Sports Medicine

Hello, and welcome to the University of Chicago Medicine at the Forefront Live. We're excited to host these programs to allow you to interact with our experts. UChicago Medicine has some of the leading researchers and scientists in the world who are here to help. So get your questions ready, we'll answer as many as possible over the next half hour. And we want to remind our viewers that our program today is not designed to take the place of a medical consultation with your physician.

Are you looking for tips to prevent common fall sports injuries, wondering if it's time to see a doctor about that knee that's been bothering you? You came to the right place for answers. Joining us today is UChicago Medicine's Dr. Aravind Athiviraham. Dr. Athiviraham is an orthopedic surgeon and specialist in sports medicine. He's also one of the team doctors for the Chicago Sky. Welcome to the program and tell us a little bit about yourself and your areas of interest and expertise, if you will.

Well, thank you very much for having me. So I've been at the University for four years now, and it's been a pleasure. And a little bit about myself. So I specialize in sports medicine. So common things I see would be knee and shoulder injuries. So things like ACL injury, minuscule injury, knee cap dislocations. For shoulder, often I'll see shoulder dislocations or rotator cuff injury. Those would be some of the more common ones I'll see. And, yeah, taking care of the Sky's been a phenomenal experience this year. And, you know, unfortunately, they didn't make their playoffs this year, but we're hoping for a great showing next year. But it was a pleasure to meet all the athletes. And working with them and taking care of them was definitely an honor.

It's a really great bunch of women and a lot of fun to watch them play and interact with them, be around them, just nice-- nice folks. So it's got to be very rewarding.

Now, remember, as you watch, you can ask our expert questions that are of interest to you. So start typing and we'll try to answer as many as possible. We'll get off to our questions right off the bat. And the first one is what is the most common injury you see related to fall sports?

So for football probably the biggest one that I see is ACL injury. Often it'll be a-- you know, it can be either a contact or non-contact injury, depending on the mechanism. Patient will often present with a pop and swelling and giving away in their knee. That's probably the most common one that I see. Kneecap dislocation can happen. And as I mentioned, shoulder dislocations where it starts with labral injury to the shoulder can happen, as well.

Now, you mentioned some of the knee injuries. I think the concern that a lot of people would probably have is they get injury like that, they're on the field, they don't realize how serious it is, or maybe it's not. What should people look for-- and if you think you're hurt, particularly with your knee or something-- along those lines? What do you do?

Yeah. So the first thing, you know, when there's pain involved, you know, it's important to know whether or not they can weight bear on the knee. So right away if they're having difficulty putting weight on that knee, that indicates a certain level of severity. The other thing is if the knee swells up significantly, that's a way the knee communicating with you that there's something really serious going on. So that could indicate, as I mentioned, a ligament injury, like an ACL, or a minuscule injury. Sometimes it can turn out to be nothing, just a really bad bone bruise.

But I think if you're starting to have difficulty weight bearing, swelling, sensation that the knee's giving way, they don't trust your knee, you know, all those are signs that, you know, we need to get that checked out.

You know, as-- as fall hits us, the weather starts getting nice. It's cool and a lot of folks want to start running. How does somebody pick the right pair of shoes if they're going to go out and start running?

Yes. I would say probably the biggest thing is pick one that are comfortable for you. Some things to keep an eye out for would be more flexible shoe that's lightweight. And you certainly don't want to be running with a lot heavier shoe. You want something that has good cushioning. And running shoes tend to be more cushioned in more of the heel area. Also, folks, on the heel area you want something that's comfortable for your Achilles tendon in your heel. So, for example, you know, there's often a cut out for the Achilles tendon called the Achilles notch, they want the shoe to have. And the ankle collar wraps around the ankle and it needs to be well-cushioned as well.

So those are some things that, you know, you can look out for. But I would say, you know, try it on, you know, use it, you know, at least in the store and, you know, really try to get a sense of it. And it's probably the best way. But those are some tips.

I had no idea there was actually a name for that little notch at the back of your shoe. So now I know that. So here's a question. I run three or four times a week. How often should I replace my running shoes?

You know, the surprising thing is running shoes don't have an expiry date on them, you know. So there's some studies that show that running shoes can last up to like 600 miles and, you know-- and that's even a subjective thing. So, you know, with the people that are knowledgeable about that sort of feel would say would be that if the shoe starts-- stops feeling comfortable, that's often the time to replace them. So if you're running and the shoe's comfortable, you don't have to just replace them because it's a brand new year. But if you're trying to wear them and it's not feeling right, there's a little more pain in areas that you normally didn't have pain in, or there's, you know, definitely a lot of areas of wear on the sole of the shoe, those are things that you should look out for.

So if you're running and you're thinking that while you're running, oh, should I get a new shoe, then probably-- you probably should.

So what are shin splints? I'm curious-- and how do you know if you actually have them?

So there's kind of two different categories of what people relate it to shin splints. So, you know, the-- one of the shin splints are, you know, medial tibial stress syndrome. So, basically, it's kind of an earlier version of a stress fracture. So this is common where a person has been inactive for a period of time, and then it starts to really ramp up their activity. So sometimes we see that in military recruits, things like that. And this is more on the inner part of the distal tibia. So the medial distal tibia, which is the leg bone, and, you know, it occurs with permanent weight bearing activities. And if that pain in the area is more bony related again, it could be like an early form of stress fracture called the stress reaction syndrome. So that's one form of what people could call a shin splint.

So is it mainly pain on the front of--

Yeah. Front and inside. That's for the stress syndrome. The other one is a little on the side, more lateral, and lateral where over the muscle belly. And this is more along the spectrum of what we call exertional compartment syndrome, which is, basically, when you're putting weight itself it doesn't bother you, but when you start to like, you know, run or like really over exert that compartment, it really feels really tight. And, again, there's kind of different sections of this. But that's more in the structure of what we call exertional compartment syndrome. So the treatment for either those are fairly different.

So as far as preventing shin splints, what's the best advice you can give?

So in terms of preventing it, it depends on the mechanism. So for bone related incidents the stress syndrome that I talked about, you want to kind of ease into activity so you don't want to start from like zero to 100 right away, you want to kind of-- you know, if you want to train for a marathon, for example, like I wouldn't recommend going from like not running at all to training with your friend that's done this for the last 12 years. And you really want to build up to the point where you can do that.

For the muscular exertional composite syndrome type shin splints, which is more muscular on the outside, you really want to stretch, you know, the muscular compartment, you know, things like foam rollers can really help, you know, stretch out the muscle fascia there to help reduce the incidents of that.

Any tips to get them to heal faster?

Again, this relates with probably say prevention is probably the biggest thing. But in terms of if it's a bone related shin splints, I would probably-- to be safe, probably see a physician just to make sure it's not a stress fracture. If it's a muscle related variety, again, use the, you know, stretching and the foam rollers to try to get it to heal faster. But that one's a little less urgent in terms of you can try to work that out a little bit before going. The bony one I would just to be safe, to make sure you don't need to be, you know, any further intervention like crutches or a boot, just to see a provider for that.

We're getting some viewer questions in and I want to make sure we hit those, and I also want to encourage our viewers, if you do have any questions, please type those in, we'll try to get to as many as possible as we can during the program. John asks what's the best way to treat swelling in the knee after running?

That's a great question. So in terms of most swelling-- this goes for swelling in any joints. I would say, you know, we term it the RICE protocol. So, you know, the R in the RICE stands for rest. I stands for ice. C stands for compression. E stands for elevation. So, you know-- you know, it's kind of familiar to everybody but, you know, if it's just kind of an off and on thing, you know, ice the knee, you know, wrap it up with an ACE wrap or even, you know, you can get from a pharmacy a compression sleeve. All that can help alleviate some of the swelling. Sometimes if it's really severe, you might want to take some anti-inflammatory medications. Look, as long as you don't have stomach problems, all that can help, as well.

And, again, kind of along the same line as my question earlier. If you have that swelling issue, how do you know that it's-- you have to be cautious, obviously, and how do you know that you're to that point where you can take care of it with the RICE method or you actually need to go see someone like yourself.

Yeah. So, you know, if it's a system with an injury, for example, it depends if it's in what we call an acute injury, which is something that specifically happens you can associate with that injury, or more of a chronic condition where, you know, every time you run like 10 miles, it starts to flare up, you know. So that's really different. So, you know, for any acute injury which we talked about, for example, the athlete playing soccer or football where they suddenly feel, you know, pop and swelling, that's a lot more concerning than a runner that, you know, they know that after a certain amount of mileage they're going to feel a little bit of, you know, pain and swelling in their knee. That's really different.

So let's say for the former, the acute injury, I'd be more aggressive about seeing the physician right away versus a more chronic condition where you know your limitations, you know what to do, you've been doing that for a while. You know, as long as you know how to manage that for yourself and you've tried the-- you know, the rest, ice, compression, elevation protocol, you know, I think it's OK to wait a little bit longer before you see a provider for that.

Now, Alexis has a question. Apparently, she had knee surgery. It's not getting better. Been to physical therapy for years and just really struggling with it. Any advice?

So it depends on-- since arthroscopy is done for a variety of different pathologies, you know, for the knee, often, I would say the biggest pathology that we do it for is, you know, meniscus pathology or meniscus tears. And depending on the individual's age, you know, they're-- it's not just restricted to one thing. There's also some cartilage injury that comes with that. So, you know, with-- when surgeons perform a procedure for a meniscus, often they're able to adjust the meniscus while the-- the arthritis, you know, we haven't discovered anything yet that will regrow cartilage to, you know, a great extent. Like there's no, you know, injection option that will magically make cartilage kind of grow back to where it was when, you know, people are once 20 years old, that sort of thing.

So, you know-- so from that standpoint, I would say-- again, I don't know your individual condition, but I would say for the most part, you know, let's say you're through the immediate recovery phase, you know, I would say definitely by three-- three, four months, most people start to feel good. And by six months I would say, you know, most of recovery is done from a knee scope. Then you start thinking about, OK, was there some arthritis in the knee that could have contributed to the pain? So that could be the scenario there. But in terms of trying to deal with it, again, it's a difficult problem and, again, assuming that it is really with arthritis, anything to do with core strengthening of the knees or working on the quad strength, you know, all that can help. Again, if the pain is really bad, things like anti-inflammatory medications can help as well.

But those are all the things that could potentially help. Bracing's a little more controversial, you know, there's no real-- depending on the location of the pain, so if the pain is all in the inside and, you know, you want to try to unload abrasiveness, sometimes that can help, too. But it depends on the individual, I would say.

Sure. So I think I know who's asking this question. Skip asks what's the best treatment for plantar fasciitis?

So that's a very good question. And a couple of things, you know, one is, you know, stretching it like everyone knows is probably the most important thing. And not only is it stretching but also the way you do the stretches so, you know, I would definitely search for videos of how to do it properly. So you want to stretch the plantar fascia such that, you know, you're locking the foot. So it's stretching what you wanted to stretch. So there's kind of a different strategies on that. Again, there's probably videos online they can look to do that. So that's probably the biggest thing.

You know, night splints can sometimes help if the pain's really bad. Anti-inflammatories can help, as well.

So what is the specific injury here, though? What Is going on?

So it's most likely really with overuse, you know, micro trauma to the plantar fascia, which is a structure on the bottom of the arch of the foot. And that's what's causing the pain.

I see. I see. So John from [? Alarie ?] asked is it accurate that surgery for a meniscus tear is not recommended after 40 because this surgery will increase the onset of arthritis?

So that's, again, a very good question. So there's actually multiple studies on-- again, I alluded to what we talked about earlier. So in the setting of significant arthritis, you know, meniscal treatment of meniscal pathology with a scope is less-- is more unpredictable and maybe less successful. But ages is, you know-- you know, one thing in the equation, you know. You know, what I would say is, you know, it depends on the acuteness of the injury, you know, the type of the tear.

But, yeah, in general, the older the individual with more of what we call a degenerative type tear associated with lumbar arthritis, that's less amenable to, you know, knee arthroscopy versus a more traumatic tear where, you know, you associate with a specific injury that's associated-- well, you know, surgeons call mechanical symptoms. So these are things like locking when you try to straighten the knee, you can't do that, you know, either permanently or temporarily, you would term that, you know, locking or catching, you know, sharp, you know, pain on the inside. And, again, very localized pain.

And if it's an acute injury, again, that could mean it's a more acute type tear or traumatic type tear versus, again, if it's something that we've been deal with this for a year and you're a little more, you know, older and doctor gets x-rays and you see significant, you know, narrowing in the joint space which is what you look for when you get these weight bearing x-rays. Then that's something that's less amenable to knee arthroscopy. So the overall premise of that is correct.

Interesting. So [? Nevit-- ?] [? Nevitatha, ?] I believe, asks if your knee hurts while running and you think it may be related to the LCL, how long do you recommend holding off on running?

Yeah. So for any-- so the LCL's one of the collateral ligaments in the knee so the one on the inside's called a medial collateral ligament. The one on the outside is called the lateral collateral ligament. So for any of these ligament injuries, you know, especially on the collaterals, we're actually pretty successful with treating it nonoperative so-- so that's different than the cruciate ligament injury, which is like an ACL injury, where often, you know, especially in the younger athlete where, you know, it might be more aggressive about pursuing surgical management.

For the cruciate injury-- or for the collaterals, you can try healing it non op. And especially if it's a partial low grade injury, I would say anywhere between three to six weeks, you know, things should settle down. Often when the patients come and see me, you know, if it's a higher grade injury, I'll prescribe them what's called a hinged knee brace, which is, you know, braced with some supports on the sides with a hinge so that you can still move your knee. And then physical therapy, you know, usually in the range of 6 weeks. So usually by then things start to feel better. But there's a big wide range depending on the severity of the injury.

And a follow-up on that. Low impact exercises during the rehab time, is that-- would you recommend that or not?

Yeah, absolutely. So, you know, for any sort of-- if a patient has a lot of knee complaints when they're doing running, I would often ask them, OK, how much are they mixing up? They're, you know, running with other low impact activities. So things like bike-- biking, you know, aquatic exercises, elliptical. I think it's important to mix all that in in terms of getting the athlete to get the cardio that they need, but at the same time, minimize an impact on their knees.

So, yeah, I would encourage, you know, especially when you're recovering from an injury, to focus more on those low impact exercises.

Now, this one hits a little close to home. Why did-- why do my hip and knee joints crack more often as I get older?

So, again, there's so many different reasons, you know, for, you know, cracking joints. You know, again, you know, but most often in the older individual it could be related with some early onset of arthritis where the cartilage surfaces could be a little more rough. And, you know, that could be what's producing that.

I see. And we want to remind people that if you have any questions for the doctor, just type them in and we'll try to get to as many as possible.

Next question. Excuse me. When I pull a muscle, should I put ice or heat on it or both?

Yeah, good question. So what I would say is in the initial period what I would do is, you know, again, the same thing, the RICE protocol. So rest, ice, compression, elevation. So I would ice it, initially, and, you know, stretch-- probably not overdo the stretching initially, you know, maybe some light stretches might be OK. You know, as, you know, the inflammation settles down and it can take some anti-inflammatories to help with the initial pain, once the initial inflammatory phase settles down, then you can start thinking about putting some heat on it and be more aggressive with stretching.

The risk of putting heat on it too early would be that it could potentially increase inflammation if you do that too early. So let's say as a anti-inflammatory aid, icing probably initially in the acute period and maybe down the road you can see which one works best for your individual condition.

How about stretching the pulled muscle, does that help, or does that cause more damage?

Again, as long as it's not hurting it too much, at least initially, I think that's OK to do and, you know, very light moderation, at least initially. But, initially, I would say, probably the most important thing is just to rest it, you know, let the inflammation, the pain, settle down. And then as things evolve and become less inflamed, definitely try to push the stretching, you know, further.

Alexander has a question for us. As a runner, what steps should I be taking to ensure the health of my feet and ankles before a big run? And as-- is water exercise class a good way to relax those muscles?

Yeah. So we talked earlier, I think, you know, stretching is really important. You know, you especially want to make sure that your Achilles tendon is not too tight and there's a variety of mechanisms of trying to do that. Stretching your calf, your hamstrings, I think, all those are very important to do. You want to make sure like we talked about earlier that your footwear is appropriate and, you know, not hurting. In terms of aquatic exercises, I think that's very reasonable. Again, just in terms of low impact activity is one form of low impact activity things could be biking and elliptical like we had talked about. But, you know, everything that he mentioned is-- it's a reasonable thing.

I am curious about the Achilles just a little bit as you mentioned. My brother who's world class athlete-- I'm joking in case he's watching this. He actually ruptured his Achilles tendon playing basketball and snapped it, which is a terrible injury, but how do you-- again, how do you prevent something like that? Again, same thing with stretching and--

So, again, we kind of termed this a classic weekend warrior injury where, basically, you know-- you know-- you know, athlete or-- may not be as active, kind of throughout the course of, you know, the-- you know, Monday to Friday or, you know, on a weekly or monthly basis. And then suddenly decides, hey, let's play a game of pickup basketball with my friends and-- and that's when this happened.

So what I would say is definitely ease up into things, you know, stretch it. I think, you know, stretching the Achilles is really important. Certain type of antibiotics, you know, fluoroquinolones can sometimes pre-suppose people to that. But I would say probably the most important thing, particularly for your brother would be, you had-- definitely stretch beforehand. You know, ease up into activity. You know, if you know that you have a pickup game with your, you know, friends coming up and really kind of work up towards that. Do a lot of stretches, a lot of activity, you know, in the lead up to that so that your body is not shocked with a sudden burst of activity. I think all that can definitely help.

A question from Chuck. And, he says, regarding tibial stress fractures. So 10 years ago, he was diagnosed with one from over use in a track and a field event that he participated in, and he still has pains in that area every so often. And he's curious is that normal, or is that something he needs to be concerned about? Does he need to come and see someone like you?

Yeah. I think as long as he's able to do all the activities that he can do, he's been dealing with it for a while, it's-- you know, I'd say no acute progression, meaning that things haven't dramatically gotten worse. I think from his description, I think he's safe to wait. I think it's not uncommon for, you know, minor aches and pains to pop up now and again. But if things are acutely getting worse and to the point where he is having difficulty doing activities that he normally would able to do, then I would see a provider.

Unfortunately, you know, my experience has also been the same where, you know, these stress fractures or stress syndromes can take a while to heal in a lot of individuals, and they're doing everything right. Especially, if it's just on the one side. Sometimes for these recalcitrant stress-- stress syndromes where we'll often give the patients, you know, crutches to try to even completely offload that area to try to accelerate the healing, you know, a walking boot can-- sometimes it helps as well. You know, a bone stimulator is a little more controversial. I mean, sometimes we use that on some of our athletes, but often, a combination of all the approaches work.

But from his description, I think he's safe to wait and just kind of keep working on the stretching and things like that we talked about.

Yeah. Maybe it's preparation a lot of it.

Yes.

And you've already addressed this, but I want to ask it again because we do have a viewer that popped in that's curious about shin splints, just as far as prevention, just some quick tips there.

Yeah. So, again, it depends on if it's bone related or muscle related, if it's muscle related, that's more on the outside, then, you know, sometimes foam rollers to really work out and stretch the fascia, the muscle can help. If it's, you know, bony related, again, something that it depends on how much of interference it's causing. If it's something that is really causing your problems weight bearing then, you know, something is-- sometimes, you know, just like easing off on the area, you know, protecting your weight, using crutches, all that can potentially help. But for the bony related, you know-- because it could be part of that stress syndrome or stress fracture spectrum, I would probably see a provider if you've never seen one.

But, in general, I would say, you know, just-- you know, try to be mindful of like overuse. Listen to your body in terms of how much miles you can run before starting to get the pain. But I would say definitely try to distinguish between if it's muscular or bony.

Sure. Here's one. What if I pull a muscle, how much rest do I need before I regular workout?

Yes, that's a good question. It depends on the severity of the muscle strain. So usually when people talk about pulling a muscle, it would be in the-- you know, a mild, what we would call a mild muscle strain. So for that I would start off with, like we said, you know, stretching activities. You know, icing, anti-inflammatories as needed. And, generally, I would say by about three weeks, things should start to get better. If it's more severe, you know, things could take up to six weeks to get better. So it just depends on the severity of the pulled muscle.

Talk a little bit about shoulders if we can.

Yeah.

People injure their shoulders a variety of ways, golfing, playing softball, baseball, that kind of thing. Again, when do they need to come see somebody like you?

Yes. So it's really common for people, you know, to have some pain in their shoulders, overhead activity, you know. We call that often impingement syndrome. So, basically, when the person elevates their arm, the rotator cuff can become pinched on the roof of the shoulders, called the acromion. Sometimes there's a bone spur associated with that, as well.

So, again, as long as the patient is able to do all their activities, it's not a big nuisance, you know, pain is like, let's say, under like a three out of 10, I think that's fine to keep doing that. Maybe take anti-inflammatories. I think if it starts to get to 4 or 5 out of 10, then you may want to see a provider. You know, again, if the diagnosis is impingement syndrome, you know, things like anti-inflammatories, cortisone injections, physical therapy, can all be a part of the treatment.

If it's an acute injury, again, that's when I would be a lot more aggressive about seeing the provider early. So if you're lifting your bag over a overhead compartment and suddenly it falls or you feel a sharp pull in your shoulder and you're no longer able to do any overhead activity, that could indicate definitely a higher degree of injury like a rotator cuff tear. So, again, I think for me, you know, the acuteness of the injury definitely is very helpful.

But if you had that pop or that click in your shoulders, that-- what's that potentially a sign of?

So, again, it depends on the age group that you're dealing with and-- but as an in general statement, I mean, potentially, it could be a labial injury. And, again, the labrum is a structure that goes all around the shoulder so there's a lot of ligaments that are attached to it. It, you know, kind of increases surface here and also provides, you know, for the support you know, through the ligaments attachments. And depending on the age group, you know, it can injure the front inferior port-- you know, the lower portion of the labrum, like a dislocation, or with, you know, kind of the older individual, or even with, you know, maybe throwing athletes, you know, maybe higher up.

So, you know, sometimes these labral injuries can produce or get a clicking sensation. You know, in terms of treatment for that, again, it depends on the mechanism. Like in the shoulder dislocation, especially, if it's a recurrent shoulder dislocation and the patients fail like physical therapy, and they always have instability in a particular position, then you might be more aggressive about offering, you know, surgical management versus if the patient is, you know-- the only symptom is the click and they have no, you know, pain or instability with that, then you would probably treat that conservatively, and at most, maybe recommend anti-inflammatories, physical therapy, things like that.

What do compression socks do? That's a question that we got that-- is this something that people need to be wearing when they exercise, play sports? What do you think?

Yeah, I think it's, you know, the athletes choice. I think there are some benefits to that, especially, if there's some prolonged standing involved. So the way, you know, compression socks work is that it provides, you know, compression like through a gradient to help with the venous return. So the veins are what carry the deoxygenated blood, you know, back to the heart. And, basically, it kind of helps with that process.

So if you're engaged in a sport with a lot of prolonged standing where you're not having the ability to sit, I think it can by improving the circulation, potentially, aid with recovery. So I think you have to try it and see if it works for individual sport. So, but yeah, there's-- I wouldn't say any harm in wearing it. You have to make sure that the-- fits you well for different body types you have to have different sizes. So make sure that when you're buying it, that you find one that's comfortable.

Yeah. So we've just got a couple of minutes left and I'm just curious. The injuries you see with Sky players, are they a lot different than the injuries you see for nonprofessional athletes?

Again, a very good question. I would the injuries themselves are probably not very different. You know, the management might change a little bit because-- so, you know, for example, you know, in a nonprofessional athlete you may-- you may have the room for trying, you know, non-surgical measure for a meniscus tear, for example, where you may say, OK, let's try anti-inflammatories, let's do physical therapy, we'll see if it bothers you, and then we'll see you back in six weeks to see if things get better.

In a professional athlete, that would not be a great option to say, OK, let's see you back in six weeks. The season may be done. They may not be able to return the next season if we told them that. So in terms of the management of the injuries, we're a lot more aggressive about how can we fix these as soon as possible. And often that will lead to surgical management, you know. So from that standpoint, we're a little more aggressive.

But the injuries themselves are similar. The management of those injuries are a little bit different.

Yeah. Well, you did a fantastic job.

Thank you. I really appreciate it.

Thank you. Yeah. Really appreciate you being on. That's all the time we have. Want to definitely thank Dr. Athiviraham for appearing on At the Forefront Live. If you want more information about UChicago Medicines Orthopedic Program, please visit our website site at uchicagomedicine.org/ortho. Or call 888 824 0200.

Thanks, again, for watching At the Forefront Live and have a great week.