In This Issue

In This Issue

FEATURES

6. Avoiding Overuse

Injuries in Young Athletes A little prevention can keep kids playing for life

An increasing number of children are focusing on one sport and training yearround for it. While they and their parents may feel that this concentration is necessary to be competitive, it leaves little time for important rest and recovery.

14. Game On!

Getting ready for hockey Whether you play competitively in a league or enjoy pick-up games on the local pond, these simple exercises will help you regain your skate shape faster. First and foremost, hockey is about balance.

8. Stretching and Flexibility

Practice is the key to making strides

Making significant increases in flexibility will bring marked improvement in performance. Larger ranges of motion (ROM) will allow for longer periods of applied force, improvement in technique, increases in biomechanical advantages, and reduction in joint strain.

16. Nerve Blocks

Exploring new frontiers in the management of postoperative pain Pioneering anesthesia departments across the country have begun utilizing nerve blocks as a part of a multimodal treatment of postoperative pain. Injections of local anesthetics around key nerves that supply pain fibers to the legs and arms can block for a period the pain that follows surgery.

12. A High Activity Hip Replacement

Resurfacing procedure may be the treatment patients are looking for Fifty years ago the miracle of total hip replacement was that it allowed patients with severe arthritis to walk, sometimes for a decade or more before needing another surgery. Today, hip replacement is one of the most successful operations performed.

19. Carpal Tunnel Syndrome Relief is available

Carpal tunnel syndrome is often the result of a combination of factors that increase the pressure in the carpal tunnel. Contributing factors may include: hypothyroidism, rheumatoid arthritis, work-related repetitive use, use of vibratory tools, or the development of a cyst or tumor in the carpal tunnel. In many cases, no specific cause can be identified.

Departments 5. OA in Motion: What’s New? 10. Tools and Technology: It’s Electric! The OA Update is published by QuestCorp Media Group, Inc., 885 E. Collins Blvd., Ste. 102, Richardson, TX 75081. Phone (972) 447-0910 or (888) 860-2442, fax (972) 447-0911, www.qcmedia.com. QuestCorp specializes in creating and publishing corporate magazines for businesses. Inquiries: Victor Horne, [email protected]. Editorial comments: Darren Nielsen, [email protected]. Please call or fax for a new subscription, change of address, or single copy. Single copies: $5.95. This publication may not be reproduced in part or in whole without the express written permission of QuestCorp Media Group, Inc. To advertise in an upcoming issue of this publication, please contact us at (888) 860-2442 or visit us on the Web at www.qcmedia.com. January 2008

The OA Update  3

Opening Remarks The physicians and staff of Orthopaedic Associates of Portland (OA) welcome you to the latest issue of The OA Update. In publishing this magazine, OA hopes to create an opportunity for educating patients and their families about various orthopaedic conditions, preventive strategies for avoiding injury, and treatment options should an orthopaedic problem arise. We believe that offering information on new and evolving techniques and treatments enhances our patients’ ability to participate in making educated treatment decisions. First established in 1982, OA has been committed to providing high-quality health care using an integrated specialty center model. We hope to provide you more information about the various areas of expertise provided by the physicians and our centers at OA in this issue and future issues of The OA Update. In this issue, we feature tips for flexibility and overuse injuries. We also provide some information regarding hip replacement surgery, carpal tunnel syndrome, electromyography and nerve conduction studies, and pain management. We hope you find this issue informative and helpful, and welcome any suggestions for future publications. We’ve already heard from some of you and are appreciative of your comments and feedback! Sincerely, The Physicians at Orthopaedic Associates of Portland

Satellite Locations: Scarborough Office 306 Rte. 1, Building D Southpointe Professional Park Scarborough, ME 04074 (207) 883-4501

Orthopaedic Associates of Portland, P.A. 33 Sewall St. Portland, Maine  04102 (207) 828-2100 • (207) 828-2190 fax [email protected] John Wipfler Chief Executive Officer OA is the premier orthopaedic practice in Maine. Our 23 highly specialized physicians are experienced in the latest techniques and innovations. OA specialty centers include sports medicine; hand surgery; joint reconstruction of the hip, knee and shoulder; foot and ankle surgery; and complex fracture treatment. OA — Experience in motion! The information contained in this publication is not intended to replace a physician’s professional assessment. Please consult your physician on matters related to your personal health.

4  The OA Update

Windham Office 4A Commons Ave. Rte. 302 Windham, ME 04062 (207) 893-1738 Yarmouth Office 10 Forest Falls Dr. Yarmouth, ME 04096 (207) 846-5545

Specialty Centers Joint Replacement Center Orthopaedic Trauma Center Hand Center Foot and Ankle Center Sports Medicine Center Spine Center MRI Center Orthopaedic Surgery Center Orthopaedic Athletic Performance Therapy

OA in Motion June 2007 — Sacha D. Matthews, MD, was elected as a full member of the American Society for Surgery of the Hand (ASSH). Founded in 1946, the American Society for Surgery of the Hand is the oldest medical specialty society in the United States, and is devoted entirely to continuing medical education related to hand surgery. Dr. Matthews, now in his fourth year at Orthopaedic Associates of Portland (OA), joins fellow OA physician John T. Chance, MD, as the only ASSH members in Portland and one of only eight in the state of Maine. He is certified by the American Board of Orthopaedic Surgery and has obtained a Certificate of Added Qualification in Hand Surgery.

July 2007 — OA opened a new facility in Windham, which offers expanded hours and services to the Lakes Region community. This facility now offers on-site casting and computerized radiography services and is located at 4A Commons Avenue in Windham.

August 2007 —

The physicians at OA made the decision to update our look by introducing a new logo, as seen on the cover of this issue. Changing our logo reflects our commitment to remaining current in our field, whether that is through introducing new surgical techniques and treatment options, or by simply updating our  look. We believe the new logo affirms our identity as a specialized orthopaedic practice while also retaining a strong connection to our past.

Surgery in New York City. He spent a year as a Sports Medicine Fellow at the Steadman Hawkins Clinic in Vail, Colorado, training in minimally invasive surgery and arthroscopic treatment of soft tissue injuries to the hip. He specializes in arthroscopic surgery of the hip, knee, and shoulder. Orthopaedic Associates is proud to announce the expansion of their practice to a new Sports Performance facility in Saco, Maine. This 100,000-square-foot facility is an exciting new opportunity for athletes to have access to a sports complex that will meet all of their performance and medical needs: •  A 12,000-square-foot performance enhancement facility complete with a 4-lane rubberized sprint  track, 30-yard turfed training area, a full compliment of high-tech weight training and cardiovascular equipment which is integrated with a state-of-theart training program designed to maximize power, speed, and flexibility. •  A 4,500-square-foot physical therapy sports clinic for efficient management and prevention of injuries to minimize lost time on the field or court.

•  A 4,000-square-foot sports medicine center for efficient and comprehensive evaluation and treatment of orthopedic injuries. •  A sports physiology clinic for metabolic testing by a sports medicine physician with services to include VO2max testing, lactate testing, and anaerobic capacity testing. Evaluation of decreased  performance, unusual fatigue during exercise, and shortness of breath during exercise will also be offered. •  A biomechanics lab with high-speed, 12-camera motion analysis ability for all athletes. Services will include golf swing analysis, gait analysis, bike fit analysis, as well as biomechanical evaluation of injuries. •  Consultations with a sports nutritionist, sports massage therapist, and sports psychologist will also be offered. •  A collaborative partnership with the Portland Junior Pirates ice rink in the building. OA was built years ago to meet all of the needs of a patient after the injury occurred. Our new facility will focus more directly on building better athletes — faster, stronger, and more skilled — to enhance their performance and decrease the risk of injury. Getting safely to the next level of athletic ability is the name of the game. ■

September 2007 — Benjamin H. Huffard, MD, joined the Sports Medicine Center. Dr. Huffard completed his internship in general surgery at New York Hospital in 2002 and in 2006 completed his orthopaedic surgical residency at the Hospital of Special

OA’s proposed Sports Performance facility

The OA Update  5

Avoiding Overuse Injuries in Young Athletes

A little prevention can keep kids playing for life By D. Scott Marr, MD, FACSM

An increasing number of children are focusing on one sport and training yearround for it. While they and their parents may feel that this concentration is necessary to be competitive, it leaves little time for important rest and recovery. I often remark to young athletes that professional athletes all schedule a “down-time,” so why not young athletes? A recent Youth Sports Injuries public service campaign used the tagline: “What will they have longer, their trophies or their injuries?” While somewhat sensational, the 6  The OA Update

message should be given careful consideration. With 35 million children (6 to 21 years old) in the United States participating in sports, the risk for overuse injuries is high. According to the U.S. Consumer Product Safety Commission, more than 3.5 million sports-related injuries in children younger than 15 were treated in 2003. Thirty to fifty percent of these injuries were caused by overuse, with the frequency of injury equal among boys and girls. We are now seeing many repetitive strain injuries such as tennis elbow and

Achilles’ tendonitis that we used to see only in adults. The following is a look at overuse injuries commonly seen in children and their symptoms. Overuse injuries are a result of repetitive strain on tissues such as bone, tendons, ligaments, or specific muscles. Injury occurs when these tissues undergo sustained stress without enough time for recovery. This can lead to pain, inflammation, and a cycle of tissue damage that unchecked, can lead to chronic injuries. Injuries may occur because

Prevention Tips

Common Overuse Injuries Injury

Possible symptoms

Tibial stress fracture

Focal shin pain, worse with activity

Swimmer’s shoulder

Shoulder pain worse with overhead motion, may feel loose

Little League elbow

Pain on medial elbow, usually with throwing motion

Runner’s knee

Pain around kneecap

Shin splints

Diffuse shin pain, less focal than stress fracture

Sever’s disease

Heel pain, worse with activity

Osgood-Schlatter disease

Pain, swelling below kneecap at patellar tendon insertion

Apophyseal avulsion fracture

Abrupt onset of pain at tendon insertion on bone

Gymnast’s wrist

Diffuse wrist pain from repetitive wrist extension loading

of intrinsic factors in the athlete such as anatomical malalignments, flexibility issues, or strength imbalances. However, extrinsic factors, such as training volume and progression, are often the trigger Young athletes are particularly vulnerable because of skeletal immaturity and incomplete or imbalanced muscle development. Susceptible areas of injury include growth plates (physis), tendon attachments at these growth plates (apophysis), and tight ligaments and tendons that result from growth spurts. These injuries can be categorized three ways: • Repetitive micro trauma is caused by normal stress to the bone without adequate recovery. (i.e. stress fractures) • Growth plate injuries or fractures, which can cause permanent damage and interfere with proper growth if untreated. • Muscle, ligament, and tendon injury; these are often related to different mechanical properties in growing children. Parents are the first and most important factor in overuse injury prevention. Many children will not willingly pull themselves out of a sport. They do not want to miss the experience, may be concerned about

losing a spot on the team, or may worry about letting down parents, coaches, and/ or teammates. A classic example of a parent’s importance in prevention is the Little League pitch count. This rule is in place to avoid excessive stress to the shoulder and elbow by limiting the number of pitches a youth can throw in a game and per week. However, many kids play on multiple teams and spend hours in their backyards “practicing” their throwing. Coaches may have no idea how many pitches that athlete may actually have thrown in a given week. Without parent supervision and diligence, the pitch count is meaningless. While prevention is optimal, early recognition of overuse injuries is paramount to a quick recovery and avoiding longterm consequences. If a complaint of pain and disability is not forthcoming from a young athlete, several signs may be present. These may include: excessive use of overthe-counter pain medications, changes in performance or techniques (i.e. funny gait), and psychosocial signs such as social withdrawal, anxiety, or depression. The bottom line is that our children participate in sports for fun, to boost self-esteem,

• A ll children involved in organized athletics should undergo a pre-participation exam. If done properly, this exam can detect conditions that may limit participation or predispose an athlete to an injury. • Prevent overuse with conditioning and training to address muscle imbalances. • Avoid sudden activity increase and always allow for a progressive increase in activity level. • Cross-train throughout the year to prevent any one area of the body from becoming overworked and stressed. • Do not push children to participate in sports at a level inconsistent with their interests and abilities. • Avoid sport specialization in a single sport before adolescence. • Never encourage a child to “play through” the pain. • Follow the 10 percent rule: training (intensity, frequency, duration) should increase no more than 10 percent per week. to maintain physical fitness and to foster selfdiscipline. Accidental injury may be a part of sports, overuse injuries should not be. ■ D. Scott Marr, MD, FACSM, graduated from Dartmouth College and the University of Massachusetts School of Medicine. He holds a Certificate of Added Qualification in Sports Medicine. Dr. Marr has a special interest in elite endurance athletics including performance physiology and injury prevention.

The OA Update  7

Stretching and Flexibility practice is the key to making strides

Gaining flexibility is primarily about discipline. It requires neither great pain nor specialized knowledge. The primary key to gaining flexibility is simply to stretch often. If you do not stretch, or do so only sporadically, your gains will be limited. To improve your flexibility, you should stretch at least once a day, and, if possible, multiple times. Short, repeated exposure to stretching is more productive than a single intense or long bout of stretching. It is far better to stretch 10 minutes per day, every day, than to stretch 70 minutes once a week. Making significant increases in flexibility will bring marked improvement in performance. Larger ranges of motion (ROM) will allow for longer periods of applied 8 The OA Update

By Stanley Skolfield, ATC, CSCS

force, improvement in technique, increases in biomechanical advantages, and reduction in joint strain. While stretching should be done as often as possible, and any time is better than no time, when you stretch matters. Some light stretching and an active warm-up should be undertaken before working out to prepare for activity, but stretching immediately following a workout will have a significantly greater impact on flexibility. After a workout, muscles are warm and fatigued, which state allows for greater ROM and helps ensure that muscles are actually being stretched in a relaxed state rather than fighting against contracted muscle fibers.

One of the keys to rapidly gaining flexibility is learning how to relax when stretching. Antagonist muscles should be as relaxed as possible when stretching. Otherwise, contracted muscle fibers are providing significant reduction in ROM, and the muscle is not being effectively stretched. For example, when doing a pike stretch, the hamstrings, glutes, and lower back should be as relaxed as possible. The primary method for relaxing a muscle while stretching is simply to practice doing it. Focusing on relaxing and breathing regular while you stretch has a dramatic impact on the effectiveness of your stretching sessions. In addition, “shaking out” muscles between stretches aids with relaxation and helps release contracted fibers. After holding a pike for 15 seconds, come  out of the pike, shake out both legs, and then return to the pike stretch. Stretching should be performed so that muscles, not connective tissue, are stretched. Stretches that push joints outside of normal function should not be performed; any stretch that stretches the knee side to side should be avoided. Stretching connective tissue or stretching joints in an abnormal fashion can destabilize joints and lead to severe injury. Aim to be flexible enough so that you do not reach a fully stretched point during movements you regularly perform. For example, if you feel resistance in your shoulders or hips when performing an overhead squat, then you are not flexible enough and this resistance is hindering your performance. Overall, stretching is severely underemphasized in most training programs. There are significant performance benefits to flexibility and severe performance penalties for a lack thereof. Gaining flexibility does not require an enormous time investment, just a commitment to stretch regularly. Resolve to stretch after each and every workout.

Surgi-Care, Inc. 71 First Avenue Waltham, MA 02451 (800) 797-8744 (800) 338-6304 fax

www.surgi-careinc.com

The OA Update  9

TOOLS AnD TECHnOLOGY

Electrodiagnostic studies are vital in the diagnosis of many nerve and muscle disorders. At times, they are used to differentiate between a central nervous system (spinal cord) malady and peripheral problems of the limbs. Electrodiagnostic studies are used to help diagnose illnesses and assist with identifying appropriate surgical or nonsurgical treatments. At Orthopaedic Associates (OA), Michael Totta, MD, and Elissa Charbonneau, DO, are both physiatrists (specialists in physical medicine and rehabilitation) who perform these studies as part of their clinical practices. Electromyography (EMG) and nerve conduction studies (NCS) are two tests that work together for a common goal.

It’s Electric!

The NCS test studies the ability of a nerve to conduct electricity from one point to another. The EMG portion of the test determines how the nerve feeds the muscle. The EMG can differentiate, for example, between weakness and reduced use due to pain. The test was developed in the late 1950s, explains Dr. Totta, but has been refi ned  a great deal over the years. The test’s diagnostic value far outweighs any discomfort, which is minimal. It is offered to people who have muscular or neurologic problems such as weakness, numbness, tingling, and pain. Because some ailments’ symptoms can imitate others, the EMG/NCS is helpful in pinpointing the source of the problem by monitoring

Electrodiagnostic studies can be the key to pinpointing muscle and nerve problems By Mali R. Schantz-Feld

10 The OA Update

conduction along the nerve pathways. For example, if the sixth cervical vertebra is compressed, it can impinge on its related spinal nerve, producing symptoms similar to carpal tunnel syndrome. EMG allows a definitive diagnosis, explains Dr. Charbonneau. She adds, “It gives you a functional look at the nerve. There’s no faking it, no skewing results.” “An accurate diagnosis is the first and foremost reason for doing the test,” says Dr. Totta. EMG/NCS helps assess the existence and extent of neuropathy, or nerve disease, caused by a variety of conditions. Neurologic neck or back pain or numbness in the hand may result from a compressed vertebral disc that is putting pressure on a nerve root or compression of a nerve of the limb. Conditions such as peripheral neuropathy due to medications, diabetes, or damage from a herniated disc are often diagnosed by EMG/ NCS. Other muscle conditions, such as muscular dystrophy, may be aided by use of the EMG.

Electrodiagnostic studies are used to help diagnose illnesses and assist with identifying appropriate surgical or nonsurgical treatments. EMG test results help orthopaedic surgeons decide whether surgery is required. “Surgeons want EMG/NCS tests,” Dr. Charbonneau says, “because this could save money and valuable time, and more insurance companies are beginning to require the vital information that they provide.” With the modern medical tools of the EMG/NCS test, Dr. Totta and Dr. Charbonneau work with referring physicians to provide quality medical care and improved health for their patients. ■ Michael Totta, MD, graduated from Cornell University and the University of Rochester School of Medicine and Dentistry. He has pursued special training in orthopaedic medicine and spinal injection procedures. Dr. Totta is certified by both the American Board of Physical Medicine and Rehabilitation and the American Association of Neuromuscular and Electrodiagnostic Medicine. Elissa Charbonneau, DO, graduated from Cornell University and received a Master of Science Degree from the State University of New York at Buff alo. She attended the New York College of Osteopathic Medicine and completed an internship at Peninsula Hospital Center. Dr. Charbonneau is certified by both the American Board of Physical Medicine and Rehabilitation, the American Osteopathic Board of Rehabilitation Medicine. She is a member of the American Association of Neuromuscular and Electrodiagnostic Medicine. The OA Update 11

A High Activity Hip Replacement Resurfacing procedure may be just the treatment patients are looking for By Lynn Shorty with Brian McGrory, MD

Fifty years ago the miracle of total hip replacement was that it allowed patients with severe arthritis to walk, sometimes for a decade or more before needing another surgery. Today, hip replacement is one of the most successful operations performed and most experts feel that 20 or more years is the lifespan of the artificial joint. Newer biomaterials (the substances that artificial joints are made from) have allowed surgeons to return to an older design of hip — the resurfacing hip replacement. This may have led to a breakthrough in what patients can expect after their total joint surgery. “A week doesn’t go by that I have to tell a patient that he or she has to give up running because of hip arthritis,” says Dr. Brian McGrory, a hip replacement special12 The OA Update

ist at Orthopaedic Associates of Portland (OA). “When I found out that Dr. Derek McMinn, the developer of the Birmingham Resurfacing Hip, had patients that were not only running, but running competitively in long-distance events, I was very intrigued.” Dr. McGrory visited Birmingham, England, and learned the resurfacing technique that Dr. McMinn had perfected. As one of the only surgeons trained to perform this procedure in Maine, Dr. McGrory sees many patients who have an interest in the Birmingham Resurfacing Hip. “I’m very selective in whom I offer the surgery to, because the outcome depends on picking the right patients for this surgery,” Dr. McGrory says.

The patient’s degree of arthritis, age, sex, bone strength, and bone shape all must be right for the surgery to work. Even following these criteria, 1 to 2 percent of patients have early failure of the replacement. This compares to less than 1 percent of patients with a more traditional hip replacement. The fact that some surgeons allow patients to run after resurfacing hip replacement and that patients feel like they can run does not make it the right thing to do. Unlike a normal joint, the metal-on-metal implant does wear and can’t repair or The Birmingham Hip Resurfacing System is the only FDA-approved hip resurfacing system available for use in the United States. Hip resurfacing is an alternative to traditional total hip replacement for some arthritis patients.

Hip resurfacing is a form of arthroplasty which has been developed as a less radical alternative to total hip replacement. In the United States, the FDA approved hip resurfacing using the Birmingham Hip Resurfacing (BHR) on May 9, 2006. The BHR is a metal-on-metal hip device which differs from a total hip replacement device because it is bone conserving.

regenerate itself. Whether the amount of wear is insignificant, and if the body can dispose of the metal breakdown products, remains to be seen. “For my patients who believe that they must run, I’ll allow them to do so if everything looks good and a year has passed since their surgery (research has shown that the femur strength is increasing up to one year after surgery),” Dr. McGrory says. “Time will tell if their new hip can take it. Patients in this category are, in my view, taking a calculated risk.” When failure occurs with resurfacing hip replacement, revision to a conventional replacement remains an option because more bone remains and may be better than a standard revision. A recent study showed that a revision of a resurfacing hip

replacement is tolerated like a first-time hip replacement for most patients. Because the current style of resurfacing is a relatively new procedure, with a small number of patients being appropriate candidates, only the largest centers have had extensive reoperation experience for failed resurfacing hip replacements. “Patients often ask what is the best hip,” Dr. McGrory says, “and are astounded that there is no straight-forward answer. The newest technologies and techniques do not have enough follow-up to know which, if any, will be better than the current gold standard. At OA, we have an approach that is both conservative and cutting-edge.” Clinical follow-up studies in ceramics, metals, and cross-linked

For more about resurfacing hip surgery, visit www.orthoassociates.com/ resurfacing.htm To learn more about bearing surfaces, go to www.orthoassociates.com/ Totalhip2.htm

polyethylene are ongoing, as are studies assessing newer approaches to surgery and speedy recovery. “OA surgeons strive to bring safe, proven techniques to Maine. At the same time, we want to take advantage of potentially better innovations for our patients. Our focus on subspecialty care and follow-up of our patients allows us to achieve these seemingly disparate objectives,” Dr. McGrory says. Not all patients are candidates for resurfacing hip replacement surgery, but all have common goals for having surgery: reduced discomfort and restored function. The physicians at OA’s Joint Replacement Center are committed to achieving those goals. ■ Brian McGrory, MD, graduated from Cornell University and the College of Physicians and Surgeons at Columbia University. He is one leading investigator of a national study evaluating cross-linked polyethylene, a biomaterial that could extend the longevity of total hip replacements. Dr. McGrory is a clinical associate professor at the University of Vermont College of Medicine and the author or co-author of many medical journal articles dealing with osteotomies and hip and knee replacement surgery. The OA Update 13

GAME ON! Getting ready for hockey By Doug Brown, MD Bowdoin defenseman Ryan Seymour (20) battles for the puck with Norwich forward Vadim Beliaev (15) in front of goalie Mike Healey during the NCAA Division III quarterfinals in Northfield, Vt., in March 2002. At rear is Mike O’Neill (27).(AP Photo/Toby Talbot)

Whether you play competitively in a league or enjoy pick-up games on the local pond, these simple exercises will help you regain your skate shape faster. First and foremost, hockey is about balance. The successful hockey player has balance between left and right skates, upper and lower body, cardio and strength, finesse and ferocity. Therefore, any exercise that helps improve your balance is a must. Working with a balance ball, both with eyes open and closed, 14  The OA Update

and combining strength exercises with balancing tasks are amazingly powerful tools to develop balance and strength. Strength training for hockey players should focus on upper body (shoulders, arms, forearms, wrists, and hands) and trunk, or the mid-section also known as the core. Upper-body strength is a must because of all the contact with other players and because of work with the stick. A balanced program of upper-body

strengthening should be done during the season as well as in the off-season. During the season, the frequency and intensity of strength workouts must be decreased because of all the other workout demands. Once a week should be enough, preferably after practice. The need for leg strength and power are also obvious. Leg exercises such as the leg press, squats, lunges, step-ups, and step-downs will build leg strength while

improving stability and explosiveness on the ice. Be careful, though, of doing too many plyometric (explosive) exercises during the season because they are so taxing with all of the other demands on your legs. Additionally, core abdominal exercises such as crunches and oblique twists will toughen up your mid-section and benefit your lower back. Don’t forget the balance ball when designing your core-strengthening program. With any sport, stretching should also be an important part of your daily routine to prevent injury. Focus on the lower

you hit the ice. Your body will thank you for it tomorrow. ■ Doug Brown, MD, has been a team physician for the U.S. Naval Academy, the U.S. Men’s and Women’s National Soccer Teams, and for Portland High School for the last 26 years. He is also

the team physician for the Bowdoin men’s hockey team. He grew up playing hockey in Watervillle, and captained the hockey teams at both Phillips Andover and Bowdoin. He is the senior founding partner at Orthopaedic Associates of Portland and past president of the American Orthopaedic Society for Sports Medicine.

Hockey is a terrific, fastpaced team sport. Just remember to take time to prepare yourself and your equipment before you hit the ice! back, hamstrings, and groin, and stretch them routinely, preferably as part of your on-ice warm-up. Of course, you’ll be able to play longer and recover faster if you increase your cardio capacity. This is best accomplished on-ice because of the unique demands of skating, but at least a month of preparation before the season is essential. Sometimes, later in a demanding season, selected “off” days to rest and recover energy are beneficial. Coaches constantly try to assess whether players are “stale” or sluggish because of overtraining or whether they need more conditioning. As you prepare your body for hockey, also take time to make sure your equipment is in good shape. Helmets, pads, gloves, and skates should all fit properly and be replaced if needed. Hockey is a terrific, fast-paced team sport. Just remember to take time to prepare yourself and your equipment before The OA Update  15

Exploring new frontiers in the management of postoperative pain

NERVE BLOCKS

NERVE BLOC

16 The OA Update

nerve block is a general term, but

By Charles Higgins, MD Spectrum Medical Group Anesthesia Division

CKS

it basically means the injection of a local anesthetic or a neurolytic agent into or near a peripheral nerve, a sympathetic nerve plexus, or a local pain-sensitive trigger point. Nerve blocks relieve pain by interrupting pain sensory pathways and preventing them from reaching the brain. A local anesthetic is used to temporarily block the transmission of pain along these pathways. Pain after orthopedic surgery has traditionally been treated with narcotics, either intravenously or orally. For patients who need large doses of narcotics or who cannot tolerate oral doses of narcotics, overnight hospitalization is required. The hospital stay is often solely to control pain with IV narcotics. While the pain control may be adequate, side effects such as nausea, vomiting, and excess sedation can be unpleasant and difficult to control. Pioneering anesthesia departments across the country have begun utilizing nerve blocks as a part of a multimodal treatment of postoperative pain. Injections of local anesthetics around key nerves that supply pain fibers to the legs and arms can block for a period the pain that follows surgery. Current local anesthetics can block nerves for eight to 15 hours, an accomplishment  that allows patients to leave the recovery room without pain or the side effects of narcotics. This long-lasting block provides a window of pain relief during which patients can transition to their hospital rooms or travel home. Nerve blocks are not the total answer to postoperative pain, as they only last for a limited period. Modern postoperative pain control takes a multimodal approach, using every available tool to reduce pain. NSAID drugs, oral narcotics, and even acetaminophen are used together to attack pain from every angle. When these medications are given preoperatively and immediately after surgery, they mitigate and render manageable the pain that ensues after the nerve block subsides.

Currently, the ultimate method of pain control after limb surgery is a perineural catheter. Using recently developed techniques in ultrasound and electrical nerve stimulation, the anesthesiologist places a catheter, which is the caliber of fishing line, next to the appropriate pain nerves. Patients are sedated for this producer for their comfort. New micropumps are available that allow anesthesiologists to send their patients to the hospital room, or even home, with a constant infusion of local anesthetic bathing the pain nerve. Depending upon the unit, these pumps are the size of an apple or a deck of cards and can function for several days. Providing a postoperative nerve block service is a complicated undertaking that requires the cooperation and communication of surgeons, anesthesiologists, nurses, and support staff. Nerve blocks must be administered painlessly and safely and be effective. Support must be available to patients, both before and after surgery. Surgeons, nurses, and patients must be well informed of the benefits, drawbacks, and limitations of these techniques. The use of perineural catheters, while exciting, requires much more support. Patients who are at home with these catheters need 24 hour access to a clinician who can answer questions or concerns about the catheter or pump. The Regional Block Program at Maine Medial Center was developed in 2002 by Spectrum Medical Group anesthesiologist, Charles Higgins, MD. Under his careful nurturing, the program has grown and now provides routine postoperative pain relief for total knee replacement surgery. Perineural catheters have been used in select patients for pain control after foot and hand surgeries. Noncatheter (single shot) nerve blocks have been used for shoulder, upper extremity, and lower extremity surgeries. While all of these nerve blocks are possible, it is vital important that the necessary support and multimodal pain medication be maximized. ■ The OA Update 17

18  The OA Update

Carpal Tunnel Syndrome The carpal tunnel is a narrow, rigid passageway composed of the transverse carpal ligament and the carpal bones in the wrist through which nine flexor tendons and the median nerve pass. Carpal tunnel syndrome (CTS) develops when the median nerve is pinched within this tunnel. The median nerve provides sensation to the thumb, index, middle, and ring fingers and also supplies small muscles in the thumb that coordinate its movement. Some of the most common symptoms of CTS include: • Burning, tingling, or numbness in the palm or fingers • Nighttime awakening due to numbness or pain • Desire to “shake out” the hand or wrist • Difficulty grasping small objects It is not just repeated use that causes carpal tunnel syndrome. An injury to the wrist or mechanical problems can also be to blame. Even fluid retention from pregnancy or with certain medical conditions can cause CTS.

Carpal tunnel syndrome is often the result of a combination of factors that increase the pressure in the carpal tunnel. Contributing factors may include: hypothyroidism, rheumatoid arthritis, work-related repetitive use, use of vibratory tools, or the development of a cyst or tumor in the carpal tunnel. In many cases, no specific cause can be identified.

Treatment of CTS The goal of treating carpal tunnel syndrome is to return to normal function and activities and to prevent ongoing nerve damage, which can result in a loss of sensation and muscle strength. Treatment is based on the severity of the condition, whether there is any nerve damage, and whether other treatments have helped. Treatment options include nonsurgical and surgical methods. The earlier CTS is identified and treated, the better the results. Carpal tunnel syndrome is diagnosed by history and physical examination. An EMG (nerve test) is often ordered to confirm the diagnosis and evaluate its severity. In mild carpal tunnel syndrome, splinting to avoid bending the wrist in combination with

Relief is available By Sacha D. Matthews, MD

anti-inflammatory medicines, occupational therapy, and corticosteroid injections can alleviate the pain and numbness from CTS and can even be curative. More advanced carpal tunnel syndrome may require a carpal tunnel release — a surgical procedure, during which more space is created for the median nerve by cutting the ligament covering the tunnel. A carpal tunnel release is typically done as an outpatient procedure by a qualified surgeon. ■ Sacha D. Matthews, MD, graduated from Amherst College and the College of Physicians and Surgeons of Columbia University. He is certified by the American Board of Orthopaedic Surgery and has obtained a Certificate of Added Qualification in Hand Surgery.

Carpal tunnel syndrome is a painful condition that occurs when the median nerve, which runs from the forearm into the hand, becomes pressed or squeezed at the wrist. Carpal tunnel syndrome can be caused by repetitive motion, injury, or inflammatory types of arthritis.

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DIRECTORY Orthopaedic Associates of Portland, P.A. thanks the following advertisers for making this publication possible. Mercy Hospital ................................... page 9 Berry, Dunn, McNeil & Parker .......... page 21 DePuy Mitek ..................................... page 22 Ethos Marketing and Design ...................... inside back cover Genzyme Biosurgery ........................ page 11 Holbrook Health Center .................... page 15 Iron Mountain 745 Atlantic Ave. Boston, MA 02111 (617) 445-9493 • www.ironmountain.com Johnson & Jordan Mechanical Contractors .................................... page 20 Ledgewood Construction . ................ page 18 Maine Cardiology Associates ........... page 21 Maine Medical Center ....... inside front cover Marzilli’s Embroidery Plus Deb and Larry Marzilli 6 Marzilli Way Windham, ME 04062 (207) 893-2948 • (207) 893-0558 Fax [email protected]

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New England Medical Transcription, Inc. . ........................ page 18 New England Rehabilitation Hospital of Portland ....................... page 20 Outdoor Service Company, Inc. 219 Roosevelt Trl. Windham, ME 04062 (207) 892-7700 Pratt-Abbott, Inc. . ............................ page 18 RBC Dain Rauscher, Inc. . ................. page 20 Smith & Nephew, Inc. Endoscopy Division 150 Minuteman Rd. Andover, MA 01810 (800) 343-5717 [email protected] Spectrum Medical Group ............. back cover Steris Corporation ............................. page 9 Surgical Systems. Inc. ..................... page 20 Surgi-Care, Inc. ................................. page 9 TD Banknorth ................................... page 21

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