Erol Yoldas is an orthopaedic surgeon in Fort Lauderdale who specializes in sports medicine. He also serves as team physician for the Miami Dolphins and the Florida Marlins. Dr. Yoldas received his undergraduate degree in biomedical engineering from Duke University and his medical degree from Yale University.To ask a question,e-mail The_Meds@SouthFloridaAdventures.com.

Q: My girlfriend has rapidly delved into an aggressive diet and training routine with a lot of running. One of my friends mentioned that she could get a stress fracture. Is that true?

A: She may be at risk. A stress fracture can come from repetitive exercise causing a strain within the bone that exceeds its local strength and causes microdamage. It is characterized by pain during the activity that is relieved by rest. On physical examination, there is discrete tenderness over the area of the stress fracture (occasionally some thickening of the bone can be felt as well).

Initial x-rays are often negative. An MRI is very accurate in diagnosing stress fractures because it depicts the degree of bone involvement and helps to identify other injuries.

Risk factors include a rapid increase in exercise time or intensity, decreased strength, low bone density and/or history of menstrual disturbances.

Stress fractures are most common in the tibia (shin bone), followed by the metatarsals, femur and fibula. Most can be successfully treated by limiting activity, followed by muscle strengthening and a graduated return to activity. In the cases that don’t heal or even progress to a fracture, surgical intervention for fixation and bone grafting is often needed.

 

Q: In the gym, I’ve heard people use words such as “isokinetic” and “closed chain” to describe their training. What do they mean?

A: There are many terms to describe the way the body moves and with what force. Isometric exercise is contraction of a muscle against resistance with no change in length. This is useful early in rehabilitation when injured or healing structures are being protected from motion.

Eccentric exercise is contraction of a muscle against resistance with lengthening of the muscle. Eccentric activity is fundamental to most athletic endeavors, and is usually involved in the later stages of rehab.

Isotonic means that the muscles are working against a constant force, such as with free weights.

Isokinetic means that the exercise is done at a constant velocity. Isokinetic machines can be done at slow (60 deg/sec) or high (300 deg/sec) angular joint velocity and are useful for assessing muscle strength and rehab progress.

Open-chain exercises are those in which a muscle group is working without any contraction from its antagonist group. An example is a leg extension—only the quads are working.

Closed-chain exercises are those in which there is contraction of the opposing muscle groups. An example is a leg press which contracts both the quads and the hamstrings. Closed-chain exercises more closely simulate functional activity and minimize sheer forces across the joint.

Lastly, plyometrics are resistance-training exercises that involve conversion from eccentric muscle contraction to concentric to produce a forceful movement in a short period of time. An example is jumping off a box and on landing, immediately jumping back off the ground.

 

Q: I am traveling to a tropical climate, and one of the people in the group is anxious about the mosquitoes causing illness. Is this a legitimate concern?

A:  Absolutely. There are very real and deadly diseases that are transmitted by mosquitoes in countries across the globe, including the United States. Some of them include the well-known malaria and the Nile virus, which has been present in South Florida. More rare diseases associated with mosquitoes include yellow fever and dengue virus, and there are tens of others.

Symptoms usually fall into three categories: encephalitis, which is infection of the brain tissue and causes headaches, nausea, vomiting and change in mental status; hemorrhagic fever, which causes shock and gastrointestinal bleeding; and fever with muscle and joint pain and rash. Any of these symptoms require urgent medical attention.

Without question, when traveling outside the US to tropical climates, you should check the Centers For Diseases Control and Prevention website (www.cdc.gov) for current medical recommendations to individual countries. In some cases, immunizations are available or prophylactic medicines should be taken. Common sense would also dictate using appropriate insect repellent, long sleeves and slacks, and considering using mosquito netting for sleep. These are very real and potentially devastating diseases and should not be taken lightly.

 

Q: I often hike in “off the beaten path” locations throughout the Everglades and Big Cypress, and I’m thinking of expanding my travels overseas. I do protect myself from untreated drinking water, but are there other concerns when I am in the backcountry?

A:  Traveling off the beaten path and being self reliant, whether here in the States or overseas, can be a wonderful and exhilarating experience. However, there can be many health hazards that are not visible to the naked eye.

There are textbooks devoted to tropical medicine and parasitology, which require years of study and are beyond the scope of our page. In general, parasites attack by penetrating our skin barrier through cuts/sores or we invite them in by ingesting them through water or food. Some parasites such as flukes (cestodes) can have their larvae in fish or meat so when we undercook the food the larvae travel into our system and can attack the GI system, liver or even the brain. So proper food preparation when roughing it is a must. Overcook food to be sure.

Tapeworms (schistosoma) or nematodes penetrate the skin through cuts and abrasions—particularly through the feet—and attack the liver, bladder and GI tract. Consequently, proper wound care such as cleaning with antiseptics and bandaging is important. Also, proper shoes and foot care, particularly with long excursions, are key in preventing the parasites from entering our system.

 

Q: I’m a healthy scuba diver in my late 20s but I’m wondering if there are any long-term effects on my body from diving?

A:  Most people are aware of the risks of scuba diving such as the “bends” or dysbarism. Without going into great physiologic detail, the pressure changes that are experienced in scuba diving can expose our skeletal system to changes or damage.

Bones do have a blood supply which in some locations are more tenuous than in others. Once the blood supply to these areas is compromised due to pressure changes, the bone can die. Once the bone dies, it often collapses and requires surgery such as joint replacement.

The areas of concern are typically the hip joint (femoral head) and the shoulder (humeral head). These vascular insults can be the result of one event or the accumulation of micro-infarcts over time.

While there is no study to document the effect of number of dives on the risk to our skeletal system, it goes without saying that one should not dive on the edge of safety. You may be able to escape a single major event by being reckless, but repeated risky dives can cause small damage to the bone over time.

 

Q: I’m 52 and have been scuba diving for years. Will I ever come to a point when I need to stop?

A:  Previously, the effect of aging on the risk of development of decompression illness in divers has often been reported as an incidental finding in epidemiologic analysis of diving accidents.

A recently published study found that aging increases risk for overall injury, serious injury in particular, and lessens recovery potential. Hence, a full medical clearance should be issued for those who are 50 and older. Even with a clean bill of health, the dangers are still present for the “older” diver.

 

Q: A friend of mine turned me on to trail running, through a park in our neighborhood. With all the shifts in terrain (dirt, sand, tree roots, rocks), is it better for my ankles and legs than road running? I’m a 24-year-old woman.

A:  Running off the concrete and on grass/dirt is great for the knees and joints. Those surfaces are softer and create less impact force. Consequently, you may feel less “ache” after running. However, the uneven terrain does expose you to risk of injury such as ankle sprains. These usually occur when you are tired and cannot respond quickly to shifting weight or surfaces. So with trail running, it is very important to slowly increase your distance and intensity (more so than road training).

 

Q: I was on my mountain bike when I took a spill and was launched into the air, and I broke my fall by putting both my hands out in front. I didn’t hear a crack but went to the ER where the X-rays were negative. My wrist still hurts when I move it. Should I worry?

A: There are a few reasons you could still be sore after such a fall, with or without breaking a bone. First, you could have a bad bone bruise in the wrist. Soft tissue bruises (muscle, tendon, etc) tend to hurt for a few days then start to get better. However, a bone bruise can take several weeks or even a few months to resolve.

Secondly, there is a bone in our wrist called the scaphoid that is susceptible to injury when we land with our wrists dorsiflexed (flexed back). It is one of eight bones in our wrist, and has a curved shape to it. Consequently, poor positioning or technique during the X-rays can often cause a fracture in that bone to be missed. Compounding that issue is that some fractures in the bone do not show up (even with perfect X-rays) for 48 hrs or so. If this fracture is not treated well initially, it often heals poorly or not even at all. This process will often lead to wrist arthritis.

Lastly, there is a ligament that connects two of the bones, the scaphoid and lunate, together. It is possible to tear that ligament without breaking the bones. Often a specialist can pick up the altered motion on wrist exam, plus see the change in position of the two bones on X-ray. If left untreated, this ligament tear can precipitate degenerative changes.

With all that in mind, I would highly recommend seeing a hand/wrist specialist.

 

Q: I have been an avid cyclist for years and have recently developed some hip and back pain. I tried working through it but now have noticed that my rotation of my legs is off. I feel that my one side has to change position to complete a revolution of the pedals.

A: The pain in the hip/back area could have many sources. However, when you mention that you are now developing a “mechanical” problem it makes one possibility more likely.

I would be concerned that you are developing arthritis in that hip. Once the joint gets worn down, it can often get misshapen as well. This will lead to loss of motion in certain directions. Usually, it will cause a loss of internal rotation. So as your hip is brought up into flexion, it will want to rotate out. As a high level cyclist, you may have noticed that change in motion on the revolution of your pedals. I would suggest having it evaluated by an orthopaedist.

 

 

Q: I am 35 years old and was a competitive swimmer through college. I stopped swimming for years but recently started again. The past couple of months I’ve noticed a vague ache in my shoulder and I thought I could work through it. Then recently my girlfriend noticed that my muscles around my scapula look different. Is it something I should worry about?

A: In general swimming is a great activity that puts low stress on your body, except for the shoulders. A couple of things should be evaluated.

First, it is possible that your girlfriend noticed some atrophy of your scapular muscles—specifically the supraspinatus and/or infraspinatus. The suprascapular nerve passes from the front of your shoulder to the back through two tight notches. If this nerve gets pinched in those places, the muscles will not get the normal nerve input and the muscle will atrophy. It can give you a vague sense of pain and weakness. When it progress, the atrophy can show as a hollowed out scapula when viewed from behind. Usually an MRI and nerve-conduction tests are done to confirm the diagnosis.

The second possibility is a movement problem (dyskinesis) of the scapula. As you move your shoulder, the scapula may tip or wing out and look asymmetric. This happens because the long thoracic nerve can get irritated and cause the serratus anterior muscle, which holds the scapula to the chest wall, to weaken. This often can resolve on its own.

Both problems do require evaluation by an orthopaedist who specializes in shoulder/upper-extremity problems.

 

Q: I am a 54-year-old woman who likes to cross-train with biking, running and swimming. Over the past few months I have felt an “ache” in my shoulder, which I thought would pass. But the pain has stayed and now I notice that when I swim, I have a hard time getting my arm out of the water. My shoulder is getting “tighter” and affecting my form.

A: There are a few things to think about. If your shoulder can passively be moved fully, but you have a hard time taking it through full range of motion (ROM), then you have to worry about your rotator cuff muscles. A tear in them will cause pain, weakness and inability move the arm fully. A good physical exam and MRI often confirm the diagnosis.

However, if your arm, even passively, does not have full ROM, then there are two possibilities. First, you could have arthritis in the joint. It becomes an incongruent joint (“a square peg in a round hole”), and acts as a mechanical block preventing ROM. This is usually appreciated best on plain x-rays.

The second possibility is a “frozen shoulder” or “adhesive capsulitis.” This is a process where the joint lining of the shoulder becomes thick and inelastic. It is often accompanied by a constant deep ache. The x-rays and MRI are usually both normal.

It is not easy for me to recommend treatment options for these three distinct problems based just on your question. While these processes are not dangerous, I would not hesitate in getting it evaluated.

 

Q: I run four days a week on the streets in my neighborhood. Amelia Earhart Park has some great trails nearby and I might start running them. Are trails better or worse for my legs?

A:  You bring up an excellent point for all runners to know. Running on the street or concrete is a harder surface and consequently more stressful to our joints. This may make you more achy or even fatigued by the end of your run. One has to be more conscientious about the mileage on the shoe and maybe get newer pairs more often. However, one advantage is that the surface is usually regular and predictable.

Trail running will offer a more cushioned surface that will place less stress across our joints. Inherently the surface will be uneven, which will make other muscle groups work harder to keep you stable through your stride. This may be advantageous to overall conditioning. Yet, cross-country terrain can bring surprises such as roots and rocks that cause us to trip. We are more susceptible to this happening when were are fatigued. With that in mind, try to avoid cross-country and trail-running to extremes.

 

Q: I lift weights a lot and play various sports and for the past few months have felt pain in both shoulders even though I’m only 21 and I never injured my shoulders. What could this be?

A: It would be better if I had more information, but one thing comes to mind. Pain in the shoulders of a young, healthy athlete is usually related to a specific episode (one throw, lift, hit, etc.) which is often related to tearing certain tissue.

However, when there is no specific event and the pain persists, it is usually related to overuse. This is common in Florida due to our great weather, which allows us to be active year-round with no rest due to “winter” conditions like up north. So, even though you may not be playing the same sport 24/7, you may not be allowing your shoulders and rotator cuff muscles to rest. I would take a few weeks off from sports and lifting, and more than likely the pain will subside. If not, then seek evaluation by a sports medicine orthopedist.

 

Q: I’m 26 and hike a lot with a 30-pound backpack. I don’t have any back problems but with the added weight, should I be using hiking poles?

A: Recently there have been some good clinical reports and good biomechanical studies validating the use of hiking poles. They do offer a mechanical advantage for our legs when hiking. This gets particularly important because for every 10 extra pounds we are carrying in a pack, the knee will see an additional 30 to 50 pounds of pressure. So, in practical terms you may find that you experience less fatigue as you hike and are able to enjoy things more.

Finally, purely from an anecdotal perspective, every time I visit the Rockies during the summer, I see more and more people using them.

 

Q: I am a 35-year-old male who enjoys multisport adventures such as a long weekend of kayaking and hiking. Recently I’ve developed pain in my groin and butt when I’m in a crouched position and the pain can last for several hours afterward. My family doctor had an X-ray done and I don’t have arthritis.

A: Interestingly, this is not as uncommon as you might think. While we in sports medicine have made great strides in understanding the knee and shoulder, we have only recently begun to appreciate the intricacies of the hip joint.

There are two common culprits for hip pain in the young, active population. One is torn cartilage in the hip, called labrum. It is a ring of tissue that gives support to the hip for a range of motion and stability. It can tear just as one gets a torn meniscus tissue in the knee. It is often underappreciated by physicians and only recently are we getting better at identifying it with a physical exam and MRI.

The second possibility is called femoroacetabular impingement. It is a bone spur on the socket side of the hip, which in certain positions may pinch on the femoral ball or neck. It can cause pain and even limitation in motion. It is not often picked up on X-ray because it does not show up as the typical hip arthritis. But more importantly, few physicians are trained to pick it up and know what to look for on X-ray.

I would not hesitate to seek the opinion of an orthopaedic surgeon who has fellowship training in hip arthroscopy/hip disorders.

 

Q: As a 42-year-old active hiker, I enjoy single-day and multiday trips. Recently I’ve noticed that right below my knee cap I’ve developed a pain which often lingers after I return from my trips. I’ve tried resting it for longer and taking NSAIDs but every time I get hiking, it comes back.

A: I am worried that you may have chronic patella tendonitis. It is not uncommon for athletic individuals to get this, but usually with rest and medicine it goes away. Occasionally the use of a strap (Cho Pat strap) across the tendon or physical therapy is added. However, if it persists, the tendon can break down and form a pocket of scar tissue that acts as an irritant. It is not dangerous but once it develops it often doesn’t go away.

If activity modification and treatments don’t help, then sometimes surgery to remove that scar tissue is indicated.

 

Q: I’m a 55-year-old healthy male who cross trains to keep my weight down and enjoy the outdoors. Over the past year I’ve developed back pain that goes into my thighs but when I bike or kayak the pain goes away. Should I be concerned?

A: A: There are many reasons for back pain, such as arthritis, bulging/herniated discs, muscles strains, etc. Most people are familiar with sciatica, which is when a group of nerves that comprise your sciatic nerve get compressed and cause pain, and sometimes numbness or weakness all the way to the toes. Consequently, when their symptoms don’t present as such they tend to be less alarmed. But when your back pain lessens with certain positions, particularly forward bending (flexion), it may be a sign of spinal stenosis.

Stenosis is when scar tissue or bone spurs grow around the spinal cord and begin to compress it, causing pain that starts going into the thighs. People often find relief by bending forward as that opens up the spinal canal. Often physical therapy and/or epidural injections are successful in managing this problem. Regardless of the ultimate diagnosis, you should seek evaluation from an orthopaedist who specializes in the spine.

 

Q: I heard from one of my friends who is in the medical field that significant muscle damage can cause your body to shut down and require dialysis. Is this true?

A: I believe that your friend was alluding to rhabdomyolysis. This term refers to the process when there is a significant injury to the muscle, usually crushed in a trauma (imagine being pinned under a car for hours) or from constant pressure (imagine an addict passed out and lying in the same position for several hours). When this occurs, muscle cells die and release proteins into our bloodstream. They may be of such significant amounts that our kidneys cannot process and eliminate all of them so they cause kidney failure that requires dialysis or else our bodies would metabolically fail. This does not occur with simple bumps or bruises that are part of our daily lives.

 

Q: I’m a 29-year-old former collegiate athlete who has gotten into scuba diving since moving to South Florida. I’ve been feeling a pain just above my pubic bone that only bothers me when I’m active, not at rest. Should I be worried?

A: Maybe. Sometimes a simple abdominal strain (rectus muscle) can be very painful. It runs from the bottom of your rib cage to the top of your pelvis and when developed forms the “six pack” look. Like any muscle strain, usually rest and time allow it to heal. However, we use those muscles every minute of the day in maintaining our posture, turning, bending, etc. Hence it can be a slow recovery.

The other thing that I would worry about would be a sports hernia. This used to be a very poorly understood entity. We think about traditional hernias as being in the inguinal region (i.e., where your thigh meets your abdomen). Sports hernias can occur anywhere a defect arises in the floor of the abdominal wall. So there can be pain up front or even deep in the lower part of your belly. There are many tests for it, but pain that is reproducible by doing a “crunch” can be a concerning sign.

If it persists, I would seek evaluation by a general surgeon with expertise in that area.

 

Q: I am a 50-year-old male who has been doing snorkeling/scuba for my whole life. But now I notice a pain in the front of my knees when I use my fins. Occasionally, after a long dive, it gets so painful that I cannot bend my knees.

A: There are different degrees of pain that we all experience. Most aches are more of a nuisance that we work through. However, when that pain becomes sharp and causes us to alter our normal function then it is time to take notice and be concerned.

Pain in the front of the knee usually has two possible sources: the cartilage in the patella-femoral joint (under the patella and, where it rubs, the trochlea) and the tendons that surround the patella.

In the first etiology, the patella cartilage, the root of the problem lies in the fact that the patella sees up to five times your bodyweight in pressure during certain sports, including kicking while snorkeling/swimming. Over time that cartilage can breakdown. Sometimes it can just soften and become weak (we use the term chondromalacia) over the entire surface. Other times, the damage can be significant enough where pieces of cartilage break off and leave exposed bone underneath.

Typically, I inform patients that a short period of rest and some anti-inflammatory are the only things necessary initially. But those do not “treat” the underlying problem. I also usually recommend taking glucosamine and chondroitin, nutritional supplements that help the health of cartilage. Take it for six weeks before passing judgment. If you are feeling better, then it should be continued as maintenance.

During this time, activity modification or physical therapy are often useful adjuncts to treatment. Arthroscopic surgery is rarely necessary unless the pain fails this program or a person is carrying fluid in the knee regularly.

The other source of pain can be a tendonitis in either the quadriceps tendon (just above patella) or in the patella tendon (just below patella). We have recently talked about those problems so I won’t say more than that rest and therapy are helpful. In your case, I would not hesitate in seeking an evaluation by an orthopaedist to begin the healing process.

 

Q: An MRI recently showed a bone bruise on my right wrist. I’m an avid tennis player and back in April changed my grip, which led to my wrist hurting. Stupid me, I didn’t stop playing tennis, just went back to my old grip. Well, I guess the damage was done. I know a bone bruise could take months to heal, but how will I know if I’m ready to play tennis again? Is it normal to have pain on the “meat” part of my palm as well?

A:We often take our hands and wrists for granted but as part of our musculoskeletal system they have an amazing balance of design and function.

The wrist has eight small bones that are linked together by a series of ligaments. This means movement in one bone can cause a direct effect on its neighbor. So if one part goes bad it can have a “domino effect” of damage.

A few areas of the wrist are of usual concern. The scaphoid and lunate bones are connected by the S-L ligament, which can get torn and cause pain and dysfunction. It may even cause some snapping in the wrist. Also, the scaphoid bone has poor blood supply so if it’s injured or fractured it has difficulty healing.

Another area of usual concern is the hamate bone. It has a small hook that can fracture from a direct blow or repeated trauma in sports such as hitting a baseball, golf ball or tennis ball. This fracture causes pain to palpation in the meat of your palm, so it can be difficult to pick up your bat, club or racket. It can be difficult to diagnose because the bone is so small. Often a CT scan is necessary.

Lastly, the triangular fibrocartilage complex sits at the base of the wrist bones on the ulnar side (side closest to your fifth finger). It is a disc of cartilage that can tear and cause a spectrum of symptoms from vague pain to mechanical clicking.

As you can see, the wrist is a very complex area of our body and it is easy to miss some problems. While the MRI showed just a bruise, which can take several weeks to get better, one should not forget that MRIs are far from perfect, particularly with the wrist. If this continues, I would ask you to see a fellowship-trained hand specialist before embarking on any treatment plan.

 

Q: I last saw an orthopedic surgeon for a third metatarsal stress fracture in January. He said it healed and that I could resume running by building mileage gradually with the use of a graphite orthotic. I’ve followed his advice but still have pain where the fracture was. Is this normal or could I have refractured the bone? Should I still be using an orthotic? It doesn’t help much.

A:Stress fractures in the foot are very difficult problems to manage. Treatment usually involves rest and/or immobilization for six to 12 weeks. After that period of time you should be able to walk and do nonimpact sports such as swimming and biking. This should be pain-free.

After several weeks of pain-free function, one should get back to impact sports such as running, with or without orthotics. If there is any pain, you should stop running immediately. X-rays are notorious for being slow in picking up the signs of a stress fracture. You should obtain an MRI or a bone scan.

It would not surprise me to find out that your fracture has returned. If so, then you have to go through the whole treatment process again. After the several weeks or months of nonimpact function, a follow-up MRI/bone scan should be done. If it is negative, then you can resume running.

In regards to the orthotic, I imagine it was prescribed to correct a malalignment of your foot such as too much pronation from a flat foot. While it may correct that problem and restore normal biomechanics in your foot, it is not enough to overcome a stress fracture that is causing you pain. Only rest and immobilization can take care of that. The orthotic would be useful once you are already healed to prevent it from recurring.

 

Q: I have been suffering from pain in my patella for the last four years, especially when I run through my neighborhood in Hialeah. Should I stop exercising until it gets better?

A: Pain around the patella, sometimes referred to as chondromalacia, is a difficult problem to treat. It is often due to the cartilage underneath the kneecap breaking down/wearing out. We often recommend glucosamine/chondroitin, which is a nutritional supplement found over the counter. It has been shown to help the “health” of cartilage. Also we recommend activity modification. Exercises such as running and going up and down stairs can put five times your body weight in pressure on the patella. Switching to exercises such as swimming and biking put far less pressure across the patella, and consequently do not hurt as much.

 

Q: I’m a healthy male (42 years old) who started cycling four years ago to get in shape. Now I’m big time into it, pedaling 100 miles a week. A few weeks ago I was riding on A1A in Boca when my tire hit a rock and I dumped my bike. One of my clips failed to release and I twisted my ankle. I thought it would be just a sprain and I would shake it off, but I’m still limping. What should I do?.

A: Most simple lumps and bumps go away quickly but there are a couple possibilities to explain your symptoms. One is that you sustained a fracture of your fibula (the small outside or lateral bone of your ankle). With certain rotational injuries you can get a fracture of that bone. Usually it precludes you from ambulating but occasionally you can have a nondisplaced fracture that allows you to function somewhat. If the fracture is not immobilized, the fracture ends continue to move and thus prevent it from healing.

The other possibility is that you sustained a “high ankle” sprain. Most ankle sprains usually involve an inversion injury. A high ankle sprain (or syndesmotic injury) happens during external rotation or eversion. The energy of the injury passes between the two leg bones, the fibula and tibia, and tears the connective ligament—the syndesmotic ligament. It can occasionally be so violent that the energy of that injury can pass all the way up to the knee and crack a bone there.

High ankle sprains, when mild, are notorious for taking a long time to heal. They usually require strict immobilization for several weeks. If the sprain is significant, the two bones may be unstable and split apart from each other with any force. This can often be visualized with a stress radiograph—externally rotating the ankle while taking the x-ray. In this situation, surgery is required to prevent the bones from splaying apart and to allow the ligament to heal.

So you can see that it is more than appropriate for you to see an orthopedic surgeon and get a complete examination with x-rays, and maybe even stress radiographs and MRI.