedic surgeon who treats all manner of injuries to the extremities, such as the shoulder, hip, and knee; the impact of osteoporosis on my patients is a major concern of mine. The treatment of osteoporosis has been greatly improved with the development of a class of medications called bisphosphonates. This treatment has resulted in a decrease in the rate of the typical hip fractures and other sequela of osteoporosis.

Unfortunately, there has been a growing awareness of an increased incidence of relatively atypical femoral stress fractures in those patients who have been on bisphosphonates for a long time. These atypical femoral fractures are harder to treat and slower to heal than the more typical type of hip fractures.

Recently, I have treated three individuals with atypical femoral stress fractures who had been on long-term bisphosphonate therapy. All of them reported experiencing hip/thigh pain for weeks prior to the stress fracture completing itself. This experience has shown me that the awareness of this problem has to increase. To that end, followers of my Facebook page (facebook/Robert-Purchase-MD) have seen the recent posts, including the recently made Youtube video (

Patients who have been taking these medications need to be more aware of this association, and doctors, myself included, need to consider this as an explanation of hip/thigh pain. It is suggested that a holiday from the medication can prevent the development of the problem all together, and appropriate treatment of the stress fracture can prevent the painful, acute event of fracture completion.

- Robert J. Purchase, MD

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