All posts by Shashwat Tripathi

Achilles Rupture, All Blogs, Ankle/Foot, Football

Richard Sherman’s Achilles Tendon Rupture

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After the Seattle Seahawks’ win on Nov. 9, it was determined that cornerback Richard Sherman had ruptured his Achilles tendon during the game and will miss the rest of the season. Sherman was on Seattle’s injury report the week of Oct. 30 because of his Achilles. It was painful for most of the season.

What causes Achilles tendon rupture?
A normal Achilles tendon is unlikely to rupture. Usually, there is a pre-existing tendinopathy (tendon disease). This tendinopathy is often not painful prior to the rupture. And not all painful tendinopathies rupture. As with other muscle, tendon or ligament insertion site problems (enthesopathies), Achilles tendinopathy is most common in middle-aged people (those ages 35 to 60). Athletes sometimes develop tendinopathy or rupture in their late 20s or early 30s. Patellar tendon, quadriceps and Achilles tendon ruptures are generally problems of an athlete near the end of their professional career (e.g. Kobe Bryant, Tony Parker, etc.).

The media has portrayed Richard Sherman often as a critic of Thursday Night Football because it requires players to play after minimal time off. Did the short interval between the Seahawks’ last game and the Thursday night game cause Sherman’s Achilles injury?
The relationship between activity (painful or not) to tendinopathy is unclear. Patients with painful tendinopathy often don’t rupture. Many ruptures are not preceded by symptoms. Tendinopathy most often occurs in middle-aged patients of varied activity levels and is not clearly related to activity. Rupture is often the result of a stretch to the muscle when it is contracting, called an eccentric load.

Is surgery necessary for an Achilles tendon rupture?
Rupture of the Achilles tendon can be treated operatively or nonoperatively. The tendon heals when immobilized with the foot pointed toward the ground (plantarflexion). This can be done in with a removable splint, with weight-bearing and with graduated motion exercises. Surgery adds risks of infection and wound problems, but is felt by some to speed recovery and limit re-rupture. Studies have shown similar outcomes between patients treated with and without surgery, including similar rates of re-rupture, which is uncommon in general.

All Blogs, Baseball, Elbow

Mark Melancon’s Pronator Syndrome

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The San Francisco Giants right hand pitcher Mark Melancon has stated he is day-to-day and will undergo surgery for pronator syndrome if his symptoms persist or at the end of the season.

What is pronator syndrome?
Pronator syndrome is a diagnosis that some doctors believe exists and others do not. The syndrome is troublesome forearm pain that is fairly diffuse and activity-related. Numbness is not one of the symptoms. The proposed pathophysiology is a compressive neuropathy in the front of the elbow or in the upper part of the forearm.

How do you diagnose pronator syndrome?
One of the sources of debate is that pronator syndrome cannot be confirmed by an objective test such as electrodiagnostic testing. The examination is normal except for imprecise and subjective things like tenderness and slight weakness resisting substantial force. Press reports indicate that Mark Melancon’s diagnosis of pronator syndrome was suggested by MRI findings, but there is no evidence that MRI can accurately and reliably diagnose pronator syndrome.

Why do some doctors use the diagnosis of pronator syndrome and others do not?
Non-specific, activity-related forearm pain is very common. For surgeons that believe in pronator syndrome, the “proof” is that patients feel better and thank them after surgery. However, people can be very resilient after surgery; even pretend or sham surgery. People can feel better and do more not because the surgery addressed an important problem, but because it gave them confidence and energy that allowed them to adapt. In research, we call this the placebo effect.

How could we determine if pronator syndrome is a useful diagnosis?
They only way to know if pronator syndrome is a useful diagnosis would be to compare real surgery and sham surgery and make sure the patient and evaluators had no way of knowing which one they got. Until we have a few such studies, people that have surgery for pronator syndrome are putting faith in what may be a social construction (a diagnosis that exists only because we behave as if it exists) and exposing themselves to the potential harm of surgery unnecessarily.

http://sites.utexas.edu/sports-blog/pitchers-elbow/ ‎

References: Rodner, C.M., B.A. Tinsley, and M.P. O’Malley, Pronator syndrome and anterior interosseous nerve syndrome. J Am Acad Orthop Surg, 2013. 21(5): p. 268-75.

All Blogs, Other

Is Opioid Misuse a Problem Among Professional Athletes?

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The United States is currently in the midst of a crisis of opioid misuse and overdose deaths. Former NFL players are increasingly open about their troubles with prescription opioids. Under pressure to perform in spite of injury and pain, doctors and athletes sometimes used anesthetics and pain relievers to allow professional athletes to play more comfortably. When opioids are used in this way, athletes are at risk for future opioid misuse.

What is the role of opioids in pain relief?
Patients in other countries (and many if not most patients in the United States) experience adequate pain relief using few opioids. Nociception is the physiology of actual or potential tissue damage. Pain is the unpleasant thoughts, emotions and behaviors that can accompany nociception. The intensity of pain for a given nociception is largely related to stress, distress and less effective coping strategies. Greater pain and more prolonged opioid use is associated with psychosocial factors. The best pain reliever is peace of mind and opioids should be used in the smallest doses for the shortest time possible.

Are opioid medications dangerous?
The last three decades’ experience with increasing opioid use reaffirms how addictive and dangerous they are. Surgeons in the United States tend to give more pills than people use. That can lead to using the pills for fun rather than for pain relief, which leads to problems. Unused pills can be diverted to friends and family or sold and misused.

Tiger Woods’ recent DUI is a good example of how dangerous these medications can be. Opioid medications when taken can lead to mental impairment and are dangerous when operating a motor vehicle. They are addictive and can slow and even stop your breathing, which can kill you.