Physician Articles

By Dr. Jerome Barton, MD

Nursemaid’s elbow is a common injury occurring in preschool children usually between the ages of one and four. It is a partial dislocation (subluxation) of the upper end of the major forearm bone (radial head) when it slips partially out of the annular ligament which holds it in place.

It is frequently caused by an adult pulling on the child’s extended arm. The child is most often offering no resistance to the pull. The radial head is pulled downward out of its usual position where it is held by the annular ligament.

The child experiences pain and may later be relateively comfortable but will resist elbow motion. He or she will refuse to use the arm and will hold the arm against the body with the palm facing downward. It is usually evident that there has been an injury but it is sometimes hard to judge exactly where. There is usually no swelling associated with Nursemaid’s elbow.

A careful history including the pulling incident, the absence of a history of trauma, the absence of swelling and a gentle examination will usually make the diagnosis evident. X-rays are usually not necessary unless fracture is suspected.

The subluxation is reduced by the doctor by completely supinating the forearm by turning the palm upward. A click at the elbow can be felt as the radial head slips into place. After reduction the child is comfortable and returns to using the arm. No further treatment is necessary. If reduction was difficult or required several attempts or recurs, the elbow can be immobilized in a splint for a short time.

Nursemaid’s elbow may recur and parents should be careful to avoid traction on the arm and should so instruct other caregivers. It is very rare to have any residual problems from Nursemaid’s elbow even after recurrent episodes.

Nursemaid’s elbow is a relatively common problem in preschool children. It responds to gentle reduction, may recur but will respond to repeat reduction. It will stabilize with growth and usually has no long term effects.

By Dr. Jerome Barton

Injuries to the acromioclavicular joint are also known as shoulder separation injuries. They are distinct from shoulder dislocations which take place at the shoulder joint itself, the gleno-humeral joint. Shoulder separations occur at at the small joint at the top of the shoulder where the outer end of the clavicle ( collar bone ) meets the acromion, the superior outermost portion of the scapula

Injury to the acromioclavicular joint (AC joint) usually occurs from a fall on to the outer portion of the shoulder and usually with the arm at the side. It is characterized by varying degrees of pain and swelling dependent upon the extent of the injury to the supporting ligaments. The patient will point directly to the top of the shoulder as the painful injured area.

The AC joint is held together and stabilized by the acromioclavicular ligaments that surround the joint and by the very strong coracoclavicular ligaments that hold the clavicle at its mid portion to the coracoid, another adjacent part of the scapula.

The extent of injury to the AC joint is determined by the degree of trauma sustained and is measured by the extent of injury to both the AC (acromio-clavicular ) and CC ( coraco-clavicular ) ligaments.

Injuries to the acromioclavicular joint may be classified into three major groups.

Grade 1 injuries are a sprain or partial tearing of the AC ligaments and capsule that surround the AC joint and do not give rise to any clavicular instability.The coracoclavicular ligaments remain intact.

Grade 2 injuries involve a complete rupture of the AC ligaments and capsule and allow some displacement ( subluxation ) of the clavicle from its normal relationship to the acromion. The patient presents with pain and swelling about the AC joint and possibly some limited prominence of the distal end of the clavicle.

In both Grade1 and Grade 2 injuries the coracoclavicular ligaments remain intact.

Grade 3 injuries involve complete tearing of both the AC and CC ligaments and those injuries allow significant upward and posterior dislocation of the clavicle in relation to the acromion. The patient presents with considerable pain and swelling and obvious upward displacement of the clavicle.

Treatment of these injuries varies, of course, with the extent of injury.
Grade 1 injuries are treated with ice for swelling, possibly anti-inflamatories and analgesics as needed and a sling for support. As the acute symptoms subside a self-administered or formal therapy program is used to help regain motion and function and when appropriate the shoulder is guided back to a full activity schedule. The results are almost always good.

Grade 2 injuries are treated in a similar conservative manner. They take longer to resolve but results are usually good as is the return of function of the A-C joint. On occassion Grade 2 injuries may result in late symptoms related to the AC joint Attention to the joint at a later date will usually yield good results.

Grade 3 injuries are also mostly treated conservativly and on occassion with support to bring the clavicle down to more normal position. There are further subclassifications of the Grade 3 injury depending on the degree of soft tissue damage. Grade 3 injuries are frequently considered for surgical repair. Surgical repair involves operative fixation and repair of both the CC ligaments and the AC joint and the other injured soft tissue structures. Results are usually good but both the extent of injury and surgery lead to a more prolonged recovery and rehabilitation period.

Rehabilitation is an important part of the recovery process and becomes more important and prolonged with the more severe Grade 2 and 3 injuries. The patient must be guided through a program designed to recover range of motion, strength and neuromuscular control of the shoulder.

Results of treatment for AC injuries are generally quite good for the less extensive injuries but results may be compromised to some degree in the more extensive injury. Patient perception of outcomes will vary with age and functional demands of the shoulder.

In summary – Acromioclavicular separation is usually caused by a fall on the outer aspect of the shoulder. The degree of injury is related to the extent of injury to the acromioclavicular and coracoclavicular ligaments and varies from the more simple sprain to complete rupture of all noted ligaments and dislocation of the clavicle. Treatment is usually conservative but the more extensive injuries may require a more aggresive surgical approach.

By Dr. Paul A. Markey

Every day, people come to orthopaedic surgeons because of “hip pain”.  But often, what they are calling hip pain is not true hip pain.  How can this be?  It is because what most people call the hip is not the hip joint.  The hip joint is a ball and socket, and it is located in the groin.   The place that most people call the hip is on the side, at or below the belt line, where they put their hands when they stand with their hands “on their hips”, where a mother carries a baby on her “hip”, where the hip pockets of pants are, or where a policeman carries his pistol in a “hip holster”.  If you ask people to point to their hip joint, many will point to that area on the side, not to the groin.  We can speak of hip pain, therefore, as being either “true” hip pain—that is, coming from the hip joint itself—or “false” hip pain—that is, coming from another source.

True Hip Pain

True hip pain is most commonly felt in the groin, because that is where the hip joint is.  Sometimes it is felt also in the thigh or knee because of what is called referred pain, which is pain felt in a place other than at the source of the pain.  True hip pain is often accompanied by limping and decreased motion of the hip joint, causing the patient to have difficulty reaching his or her foot to cut toenails or tie shoes.

The most common cause of true hip pain is osteoarthritis, which is the most common joint disorder in the world, affecting more than 50% of people by age 65, and 80% by age 75.  It most often occurs in knees, hips and hand joints, and less often in other joints.  It causes destruction of joint cartilage, which is the smooth, slippery surface covering the ends of the bones.  You can see joint cartilage on the ends of a chicken bone.  As long as it stays smooth and slippery, joint motion is full and comfortable.  Osteoarthritis causes the cartilage to become soft and rough and to disintegrate, causing the joint to get painful and stiff.  If the pain is not too bad, it can be managed with over-the-counter or prescription pain relievers and a cane.  In some cases, a relatively new, minimally invasive operation called hip arthroscopy can help by recontouring and rounding the bones of the ball and socket if they have started to become deformed as part of the osteoarthritic process.  If the pain becomes too severe for the patient to tolerate, which is a common scenario, total hip replacement can be done.  Total hip replacement is one of the most common operations in the world, and one of the most successful, achieving in the great majority of cases complete relief of pain and restoration of normal walking and daily activities.

Another relatively common cause of true hip pain is a torn acetabular labrum.  The acetabular labrum is the rubbery cartilage rim of the hip socket, and it can become torn in slightly aging athletes doing vigorous sports, resulting in sharp groin pain with certain motions of the hip joint.  If it gets bad enough, that pain can often be greatly relieved by hip arthroscopy to repair or remove the torn cartilage.

Other causes of true hip pain include other kinds of arthritis, such as rheumatoid arthritis, and other conditions such as avascular necrosis and infection.  Avascular necrosis of the hip is death of the femoral head (the “ball” of the ball and socket hip joint) from loss of blood supply.  It can occur in people who have taken steroid medication for a long time, alcoholics, and after a femoral neck fracture or hip dislocation.  Rarely, it occurs spontaneously in young children, in which case it is called Perthes’ disease.  Infection in the hip joint can occur at any age, but is most common in infants and very young children, and causes fever and extreme pain. In young adolescents, a somewhat uncommon condition called slipped capital femoral epiphysis occurs, causing true hip pain and limping.  As a rule, sometimes with the exception of Perthes disease, these conditions will require surgery.  Occasionally, runners will develop a stress fracture of the femoral neck, resulting in groin pain and limping.  These stress fractures usually heal by themselves with time and rest from running.

False Hip Pain

The most common cause of false hip pain, which is felt in the side or back of the “hip” region, is referred pain from the lumbar spine (the lower back part of the spine), and it is more common than true hip pain.  The most frequent causes of  this pain originating in the lumbar spine are disc degeneration resulting in bulging or herniation of discs—either acute or chronic—and arthritic changes in the small spinal joints called facet joints.  These spinal conditions usually cause low back pain, and very often cause pain in the “hip”, groin, buttock, and thigh or farther down the leg.  This pain in these areas other than the lower back occurs either because of referred pain or because of radicular pain (sciatica) caused by pressure on a spinal nerve root from a herniated disc or the bone spurs of an arthritic facet joint.

The good news about pain coming from the lumbar spine, including false hip pain, is that it usually goes away, either by itself or with help from doctors and physical therapists consisting of advice about posture and body mechanics, pain-relieving exercises and sometimes medications.  Many patients have gone to see an orthopaedic surgeon complaining of severe “hip” pain, fearing that they might be heading for a hip replacement, and have been greatly relieved to find out that the culprit is not the hip joint but the lumbar spine, and that relief can be expected.

Another, less common, cause of false hip pain is trochanteric bursitis, which causes pain and tenderness over the bony prominence on the side of the hip region, often because of prolonged sitting which puts pressure on that spot.  It is commonly very long-lasting but not permanent, and can usually be relieved by changing one’s sitting posture and the type of chair one uses, by physical therapy, and/or by a cortisone injection.

An even less common cause of false hip pain is polymyalgia rheumatica, which can cause vague and diffuse pain and stiffness around the hip and shoulder regions, among other symptoms.  It is a vascular inflammatory disease, which can be very effectively treated with oral steroids.

Severe or persistent “hip” pain is a good reason to see a primary care doctor or orthopaedic surgeon.  By means of a history and physical examination, and sometimes x-rays and other tests, the doctor can diagnose and treat the problem with a high likelihood of success.

All of us, at some time or another, have twisted an ankle, on uneven ground, or have come down awkwardly, while playing a sport, such as tennis or basketball. What often results is a painful ankle sprain, a tearing of the fibrous ligaments that stabilize our joints. Ankle sprains are some of the most common injuries seen in an orthopedic practice, with about 25,000 people, in the US, each day, seeking treatment for an ankle sprain.

“My sprained ankle still hurts after 2 weeks - Why?”

Over 90% of ankle sprains involve an inversion, where the bottom of the foot turns inward, and the structures on the outer side of the ankle are put on stretch. Sprains are often graded from I to III, where a grade I sprain is a mild stretch injury, a grade II is a more significant partial ligament tear, and a grade III sprain is a complete rupture of one or more ligaments. Generally, there will be more bruising, swelling, and pain as the severity of the sprain increases.

When a patient first presents to the office after a sprain, the orthopedist will determine whether an x-ray is necessary, in order to rule-out a fracture or dislocation. Patients are relieved when they hear that there is no fracture, however, even severe sprains may not be visible on x-ray. It’s possible that a severely sprained ankle still hurts after 2 weeks, and may have a longer recovery and lead to more long-term problems than some simple fractures.

Do Sprained Ankles Ever Fully Heal?

Regardless of the grade of sprain, most, if treated properly, will heal without residual pain or instability. The initial treatment involves the well-known mnemonic, RICE (Rest, Ice, Compression, and Elevation). Depending on the severity, the orthopedist may prescribe a brace, a walking boot, crutches, or physical therapy. Exercises to strengthen the surrounding muscles and tendons are essential to restore flexibility and stability.

How Long Does Ankle Pain Last After Sprain?

Additional studies, such as MRI or CT scan, are usually not necessary immediately after an ankle sprain, as the results of these expensive and time-consuming studies rarely affect the initial management of the sprain. We have found that a sprained ankle still hurts after 2 weeks, however, if pain persists for 6 to 8 weeks or more, and does not seem to be improving, these additional studies may be required to make a proper diagnosis.

One problem that may lead to long-term dysfunction and pain after an ankle sprain is instability. Patients may feel loose or say that their ankle is giving way without the ligaments actually being stretched. If laxity of the ligaments cannot be determined on the physical exam, the orthopedist may do a “stress x-ray”, where he or she manipulates the ankle while an x-ray is being taken. This is a quick and usually painless procedure that may give even more information than an MRI. Patients, who are found to be unstable, and remain functionally unstable, despite bracing and therapy, may be candidates for surgical reconstruction of their ligaments.

If the stress x-rays are normal, an MRI may be ordered to look for other sources of pain. These sources could include residual scar tissue from the sprain, subtle injuries to bone or cartilage, at the joint surface, as well as tears or instability of the tendons that surround the joint. If these issues remain symptomatic, despite conservative treatment, many can be treated with minimally invasive surgery using arthroscopy. These arthroscopic procedures are usually done with local anesthesia and light sedation. Tiny incisions are made around the ankle through which narrow instruments and a fiberoptic camera can be inserted. The procedures take less than an hour, and patients return home the same day. Crutches are often required for only a week or two.

Seeking Treatment for Ankle Pain

Although many minor sprains are treated at home, without patients ever requiring medical attention, consultation with an orthopedic surgeon should be sought if there is significant bruising or swelling about the ankle, if there is pain and swelling above the ankle joint, or there is an inability to walk more than a few feet, without significant pain. Patients with poor sensation in their feet, such as diabetics, have to be especially cautious so as not to overlook more serious injuries. Many long-term problems, after an ankle sprain, can be prevented if a prompt diagnosis is made and treatment is instituted soon after the injury.

By Jerome Barton, M.D.

Injuries to the acromioclavicular joint are also known as shoulder separation injuries. They are distinct from shoulder dislocations, which take place at the shoulder joint itself, the gleno-humeral joint. Shoulder separations occur at the small joint at the top of the shoulder where the outer end of the clavicle ( collar bone ) meets the acromion, the superior outermost portion of the scapula.

Injury to the acromioclavicular joint (AC joint) usually occurs from a fall on to the outer portion of the shoulder and usually with the arm at the side. It is characterized by varying degrees of pain and swelling dependent upon the extent of the injury to the supporting ligaments. The patient will point directly to the top of the shoulder as the painful injured area.

The extent of injury to the AC joint is determined by the degree of trauma sustained and is measured by the extent of injury to the shoulder ligaments. Treatment of these injuries varies, of course, with the extent of injury.

Some injuries are treated with ice for swelling, possibly anti-inflammatory medication and analgesics as needed and a sling for support. As the acute symptoms subside a self-administered or formal therapy program is used to help regain motion and function and when appropriate the shoulder is guided back to a full activity schedule. The results are almost always good.

More severe injuries are frequently considered for surgical repair. Surgical repair involves operative fixation and repair of both the CC ligaments and the AC joint and the other injured soft tissue structures. Results are usually good but both the extent of injury and surgery lead to a more prolonged recovery and rehabilitation period.

Rehabilitation is an important part of the recovery process and becomes more important and prolonged with more severe injuries. The patient must be guided through a program designed to recover range of motion, strength and neuromuscular control of the shoulder.

Results of treatment for AC injuries are generally quite good for the less extensive injuries but results may be compromised to some degree in the more extensive injury. Patient perception of outcomes will vary with age and functional demands of the shoulder.

By Dr. Paul D. Protomastro, M.D.

Arthritis is a common cause of shoulder pain and dysfunction that drives many people to need the care of an orthopaedic surgeon. The shoulder joint is formed by a ball on the upper end of the humerus bone that rotates within a small socket on the shoulder blade bone known as the glenoid. The surface of both the ball and socket are coated with a thin, frictionless lining known as articular cartilage. The gradual thinning and ultimate loss of the cartilage lining from the joint is known as osteoarthritis. Osteoarthritis more commonly affects the hips, knees and hands but it frequently affects shoulders. As the cartilage on the surface of the ball and socket joint wears out, the bones begin to rub and grind against one another causing inflammation, swelling, stiffness and pain. As these symptoms increase shoulder function gradually deteriorates. Thankfully mild to moderate shoulder arthritis is far better tolerated than that of the hip or knee, likely due to the non-weight bearing nature of the shoulder.

In the early stages of shoulder arthritis, a variety of non-operative treatments can decrease pain and improve function. Gentle stretching and strengthening in combination with over the counter pain medications such as Tylenol or Ibuprofen are often effective. If these simple measures fail to provide acceptable relief, injecting cortisone (steroids) into the shoulder joint is a safe and effective way to achieve significant yet temporary pain relief by decreasing inflammation. Injection of joint lubricant (Hyaluronic Acid, eg. Synvisc) into the shoulder is currently under investigation as a means of decreasing pain and improving function, however, the safety and efficacy of this treatment has yet to be determined. Alternative treatments such as oral supplements (Glucosamine and Chondroiton Sulfate), acupuncture, massage, and rehabilitation (electrical stimulation, ultra-sound and supervised exercise) to reduce symptoms may also be effective.

When these simple measures prove insufficient and the pain and compromised function of shoulder arthritis become severe, surgery is a valuable option. Despite years and millions of dollars of research, there is currently no way to restore or regrow healthy cartilage on arthritic joint surfaces. Minimally invasive arthroscopic procedures to “clean out” and “smooth down” the joint surface are of minimal long term benefit and have largely been abandoned. The most reliable and effective way to restore a painless and frictionless surface to the shoulder ball and socket is a Total Shoulder Joint Replacement. Replacing (resurfacing) the arthritic bone ends with a metal-on-plastic artificial joint is a safe, common and durable way of eliminating pain and restoring function. Although hip and knee replacements are more common, shoulder replacements have successfully been performed in the United States for over 30 years. Breakthroughs in anesthesia, implant engineering and surgical techniques have made shoulder joint replacements safe, effective, and reliable when performed by Orthopaedic surgeons with appropriate training and experience.

A shoulder replacement is a major operation performed in an operation room under anesthesia. Through a 4-inch incision on the front of the shoulder, the socket is re-surfaced with a plastic dish and the top of the humerus is replaced by a metal ball mounted onto a metal stem placed down the middle of the humerus bone. One of the four rotator cuff tendons must be detached from the humerus to resurface the joint and it is repaired back to the humerus with sutures at the conclusion of the operation. In the hands of a trained and experienced shoulder specialist, the operation can be performed in about an hour with minimal blood loss and a very low risk of complication. A post-operative short stay in the hospital (1 to 2 days) for antibiotics, pain medication and physical therapy is typical. A sling to support and protect the shoulder is used for 3 to 4 weeks. Patients can resume elbow and hand use almost immediately. Outpatient physical therapy several times a week for 2 to 3 months is required to regain motion, strength and function.

For those who suffer the pain and disability of advanced shoulder arthritis, the benefits of shoulder replacement surgery far outweigh the risks. This major surgery carries the risk of infection, bleeding, nerve injury, anesthetic complications, stiffness, incomplete pain relief or residual limitation of function. The combined risk of complication following a shoulder replacement is under 5%. Over 95% of patients that undergo shoulder replacement achieve satisfactory pain relief and dramatically improved shoulder function. On average it takes 4 to 6 months to fully recover from a shoulder replacement. Over 85% of shoulders replaced in the last 15 years are still functioning well without need for subsequent treatment. The plastic and metal surface of joint replacements can wear out given enough time or abuse. Plastic surface wear can lead to loosening of the implants from the bone. If this occurs and symptoms return, revision surgery to re-implant a new ball and socket can be performed successfully.

People who suffer from shoulder pain, stiffness and diminished function should seek the help of an orthopaedist. The symptoms of shoulder arthritis can usually be minimized with medication, exercise and injections. If these simple treatments fail to provide sufficient or lasting relief then shoulder replacement is an effective, safe, durable and common way to eliminate pain and restore shoulder function.

By Dr. Michael M. Lynch

During knee replacement surgery, an orthopaedic surgeon will replace damaged knee surfaces with artificial implants. Most of the time, all of the surfaces are replaced, but in some instances, only part of the total bearing surface of the knee warrants replacing. This is known as a partial knee replacement. This can be either the inner or outer half of the knee (unicondylar replacement), or isolated to the knee cap and its bearing surface on the femur (patellofemoral replacement).

Most commonly implants are made of metal alloys covering the femur and tibia bone with a plastic insert placed between them. A small patella “button”, usually made of plastic, is used to resurface the contacting part of the kneecap. Alternatively some devices are made of ceramic in lieu of metal.

There are many manufacturers of total knee implants and up to 150 designs on the market today. While there is general agreement amongst surgeons, engineers, and researchers on the basics of implant design, there are many variabilities within these parameters. These include: materials for metal, ceramic, and plastic components, whether the plastic insert is fixed to the tibia, or rotates freely between the components or which ligaments are sacrificed, and which remain; the use of acrylic cement to aid in implant fixation versus the use of ingrowth technology where the bone is encouraged to grow into the metal implant and size variation, and gender specific implants are also a consideration.

The materials used for implants must meet certain criteria. They must be biocompatible (exist in the body without an adverse reaction. They must be strong enough to withstand large loads without breaking (this from both onetime large loads such as in a fall or twist of the leg) but also have durability over the long term from the repetitive cyclical loading to which they are subject. For instance, while titanium is a tremendous material for making golf clubs, in knee implant design it proves too “soft” over the long term, leading to deformity and wear. Polished cobalt chrome metal against high molecular weight

Q&A with Dr. Michael G. Soojian

What is Carpal Tunnel Syndrome (CTS)?

It’s a condition in the wrist caused by pressure on the median nerve. The tendons that bend your fingers share the carpal tunnel with the median nerve. When compressed, pressure builds up in the carpal tunnel, irritating and inflaming the nerve and causing tingling, burning and numbness in most of the fingers and thumb. CTS is most commonly associated with repetitive motion of the hands in both work and leisure activities, but can also occur from other conditions like pregnancy, diabetes, hypothyroidism, rheumatoid arthritis, and wrist fractures or traumas.

How can CTS be treated?

If detected early enough, it may be treated non-surgically. First, it’s important to identify the cause and take immediate action. For example, ergonomic equipment and special wrist braces can be used to keep the wrist straight. Cortisone injections can also help decrease the nerve inflammation.

If non-surgical methods fail, or symptoms are severe, surgery is considered after carefully testing to help rule out other causes of nerve inflammation and to confirm a CTS diagnosis. Surgery for CTS is an outpatient procedure using local anesthesia and an IV sedative. Wrist function is not impaired, and many patients feel immediate and dramatic relief, while others may take weeks or months to fully recover. In rare cases that were not caught early, full recovery is not achieved, but symptom relief is possible.

What should I do if I think I have CTS?

If you have persistent tingling, burning and/or numbness in your fingers, consider making an appointment with a carpal tunnel specialist so you can be examined and treated properly. Remember, early detection is important so you can keep doing all the things you love to do.

by Brian A. Bast, D.O.

Although referred to as a ball-in-socket joint, the shoulder socket is relatively flat and more of a suspended joint where ligaments and muscles account for the stability of the joint. Without a deep socket like the hip, the shoulder loses stability in return for increased range of motion. The important structures that give stability to the shoulder include ligaments, which connect bone to bone, and muscles, which are connected to bone by tendons. The ligaments are the innermost support structures and are covered by an intricate layering of muscles. The rotator cuff muscles (subscapularis, supraspinatus, infraspinatus, and teres minor) are the muscles that are the most intimately attached muscles of the shoulder and are surrounded and covered by larger more powerful muscles like the deltoids and the pectoralis major.

The shoulder relies on a delicate balance of muscle coordination and strength to perform without excessive wear on any one muscle. When a particular motion is repeated thousands of times in one practice, stroke flaws are magnified and certain muscles may be overworked. Or, a muscle may be placed in a difficult position where it may rub against nearby bone creating an impingement position. Dubbed “Swimmer’s Shoulder”, the most common swimming injury often involves one particular rotator cuff muscle, the supraspinatus, either being overworked or repetitively pinched. This injury can occur for numerous reasons, but the most common causes are overuse, improper technique and muscle imbalance.

A frequent pitfall in early swimming technique is to overuse the group of muscles that brings the arm closer to the body during the pull phase of the freestyle stroke. The muscles that bring the hand under the body include the pectoralis major, one of the strongest muscles around the shoulder, making it a great power generator. The pitfall is that this muscle may be relied on over other muscles if shoulder strength is not balanced. Ideally, in the freestyle stroke the hand reaches and enters the water finger tips first and then begins pulling water towards the chest along an imaginary line that splits the right and left side of the body. The concern is when the hand crosses this line to the opposite side of the body, putting the shoulder, albeit momentarily, in a bad position. In this position there are increasing demands on the smaller rotator cuff muscles that intimately surround the shoulder. Under these greater demands, rotator cuff muscles like the supraspinatus may become fatigued and inflamed and this muscle may rub against the ridges of the shoulder causing further inflammation and pain.

Key Points

1. Ample stroke technique at young ages. Coaching by someone experienced in swimming mechanics is essential for early stroke development and technique. Biomechanical flaws are often subtle and more easily recognized by a viewer and not the swimmer. Videotaping practice sessions is a useful tool, where stroke mechanics are reviewed with the swimmer.

2. Reinforcement of drills for all swimmers that focus on good technique. Drills that focus on proper stroke mechanics has a place in training regimens at all levels. While the amount of time dedicated to proper form will change as stroke mechanics are mastered reinforcement is important.

3. Core training provides a link in the kinetic chain between the legs, trunk and shoulders. This allows better streamline and less strain on the shoulders.

4. Strengthen scapula stabilizing muscles like the external rotators (teres minor and infraspinatus) which are on the back side of the shoulder. These rotator cuff muscles are often weaker than the opposing pectoralis major which is on the chest side of the shoulder. Strengthening these muscles can limit overuse of other rotator cuff muscles like the supraspinatus. Along the same thinking, stretching of the frequently tight pectoralis major and latissimus dorsi are effective in keeping the shoulder balanced.

Conclusion
The shoulder relies on a delicate balance of muscle strength and flexibility for optimized performance. Proper conditioning and stroke technique are necessary for long-term, injury-free, participation in the sport. Balanced strength allows for faster swimming because more muscles are engaged and working together.

By Robert L. Brady, M.D.

The term Scoliosis was first introduced by the ancient Greek physician Galen and is literally translated as “crookedness.” Physicians today display a fair amount more discretion and sensitivity in discussing medical conditions with our patients, and especially when they affect our children. Therefore, we define Scoliosis as a lateral (side-to-side) curvature of the spine measuring more than 10 degrees on radiographs (x-rays). Adolescent idiopathic scoliosis, which is the most common subtype of idiopathic scoliosis, presents typically between ages of 10 and 13 years old.

Although the cause of AIS still eludes us, we know a few facts. First, AIS has a definite genetic predisposition. Although it is not uncommon for a child or adolescent to be the first in the family diagnosed with AIS, that child or adolescent’s children will have a significantly increased probability of developing AIS. Secondly, we know that the younger patients with larger magnitude curves have a greater risk of progression of their curvature. The overall risk of progression in a patient who presents with AIS between the ages of 10 – 12 years old is 88%.

The screening for AIS usually begins in the 5th or 6th grades and is often performed by school nurses or child’s pediatrician or both. The treatment of AIS involves primarily regular follow-up evaluations and radiographic monitoring for progression of the curvatures. Of the active treatment offered, only bracing or surgery is considered the universally accepted methods of preventing the progression of the curvature or correcting the deformity. Surgery is considered when the curvature progresses greater than 45 – 50 degrees.

The current surgical techniques employed for progressive AIS allows for excellent correction of curvatures and significant improvement of cosmetic deformity. Most normal activities are resumed within 6 months after surgery. We employ the latest technologies when treating scoliosis including genetic testing, minimally invasive techniques and utilization of biologic healing proteins.