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 (http://youtu.be/I4KioZS9fAQ).

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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Medical Literatures

Those readers who have had an office visit with me know that I like to base our discussions on available scientific literature. Those of you who have visited my facebook page know that I remain cautiously optimistic about the reform of our health care delivery system.  However, one of the proposed changes has me slightly concerned. The reforms suggest that all clinical recommendations, and the administrative rules that stem from them, should be based on the information within the body of literature.

The idea of using peer-reviewed double-blinded placebo-controlled studies to guide our decisions is the goal of every physician. It is the widely recognized ideal. The problem lies within the reality of the current state of the medical literature. There are not just gaps in the body of knowledge; there are wide chasms of unknown between the sharp cliffs of fact.

Take for instance, the common problem of blood clots (Deep Vein Thrombosis, aka DVT) after total joint replacement and the rare but potentially fatal secondary problem of those clots migrating to the lungs (pulmonary embolism, aka PE). The April issue of the Journal of Bone and Joint Surgery published the updated American Academy of Orthopaedic Surgeons Clinical Practice Guideline on Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty. This is a document intended to take all the current scientific literature on the topic in consideration and distill it into clear, concise clinical recommendations. Of the 12 recommendations that were generated, only one was rated as “strong”. Based on the literature, the American Academy of Orthopaedic Surgeons could recommend against the routine post-operative screening for DVT’s with an ultrasound test in the absence of symptoms.

Regarding the rest of the recommendations, the literature was found to be either incomplete, contradictory, or sometimes completely absent. I posted a summary of all the recommendations on my Facebook page for your review.  DVT’s are common in orthopedic surgery, and the rare PE is devastating. As a result, a great deal of time and effort is directed to their research. Even at that, there are many unknowns.

One of my first lessons in med school stressed the dichotomy of doctoring. It is equal part science and art. It has been true of medicine in the past, remains true, and will remain so well past the end of my career. I celebrate the focus on science in the health care reforms since it a worthy goal and a challenge to the research community. But it needs to be tempered by reality. Treatment guidelines and protocols need to recognize the gaps in the literature. There needs to be awareness that these guidelines and protocols cannot be a substitute for appropriate decision-making, the kind of decision making that doctors work hard to develop during their training and throughout their careers. I am afraid of the consequences of a health care delivery system that loses sight of either the science or the art of medicine.

-Robert J Purchase, MD

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Where Is The Service?

Have you tried to get anything fixed these past few weeks?  I am not talking about a knee or shoulder, but my example is about Comcast.  Recently, I had my internet go out in my home. Kind of important as I have an electronic medical record and could not access the patients charts. Anyways…it took three weeks, 15 phone calls, 7 visits from various technicians; all of whom had a different idea of the problem and a different solution. During each phone call after they left and the problem was not fixed, I was asked to take a satisfaction survey while on hold.  As you know, you think if you agree to take the survey, that  your call will be answered sooner.   Nope, it doesn’t work, you still wait a long time- but you do think maybe you waited less than the guy who did not agree to take the survey. Interesting psychology around that.  Well, after 7 visits from Comcast, which of course I had to be home for, one no show, no communication between any of them. It didn’t get fixed until I told them they couldn’t leave until it was fixed. You see, a new neighbor signed up and was added to the Comcast rolls, and they split our cable line, which cut our signal in half.  Think about it this way, each service person charges for their time to come out, whether or not the problem is fixed, they get paid either way. Yes, they come in 24-48 hours, but what is the use, if nothing is fixed. Kind of like the airlines telling you they have a 90% on time arrival time, when they build in 45 minutes sitting on the tarmac as to the flight time. Is this service in the new decade???

This blog is not about my woes with Comcast.  God knows, we all have our own stories about our various telecommunication providers.  But this reminded me about is how grateful I am about the unique and amazing staff I have in my office.  This past week, we have been down two staff members, both due to illness in their families.   As many of you know, our office really tries hard to provide real service; we answer the phones, not an answering machine, you know the name of the person answering the call. We call to provide appointment reminders, our staff tries to get back to you within 24 hours unless it is an urgent message and respond to concerns or complaints in the best manner that we can.

I have often told the staff that the reason a I am busy or successful is not necessarily only about my happy-go-lucky sunny disposition (right?), but really, it is as much about the service that is provided by one’s staff as well as the skills and care the surgeon provides. 

After my experience with Comcast, I wanted to provide some gratitude and appreciation of the hard work that my staff puts in everyday to go way beyond in terms of providing real care and support for our patients.  Yes, they get cranky from time-to-time, we all do, and occasionally aren’t up to our best. Sometimes we are late, too. And we all know that patients are not always the most polite people when they are in pain. But on the other hand, in this day of changing healthcare where people will become just an MRI or CT scan, a number or statistic for the government to track like Big Brother (no-not the TV show), we don’t mind being called a  “dinosaur”-  because that means we are providing care like it used to be performed and provided, and I thank my staff for allowing me to do that.

-Lesley J. Anderson, MD

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Physicians as Educators

As I had mentioned in a previous blog, I have been attending meetings to stay abreast of the many changes in healthcare. One of these meetings was hosted by a hospital system. The hospital wanted to lay out their strategy to deal with the anticipated changes to the healthcare landscape.

One of their basic tenets rang true to me. Their goal was increase the number of patients that would choose their hospital by providing what they called “a differentiated patient experience.” This is something that Dr. Lesley Anderson and I strive to do every single day.

One of the most important roles that a doctor fulfills is the gatekeeper of information. Due to their expertise, doctors have the key to a vast amount of knowledge. They can enlighten a patient about their disease/problem and potential treatments. In the information world, they can direct patients to reputable sources of information and steer them away from unreliable sources.

This is one of the more challenging aspects to the job. First of all, education takes time. Performing a thorough evaluation, formulating a treatment plan, and answering the patient’s questions doesn’t leave much time for education. Secondly, it can be very difficult to explain medical topics at the appropriate level. Finally, it is well known that it is difficult to communicate more than 2 or 3 important facts in one office visit.

Dr. Anderson and I take our role as educator very seriously. The practice’s website is full of educational content. Even this long-running blog, initiated by Dr. Anderson, is an attempt to educate our patients about issues that do not fit nicely into a disease-defined box.

However, we can do better. We are actively pursuing educational tools to supplement our patient’s office experience.  We anticipate adding to the current educational content with both commercially available content and some “homemade” offerings.  I have been emailing informational links to patients that speak to their unique musculoskeletal problem. With an eye to making this interaction more robust, we are looking at new software to facilitate communication and dissemination of information. In the spirit of exploring social media and medicine, I have started a professional facebook page www.facebook.com/pages/Robert-Purchase-MD/148246755251988?ref=tn_tnmn. It allows me to explore musculoskeletal topics in a completely different way. Hopefully, it is a non-traditional source of medical information that benefits the community at large.

Dr. Anderson and I have always been fully committed to our role as educators. It has always been and will remain key to our attempts to provide high quality orthopedic care and a differentiated patient experience.

-Robert J Purchase, MD

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A Rising Tide Lifts All Boats

Unless you are living under a rock, you are aware that there is a veritable revolution going on in healthcare. Many forces are converging to change the way healthcare is delivered in this country. There are many stakeholders; physicians, hospitals, drug companies, insurance companies, etc; who are anxious about how these anticipated changes will affect their future.

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

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ILIOTIBIAL BAND SYNDROME or “RUNNERS KNEE”

I have seen several cases of IT band syndrome this week in the office and as the weather gets a little bit better, people are starting to get out and run more.  The iliotibial band syndromes are a very common cause of pain on the outside of the knee and most commonly seen in active athletic population.  This can occur in up to 12% of runners and among cyclist can account for 15-24% of all overuse injuries.  It can be seen in any sports, but these are the most common. 

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

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Advancements in Running Shoes

As a runner and an orthopedic surgeon, I have two reasons to keep abreast of the advances in running shoe design. The design of running shoes is experiencing a revolution. What started as a fringe movement of barefooted runners morphed into a fad of minimalist shoes and is now becoming a more mainstream trend towards light weight shoes with low heel heights.

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

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Changes in Orthopedics

Two weeks ago, the American Academy of Orthopedic Surgeons (AAOS) held its annual meeting in San Francisco. The meeting brings orthopedic surgeons from around the world together for a week of education, exchange of ideas, and camaraderie.  

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

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