Arthroscopy

To understand the theory (and folly) of this seemingly “harmless” procedure, one needs to understand the physiological composition of the joint. Most of the joints in the body are synovial joints, which are flexible and self-lubricating.

The ends of the bones are covered with a protective substance known as articular cartilage. These thin coatings are separated by a layer of synovial fluid, which further cushions and lubricates them where they meet to form the joint.

Ligaments add support and hold the joints together. Tendons secure the muscles, which provide movement to the body. The whole structure is wrapped in a capsule of tissue known as the synovial membrane, which also secretes the lubricating and somewhat revitalizing synovial fluid.

The knee and the wrist joints also contain pads of fibrous cartilage, known as menisci, which help these overworked joints bear the extra stresses to which they are often subjected.

The articular cartilage which protects the inner surfaces of the joints is a homogenous substance devoid of nerves, lymphatic vessels or blood cells, made up primarily of water, collagen and specialized proteins (proteoglycans). Its structure is fairly simple; it contains a small percentage of cells known as chondrocytes, which are solely responsible for the maintenance and repair of the articular cartilage, via their ability to synthesis collagen and proteoglycans.

The high water content of the articular cartilage, coupled with the innate compressibility of the proteoglycans, give it the slick, cushioning properties so essential to maintaining healthy, pain free joints, minimizing friction and stress between the bones.

All the available evidence seems to indicate that chondrocytes are fully capable of regenerating articular cartilage throughout the course of a lifetime, which would account for the healthy cell counts even in very old people. However, since they are not fed by blood vessels, they are wholly dependent on nutrient delivery from the synovial fluid; this lack of blood supply puts a damper on their proliferative capabilities.

It is the movement of the joints that loads nutrients into, and waste out of, the cartilage. Despite their limited metabolic resources, chondrocytes can still churn out large quantities of collagen and proteoglycans.

The invasive tools of arthroscopic surgery are used to excise injured ligaments, cartilage and meniscus (which leads to a further depletion of the articular cartilage because the meniscus supplies nutrients to it)—either through shaving or slicing with a high-powered electrical instrument. The immediate result is a temporary respite from whatever pain existed before the procedure— followed by more or less permanent weakness and instability in the joint.

Unfortunately, such “collateral damage” seems more acceptable to the industrialized medical establishment than less invasive (and less profit-oriented) therapies like trigger point injections and Prolotherapy. It would be somewhat comforting to know that such intensely destructive procedures are falling from favor, if it weren’t for the fact that other, less obvious, but equally damaging techniques are still widespread.

Discussions from our Radio Show:
KNEE REPLACEMENT

 
CALLER: I have a knee that a couple doctors told that I should have a knee replacement surge. IT is pretty swollen and sore, I sure would like to avoid the knee surgery.

Dr. Darrow: With this process of Prolotherapy there is a very good chance of building up enough collagen and cartilage so that you can walk around, hopefully pain free after a few series of injections.

It’s an amazing thing. You know any doctor that you go to will tell you that knee replacement is the way to go, and it seems silly to me to jump into a surgery when there is something else that can be done. Surgery is something, it seems to me, should be the last option, and it is very rare for someone to come to our clinic and then have to go onto surgery.

What Causes Golf Injuries?

Researchers writing in the American Journal of Sports Medicine examined what causes golf injuries.

McHardy A, Pollard H, Luo K. One-Year Follow-up Study on Golf Injuries in Australian Amateur Golfers. Am J Sports Med. 2007 Mar 28;

 

BACKGROUND: Considering its popularity, little epidemiologic literature exists on golf injuries.

HYPOTHESIS: The low back is the most common injury location for golf-related injury. Most golf injuries occur as a result of the golf swing, and occur mostly at impact. The variables age, handicap, practice habits, and warm-up habits are associated with injury.

METHODS: A prospective survey over 1 year was used to study golf injuries among 588 golfers at 8 Australian golf clubs. Information collected included golfers’ injuries sustained during the year, location of injury, onset, mechanism of injury, and whether injury occurred during the golf swing or at another time. Additional information was sought on the type of treatment received after injury. Logistic regression was used to examine the epidemiologic patterns of golf-related injury and any possible risk factors for the injury.

RESULTS:
The overall 1-year incidence rate of golf injury was 15.8 injuries per 100 golfers, which equates to a range of 0.36 to 0.60 injuries/1000 hours/person.

Recurrent injuries were most common, while injuries were more likely to occur over time as opposed to an acute onset. The lower back was the most common injury site (18.3%), closely followed by the elbow/forearm (17.2%), foot/ankle (12.9%), and shoulder/upper arm (11.8%).

A total of 46.2% of all injuries were reportedly sustained during the golf swing, and injury was most likely to occur at the point of ball impact (23.7%), followed by the follow-through (21.5%). Multivariate analysis revealed that the amount of game play (odds ratio [OR] =3.73, 95% confidence interval [CI] 1.29-10.75) and the last time clubs were changed (OR =0.32, 95% CI 0.12-0.86) were significantly associated with the risk of golf injury (P <.05). Other factors such as age, gender, handicap, practice habits, and warm-up habits were not significantly associated with golf injury.

CONCLUSIONS: Nearly 16% of Australian amateur golfers may expect to sustain a golf-related injury per year. The injuries in golf are most likely sustained in the lower back region as a result of the golf swing. Based on statistical analysis, only game play and a changing of clubs seem to be significantly associated with risk of injury after adjusting for other risk factors (P <.05). Other factors such as age, gender, handicap, practice habits, and warm-up habits were not significant.

When You Feel Below Par

While playing golf may not be as dangerous as Australian rules football, anyone who’s played the game for any length of time has woken up with aches, pains and strains. It’s a non-contact sport that beats the heck out of you. So, if you want to be able to walk fairways for the rest of your life, you should be aware of potential injuries and how you could prevent and treat them.

First of all, golf is not as sedate as you might think. Dr. Marc Darrow, a Physiatrist (a doctor of physical medicine rehabilitation) at the Darrow Sports & Wellness Institute in West L.A., says, “Surprisingly, golf probably causes more injuries than most sports. Swinging a club at a hundred miles an hour creates great torque (twisting) on your body.”.

This is particularly dangerous for the senior golfer because, as he notes, “collagen, the basic material for ligaments, cartilage and tendons, starts drying out as you get older. Stressing the joints causes strains and tears.”

Dr. James Fox, a senior partner at SCOI (Southern California Orthopedic Institute) in Van Nuys, agrees. “The tissues have lost elastic fibers,” he says, “and don’t stretch. Because they’ve lost some water content, they tend to fragment more easily.”

Okay, the fact that you’re more vulnerable to injury as you get older is not exactly a news bulletin. But, what are the golf injuries that occur most frequently and how can you avoid them?

Dr. Darrow ominously warns, “Golf can affect every joint in your body” while Dr. Fox says, in his experience, “the most common injuries affect the elbow, shoulder, back and knee.” Dr. Jeff Anthony, a sports medicine specialist at San Diego State University, sees “more lower back, elbow and shoulder injuries.” In other words, most of your body is at risk.

While each injury may present unique problems, Dr. Fox classifies injuries into two basic categories. “One, I call the “macro” injury,” he says. “This is the sudden injury, like when you fall into a sand trap. The other is the “micro” injury where repetitive actions add up. The muscle or tendon is constantly stressed, causing little tears. When someone says, `I only hit one drive and my back is killing me,’ it’s usually the result of long-term damage.”

“To prevent the macro injury,” Dr. Fox cautions, “use some planning and forethought. Look out for branches or walk out of the shallow side of the bunker. Sometimes we’re too competitive and take chances.”

To prevent the micro injuries, he says, “Warm up before the round. Stretch. Get in good shape, particularly cardiovascular shape.” And– where have we heard this before?– “Keep your weight down,” he warns. “Every extra pound is multiplied six times across the knee. If you’re ten pounds overweight, that’s an extra 60 pounds per square inch of pressure on the knee.”

Dr. Darrow agrees, “Work out, stay in shape. Don’t be a weekend warrior. That’s how you get hurt.”

If you’re at all not sure what to do, Dr. Anthony advises, “There are several good books available on exercises specific for golf. They show you how to stretch and warm up before playing.”

Stretching is probably the most important and the most overlooked exercise for golfers. Instead of getting to the course late, rushing to change your shoes, hacking away frantically at a bucket of balls, then-dashing-to-the-first-tee …sloooow down, get there 15 minutes earlier and stretch all the muscles. Your back will thank you in the morning.

Some work at home could help prevent one of the most common injuries, “golfer’s elbow.” To prevent this type of injury, strengthen your forearm. While you’re watching TV, just squeeze a tennis ball with your free (non-remote control) hand. Or, better yet, do wrist curls with a light dumbbell.

This strength development may be especially important for women, as Dr. Anthony claims, “Elbow injuries seem to occur more frequently with women golfers; men seem to have more problems with their backs.”

Lessons can have a double benefit– besides cutting strokes from your handicap, they can help you avoid serious injury. As Dr. Fox notes, “If you’re swinging the wrong way a hundred times in four hours, you’ll pay the price. You need good biomechanics.”

Speaking of lessons, if you do have an injury, however minor, however temporary, inform your instructor. Tom Barber, the head professional at Griffith Park Golf Courses, says, “I need to know what physical limitations you have, are there neck problems, back trouble? That goes for everyone, not just seniors.”

Besides giving you a chance to reach the green in regulation on long par-4’s, the new technology of golf clubs also helps limit the possibility for injury. Dr. Fox says, “The forgiveness of clubs today have helped seniors and the high handicapper (avoid injury). They probably have lowered the ratio of injuries to golfers today, although the absolute numbers may have increased because there are more golfers than ever out there.”

One of the reason for this benefit, according to Dr. Darrow, is that “the looser (more flex) shaft takes some of the stress away from the body.”

Even with all these precautions, if you golf often and long enough, injuries are inevitable. What are the best treatments?

“I’m the King of Ice,” claims Dr. Fox. “Icing the damaged area will help with healing.”

To help control the pain and inflammation, Dr. Fox also recommends the use of anti-inflammatories, such as aspirin and ibuprofen.

Once you’ve suffered an injury, you must be concerned about a recurrence. For example, Dr. Anthony says, “I often recommend wearing an elbow sleeve for injuries to that joint. Elbow and shoulder injuries can be trickier than others.”

If injuries are chronic and never seem to disappear completely, there are additional steps you might want to consider. You might ask your physician for a referral for physical therapy. Don’t think that PT is only for the recovery from major traumas, like a broken hip. A lingering strained Achilles tendon or sore shoulder might respond to Ultrasound, specific prescribed exercise and massage. And the longer you wait, the more difficult it may be for a full recovery.

If you’ve never tried acupuncture, it may seem strange and a bit disconcerting, but it’s becoming an increasingly popular form of treatment. Talk to someone who’s tried it; they probably liked it. A tip: some physicians practice the Chinese art of body pin-cushioning which may make the treatment Medicare-eligible.

Dr. Darrow also practices Prolotherapy, which is the injection of a sugar solution into the area of inflammation around tendons and ligaments; this promotes the blood supply to the area and overall healing. In Dr. Darrow’s experience, some patients feel almost-immediate relief from pain.

Basically, there are as many remedies as there are ailments. Not everything works universally; you might have to look in more than one place for relief. But, the bottom line is: living with pain is not a given as you age. There are things you can and should do to prevent injuries and there are things you can do to heal quicker. Get in shape, stretch, ice and you can play golf forever. Not necessarily better, but forever. And that’s good enough for me.

The Golfer’s Wrist Pain

Like so many golfers, James Lee, experienced chronic wrist pain. However, for Lee, a member of the UCLA golf team, the acute pain threatened his ability to turn professional.

“The wrist pain started when I was a junior golfer… But, I chose to fight through it.” notes Lee.

Lee’s attempt to disregard the pain only made matters worse. In 2008, a test showed that a tear in the Triangular Fibrocartilage Complex of his left wrist (TFCC) would not heal without surgery. Lee was told that the success rate of this procedure was less than 75 percent.

While researching alternative treatments, Lee learned about Prolotherapy. Prolotherapy is a simple, natural technique that stimulates the body to repair itself, whether the injury be lower back pain, a rotator cuff tear or something else. A Prolotherapist injects a non-toxic substance into the body’s affected ligaments, tendon, or joints, which leads to local inflammation. According to studies, the localized inflammation triggers a wound healing cascade, resulting in the deposition of new collagen and cartilage to rejuvenate the body. Prolotherapy treatment is used from head to toe to eliminate pain in necks, backs, knees, shoulders, legs, feet, ankles and wrists as well as arotator cuff tear.

“Dr. Darrow treated me with Prolotherapy injections, which created collagen to repair the tear. There were no side-effects to these shots. With each injection the pain in my wrist slowly subsided,” Lee notes with a smile.

After treatment, further testing showed complete healing of the TFCC. “I feel fortunate that I was introduced to Prolotherapy before having a surgery that could have ended my golf career,” Lee stated.

Earlier this year, James Lee realized his dream and became a professional golfer.

In closing, Lee notes, “I have been playing golf six days per week, hitting thousands of golf balls. I’m pain free. My surgeon told me that he has never seen one of these injuries heal without surgery. I am grateful for Prolotherapy and Dr. Darrow.”

Carpal Tunnel Syndrome

Dr. Marc Darrow, M.D.. J.D.

 The overuse epidemic of the computer age CTS is a compression of the median nerve at the wrist, leading to numbness tingling and pain in the hand. The median nerve passes through the carpal tunnel at the wrist and into the palm where it sends branches that control feeling to the thumb, index, middle and half of the ring finger. Symptoms include tingling, pain or numbness in the hand and fingers.

The biggest problem with carpal tunnel syndrome is that it is highly over-diagnosed. Doctors unfamiliar with trigger points and the referred pain theory often overlook the true causes of problems in the areas associated with carpal tunnel. The most common reasons for misdiagnosis of CTS is weakness in the annular ligament of the elbow, or referred pain from the cervical vertebrae to the thumb, index and middle fingers. A problematic annular ligament when pressed may be a trigger point to the carpal tunnel distribution in the hand. Once the annular ligament is injected with Prolotherapy or trigger point therapy, it is often deactivated and the symptoms of carpal tunnel syndrome disappear.

Traditional methods of treating CTS include wearing a splint at night or injections of cortisone to reduce swelling. If these measures are not successful, carpal tunnel release surgery, which sections the tough transverse carpal ligament and relieves pressure on the median nerve, may be performed. But surgery should be the last treatment a patient should ever consider. Countless patients have presented to my office with worse symptoms after they had the carpal tunnel surgery.

Prolotherapy to strengthen the annular ligament will often cure chronic elbow pain.

Saline Injections
We have been having great luck with injection of saline around the median nerve to release it from surrounding tissue. A tiny needle is used under ultrasound guidance. It takes a minute and alleviates the carpal tunnel syndrome without surgical release.

Under no circumstances should a patient consent to surgery for CTS until an evaluation is performed by a physician trained in the referral patterns of pain in ligaments.