In an attempt to stay abreast of these changes, I have recently attended two meetings in as many days, one hosted by an insurance company and another by a hospital. At each meeting, I heard the same quote, “A rising tide lifts all boats.” I had heard it before, but the quote rang out to me on both instances. In the setting of a business meeting where one group is discussing its plans to outperform another group, it initially seemed out of place. Eventually, I was able to see its veracity and relevance.

The phrase has been mistakenly attributed to John F. Kennedy, but it was in common use by a regional New England Chamber of Commerce prior to JFK’s speech. The phrase suggests that each individual that makes up an economy benefits when the economy, in general, improves. It may apply to medicine as well as macroeconomics.

Health care reform is supposed to improve the delivery of health care in this country. If this goal is attained, it will benefit all those who participate in healthcare, both patients and providers. Out of this painful and anxiety-provoking process, I hope that we will have a healthcare system that is more transparent, better at its primary task, friendlier, and more financially sustainable.

In our country, many societal goals are achieved through competition. One group tries to differentiate itself from another. This motivates the other group to do the same. And in the end, both groups are better as a result.

I wish I had a crystal ball into which I could peer and see the future structure of healthcare. As a small business person, I would then know exactly how to change and grow to fit into the coming reality. But alas, I have no such insight into the future. Instead, I will continue to attend meetings in order to stay informed and “ahead of the curve”. But I will do so with the belief that a rising tide lifts all boats.

-Robert J Purchase, MD

There is the thick band which goes from the pelvis all the way down to the tibia or shin bone on the outside called the iliotibial band. This rubs over the prominence of the lower femur on the outside of the knee causing friction.  The iliotibial band is a large piece of fascia and it basically has very little give to it, unlike a muscle.  As it rubs across the prominence on the outside of the knee it causes friction, inflammation, and then pain which is very localized.  Newer theories as to the cause of the pain is that there is a layer of fat underneath of the band where it crosses over the edge of the femur and it is this structure that causes the pain rather than the band itself.  A third theory is that it is a small bursa or sac behind the band that can cause pain.

Most commonly the cause of iliotibial band are training errors including rapid increase in training routine, running on hills, increased milage, running on uneven or down slopping surfaces, and downhill running.  In addition, if you have a slightly “bowed leg”, increased foot pronation, weakness in your hips or some rotation of your tibia these can predispose or cause you up to develop IT band syndrome.

Other conditions that can look like iliotibial band syndromes include lateral meniscus or cartilage tear, arthritis of the outer compartment of the knee, stress fractures, or patellar pain syndromes.  Most cases can be diagnosed with a simple physical examination and some tests to check for tightness in the IT band.  MRI can be used as a diagnostic tool if basic treatment fails. It is usually not needed, unless surgery is considered.

Nonsurgical treatment generally includes anti-inflammatory medications for reducing the pain and acute inflammation, but overall that has not been that helpful.  Cortisone injections are done infrequently, and primarily done to confirm the diagnosis.  Physical therapy however is a very important part of the nonsurgical management and includes stretching of the IT band, strengthening and stretching of the hip musculature, use of a foam roller to massage and break up any adhesions present there, in addition to ice.  Obviously getting to the cause of the IT band syndrome is most important with occasional reevaluating foot, shoe wear, and running techniques.  Most people get better in 6-8 weeks with nonsurgical treatment and only a small percentage come to surgery.

Surgery:  The fact that there are many different types of surgery to treat IT band syndrome that has failed conservative treatment,  really indicates that one is not superior to the other, and the jury is still out as to which one is the best technique.  Personally, I am very slow to recommend surgery in these conditions unless nonsurgical treatment has been exhausted.  Most of these require an open incision either lengthening of the IT band, removal of tissue or bursa underneath the IT band or removal of the fat that may be cause of the pain.  A recent arthroscopic technique has been described which holds some promise, and has had very encouraging results.

As always, prevention is the best cure, so make sure you check your shoes, increase your mileage slowly and keep those hips and hamstrings flexible! And enjoy the weather!

- Lesley J Anderson, MD

All of this began with Christopher MacDougall’s book Born to Run in which he tells of the Tarahumara Indians who can run unlimited miles while only wearing what can best be described as a thin-soled sandal. The author observed that these Indians had a mid-foot strike which is vastly different than the heel-first strike, typical of most shoe-wearing runners.

The belief is that a natural running stride begins by landing on your mid-foot. This allows the foot to absorb the impact, store that energy, and ultimately release it at toe-off. It is hypothesized that the foot has evolved for this particular purpose. However, the modern shoe developed big, cushy heels that allowed for a heel strike. This heel-first approach stops forward motion and theoretically exposes the hip, knee, and ankle to greater forces and unnecessary stress.

From a biomechanical and evolutionary point of view, this made sense to me. Furthermore, there is literature to support the above theories. Studies have shown that runners wearing traditional shoes hit heel first and with greater force than barefoot runners, that shoes with a higher heel place greater stress on the knees, and that runners with a mid-foot or fore-foot strike experience less stress on certain joints. However, I have to say that no one has been able to show a direct cause-and-effect relationship between shoe wear and injuries.

So, despite being a relatively heavy, flat-footed runner who had never worn anything but bulky stability shoes, I experimented with minimalist shoes. I started with light weight trainers with a low heel height. And while I haven’t run barefoot since that one night in college, I do have a pair of Vibram FiveFingers. I can say one thing for sure; I will never wear my old stability shoes again. Not only are my lighter, lower shoes a blast to wear, they even look fast.

In my mind, there is something to these minimalist shoes, but you have to be careful. Long before I started changing my footwear, I started changing my stride, making a conscious effort to avoid a heel strike. A fore-foot strike produces approximately 42% more force in your Achilles tendon than a heel-strike, not to mention the additional stress on the plantar fascia. Predictably, my calves and Achilles tendon required some time to adapt (read pain and tendinitis). With any such drastic change, do it slowly and give it time. Finally, we are all a little different. For many biomechanical reasons, I will never be able to log more than a couple miles every once in awhile in my Vibrams while others may actually be able to run barefoot.

Either way, running shoes will never be the same, and our knees and hips have much to celebrate as a result.

-Robert J Purchase, MD

Physicians, like many other professionals, must continually renew their base of knowledge and update it as the field evolves. While not every technological advance outperforms the current standard, medicine is advancing at a rapid pace. It is important for physicians to remain current in their field. I am inspired and humbled by the collection of thinkers and innovators that this meeting brings together.  

In my lifetime, orthopedics has changed completely. When my older brother tore his ACL, surgical reconstruction was not recommended. He continued to have difficulties that ultimately cut short his collegiate wrestling career. Armed with that historical perspective and with the latest reconstructive techniques, a non-operative approach in the young, athletic population is not common today. Likewise, the shoulder techniques I learned during my training were cutting-edge just a few short years ago. As a shoulder fellow, I published a description of an advanced arthroscopic technique to help solve very unstable shoulders. At this year’s meeting, I saw several posters, presentations, and papers about that technique.

That is not to say that all of the advances in orthopedics have come recently. Some of the fracture techniques we still use are based on principles that have been around for decades or more, and all of today’s advances rest on the bedrock of sound orthopedic principles.

The point is that it is meetings like this one force us all to re-evaluate what we are doing. The opportunity to discuss and debate the merits of new techniques makes us all better doctors. I am grateful for the opportunity to reaffirm and challenge my knowledge base and participate in the community of orthopedic surgeons.

- Robert J Purchase, MD

One of the reasons I love orthopedic surgery is because there is always something new to learn, innovation has been fostered and through this innovation has brought total knee replacements, total hip replacements, and surgeries to improve the quality of life for millions of Americans.  Today, I am actually taking the day “off” from the Academy and spending time sifting through  what I have been learning and integrating that into some self assessment examinations.  (Yes, at my age, I still have to take tests and questions). 

In the next few blogs, I am going to talk about some of the updates that we learned during this meeting. 

Today, I will just say a few words about smoking.  As you know, smoking is no longer as big an issue that we see in California since laws have restricted ones ability to smoke in most public places and even near public buildings.  So, smoking is much less prevalent here in California, and especially in Bay Area.  So, most of us do not think it as a big issue.

However, it is well established that smoking increases risks of bones not healing (called nonunions), failure of fusions of spine surgery, poor wound healing and increased infections in joint replacement, rotator cuff repair, and has a huge impact on healing.  Many orthopedic surgeons refuse to operate on a patient for a spinal fusion or a cervical spine fusion if they are smokers.  I insist my patients that are smokers to stop before I will perform rotator cuff repair since it has been established that there are higher incidences of failure of healing of these tendons.  In my next blog, I am going to speak about osteoporosis and some of the new controversies surrounding that.  This is one of the current “hot topics” in orthopedics.  So, stay tuned in the next few weeks.

- Lesley J. Anderson, MD

Like many of you, I grew up in a time when concussions received little attention. In fact, many sport specific cultures encouraged early return to play after “getting your bell rung”. It was taken as a sign of toughness. Fortunately, that culture is slowly changing, even at the professional level. We would never expect today’s children and teenagers to unduly endanger their brain health.

In keeping with this shift, the slopes are filled with kids wearing helmets. Yet it amazes me to see the adults, the children’s parents and mentors, wearing nothing but a winter cap. This not only jeopardizes their personal health, but it also models reckless behavior and establishes an unnecessary double-standard.

The statistics regarding traumatic brain injuries (TBI) from skiing have been widely published. There have even been some highly public deaths from ski-related brain injuries. Nonetheless, adults continue to choose to ski without protecting their most precious asset, their brain.

One of the most rewarding aspects of orthopedics is that musculoskeletal injuries are universally amenable to care, whether rehab or surgery. Modern medicine has limited ability to positively impact upon the primary brain injury. The care of TBI patients is generally focused on limiting secondary damage, maximizing Mother Nature’s capacity to heal. Unfortunately, the adult brain has little capacity to heal.

Even the most subtle TBI leaves permanent damage. Often times TBI patients note ongoing cognitive problems, such as memory deficits and difficulty with higher order organizational tasks. As a result, some TBI patients are unable to return to work, no longer a provider but instead requiring care. Loved ones will often note subtle but troubling changes in the injured patient’s personality. In short, the TBI patient is very rarely the same person ever again.

I encourage you to fully enjoy all the outdoor activities this winter. The silver-lining of even the most gnarly orthopedic injury is that there is always next year. Just wear a helmet.

-Robert J Purchase, MD

We welcome you to come by and see our holiday train platform.

 Wishing you health and happiness,

Warm wishes for a Happy Holidays,

Lesley J. Anderson MD, Robert J. Purchase MD, Debby Anziano PA-C, Michelle, Jessica, Pilly, Jennifer, Beleny, and Ericka

As the holiday season is approaching, I thought I would talk about injury prevention.  The other day, I did a face plant in my driveway as I was trying to get a large cardboard box broken up for my recycle bin.  It was amazing how fast that one second I am jumping up and down on a box and the next I was falling face down on the driveway after slipping.  Fortunately, all I got out of it was some very sore muscles and few bruises. (I am still not sure about my rotator cuff, though.)

It did remind me, that as we go in to this holiday season, while we are trying to multitask- get that extra chore done, to get those lights up, pick up the kids, make that meeting, get the shopping done, how just an extra second of time may prevent a fall or serious injury.

Such a simple thought. Just take a few seconds, take a deep breathe, focus and center on the task at hand, and not jump to 4 other tasks you have to get to before the current one is done. Even though you are a good driver, and think that “Oh I can send just this one text message while I sit at this light,” no one will see you, and before you know it, you rear end the car in front of you. Or putting up the lights, reaching for that top light on the top of the ladder, or up on the roof, and in a nanosecond, down the ladder goes, and you could fracture your shoulder, hip or worse. Didn’t want to wait for someone to help. So slowing down just a bit and take the extra time can have huge benefits. Check out this link. http://orthoinfo.aaos.org/topic.cfm?topic=A00367.  

In regards to injury prevention, there are a few simple exercises one can do to reduce the risk of falls. And the loss of balance is the number one cause of falls. As a matter of fact,  falls and the injuries that occur have a huge physical, emotional and financial  impact on the quality of life, not only in all people, but more importantly, in those over age 65.  One of the biggest risk factors for death in women over 65 is a fall.  The consequences of a hip fracture is reduced mobility, with complications of reduced mobility such as pneumonia. For some excellent tips, check out the following link for some actual exercises.  http://www.mayoclinic.com/health/balance-exercises/SM00049

Then enjoy the holidays!  Take that extra time, take a deep breath if you are feeling rushed or stressed. We all think it can’t happen to me, but as my face headed toward the pavement, it can!

-Lesley J. Anderson, MD

Unfortunately, my recent weekend of emergency department call has highlighted a downside of the season.  With the wet weather, our landscape changes which places our musculoskeletal health in unique jeopardy. 

The rain makes our urban landscape a much more treacherous place.  The many painted surfaces of our streets and sidewalks are particularly slippery when wet as are the manhole covers and various metal coverings that we encounter as pedestrians.  So please exercise caution when walking around our fair city, especially with arms full of gifts and packages. 

When we escape to more rugged spaces for some outdoor fun, similar problems arise.  While the splash and squelch from the newly formed mud and puddles add pure fun to your normal path and trails, they also inexorably change them.  You may not have the same traction or footing.  Slipping and falling becomes almost a certainty.  I am not saying that you shouldn’t blast throw the mud or leap from tree root to rock, but situational awareness can make the difference between a good story and a trip to the emergency department.  And always wear appropriate protective equipment. 

But should you find yourself in need of orthopedic care, we would be glad to see you in timely fashion.  Please enjoy a safe and happy holiday season.

-Robert J. Purchase, MD

Dr. Purchase will also be available to see patients there in Walnut Creek as well in the coming months.  Stay tune for dates and times there!

Center for Sports Medicine
770 Tamalpais Drive, Suite 206
Corte Madera, CA 95925

Appointments: 415-927-1900

-Lesley J. Anderson, MD