Runner's Knee (aka Chondromalacia Patella)

Chondromalacia patella, also known as Runner’s Knee, is the softening and breakdown of the cartilage that lines the underside of the kneecap.  It is a very common problem that develops in runners, tri-athletes, cyclists, and other athletes.

Causes, Incidence, and Risk Factors

Chondromalacia of the patella occurs in adolescents and young adults.

The condition is more common in females. It can be related to the abnormal position of the knee.

Your kneecap (patella) sits over the front of your knee joint. As you bend or straighten your knee, the underside of the patella glides over the bones that make up the knee.

Strong tendons help attach the patella to the bones and muscles that surround the knee. These tendons are called:

·         The patellar tendon (where the kneecap attaches to the shin bone)

·         The quadriceps tendon (where the thigh muscles attach to the top of the kneecap)

Problems begin when the kneecap does not move properly and rubs against the lower part of the thigh bone. This may occur because:

·         The kneecap is in an abnormal position (also called poor alignment of the patellofemoral joint)

·         There is tightness or weakness of the muscles on the front and back of your thigh

·         You are doing too much activity that places extra stress on the kneecap (such as running, jumping or twisting, skiing, or playing soccer)

·         You have flat feet

Chondromalacia of the patella can also be a sign of arthritis of the kneecap, which is usually seen in older people.

Symptoms of Chondromalacia Patella

·         A grating or grinding sensation when the knee is flexed (moved so that the ankle is brought closer to the back of the thigh)

·         Knee pain in the front of the knee that occurs when you get up after sitting for a long period of time

·         Knee pain that worsens when you use stairs or get out of a chair

·         Knee tenderness

Signs and tests

A physician will perform a physical examination. The knee may be tender and mildly swollen, and the kneecap may not be perfectly lined up with the femur (thigh bone).

When you flex your knee, you may feel a grinding sensation below the kneecap. Pressing the kneecap when the knee is straightening out may be painful.

X-rays are usually normal, although a special x-ray view of the kneecap may show signs of arthritis or tilting.

Treatment

Temporarily resting the knee and taking nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, naproxen, or aspirin may help relieve pain, as well as electrical muscle stimulation of the quadriceps muscles. Being that there is a problem with the tracking of the patella, VMO (vastus medialis obliquus) retraining is very important.  Chiropractic adjustments of the lower extremities will help remove any restrictions to the kinetic chain.  Stretching the muscles on the back (hamstrings) and front (quadriceps) of your upper leg is also important.  If you are overweight, trying to reduce your body weight by as little as 10% can make a drastic difference.  Orthotics for your athletic shoes and kinesiotaping of the patella can help prevent symptoms.

In regards to exercise, utilize these tips:

·         Avoid running straight down hills; walk down instead.

·         Bicycle or swim, instead of running.

·         Reduce the amount of exercise you do.

·         Run on a smooth, soft surface such as a track, rather than on cement.

Also, make sure your running shoes:

·         Are made well

·         Fit well

·         Have good cushion

Lastly, if the pain does not improve and there are signs of arthritis developing around the kneecap, surgery may be an option.

Remember:

The first step in fixing chondromalacia patella is determining whether you in fact have that condition.  Visit a health professional that specializes in musculoskeletal health such as a chiropractic physician or an orthopedic physician to get an accurate diagnosis. 

Elbow Reconstruction vs. Shoulder Surgery: Which has the better outcome for Pitchers?

When you are a pitcher, the absolute last thing that you ever want to hear from your doctor is that you need surgery.  However, if the damage is bad enough, that may be exactly what is necessary to get you back on the field.  With pitchers though, especially the ones that do it for a living, surgery is never a guarantee.

More often than not, the damage done to a pitcher's throwing arm, occurs due to repetive trauma of throwing a little, white, roughly 5.25 ounce ball over many years, at high speeds.  The terms "Tommy John" (now more often associated in the minds of this generation of fans with an elbow surgery than with the individual after whom the procedure is named), "rotator cuff repair" and "torn labrum" have all made their way into the baseball vernacular, perhaps desensitizing us to just how serious these procedures are.  While much progress has been made both in terms of surgical technique and in the rehabilitation parameters following surgery, we have not yet arrived at a place in medicine where a return to play is assured.

That said, the outcomes for elite pitchers following ulnar collateral ligament (UCL) reconstruction (more commonly referred to as Tommy John surgery) are quite good. In a study published in the American Journal of Sports Medicine in 2007 that looked specifically at return to play for major league pitchers following UCL reconstruction, 82 percent successfully returned at an average of 18.5 months after surgery. The term "successfully returned" is key since no pitcher wants to come back a lesser version of his former self. In the AJSM study, reconstructed pitchers were followed for seven consecutive seasons and demonstrated no significant change in mean ERA or WHIP when compared to their pre-injury numbers. While good outcomes following Tommy John surgery have been widely reported, this study was unique in that it focused specifically on major league baseball pitchers.  This data is extremely encouraging for pitchers facing elbow surgery.

If a pitcher is facing shoulder surgery however, the outcome is not nearly as promising.  Only 35 percent to 50 percent of throwing athletes return to their previous level of performance following shoulder surgery. One study presented at the 2008 American Orthopaedic Society for Sports Medicine Specialty Day Meeting indicated that of 12 players at the high professional level (major league baseball, Triple-A and Double-A) who underwent shoulder surgery, only one made it back to that high level of play.

This might explain why former pitching phenoms like Mark Prior and Brandon Webb have been unsuccessful thus far in recapturing their glory days.

One factor has to do with the basic anatomy and biomechanics of the two joints. The elbow is a hinge joint with primary movement in one direction that allows for bending and straightening. The shoulder, however, is a more complex joint that allows for significant movement in three planes.

In fact, the human shoulder is so mobile, we can practically make a 360-degree circle with the arm. Pitchers, as a function of their position, have even more mobility in their throwing shoulder. Just look at any still image of a pitcher when his arm is in the late-cocking position (just before he begins the forward motion of his delivery) and it seems as if his arm is on backward.

But that mobility comes at a price. Increased range of motion translates to less stability in the joint, which is why shoulders are one of the most easily dislocated joints in the body. Although technically a ball and socket joint, the shoulder is somewhat unusual. The "ball" portion of the shoulder formed by the humerus or arm bone rests on a very shallow "socket" formed by the outer facing aspect of the shoulder blade. Were it not for the labrum (a ring of cartilage that lines the shoulder) -- ligaments in the joint, a fibrous capsule around the joint and finally all of the surrounding shoulder musculature -- the ball portion would fall off the socket with only minimal movement.

Consequently, any disruption of those surrounding tissues can not only cause pain, it can also spell trouble for shoulder stability. And when it comes to pitchers' shoulders, a torn labrum, ligament damage, capsular tears and rotator cuff strains can all be part of the picture. With the combination of power and finesse demanded of the shoulder in an elite thrower, compromising any of these structures can certainly alter his performance. Surgical repair may help provide stability, but the challenge is doing so while allowing the pitcher to retain enough mobility to resume pitching.

Because of the complex interrelationship of all this structures, surgery can sometimes be an educated guess.  According to Dr. Jeff Guy, team physician and medical director at the University of South Carolina. Guy, who trained under and now teaches with the renowned Dr. James Andrews, says that whereas Tommy John surgery primarily involves replacing a single ligament, most shoulder problems are complex and involve multiple structures. For a surgeon, the goal is to do enough to address the damage without overdoing it.

"It really comes down to clinical judgment at the time," Guy said. He describes shoulders that exhibit signs of severe wear and tear with fronds of tissue hanging inside the joint. "When the tissue is frayed you try to clean it up as best you can and hope that you've addressed what's causing the [athlete's] pain."  The scary thing is, that if the surgeon is clinically wrong, he/she cannot put the structures back. 

One of the challenges when it comes to pitchers and shoulder surgeries, according to Los Angeles Dodgers medical director Stan Conte, is while there are numerous outcome studies related to Tommy John surgery, good shoulder outcome studies are lacking in professional baseball.

"We talk about Mark Prior, we talk about Chris Carpenter, we look at how individuals have done," Conte said, "but we don't have very many good studies with large sample sizes. We really need a study with not 20, not 40, but 100 to 200 pitchers to find out what the outcomes truly are in professional baseball players.

Major League Baseball is working on putting together just such a study and is issuing grants to promote research. Currently, a database of player injuries does not exist in MLB as it does in the NFL and the NCAA. MLB's research committee (of which Conte is a member) is trying to change this. Gathering data would allow for retrospective studies, which could provide insight into the complex questions surrounding these pitching injuries, including how to better prevent them from occurring.

Until there are more definitive answers, baseball medical and coaching staffs will continue to tweak all the potential variables that influence the shoulder as best they can, maintaining shoulder range of motion, strengthening the shoulder, trunk and legs and examining pitching mechanics.

So while we wait for Major League Baseball to develop these definitive answers, it appears as though if you were a pitcher and had to choose between Tommy John Surgery or Shoulder Surgery, Tommy John Surgery has the best outcomes.

And while we wait, pitchers will still push the biomechanics envelope and see what the human body can withstand.

1. Stephania Bell, ESPN
2. Dr. Jeff Guy, University South Carolina
3. Dr. Stan Conte, Medical Director LA Dodgers

Steroid Use in Youth Athletes

The use of anabolic steroids is a hot sports issue. It has implications for both professional players and for young athletes who feel that they won’t have a competitive edge without steroids or other performance enhancers.  But, while professional athletes have a variety of trainers, nutritionists and health care specialists available, kids are on their own. And unlike international, professional and collegiate sports competitions and programs, high school athletic programs rarely test for steroid use.

Despite media warnings about the risks of anabolic steroids—which include fertility problems, potentially irreversible masculine traits in females and breast enlargement in males, toxic effects on the liver and cardiovascular system, arrested growth, and damaging psychiatric side effects—kids keep taking them.

According to surveys, 6.1% of students nationwide had taken oral or injected steroids without a doctor’s prescription at least once. The motivation to use steroids often comes from peer pressure, andin some cases, from parental demands to achieve greater goals. In addition, some teenagers simply want to look better.

What are Some Signs of Steroid Use?

- Increased weight gain in a short period of time

- Puffy, bloated facial features from water retention

- Increased acne on face, chest, and back

- Mood swings and irritability

- Masculine features in females

- Obsession in training

- Obsession with Sports Supplements

- Increased number of joint injuries

Additional Resources:

United States Anti-doping Association 

www.usaantidoping.org/dro/search/

NCAA List of Banned Substances

http://grfx.cstv.com/photos/schools/domi/genrel/auto_pdf/ncaa-banned-substance-list.pdf

Review of Injuries for Week 10 in the NFL via ESPN

Roddy White, WR, Atlanta Falcons: White injured his right knee in the first quarter of Sunday's game and while it did not appear serious, it gave him enough trouble to limit his productivity. According to ESPN NFC South blogger Pat Yasinskas, White left the game twice but ultimately returned to play in the second half after having the knee taped.


Naturally, the big concern for fantasy owners is whether White will be available in Week 10, given that the Falcons play Thursday night. According to Yasinskas, that question was answered when White said simply, "I'm going to be playing Thursday.'' Head coach Mike Smith has echoed that sentiment, according to D. Orlando Ledbetter of the Atlanta Journal-Constitution. Regarding White, Smith said, "[He] will be ready to go." White may not practice much given the short week, but the positive news this early is encouraging.


Austin Collie, WR, Indianapolis Colts: In perhaps the scariest moment of Week 9, Collie lay still on the field for several minutes in the second quarter following a hit across the middle while trying to catch a pass. The medical staff tended to Collie for some time, ultimately placing him on a spine board and stretcher and wheeling him off the field. As is the standard in situations in which there is concern about a potential spine injury, all precautions were taken to ensure Collie's safe transport from the field.


We later learned that Collie was alert and sitting up in the locker room. Good news indeed considering the last sight of him was motionless, other than his eyes blinking, on a stretcher. That said, it is important to remember that Collie still suffered a concussion, the seriousness of which should not be overlooked. There have been some positive signs since Sunday night. As Tom James of the Terre Haute Tribune-Star reports, Collie was able to travel home with the team and was improving on Monday. James says Collie is not expected to play this weekend against Cincinnati. Coach Jim Caldwell perhaps summed it up best saying, "He'll be released to play whenever he is cleared." Collie had just made a return from thumb surgery to repair a torn ligament when he suffered the concussion.

James also notes that there were no Monday updates on running backs Joseph Addai and Mike Hart, both of whom sat out Week 9 nursing injuries. Caldwell indicates that both players remain day-to-day.

Matthew Stafford, QB, Detroit Lions: Not good. Stafford injured his throwing shoulder again. While the Lions have not confirmed the details regarding the nature of his injury, MLive.com reports that Stafford has suffered a Grade III shoulder separation (he had previously suffered a Grade II separation, causing him to miss five games). While coach Jim Schwartz had said Monday that the team "was not talking surgical options" in regard to Stafford, Stafford himself indicated that he did not expect to play this week in his appearance on Mitch Albom's radio show.


It's a good bet Stafford may consult with Dr. James Andrews (who repaired Sam Bradford's Grade III separated shoulder) regarding this latest injury, as he has consulted with him in the past. Without confirmation as to the specifics of the injury, there can be nothing but speculation as to what sort of time Stafford could miss and what treatment he might undergo.


In the absence of anything definitive, fantasy owners at least know to prepare for an absence of Stafford of unknown duration. Shaun Hill has been recovering from a left forearm fracture and it is not known whether he could be available this week. As of now, Drew Stanton is preparing to be the starter, according to Birkett. The Lions and fantasy owners are no doubt hopeful that Hill will be cleared soon to return to play. Stay tuned for more updates in Detroit.


Jonathan Stewart, RB, Carolina Panthers: Stewart was the running back set to carry the load in Week 9 with teammate DeAngelo Williams out for a second straight week with a foot sprain. That was not to be, however, as Stewart made an early exit with a concussion. Although Stewart was able to walk off the field with assistance, he was carted to the locker room. Backup Tyrell Sutton was also forced out of the game with an ankle injury.


There is no way to predict whether Stewart will miss time, but the Panthers are no doubt hoping that Williams' recovery is imminent. Williams, who has not practiced since suffering the injury, indicated early last week that he was targeting a Week 10 return, but we need to see him run before feeling too confident. To compound the injury issues facing the Panthers, quarterback Matt Moore suffered a season-ending torn labrum in his right shoulder and has been placed on injured reserve.

This info is made possible via Stephania Bell, a physical therapist and writer for ESPN.

This year's attention to nationwide health care reform has cemented the health and fitness industry's emphasis on the need for proper accreditation and certification, according to an American College of Sports Medicine (ACSM) survey of fitness trends published in the November/December issue of ACSM's Health & Fitness Journal®. The growing demand for educated and experienced fitness professionals claimed the top spot in the survey for the fourth consecutive year.

"As the market in this sluggish economy becomes even more crowded and competitive, the need for regulation, either from within the industry or from external sources, is growing," said the lead author of the survey, Walter R. Thompson, Ph.D., FACSM. "For example, a number of states and the District of Columbia are considering legislation to regulate personal trainers just as it does physicians, lawyers and pharmacists." Thompson, an exercise physiologist at Georgia State University and a Fellow of ACSM, is also spokesperson for the ACSM American Fitness IndexTM.

The survey, now in its fifth year, was distributed to ACSM-certified health and fitness professionals worldwide and was designed to reveal trends in various fitness environments. Respondents around the world returned more than 2,200 completed surveys. Thirty-one potential trends were given as choices, and the top 20 were ranked and published by ACSM.

The most surprising findings, experts say, are the trends that have fallen off the list for 2011 - balance training, stability balls and Pilates. Pilates suffered the worst fall, disappearing after a ninth place ranking in 2010.

"It appears from this survey that Pilates may not have been a trend at all but may be considered a fad in the health and fitness industry," said Thompson. "Next year's survey will either embrace Pilates as a trend or will answer this question."

New trends to the list include worker incentive programs, clinical integration and reaching new markets. These additions directly reflect some of the work ACSM is doing to globalize the Exercise is Medicine® initiative.

"Interest in medical fitness, worker incentive programs, and worksite wellness programs may be a direct result of health care reform measures and Exercise is Medicine," said Thompson. "With an estimated 80 percent of Americans not having a regular exercise program or a place to exercise, health and fitness professionals must search for news ways to deliver their services to people who need them."

The top ten fitness trends predicted for 2011 are:

1. Educated and experienced fitness professionals. Due to increases in the number of organizations offering health and fitness certifications, it's important that consumers choose professionals certified through programs that are accredited by the National Commission for Certifying Agencies, such as those offered by ACSM.

2. Fitness programs for older adults. As the baby boom generation ages into retirement, some of these people have more discretionary money than their younger counterparts. Therefore, many health and fitness professionals are taking the time to create age-appropriate fitness programs to keep older adults healthy and active.

3. Strength training. Strength training remains a central emphasis for many health clubs. Incorporating strength training is an essential part of a complete physical activity program for all physical activity levels and genders.

4. Children and obesity. With childhood obesity growing at an alarming rate, health and fitness professionals see the epidemic as an opportunity to create programs tailored to overweight and obese children. Solving the problem of childhood obesity will have an impact on the health care industry today and for years to come.

5. Personal training. More and more students are majoring in kinesiology, which indicates that students are preparing themselves for careers in allied health fields such as personal training. Education, training and proper credentialing for personal trainers have become increasingly important to the health and fitness facilities that employ them.

6. Core training. Distinct from strength training, core training specifically emphasizes conditioning of the middle-body muscles, including the pelvis, lower back, hips and abdomen - all of which provide needed support for the spine.

7. Exercise and weight loss. In addition to nutrition, exercise is a key component of a proper weight loss program. Health and fitness professionals who provide weight loss programs are increasingly incorporating regular exercise and caloric restriction for better weight control in their clients.

8. Boot camp. Boot camp is a high-intensity structured activity program modeled after military style training and led by an instructor. Boot camp incorporates cardiovascular, strength, endurance and flexibility drills in both indoor and outdoor settings.

9. Functional fitness. This is a trend toward using strength training to improve balance and ease of daily living. Functional fitness and special fitness programs for older adults are closely related.

10. Physician referrals. Physician referrals, a key component of the Exercise is Medicine initiative, partner medical professionals with heath and fitness professionals to seamlessly integrate exercise into their patients' lives.

NFL Head Injuries Prompt Fines and Brain Concerns

The National Football League has fined three players $50,000 to $75,000 for violent helmet-to-helmet hits - which have been known to be devastating for players.

The league has been criticized for being too lax with head blows and the league's new medical committee members earlier this year  vowed to change that culture.

After several players were injured Sunday in what some fans and observers perceived as a particularly violent weekend of football, the NFL pledged on Tuesday to be more vigilant about ejecting and/or suspending players who have made flagrant hits.

The problem is by no means confined to the professional ranks. On Saturday, Rutgers defensive end Eric LeGrand was paralyzed from the neck down after his tackle on an Army player during a kickoff return.
Besides concussions, the concern is that the jarring blows to the head might accumulate damage to the brain without showing any symptoms.  Autopsies of football players have found a brain condition called chronic traumatic encephalopathy or CTE.  This can cause neurobehavioral disorders and bizarre behavior.

Former NFL players who took poundings to their heads from Pop Warner to the pros, like former San Francisco 49ers lineman George Visger has lived by scrawling the minutiae of his daily life on hundreds of small yellow notebooks, reminding himself when he left the house, when he got coffee.  His is one of several cases of ex-NFL athletes struggling with memory loss, depression and sudden, frightening bouts of rage.

"I get up in the morning and I have no clue what I have to do that day. If it's not written down it doesn't exist," Visger told CNN earlier this year.

The effects of the concussions can start early. The neurobehavioral symptoms of the brain damage are complex. In September, a 21-year-old football player who committed suicide was found to have CTE.  And in July,  it was announced that a former Cincinnati Bengals wide receiver had played in the NFL while having this type of brain damage.  Chris Henry died in December 2009 after falling from the bed of a moving pickup during a fight with his fiancée. His death was considered a tragic and bizarre end to a life plagued by behavioral problems.