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Our team of certified sports specialist doctors are at the forefront of the current research regarding health care and injury management. Many of them are active researchers themselves in the field of manual medicine, as well as instructors, and/or lecturers at their respective educational institutions.
How should you treat an athlete with a first-time dislocation of the shoulder?
This question comes to us from San Diego California:
“My 16 year-old son is a competitive baseball player who has recently dislocated his shoulder after a fall. I have had conflicting advice concerning the best way to go in terms of treatment. What do you think is the best course of action?”
Answer: The proper treatment for anterior shoulder dislocation has been long debated in the literature. The answer depends on several factors, the most important being the age of the patient when the first dislocation occurred. It may be surprising to hear that an increased recurrence rate of shoulder dislocation has been identified in younger patients. This means that the older you are when the dislocation occurs, the less chance you have of re-injury. It is also known that there is an increased incidence with participation in contact sports.
There are two main paths to take with managing this injury. The first is conservative treatment which consists of pain control and rehabilitation; the second is surgery. Recent literature states that the risk of recurrence of dislocation is 5 times greater when treated conservatively. It is also known that in young, highly active patients not treated with surgery initially, between 25 & 45% will require subsequent surgery. Therefore it would be safe to say that for a young, active/athletic person who wishes to continue sports participation, surgery is most likely the way to go. This of course must be a case by case decision between the athlete, guardian, therapist, and surgeon.
How should you treat Iliotibial Band Syndrome?
This question comes to us from San Diego California:
“I have a patient with a very “stubborn” case of Iliotibial Band Friction Syndrome. She has had it for approximately 4-5 months now, and my treatment does not seem to be getting to the root of the problem. In fact, often she describes an increase in symptoms following my treatments. What do you think?”
Answer: This is actually a common problem amongst my students who also struggle with treating cases of the so called Iliotibial Band “Friction” Syndrome. For those who are not in the medical field, the Iliotibial Band, or ITB, is a fibrous structure which starts at the lateral aspect of your pelvis, and inserts into the lateral (outside) and anterior (front) aspect of your knee. It is a common cause of lateral knee pain in runners and it was believed that the cause of the pain was due to the fact that the ITB “rubbed” along the outside of the femoral condyle (the thigh) during running (with the knee at the 30 degree range); hence the term “friction”.
A recent study however has demonstrated that this is in fact not the case, and that the problem is not one of increased friction at all. Fairclough et al. (2006) published a study in the Journal of Anatomy which demonstrated that the ITB does not rub along the outside of the knee at all. It is actually tightly adhered to the lateral aspect of the femur. Thus the assumption that friction is the root of the problem is in fact incorrect. What they found is that deep to the ITB in the area of the knee, there is a prominent fat pad. When the knee is at the 30 degree range, the ITB actually compresses tightly along the femur thus irritating the fat pad in symptomatic patients. Thus the problem is not one of friction, but one of inflammation. Therefore treatments, such as aggressive massage, in the area of the fat pad will only serve to irritate the condition. Therefore my advice would be to aggressively treat/stretch the entire ITB except for the area where the symptoms are.
This will serve to “loosen” the structure thus decreasing the amount of compression experienced at the 30 degree range. The actual area of pain should be treated as an inflammatory condition requiring ice, anti-inflammatory meds, and other anti-inflammatory modalities. In terms of rehab, Fredricson published a paper outlining the importance of strengthening the hip abductors for resolving this condition (which would improve the lateral stability of the patient).
What is the optimal treatment for Anterior Cruciate Ligament Injury?
This question was submitted by a Chiropractic Student:
“I have a friend who plays college football in the US; he has asked me to offer an opinion on how to properly manage his ACL tear (complete). The coaching and training staff at the college has advised that he should keep playing following conservative therapy. He wants to know if there are any long term implications of continuing high level activity on an ACL-deficient knee.”
Answer: The proper management of ACL ruptures has long been debated in the scientific literature. Current research allows us to make evidence based recommendations on the most appropriate course of action, however the most “appropriate” action will differ depending on the expectations of the individual. A summary of the current evidence-based recommendations is as follows:
The initial management (4-6 weeks) of an acutely injured ACL in not debated. Conservative, “first-aid” treatment should be done in the first 4-6 weeks in order to allow the hemarthrosis (bleeding within the joint) to settle and allow restoration of the range of movement.
After this, successful reconstructive surgery in the patient with an isolated ACL injury reduces the rate of subsequent meniscal damage, and may reduce future arthritic/degenerative changes in the joint.
Reconstruction of the ACL should be done by replacing the damaged ligament with a piece of the patient’s patellar tendon (“bone-patellar tendon-bone graft”), or with a piece of the patient’s hamstring muscle. Literature has shown both to provide excellent clinical results in ACL reconstruction, thus the decision is based on the preference of the patient and surgeon.
After isolated ACL reconstruction, approximately 90% of patients can return to their previous activity level.
If conservative management is selected, patients must be counseled against high-risk activities to prevent recurrent injury (ie. If a very competitive athlete would like to continue to compete at a high level, conservative management may not be the best option).
Therefore, conservative management may be recommended for those who will eliminate “knee-strenuous” exercise and activity from their lives. For those who cannot, surgical options should be explored. The patient either has to modify activity to suit the knee, or modify the knee to suit activity.
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