“You can’t help getting older, but you don’t have to get old.”

“You can’t help getting older, but you don’t have to get old.” _ George Burns

Aren’t we all always looking for tips to stay and look young? The market is flooded with beauty products to achieve this result; the media is overflowing with information to stay “fit”; and billions are spent on cosmetic surgeries to pull off what make up and exercise cannot.

The body is a continuously evolving system, and everyday billions of cells die, another billion new ones taking up their space. As we grow older, this process goes on, but there are lesser new cells generated, and this is inevitable.

Bone being a living tissue, also ages and weakens as we grow older. This is inescapable, but osteoporosis (brittle bones) is preventable!

In our quest to stay young, let us not forget the primary scaffolding of our body that upholds all else!

-Dr. Harshada Rajadhyaksha

Osteoporosis is a “silent disease”, as it progresses without any symptoms until fracture occurs. Your wrist, hip and spine are the common sites for osteoporotic fractures. Post spine and hip fracture, immobilization being essential for healing, still has a detrimental effect on health and quality of living.

Bone is a highly dynamic organ. It constantly undergoes resorption and regeneration. By third decade of life, bone attains its peak mass. As age progresses, in both men and women, balance between resorption and regeneration becomes progressively negative. Post menopause, there is an abrupt drop of oestrogen. Oestrogen hormone plays a crucial role in bone modulation. Thus, we can see old age and oestrogen deficiency are the most critical factors for developing osteoporosis. Besides this, risk factors affecting bone density  include genetics (Europeans, Asians), lifestyle (smoking, alcohol, low vitamin D levels due to less sunlight exposure, calcium deficient diet), low physical activity and certain medications.

Confirmatory tests include Bone Mass Density (BMD) analysis which determines both osteoporosis and its early signal osteopenia.

Osteoporosis has no cure but yes we can definitely stop /slow down its progress. Early detection is the best prevention. There are injections available for people who are highly osteoporotic, probably due to any medical condition like prostate / breast cancer, even may be due to prolonged immobilization as that itself causes disuse osteoporosis. These injections needs to be taken on yearly basis to improve bone density as in these scenarios prevention of associated complications is the primary concern.

For elderly population, due to improper muscle strength, balance, coordination there is increased fall risk. Even minimal stress during a fall has a good potential to cause fracture in osteoporotic bones. Simple steps like railings in bathrooms, rooms, maintaining adequate space and good footwear will help reducing the fall risk, thus preventing any incidence of fracture.

One should start working towards modifiable risk factors such as lifestyle modifications. This may include smoking cessation, avoidance of excessive alcohol. In terms of nutrition, one should have calcium and Vitamin D rich foods but also adequate calorie intake to prevent malnutrition. Prevention can be started from any age as goals differ for age groups. For childhood and adolescence – achievement of peak bone mass, middle age – preservation of bone and muscle strength and mass, old age –optimization of gait and balance, muscle strength.

Exercise plays a key role in building and maintaining bone health. Research has proved resistance, aerobic, high impact training, whether done in isolation or combination can improve bone density in osteoporotic persons. One should not rush into unaccustomed exercises (swimming, cycling may be good for your heart but not appropriate to improve bone density). It is important to do what is the most appropriate.

Everything in moderation is always better.  Combination of healthy lifestyle, proper nutrition and appropriate goal oriented exercise can prove to be extremely beneficial. No two osteoporotic individuals are same and hence one can always look out for an expert advice for an individualized program.

- Dr. V. Sivajanani

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“Love your bones, Protect your future.”

The World Osteoporosis Day has a theme this year of: “Love your bones, Protect your future”, urging people to take early action to protect their bone and muscle health.

Calcium is crucial to bone health, and most of us do not get enough of this mineral in our early life, when it matters the most.

The daily requirement of Calcium in adult life is about 1000 – 1300 mg/ day. It is extremely difficult to reach this figure unless you know how to combine foods.

This is how much Calcium you can get from common foods:

  1. Try having 1 cup low fat milk/ Soy milk with your breakfast in the morning: Maybe as a smoothie/ with oats/ cereal/ just plain, or with a nutritional supplement. Depending on what you add, you will get about 200 – 300 mg. of Calcium already.
  2. Have 1 cup Yoghurt (Low fat/ homemade) some time through the day: Maybe with lunch, or with fruit as an evening snack. You will get about 250 mg. of calcium here.
  3. Try this juice whenever convenient. Please remember to have it as soon as it is made. 1 cup any vegetable (choose watery vegetables like Cucumber, tomato), and others like carrots, beets, sweet potato + ½ cup coriander and mint leaves + 1 stick Celery + 1/2 cup a green vegetable like Spinach or Lettuce + 1 cup fruit (orange is best, but any other like apple, pineapple, etc. will do). Add ½ cup water and all diced ingredients to a mixer and blend well. Serve immediately by straining through a medium sieve, over 2 cubes of ice, and add juice of 1 lemon while serving. Have a large glass, it is refreshing, tasty, and gives you about 150 – 180 mg of Calcium, along with many other minerals equally important to bones (by the way, milk which is such a good source of Calcium, is a poor source of other important minerals)
  4. The bread, chapatti, idli, dosa, khakra, and other carbohydrates that you eat through the day will give you about 10 mg. Calcium each.
  5. The dals, lentils, and beans that you eat (white beans are higher in calcium, and soy beans are packed with calcium) will give you another 20-40 mg. of Calcium per cooked ½ cup.
  6. If you eat nuts, seeds (make sure there is 1 tbsp. sesame seeds), and dry fruits (about 1/3rd cup), this will give you another 80 mg. of Calcium.
  7. Maybe you will also eat a slice of Cheese (1 slice is 200 mg), or Paneer (50 mg. in ½ cup), or Tofu (200 mg in ½ cup), or an Egg (25 mg), or some Chicken (21 mg. in about a cup), Fish (15 mg in a cup), Quinoa in salad (60 mg in a cooked cup), or other Vegetables (30-40 mg. per cup), or maybe an Ice-cream (85 mg in 1/2 cup serving), or other Dessert (15-100 mg. in ½ cup) through the day.

Here is a sample diet that will give you about 1030 – 1440 mg. Calcium per day, with just about 1500 – 1600 Kcal Energy intake.

Of course you might not eat with this much discipline every day. But if you remember how important calcium is, and how to combine foods, you might always make sure of getting enough.

Sample Menu

Breakfast

1 slice toast

+ 1 slice cheese or ½ cup scrambled tofu OR 1 egg

+ 1 cup milk

250 – 400 mg. Calcium
Mid – Morning Snack 1 fruit 10 mg Calcium

Lunch

1 chapatti

+ ½ cup dal/ white beans/ chicken/ fish

+ ½ cup vegetable

+ 1 cup salad (use 2 florets of Broccoli)

+ 1 cup low fat yogurt

350 -450 mg. Calcium

Evening Snack

1 glass Homemade Vegetable juice OR 1 cup yogurt with fruit OR 1 soy milk with 1 banana OR 1/3rd cup seeds and nuts 100- 180 mg. Calcium

Dinner

1 chapatti

+ ½ cup dal/ white beans/ chicken/ fish

+ ½ cup any vegetable

+ 1 cup salad OR Green vegetable OR Bhindi

320-400 mg. Calcium

Remember not to eat more than 500 mg. of calcium at a time.

Do not exceed 1500 mg. Calcium in a day.

Eat varied sources so that you get all nutrients.

Eat moderate amount of salt and protein. Excess of both will cause loss of calcium.

Do not follow this plan if you have kidney stones/ any other reason to avoid a high calcium plan.

Do take an expert opinion if you do not have an idea about your exact nutritional requirements.

Love your Bones and Protect your Future: Remember, the time to save is now!

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Breast Cancer

Breast Cancer

Cancer is an abnormal growth and proliferation of cell. Breast cancer is now the most common cancer in most cities in India and 2nd most common in rural India. The incidence of breast cancer is increasing in younger women. Because of lack of awareness and lack of screening it goes unnoticed till it becomes symptomatic. To create awareness about breast cancer is very essential.

Breast cancer is caused by lots of different factors many of them are beyond our control. Broadly speaking the risk factors can be divided into modifiable and non- modifiable.


Breast cancer preventive strategies:

  1. Keep your weight in check
  2. Be physically active- 30 to 60 minutes of moderate intensity exercises which should be combination of strength, stamina and flexibility. 3-5 days/week
  3. Eat fruits and vegetables- Avoid too much alcohol
  4. Don’t smoke
  5. Breastfeed for 1 year after child birth if possible
  6. Avoid birth control pills especially after the age of 35 years
  7. Avoid post- menopausal hormones
  8. Know about family history
  9. Don’t forget screening.

Please seek a medical help if you have:

  • A lump or thickening in the breast
  • Redness, or soreness of skin
  • Swelling and dimpling of skin
  • Change in shape or appearance of the nipple-
  • Nipple discharge

    There are different types of treatment options for breast cancer survivals such as breast conservation surgeries, radiotherapy, chemotherapy, hormonal therapy and rehabilitation.

    Physiotherapy plays an important role in rehabilitation of breast cancer survivals

    Most of the women suffering from breast cancers has to go for complete breast removal or breast conservation surgeries and obviously post-surgery they have to undergo chemotherapy and radiation therapy.

    As major portion of breast tissues, lymph nodes, nerves and muscles around the breast, shoulder and neck region are cut or spared depending upon the extent of cancer pain and swelling in the region of neck, shoulder and chest wall is very common. Also weakness of muscles around the shoulder region leads to stiffness and inability to do overhead activities. Postural impairments and Chemotherapy and radiotherapy related fatigue is also very common. Combination of these factors along with psychological trauma and stress leads to poor quality of life and lack of feeling of well-being.

    Cancer rehabilitation:

    It is a process to improve the physical and social function of the person suffering from cancer in order to improve quality of life and leading to longer survival.

    Post operatively the physiotherapy aims at reduction of swelling by positioning of arm and elevation, gradual activities of wrist and hand, gradual mobilisation of shoulder and neck to prevent stiffness and to improve function. Gradual strengthening of muscles around shoulder and neck. Improving stamina through gradual planned exercise program.

    Lymphadenopathy edema is the common complication after breast cancer surgeries. It can be prevented by following measures:

    • Manual lymphatic drainage (form of a light massage in particular direction to drain the lymphatic fluid in proper channels)
    • Multilayer elastic compression bandage or pneumatic compression
    • Skin care- keep skin clean, hydrated. Use of gloves during household work.
    • Regular exercise
    • Weight control

    Psychological support from families, friends and health care professionals is very essential to the women suffering from breast cancers.

    Giving up is not an option, Believe there is a hope for a cure!!

    - Dr. Aditi Kate

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    Screening for Sport

    A fourteen year old boy who lives in America, but was vacationing in Mumbai came to me a few days ago. Let us call him Raj (name changed).

    A footballer at the inter-school level, he was playing the sport for the last eight years.

    Raj came with a history of an injury during a game that he played a month ago for his school. He was seen by the therapist from his team, but was now in my clinic because his parents were worried about an abnormal swelling that they saw in front of the knee.

    Actually what Raj had was a very common “Growing-Up” injury, which happens mostly in active adolescent boys. It is called Osgood Schlatter disease.

    Muscles are attached to bones by strong bands (tendons), and as the muscle contracts strongly, the tendon pulls on the bone resulting in a movement at the joint. When a big growth spurt takes place (increase in height), sometimes bones grow faster than the muscles. While the length of the muscle is trying to catch up with the length of the bone, the shorter muscle ends up exerting a greater force than the tendon attachment can bear.

    The Quadriceps is a four headed large and strong muscle in the front of the thigh and is attached by a relatively small tendon just below the front of the knee. In active adolescent children (Boys more than girls), this tendon sometimes pulls too hard on its attachment and dislodges a part of the bone there, causing pain, swelling, and a visible “bump” in front of the knee.

    If given adequate rest and treatment, the pain and swelling usually resolves itself (The bump sometimes stays on, but it is not significant in sporting performance later). What usually happens though is that in severe cases (like this boy who came to me) a year or two of their sporting career is lost due to pain and enforced rest.

    Can this be prevented? Maybe not. The small repetitive injuries that the strong pull of the muscle is causing cannot be detected early enough, and more often than not it is diagnosed only when significant damage has already occurred.

    But here is what I feel very strongly about. Should children in sport not be regularly screened for growth spurts, tight muscles (something as important as the Quadriceps), and many other factors that commonly contribute to injuries? Should their exercise plans not be based on such findings?
    The case in point (Raj) had such short Quadriceps that when he lay on his stomach, his knees could only bend to 90 degrees, whereas normally the heel should almost touch the buttocks.

    He was with the team for eight years, he was a valuable member of the team, and was in their care during his growth spurt. Nobody noticed that he had such tight Quadriceps.

    I do not know for certain and cannot prove that a good screening and concentrated stretching plan could have prevented his injury. But I do believe that perhaps it could have been prevented or at least its severity lessened.

    This is not an isolated case, most children in sport are not screened with care often enough to predict and prevent injuries. Most children in sport are not important enough to get much individual attention, and almost none get individualised prehab exercises.

    The sad consequence is that we lose valuable sporting talent, because the age that these injuries occur at is also the most crucial stage in their professional life: many talented children, if not adequately backed by parents and support groups, eventually give up on their chosen sport and pick another career.

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    Person! Not Diagnosis

    A patient walked in to my clinic today (I had seen him a few years earlier) wondering if we could help him with his unique problem. He had just one complaint – For the last two years his handwriting had been deteriorating.

    He is an intelligent, well-read, and knowledgeable individual of middle age, and he had already visited a few Doctors (including a Neurologist), got several blood tests done, and no one had found anything really wrong with him. He had been prescribed all the vitamins that could be required for a “nerve” problem, and he was diligently consuming them. He was active (in his own words, he would jog every day, but his speed had reduced over the last few years), worked at his job, and was in general healthy and well.

    But he was frustrated – no one had a diagnosis, and no one had a solution. Meanwhile, his deteriorating handwriting made it difficult for him to sign, creating a practical difficulty. Besides, he was worried about it.

    During a detailed examination, I found a slight weakness on the right side of his body, and a very slight imperceptible tremor. An intelligent man, he knew this himself and asked me if it could be Parkinson’s disease. Well it could be. But a Neurologist had done a detailed examination a few days ago, and had not diagnosed him.
    So this is what I think: If we do not have a diagnosis, do we NOT treat the symptoms using simple non-threatening methods? Oh we take a Combiflam if we have a head ache for God’s sake! And this is a man complaining of a very specific weakness that is causing him problems for the last two years!

    I will put him on a very specific exercise plan. We will start with strengthening of his Shoulder girdle muscles (Proximal stabilizers), and upper arm muscles. Over the next few weeks we will choose elbow and wrist muscles for our strengthening program, while increasing the work of the stabilizers. Lastly we will concentrate on fine motor skills, working on finger grip strength and functional tasks. In fact while we are at it, we may design a whole body routine improving flexibility, core strength, and lower body strength too, with his permission.

    I cannot say with surety if my plan for him will work, but what’s the harm in trying? Besides, a well-planned strength training program rarely fails us. I am hoping to see him do better in the next few months: I will keep you posted!

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    The “How to use Manual”

    I wrote this in 2010, but felt it was important to share it in my blog:

    The “How to use Manual”

    The human body is the only machine that does not come with a “How to Use” Manual. It is strange that such a complicated, well designed and priceless piece of engineering comes with no suggestions on maintenance and tips to use it better.. (Even my simple Nokia phone sends me daily tips on how to make the best use of it!!)

    Most of us stumble through life learning about our bodies from other people’s experiences; or learning by ourselves as and when we need to: from friends, peers, elders, doctors, teachers, books, trainers, the internet, etc… Unfortunately, all the people we learn from are themselves clueless or half informed because you see, there are no tips from the manufacturer himself!! In fact, since the manufacturer was a designer, he has made each of us unique, and actually there is no human exactly like another.. (Proven by the fact that each of us has a fingerprint that is unique). This means that any amount of research done on the human body cannot be absolute, and cannot be precisely applied to all humans unfailingly. Why then are we so smug about our knowledge of our bodies, why do we not hesitate ever so slightly when advising others based on what worked for us, or what we studied to be correct? When in fact, the only thing we are sure of is that we cannot be sure of anything!

    Our concepts of “hygiene” and “looking after the body” are largely dependent on our geographical location, culture, financial position, gender and generation. They also depend up on the personal beliefs of the people raising us: Parents, Relatives, Guardians, and such.. So for example whether to brush your teeth once a day, twice or thrice in a day, or whether to brush your teeth at all, may depend on your cultural and social background or upbringing. Some of these also depend up on professional requirements and financial constraints. E.g. an actress may spend several thousand rupees on beauty treatments per month, and a housewife may spend a few hundreds. In fact if we think about it none of these so-called “looking after your body” concepts are a part of normal human development. These are cultural and social “learnt” concepts, and though a necessary part of living in today’s world, not natural or necessary to the human body.

    What is most natural to the human body, and an essential part of development (as in all animals) is “Movement”. We do not need to be taught how to “move”; a foetus starts moving in the mother’s womb at the age of seven weeks and continues to learn “motor skills” throughout infancy and early childhood. Anyone that has seen the joy on a child’s face as he takes his first step, or the exhilaration that a child feels as he runs freely in a field, cannot doubt that this is what the human body was designed for.

    Social and cultural rules and norms actually rob us of our right to free movement around the time that we enter full time school at the age of six (think about the teacher insisting the child sits still in a chair for hours aiming for cerebral growth, but slowly un-learning motor skills), and by the time we are done with formal education somewhere in our twenties, we have forgotten the joys of free movement. Exercise now becomes a chore, one more thing to be “fitted” into our “to do” list for the day. Some of us may even ignore this most essential “Looking after our body” routine till health fails. We now need help to learn afresh “How to move”! This help comes from fellow humans, who have learnt these skills from other “Older, more experienced” humans and have probably been certified by institutions and academies run by “Even older and even more experienced” ….HUMANS!!

    The human body is a marvel of engineering: so uniquely designed with so many components working together tirelessly through life in the best example of teamwork. It is also an ever-changing and evolving piece of art and each individual is different from one day to the next. Each of us is unique, and none other in the world is exactly the same. It is not possible to completely understand the human body in a way that we can apply our knowledge unerringly to all that we try to help; thinking that we can, in fact is grossly arrogant and audacious. All of us in the field of medicine know that one of the first things we learn in Medicine is “Differential Diagnosis”. We arrive at a diagnosis not with conviction but by elimination, and hence it is our duty to remain “slightly uncertain” in the interest of the patient. It will also help to remember that no research ever gives a 100% conclusion, and all our treatments are based on what works for a “larger” percentage of the population.

    All of us in professions dealing with the human body (Doctors, Trainers, Coaches, etc.) need to tread lightly, cautiously and with humility because we do not have that “How to use” manual.

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    Tennis elbow and a series of unfortunate accidents

    What is “Tennis Elbow” and why does it take so long to heal? Is it because it is an incurable/ poorly understood condition or do a series of unfortunate events lead to its delayed healing?

    First of all, though it is called Tennis Elbow, it rarely affects those that play tennis regularly. To put this precisely, Tennis elbow is usually caused by ‘overexertion’, usually in some ‘unaccustomed’ activity.. It can be either somebody trying to perfect a weak stroke by repeatedly striking the ball in a new style, or a regular cyclist playing an extended game of tennis all of a sudden, or a recreational athlete playing a tennis tournament requiring him to play tennis everyday (something that he was unaccustomed to): a tennis player practising/ playing every day in his natural style rarely suffers a “Tennis Elbow”.

    Tennis elbow can of course happen without holding a tennis racquet at all.. eg. If an upper body workout was suddenly increased in intensity, or some heavy furniture was handled during renovation, a cricketer changes his bat, chooses a slightly heavier one and does an extended practice session with it, etc. The pain usually starts after an elongated period of repetitive, strenuous, unaccustomed movement. Though the patient is not usually aware at this stage that he has tennis elbow, we will call this “Stage 1”

    The pain usually starts as a minor niggle that can be easily ignored. It is usually a slight discomfort or dull ache on the outside of the elbow, the upper forearm. The pain may be transient, and not dramatic enough to seek help. Since the pain has come on due to an activity that the person has chosen to do (not really a one-time activity), the person is more often than not going to repeat that activity for a few days/ weeks: for e.g. If a cricketer has bought a new bat he is going to continue practising with it; If a tennis player is perfecting a stroke, he is going to continue practising it; If a tournament is going on, the player is going to play matches everyday; If a house is being renovated, the person may shift things around every day. The pain becomes worse because the same repetitive, strenuous, unaccustomed movement is repeated daily for days or weeks till the onset of acute pain. This is usually when the patient seeks help, and we will call this “Stage 2”

    The healing response in the human body is very strong and at “Stage 1” itself, the cells surrounding the site of tendon injury are activated to mobilize repair material to reconstruct the damaged tendon. This involves excess blood, disruption of some tissue and increase in the number of new cells, all of which increase the “Swelling” or “inflammation” in that area. A few days of rest from the aggravating strenuous activity taken at this stage, will let the body heal itself. Unfortunately, we do not always listen to the small signals our body gives us, and this healing reaction is wasted by repeating the stressful activity and leading to “Stage 2”.

    In “stage 2”, the body’s healing mechanism is still trying to repair the damage, but due to a larger area of damage, more disruption of tissue and larger collection of blood, now the healing process works against the tendon, and immature, dysfunctional cells are generated.

    Because the patient has now asked for help, help comes from all directions. He will be asked to take rest for a week or two, also given physiotherapy, medications, massage, compressive brace, etc. More often than not, none work immediately at this stage, and the patient is not much better after 1 week. We must remember that it is very difficult to “give rest” to the wrist extensors at this stage because they are involved in all hand functions! In fact even lifting a teacup or a sheaf of papers is difficult and painful!

    Two to three frustrating weeks have now passed and if the patient is a sportsman, he is not ready to wait any longer. He is probably training for a major tournament (he was perfecting a stroke when he got injured) or is insecure about his place in the team, or just does not like being away from his sport. His friends are advising him to try something different, his colleagues are practising hard, his family is worried, and he is unhappy and edgy.

    He revisits his surgeon, or goes to another, and seeing that he is so impatient, they now suggest “PRP” or “Steroid injection” for pain relief.

    “PRP” or platelet-rich plasma is increasingly being used for tissue healing of all kinds. Blood harvested from the same person is processed to make the PRP and is injected at the site to enhance healing. It has been proved that it releases at least 7 different growth factors that stimulate healing in bone and tissues.

    “Cortisone” is a natural steroid that is made by our body in adrenal glands, and released in times of stress. The injectable cortisone is synthetically made, but has the same composition as the natural one, and is used for local injection (In to site of pain). It reduces pain by reducing inflammation (swelling) and has no role in tissue healing. In fact by its very effect (reducing inflammation), it PREVENTS tissue healing.

    Let us examine the effect of either of these two choices. Though the trend is changing, the steroid shot is usually (unfortunately) tried BEFORE the PRP.

    The “Steroid shot” is given so that the player can resume play. The steroid injection can bring about pain relief after 2-3 days and if it works, the effect can last for several months or years. Unfortunately, sometimes it does not work, or sometimes also increases pain tremendously due to “crystallization”. If it does work, remember it has not caused any healing, only pain relief and compromised the healing process. If pain relief occurs, the player is going to resume play within a week, and increase intensity immediately to make up for lost time. He will also probably wear a compressive brace to protect the tendon.

    If the player is young and has injured his elbow for the first time without too much damage, he may not get a recurrence of symptoms. If, on the other hand he is older, and has had a worse damage, the case will be completely different.

    Tendons have a lower blood supply than muscle fibres. The function and structure of muscle and tendon is different, but they are both contractile in nature, and both need energy to work (contract). Tenocytes (Tendon cells) produce their own energy by aerobic and non-aerobic processes going on inside them. “Aerobic” processes require oxygen, which is carried to the cell by blood, and obviously, when blood supply is lower, the aerobic capacity decreases. But aerobic energy generation is the most profitable and desired by the cells. In sporting activities that go on for long hours at a time, eg. Tennis, Batting, etc. aerobic energy production is very important. In older tendons, blood supply is further reduced, and is actually 7 times less than younger tendons!! Obviously then, in an older athlete, with an injured tendon, especially after the steroid shot when blood supply is suppressed, the aerobic energy generation of the tendon is compromised. This is actually made worse by the compressive “Tennis elbow support” that he is wearing. Without sufficient aerobic energy, the tendon is forced to use the less efficient anaerobic systems, which lead to a build up of toxic material causing pain and inflammation to increase.

    It is now 5 weeks since the player first noticed pain, and he is again in pain and discomfort, very unsure of whether to continue playing or to take rest again. He meets his surgeon, and again the surgeon has two choices: 1. Repeat the Steroid shot, and 2. Try PRP now.

    More often than not, Steroid will be given one more chance. The whole process is now repeated again, but the steroid now may have weakened the tendon and cartilage (one of the known side effects of steroids). Now when the player plays or trains, he is at risk of actually damaging/ tearing the weakened tendon more!! Once again, pain may or may not subside, but the tendon is now more at risk, and at least 8 frustrating weeks have gone by!

    If, on the other hand, the surgeon chose PRP before the first Steroid shot (3-4 weeks after first pain was noticed), let us examine what might happen.

    As opposite of Steroid shot, PRP is given so that the tendon might heal. The surgeon here is assisting the body’s own healing mechanism by introducing platelets that will promote healing. Unfortunately as this technique and assumption is not fully understood as yet, and not too many studies (clinical trials) have been conducted, the surgeon and the patient may have different expected outcomes. Though the surgeon is giving “healing” a chance, the player probably thinks he will get quick pain relief. Ideally after PRP, a week of rest and light stretching, followed by light activities and gentle strengthening for 2 weeks, and then a gradual (over 2-3 weeks) return to play/ normal activities is advocated. This gives time for the healing process to be completed (tendon repair by the body takes between 6-10 weeks to complete). The player’s haste to play, and the surgeon’s need to prove the efficacy of the technique may end up compromising the healing process by the decision to resume training/ play early (usually the player tries to start training in a week after the shot, and resumes play within 2-3 weeks). If luck and age is on his side, all might go well and he will be rid of the symptoms. But more often than not, this haste is detrimental, and then another shot of PRP or now of Steroid is tried.

    If PRP was not tried at 4th or 5th week, and the player has taken 2 shots of steroid, PRP has almost no chance of working after 8-10 weeks. By now the tendon is weakened, damaged beyond repair, has extensive connective tissue damage, and is in a chronic inflammatory stage (here the inflammation is not curative, but more “degenerative” in nature). The principles of treatment that apply to inflammatory conditions cannot be applied here. In fact once in the degenerative stage (Tendinosis), all treatments work by “trial and error”.

    When in a chronic stage, all treatment in tennis elbow is palliative. Pain relief using drugs, electrical stimulation, heat, ice, massage/ manual techniques should be achieved along with a planned “Tensile loading” using all the principles of exercise science. Gradual strengthening, eccentric training, flexibility exercises to prevent adhesions, and “activity specific” training, all help if care is taken not to damage the tendon further. Taping and bracing for short periods of time help, if used with care. It is important to understand that what works for one patient may not work for another, and a short daily assessment is required.

    If all else fails, after several months, the surgeon may advise a surgery to relieve the symptoms. This is of course an invasive procedure, and during surgery, either the tendon sheath is trimmed, or the tendon itself is released from the bone. In most patients, surgery gives the required pain relief after 3-4 weeks, and return to normal activities in 4-6 weeks is expected. Return to play takes 12-16 weeks, a full 12 months after the patient first felt a twinge of pain!!

    Though Tennis elbow is known as “Lateral epicondylitis”, the physiology of exact damage is not understood. Tendonitis, tendinosis, tenosynovitis, peri-tendonitis, etc. are the several names given to injuries/ conditions affecting the “muscle-tendon” unit. The exact nature and area of injury cannot be determined by an examination and even after using various diagnostic tools available (Imaging: US, MRI) we will only be slightly better informed. Though some research is available on the acute inflammatory stage of tendon damage, a major drawback to understanding the chronic tendinopathy is that there are no suitable animal models available for research on chronic tendinopathies! Obviously, animals take rest when injured and let their body heal naturally. The only animal models available for research are Race Horses, who suffer similar chronic tendinopathies as humans! They are obviously not suitable subjects for research, and now research is going on by artificially creating such injuries on rabbits.

    The natural process of tendon healing after an acute onset takes about 9-10 weeks to complete and goes through the inflammatory, proliferative and remodelling/ consolidation phases. Restricting activity in the first 2-3 weeks after injury, using available treatments at that stage to help healing without causing further damage, then introducing a flexibility and light strengthening program in the second or third week, increasing the loads and adding eccentric strengthening in the fourth to sixth week and introducing sport-specific strengthening from the 7th to 9th week will ensure that the return to play is smooth and incident-free. All treatment options available do have a role to play at different stages of healing, but should be applied after evaluating their efficacy at the stage, and the goals and expectations of the player/ patient. For eg. If the player has a major international tournament of great significance to his career, suppressing the inflammatory process with a local steroid shot is warranted and acceptable. Of course explaining the expected outcome to the player is crucial. But if there is no urgent need for intervention, it is best to play a supportive role to nature and use simple modalities like therapeutic US, electrical stimulation and a wise use of exercise and taping to assist the healing process.

    Understanding the physiological and pathological processes going on in the body and conveying the need to “Go slow” effectively to the patient is the duty of the advising Doctor/ professional. Players are often overwhelmed by the diversity of advice and treatment options available, are under various pressures of their own, and their team members and coaches probably have expectations which they need to fulfil.

    Tennis elbow then is not poorly understood, nor incurable, but is a series of unfortunate events/ decisions/ actions/ accidents often leading to a very long period of pain and stress!

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    Strength and Health

    Strong women…
                May we KNOW them,
                        May we BE them,
                                May we RAISE them,
                                            May we ENSURE that their strength endures…

    Here’s what I heard from one of my women patients’ the other day: “I was recommended Vit D more than a year ago, but I chose not to take it, as I read somewhere that it’s a steroid”. Here was a young, empowered, self-employed, liberated, urban woman, making a decision that will affect her present as well as her future health, and sadly she had taken this very important decision casually and without any research!

    To young and impressionable women I would like to say this:

    Osteoporosis (weak or brittle bones) affects more women than men (one out of two women above the age of 50, will suffer from it), and to give just one statistic, 75% of all hip osteoporosis affects women (in fact the risk of hip fractures in women is so high, that it is equal to the sum of the risk they suffer of breast, uterine and cervical cancer).

    Women are genetically susceptible to OP because they start with bones that are smaller and less dense than men.  This risk increases when estrogen (a protective hormone) reduces drastically at menopause.

    Some other issues can affect Bone density throughout a woman’s life:

    1. Teenage Nutrition: Women build their bone calcium stores till the age of 18. Eating well throughout the teenage years, including about 4-5 sources of calcium through the day, getting enough sunlight or supplementing vit D, cutting down on carbonated drinks, and getting enough exercise will help to increase calcium stores that can last you for life.
    2. Pregnancy and Breast-feeding: Contrary to belief, both pregnancy and breast feeding actually increase the uptake of calcium from foods and supplements, and the increased estrogen ensures that it is deposited in the bones. In fact research shows that the more times a woman is pregnant (for 28 weeks or more), the lesser her risk of osteoporosis and fractures. I do not mean to say all women should get pregnant several times, nor do I wish to say they should get pregnant very early in life (LOL), but physiologically maybe that’s how a woman’s body is designed. This is of course considering that her diet is suitably rich in calcium and well balanced in all nutrients, she gets enough Vitamin D, and exercises moderately. If nutrition is compromised, pregnancy can increase the risk of OP as the baby’s growth requires calcium which will be drawn from the mother’s bones.
    3. Low Body Weight: Adipose tissue (fat) has been shown to have a protective effect on bone health in women, and several studies have confirmed that low body weight is linked to increased risk of fractures in later years. Of course this does not mean that obesity guarantees strong bones (!!) but being reasonable about body weight and concentrating on balanced diet and maintain a healthy body image throughout life will go a long way in preventing OP in women.
    4. A deficient diet or Vitamin D deficiency: A diet deficient in Zinc and “B” group of vitamins will affect the production of HCL in the stomach, reducing the absorption of Calcium and other nutrients. Vitamin D is a steroid hormone and facilitates the intestinal absorption of calcium and also stimulates absorption of phosphate and magnesium ions. In the absence of vitamin D, dietary calcium is not absorbed at all efficiently. Vitamin D stimulates the synthesis of proteins involved in transporting calcium from the intestine into the blood.
    5. Thyroid hormone replacements: Thyroid disorders which fall under “autoimmune disorders” where the body’s immune system targets the organs of the body itself, affect 75% more women than men.  Excessive use of synthetic thyroid replacement has been implicated in calcium depletion from bones. Whereas this cannot always be avoided, it is important to remember that regular checkups and dosage modification, good nutrition and supplementation, exercise and maintaining a good weight, all go a long way towards guarding against OP. What we also must look at is stress management, positive thinking, “being happy”, sugar control, and looking after intestinal health. Some other conditions like adrenal stress can mimic thyroid symptoms and end up in overmedication. It is actually possible in some cases to manage thyroid related issues with healthy living.
    6. Antacids: Regular and long-term use of antacids (they reduce the production of HCL in the stomach) will result in osteoporosis, especially if other contributing factors also exist, as HCL is required for the absorption of Calcium and other nutrients.  Use of antacids when medically prescribed for short periods of time is not what we are talking about: abuse of them by self-medicating to support a certain lifestyle is potentially dangerous.
    7. Cancer treatments, steroids, and anti-seizure medicines are some un-preventable causes.
    8. Smoking, drinking are some causes that we all know, and some ignore.
    9. Exercise: A good and moderate exercise program that stimulates the muscles and bones, using weight-bearing moves for the whole body is essential at all stages of life to prevent bone loss and to stimulate uptake of Calcium by the bones. Well-designed exercise can also improve balance and proprioception, preventing falls and fractures in older age.

    So to all the strong women out there, live healthy, and make well-informed choices.  May the strength of your mind, heart, soul, and body, endure for today, and for the future.

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    LINDSEY VONN INJURY REVIEW

    -Dr Harshada Rajadhyaksha
    -Dr Vipul Chavda

    Lindsey Caroline Vonn (née Kildow) is possibly the best known downhill skier in U.S. history. Four time world cup champion, Lindsey is also one of the only six women to have won World Cup races in all five disciplines of alpine skiing. After suffering a knee injury in February 2013 and undergoing a surgery as well as extensive rehabilitation, she still reinjured the same knee and had to pull out of the Winter Olympics at Sochi in February 2014. We have followed her progress from her blogs, twitter, news articles, and interviews given by her, as well as those working with her. We wish to put facts and evidence together and examine if the outcome could have been different if the decision-making and management of injury was logical instead of emotional.

    Lindsey Lindsey

    TIMELINE OF LINDSEY’S INJURY as available on her Facebook & Twitter Page:

    On the 4th of February 2013, in the opening race of Super G at the Alpine Skiing World Championship in Austria, she had a horrific fall resulting in a terrible injury to her right knee. Examined by Dr. Christian Kaulfersch, she was diagnosed to have a partial tear of the Medial Collateral Ligament, a complete tear of the Anterior Cruciate Ligament, and a Lateral Tibial Plateau fracture: what purports a COMPLEX KNEE INJURY. As is the protocol in such injuries, he advised her to wait till the acute inflammatory reaction and bruising of the bones subsided, and to later undergo a surgical reconstruction of the ACL. In fact Dr. Christian Kaulfersch described her injury as a “career delaying” and not a “career threatening” one.

    Lindsey

    The US Ski team management decided to consult doctors in USA, and Dr. William Sterett, who was Lindsey’s Doctor since she was 13 years old, immediately operated her knee (on the 10th of February, 2013), reconstructing her ACL, repairing her MCL and leaving the fracture to heal on its own.

    Lindsey
    Lindsey

    Amid speculation on her return to competitive sport, the surgeon predicted a return to the mountains in 9 months, and preparing for the winter Olympics at Sochi was definitely on Lindsey’s mind. Dr. Tom Hackett, an orthopedic surgeon at the clinic and the team physician for the U.S. snowboard squad said, ”I think so, I would be very optimistic she could come back strong. She’s a fierce competitor. She’s a fighter and chances are that she will, I would think, essentially take all of that athletic energy and put it into her rehabilitation. There’s a really good chance she could come back as strong as ever.”

    Lindsey went in to rehab.

    Immediately after surgery her questions were all to do with whether she could start exercising her upper body and core while the knee healed from the trauma of the surgery.

    She was on crutches a lot longer than the usual ACL reconstruction patient because of the Tibial Plateau fracture that had to heal. In these 6 weeks Lindsey was already going in for rehab and gym training for the upper body and core.

    Lindsey Lindsey

    Lindsey

    The crutches came off on March 27th 2013 (6 weeks post-op)

    Lindsey

    On 30th March 2013, Lindsey spoke to John Meyer of the Denver Post:

    “The more time goes on, the more confident I am that I’ll be ready for Sochi,” Vonn said. “I was a little bit nervous before the surgery, but every day since then the confidence has just gotten better and better. I have plenty of time, so I just have to make sure I do the rehab like I’m supposed to, and I don’t have any setbacks. I should be perfectly on time to be skiing, hopefully in the first speed races of the season.”

    “If I’m not ready, I’m not going to race,” Vonn said. “I would love, love, love to race at home, to race on the new world championships course. The timing is really not ideal. If I’m not ready, I’m not going to push it, because next year the main priority without a doubt is the Olympics. I think since I live here, I’ll probably have a chance to ski on the course again before world champs, so I’m not worried about getting time on it, I just would love to race at home another time. But I’m going to make sure I’m 100 percent before I start racing, and I’m not going to do it sooner no matter what.”

    Of course, competing at the highest level in February meant that she had to be ready for arduous work in the mountains at least 6 months before that, and all the rehab planning was done in reverse to achieve that Feb 10th 2014 Olympic goal. Here was “an athlete with a clear goal, and an understanding of what it takes to get there”.

    By first week of APRIL she was doing free squats with the Knee brace. (2 months post-op)

    Lindsey

    On 3rd May 2013 (11 weeks post-op), Lindsey announced that she had “dumped” her knee brace and would be back on the slopes in September. “I’m still in rehab, things are going really well. The knee is coming along quite nicely. But I should start skiing in September and everything’s right on track for the Olympics in February…” “I just dumped the brace. This is my first trip without the brace, so I’m really excited. But, unfortunately my doctor wants me to ski with it for a while, so still gonna be difficult. I can’t get rid of it entirely, unfortunately.”

    By 3rd week of MAY 2013 (15 weeks post op) she was on SMITH machine, squatting with weights, and progressing fast.

    Lindsey

    In a 29th May meeting with her surgeon, she found out that her progress was good, and she was progressing her workouts to include functional elements in the next few weeks

    Lindsey Lindsey

    By 1st Week of JULY 2013 (5 months post-op) she was doing plyometric training in the Austrian ALPS

    By 2nd week of JULY she was pictured training on rope for balance.

    Lindsey

    This picture on the 4th of August (6 months post-op) shows her in a high-load squat

    Lindsey

    And then progressing to sport-specific functional training (skiing)

    Lindsey
    Lindsey
    Lindsey
    Lindsey

    On the 28th of August (6 ½ months post-op), Lindsey spoke to John Meyer of the Denver Post again, saying that the strength of her right knee was measured at 98% of the Left knee and that she had been cleared to start snow skiing. She was off to Portillo Chile, where her surgeon Dr. Bill Sterett was going to monitor her. Vonn’s trainer Martin Hager commented that “She’s doing great, we are happy with the progress. It looks good for starting ski training that will be the focus for the first few days. Just skiing without any pain. No reaction of the knee. That will be the most important factor.”

    On 31st August 2013 (less than 7 months post-op, and 2 months before the Doctors had predicted an on-snow return) Lindsey did a few light runs on the snow, and on 1st. and 2nd September upped her training, saying SHE IS BACK!

    Lindsey

    “I knew I would get to this point. I just didn’t know how long it would take me,” Vonn said. “I didn’t know how fast or slow the recovery process would be. But I always knew I’d be back. I never really doubted it. I’m really happy that I’m finally 100 percent and I’m not injured anymore.” She said.

    In October she trained in Europe, but decided against competing in the World Cup opening event at Soelden in Austria. “My training camp in Soelden went very well and I made great progress, but I feel that I need more training before I start racing again,” she reported on her website from her home in Vail, Colo. “The Soelden race is not in the cards this year.”

    She trained downhill for the first time since her crash on Nov. 6 and, two days later, said she felt healthy enough to win a World Cup super-G race.

    Vonn said she’s reluctantly been wearing a protective knee brace under doctor’s orders, according to The Associated Press.

    “It’s in my best interest to play it safe,” Vonn said, according to the AP. “I compromised and said that as long as I don’t have to wear [the brace] for the Olympics, I’ll be fine.”

    In a training crash on the 19th of NOVEMBER 2013, she suffered a partial Rupture of Reconstructed ACL and decided to rest for a few days and undergo “aggressive physical therapy” before deciding further action.

    Lindsey

    She was allowed to continue training with a hope that she will compete at Sochi, but on 21st December 2013 in France at the Women’s World Cup Downhill event her knee “gave way”. ”The thing is I have no ACL. So unless I get surgery there’s nothing really magical that I can do that’s going to make it better. My knee is loose and it’s not stable and that’s the way it’s going to be from here on out. I just have to get used to it,” Vonn stated that no new damage had been done to the surgically repaired knee and her plans for the Sochi Olympics, in seven weeks, were still intact.

    But on 7th January 2014, without competing or skiing again after the December 21st setback, Lindsey announced that she would not compete in the Olympics. On the 15th of January 2014 she was re-operated, this time by another surgeon, Dr. Jim Andrews, and again with the goal of competing in February 2015.

    Lindsey

    OVERVIEW OF INJURY HEALING:

    When there is any injury, there are two outcomes:

    1. Loss of Anatomical continuity
    2. Loss of Physiological Function

    Immediate care after any acute injury is aimed at maintaining anatomical continuity or restoring it. Treatment choices hence depend on the type of tissue damaged, the severity of disruption of anatomical continuity, and the ability of surgeons to repair damaged tissues. When an ACL injury occurs, the velocity of the injury or the forces that act on the loaded knee, and the anatomy of the involved structures, is such that it almost never occurs in isolation. In the case of Vonn’s injury also, she suffered a complex and severe injury to the knee involving the ACL, The MCL, and the Tibia, and It is obvious that there must have been substantial bone bruising associated with the injury. In her case the surgeons had the choice (and ability) to RECONSTRUCT the ACL, REPAIR the MCL, but the bone bruising and the fractured Tibial surface do not require surgical intervention for healing and must be left alone to heal. The time required for such healing is the same in all humans, irrespective of occupation and fitness levels. Bone injuries take between 3 weeks-6 months to heal, depending on the extent of injury. The Doctor in Austria had advised a waiting period before opting for surgery. This would allow complete healing of the damaged bone tissue, and ensure that the graft tunnel will not widen after reconstructed ACL grafting.

    Though arthroscopic reconstruction of the ACL has been projected as a “sports surgery”, this suggestion actually comes from the fact that the injury often occurs in sporting activity. The primary aim of the surgery itself is not to allow early return to sports, but to slow down the onset of Osteoarthritis by improving the functional stability of the lower limb. In fact the reconstructed ACL can never accurately mimic the role of the original ACL especially in extreme sports, unless (if at all) supported by a gradual, graded, and long term rehabilitation program that concentrates on phasic execution of realistic goals corresponding to the body’s physiological healing processes.

    In Vail, the Doctors opted for an early surgery for Vonn. Though there is a school of thought that advocates early surgical intervention promising better outcomes, in the case of Vonn, the choice of an early surgery was probably taken so that the MCL could be repaired with a good prognosis, and the hope that she would be able to make a comeback in time for the winter Olympics in Feb 2014. If the ghost of the Olympics was not looming large, the Doctor would probably do the MCL repair and then post the ACL reconstruction as a second stage surgery after at least 3 months.

    SOME SCIENTIFIC FACTS ABOUT ACL RECONSTRUCTION

    The graft for the reconstruction can be taken from Patellar Tendon or Hamstring Tendons.

    The HAMSTRING (Semitendonosus/Gracilis) Graft:

    1. Is technically stronger than the patellar tendon used in the BPTB (bone patellar tendon bone) technique. However, the BPTB offers a bone to bone interface which heals faster than the tendon to bone interface in the Hamstring graft which requires more protection in the early stages of rehabilitation.
    2. Published research documents that Strength gain of DONOR area (Hamstrings) takes more than 12 months to regain original strength.
    3. This technique requires development of specific surgical skills due to certain aspects distinctive to the surgical procedure: Harvesting of the graft is a blind procedure; the position and size of the tunnel needs to be very accurate as the hamstring tendon is thinner than the patellar tendon used in the other procedure; the length of the graft is important to ensure long term stability of the knee; at the donor site, during the surgery there is a possibility of damage to the saphenous nerve which can lead to RSD, and a possibility of damage to the MCL due to its proximity to the pes anserinus complex.

    When planning rehabilitation after any injury, the first rule is that it has to go parallel to the tissue healing stages. Rehab cannot significantly hasten tissue healing, but done erroneously can in fact significantly hamper it. Decisions regarding treatment options, surgeries, and accelerating the rehab process, when taken backwards keeping a sporting date in mind, are a recipe for failure because we are dealing with human tissues.

    PLANNING A REHABILITATION PROGRAM:

    When planning rehabilitation after any injury or surgery, accounting for factors that affect rehab gains is important for its success. Some of these factors are listed here:

    • Age
    • Sex
    • Previous Fitness Level
    • Duration of immobilization/ Detraining
    • Amount of wasting
    • Profession/ Level of fitness required
    • Operative status and special aspects
    • Amount of joint degeneration
    • Level of commitment
    • Psychological status
    • Area affected/ part to be treated
    • Length of commute for profession
    • Body Weight
    • Nutritional status

    DISCUSSION:

    1. Tissue healing is a process more or less equal in all humans of a similar age and circumstances, and cannot be hastened significantly if at all. If the goal of participation in Sochi Olympics was not the crux of decision-making, the surgeon would have either repaired the MCL and immobilized the knee, or just immobilized the knee in a knee brace with 20 degree Flexion for 3 weeks, along with a non-weight bearing gait. During this period, hip strength could be maintained with exercises with brace on, knee ROM and T band non weight bearing exercises for the knee and ankle, as well as core exercises could continue
    2. After a period of 4-6 weeks, the GII (Generation II) brace which was locked at 20 degree flexion would be progressed to full range of knee ROM, and strength of hip, knee, and ankle could be worked on, first using Therabands, ankle weights and machines, and later adding closed chain exercises. At the end of 3 months, girth of the thigh and calf should be equal to the normal leg, and pain should have subsided completely.
    3. At this stage, an ACL reconstruction surgery could be planned. Delaying the ACL surgery for 6-12 weeks would have allowed for the bone injuries to heal and the inflammatory processes to quieten. Again a knee brace locked in Extension and a non-weight bearing gait will protect the new graft, full weight bearing with the brace on can start by the end of the first week and at the end of 3 weeks, the patient would have achieved full ROM of the knee with brace on. During this phase, besides work on ROM, basic strength of knee muscles, core, etc can continue.
    4. The Hamstring graft has an interface with the bone tunnel, and as bone tissue will continue to repair and strengthen around the graft for a period of 3-6 months, the graft actually needs to be protected through-out this period to varying degrees. During this period, working on girth and strength before starting excessive functional training is imperative to avoid erroneous neuromuscular patterns that may get carried forward into the sporting performance. Traditional exercises to improve girth should be the mainstay of rehab through this period, and a few elements of stable functional training (like squats, single leg VMO, etc.) can be added for variety and developing proprioception and balance. Vonn is seen participating in plyometrics and advanced functional training with high loads though her thigh girth looks poor: too much too early.
    5. Research shows that girth and strength will not improve during inflammatory phase of healing (first 3 months after surgery), no matter what is done, and the real strength, power, and muscle mass gains will only come after the tissue healing is complete. This tissue healing process is pre-determined, and cannot be shortened/ bypassed. The Hamstrings being the donor tissue for the graft, may require 6-9 months of specific strengthening post-operatively, before beginning to train them functionally. Downhill Skiing requires excellent eccentric control of the knee by the Hamstrings, and enough time should have been spent strengthening them before any skiing was attempted.
    6. After the protective period of 6 months post-operatively, at least another 3 months should be spent in progressive functional training, introducing sport-specific drills at this stage, and simultaneously continuing strength exercises to improve girth. In a highly demanding sport such as downhill skiing, the kind of muscular control (and endurance) required cannot be measured in artificial/ simulated environment. (Ideally, the first time Vonn should have ventured on the slopes for the simplest of drills is 9-12 months after surgery, or 12-15 months after her fall, i.e. Feb-May 2014). When the knee was measured at 98% of the normal, it must be remembered that the testing is done in a clinical set-up, and cannot mimic sporting demands.
    7. No grafted tissue can actually function exactly like the original ACL, and in any high risk sport like skiing enough time must be given to rehab and functional training before attempting competition. Ideally Vonn should have continued strength and functional training while increasing practice time on the slopes, adding challenging elements and speed for the next three months before considering competition (Ideal target: Oct-Nov 2014)
    Lindsey Lindsey

    Original Anterior Cruciate ligament as shown is FAN shaped and made up of 3 bundles arranged spirally making it UNIQUE and designed to control tibial rotation along with its anterior translation during knee Range of Motion (like a single chariot driven by multiple horses).

    Lindsey Lindsey

    Whereas the reconstructed ACL is nowhere near the ORIGINAL structure and can never replace the ACL, especially in its rotatory control (imagine if the chariot is now led by a single horse).

    This unique difference makes it very important for “OTHER FACTORS” to be involved in the control of Tibial Rotation.

    Lindsey Lindsey

    The Hamstrings with their anatomical Orientation are the KEY to assist the newly reconstructed ACL in controlling the tibial rotation.

    When the Graft is from the HAMSTRINGS then, we must remember that the time it will take to regain the eccentric and peak strength in the full range will be a minimum of 1 year. The Hamstrings work eccentrically in most sporting activities (especially in events like downhill skiing), and will require a lot of patience in rehabilitation to regain their “PEAK STRENGTH”.

    Time What should Have Happened Clinical Reasoning What Actually Happened
    4th Feb 2013 Injury: ACL, MCL, Tibial Plateau #
    4th Feb2013-4th May 2013
    (1st 3 months)
    Immobilization, possible repair of MCL, delay ACL reconstruction for 3 months, continue with strengthening and ROM MCL needs early repair, 3 months wait gives enough time to heal all bone bruising and Tibial plateau # Early reconstruction of ACL along with MCL repair, progressed to squats with brace on, and “dumped brace” on 3rd May 2013
    4th May 2013-4th Aug 2013
    (3rd-6th Month)
    Planned ACL reconstruction, followed by a “protective stage” with brace on, gradually progressing ROM and strengthening with open and closed chain exercises. Work on strength and GIRTH along with ROM. Core and upper body strength development. Strong and healthy bone tissue ensures tunnel integrity, protecting new ACL with brace and planned progressive strengthening ensures proper “strengthening” of bone tissue over new ACL Smith Machine squats without brace, Functional training, Plyometrics by July 2013, and high load squats by 4th August. In fact even though Lindsey is able to perform all these moves, the “girth” of her thigh still looks less.
    4th Aug 2013-4th Nov 2013
    (6th-9th month)
    Remove brace, Continue to develop GIRTH, start focusing on Hamstring strength, introduce various functional training moves while still continuing traditional strength training. Cardio elements can be cycling and swimming initially, adding elliptical trainers and step work later. “Active” flexibility training to be added. No plyometrics till strength and girth are satisfactory. Though the “protective” phase is over, we wish to continue guarding the new graft through these 3 months till the hamstring strength is somewhat satisfactory to improve rotatory and eccentric control, and bone healing is complete. Girth will still be developing and we do not want erroneous neuro-muscular patterns established. 31st August Lindsey was on the snow for the first time, brace was on (unhappily for her), the Doctors were only checking for “pain and swelling” while she skied, everyone was satisfied with the progress; in fact her knee “strength” measured at 98% of normal. She chose not to compete as she “Felt she was not ready”, but continued to practice.
    4th Nov 2013-4th Feb 1014 (9th-12th month) Build eccentric strength of Hamstrings, add various functional elements, sport specific drills including low velocity torsion loads, increase strength of all lower body and core muscles, focus on building girth, add linear sprint drills and towards the end of these three months go back on the snow, with the brace on initially. Continue flexibility drills After girth and strength have developed sufficiently, the development of skill requires training neuromuscular control and establishing desirable recruitment patterns. The amount of eccentric control required will be available at this stage as strength and girth have improved. After being on the snow since the end of August, Lindsey trained for downhill skiing on 6th Nov 2013, and immediately felt confident. She suffered a training crash on 19th Nov 2013, and partially tore her operated ACL. After a few days rest and rehab, she suffered a second setback when on Dec 21st 2013 her knee “gave way” in a world cup event in France. On 7th Jan 2014 she announced that she will not compete in Sochi.
    Re-operated on 15th Jan 2014
    Feb 2014-Sept 2014
    12th-19th month
    Plyometrics and speed drills periodically increasing velocity, power training, continue basic strength and active flexibility training. More work on the slopes and sport drills on snow. Ready for competition by Aug-Sept 2014, but can continue preparing till the competitions start toward end of October.
    October 2014 20 months after injury and 17 months after ACL reconstruction Strong and ready for competition.

    “Ability to complete a task does not guarantee true single tissue/ muscular strength especially in the case of a highly motivated elite athlete with above average overall strength and stamina”. Lindsey Vonn is an elite athlete and a strong woman, and she is seen performing well throughout her rehabilitation program, and later also in practice on the slopes. But was she ready for each stage of the rehab? Was the decision making unbiased and scientific? Was she actually benefitting from all the progress that she was seen making? After all wasn’t she herself a little unsure when she pulled out of competition in October?
    We believe that she would have fared better if the focus was on the process of healing, strengthening and preparing; not so much on the dream of the Olympic gold.

    Disclaimer:
    This article is ONLY meant to create an interest and educate physiotherapists (and anyone else that is interested) in the long term rehabilitation of sportsmen after an ACL surgery. The views expressed in this article are solely those of the authors, and are based on their long experience in the field as well as published research articles which can be provided as references.
    The article is not meant to defame/ humiliate/ hurt anyone’s feelings or doubt anyone’s clinical judgment or ability in any way, and the authors apologize for any misunderstanding caused. We have not seen/ examined/ been privy to Lindsey Vonn or any of her medical reports, and all the material, photos, information we have gathered is from what is available freely on various electronic media.
    Any comments that are made as a response to this article are the sole responsibility of their individual authors. Therefore we cannot be held responsible for any such comments.
    If any reader finds any content malicious/ harmful/ sensitive/ hurtful, please do contact us at info@prakrutihealth.com and we will rectify the problem.

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    It’s a new day, choose a new way…

    The lifestyle-related diseases that were unheard of two generations ago, hit our parents in their sixties. Our generation has suffered them in our forties and all signs point to our children suffering from these in their twenties and thirties. Onset of Cardiac diseases, Diabetes, Hypertension, and Arthritis can be prevented or delayed by promoting robust exercise, enough rest, and a wholesome diet in the growing years; and later adopting a healthy and moderate lifestyle.

    It is never too late to start on healthy changes. Every day is the first day of the next year, and the best day to make a resolution! Making small changes is all that is required.

    New Day

    Let’s cultivate a healthier generation! I encourage all young parents to be good role models by adopting a moderate lifestyle: after all, we all know that children learn more by imitation than by persuasion or punishment.

    Visit us to learn how to incorporate a few healthy changes into your present lifestyle.

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    • Dr Harshada Rajadhyaksha

      In Sanskrit, the word “Prakruti” means “Nature”: the primal motive force of the Universe; Ayurveda recognized that no two humans are alike, and called this basic, very unique, individual constitution, “Prakruti”.

      At Prakruti Sports Science and Physiotherapy Clinic, we provide the environment, expertise, and support required to assist natural healing.

      True healing begins from within the self: Doctors and Healers can only assist along the process. After 22 years, we continue to remain humble in our approach to diagnosis and treatment, our focus remains on the complete wellbeing of our patients, and we continue to promote the prevention of lifestyle-related diseases in the community.

      Our patients’ trust and faith in us, and our honest concern for their wellbeing has been the foundation of our success.