Tiger Woods' Knee

On my way to work I usually listen to sports radio and catch the top 6 sports news stories from the day before, just as I walk into the office. Today, the #1 story was Tiger Woods' season ending knee surgery. As I had a little bit more time to think about and learn what he had been diagnosed with, it brought into perspective just how amazing his win this past weekend was.

So lets summarize some the medical findings that came to light:

1) Tiger Woods will have ACL reconstruction on his left knee and will be out the rest of the season. This is for an ACL tear he say he sustained jogging in July 2007.

2) He had been diagnosed with stress fractures in his left tibia 2 weeks prior to the US Open and his doctors recommended he not compete.

Based on these findings, here are some ponderings I had today on how amazing an athlete Tiger Woods is:

Realization #1: Tiger Woods has been playing with a torn ACL. Specifically a torn ACL in his left knee. And he hasn't just been playing, he has been winning!!! He won the PGA Championship last year, the BMW championship and a few other tournaments to end 2007, he came in 2nd at the Master's this year, then won the US Open this past week. ALL ON ONE KNEE!!!!! For those of you who do not know much about the ACL, that is a major stabilizing ligament in the knee. Without it, the knee usually feels unstable and the shear forces and torque produced in the knee are higher than normal. These forces could possibly lead to incr. stress on the cartilage and meniscus. And for a right handed golfer with a swing like Tiger's, the forces on his left knee are probably ridiculous.

Realization #2: I have read articles where people have been questioning Tiger's timing in electing an April surgery, but like anybody else, Tiger Woods probably wanted to try all his options before going to the last resort- ACL reconstruction. This explains his decision to have arthroscopic surgery in April. I would assume this was a debridement type surgery where his surgeon would just clean out some of the damaged cartilage, so he would not get as much pain and stiffness. If the strength would return and his knee would feel stable, he could then opt for the ACL reconstruction at a later date. Usual timeline for rehab in this type of surgery is 4-6 weeks. Obviously this was not enough.

Realization #3: Perhaps trying to push his progress after the surgery, the stress to Tiger's knee after eventually lead to fractures in his tibia. Painful, but with time these will heal. It is amazing though that he walked 7,607 yards x 5 over the weekend with these fractures. All I can say is this guy is a gamer!!!

Realization #4: I am sure that the doctors went over all this with Tiger, and he said himself that he probably should have heeded their advice. Which probably would have meant having that knee surgery last year in July, after a problem with the ACL was discovered. But for an athlete that had yet to win a Major in 2007 and that was probably trying to win the FedEx Cup, staying in the game was the only option. Once again, the competitive nature of these elite athletes is something that is difficult for most of us in the general public to understand.

Having worked with athletes for the majority of my professional career, I understand how special some of these situations/competitions are for them and how special they are. And many times, my job is to help them just be ready and get by. Of course I have opinions about what is medically sound and what is not, but many of the decisions I leave up to the athlete. Because I'll never be their shoes. I'll never know what it's like to compete at the Olympic games or an NCAA championship. I'll never walk 18 holes in a US Open playoff at Torrey Pines with a chance to cement my place in history as one of the greatest, if not the greatest, golfer of all time. So, all can really do is watch, be amazed, and be ready when these athletes come calling.

Tendinosus vs. Tendinitis

I had a patient come to me the other day that had been dealing with achilles "tendonitis" for the last 2 years. 2 years he had this achilles pain!!! He had been to 2 other PT clinics with some minimal improvement, but had never been able to return to his recreational activities (hiking, tennis, etc.), without his achilles flaring up. He finally went back to his podiatrist, who subsequently referred him to our facility. He said that most treatment focused on modalities with some degree of LE loading, but usually involving the whole leg without any isolated ankle activities.

Unfortunately I had to be the bearer of bad news and tell him that the modalities and ROM may have made him feel better, but they would never address what was really going on in his achilles. For after hearing his subjective Hx, and after completing my objective examination, I told him that what he had been dealing with was not "tendonitis," but tendinosus.

It's disappointing to me to see that even today medical professionals are still having difficulty distinguishing between achilles tendonitis and tendinosus. In the early 1990's, it was discovered by sports medicine professionals that most people that have achilles pain have achilles tendinosus. Accoding to Wilson et. al, American Family Physician, there are such things as acute tendinopathies, but most patients that have chronic symptoms suggest they have a degenerative condition that would be better characterized as a tendinosus or tendinopathy.


In radiologic tests (such as an MRI), the difference between a tendinosus is: a) the absence of any inflammation and b) a change in the appearance of the collagen of the tendon. Histologic studies done on painful achilles tendons have demonstrated a more disordered collagen arrangement together with increased proteoglycan ground substance and neovascularization. In layman's terms, the muscle tissue is scarred and thickened, and that must be corrected to allow for the muscle to heal properly and function correctly. Otherwise loading will result in more "tearing" or further damage to the scarred collagen, leading to increased pain.

Treatment options for this patient should have started with cross-friction massage, which he did not receive at all from either of the previous PT clinics. This would have allowed for the scarred collagen to be broken down. To assist with the proper collagen repair, exercises focusing on stimulating the achilles tendon should have followed, progressing from low load isometrics to eccentric muscle activity. Something he also did not receive at the previous facility. It is important that clinicians realize the difference between the two different tendon diagnoses. For the diagnosis will help to determine the appropriate treatment plan. And the appropriate treatment plan, can help to prevent a prolonged course of rehabilitation and allow for optimal outcomes and a quicker return to full function.

For more information on achilles tendon injuries or tendinosus check out these sites:

www.achillestendon.com

www.tendinosis.org

What is a Sports Clinical Specialist?

Almost every physical therapy owner in private practice will say they provide sports physical therapy. But the truth is that most of these owners haven't really seen "true" sports PT. They've probably gone from outpatient clinic to outpatient clinic since graduation, seeing a few weekend warriors or high school athletes along the way, and say they are thus qualified to provide sports physical therapy or sports rehabilitation. I think this is why some physical therapists and athletic trainers clash. They each feel that the other is not qualified to perform some of the duties unique to each profession.

Just as there are many areas of medicine that one can specialize in (neurology, cardiology, nephrology, orthopedics, dermatology, etc.), the American Physical Therapy Association has established 7 specialty areas that physical therapists can be board certified in. Only 10% of the physical therapists in the U.S. are Board Certified in a specialty, which requires demonstrated experience in the specialty field and a passing score on an extensive written exam. This allows the Board Certified Specialist to display that they have a greater breadth of knowledge and skills in a particular area of practice than their peers. This includes sports rehabilitation.


So next time you are looking for someone with true knowledge in sports physical therapy, you want someone Board Certified as a Sports Clinical Specialist. These specialists must be certified athletic trainers or EMT's, and must have completed at least 2,000 hours working directly with athletes. They know the biomechanics of sport, exercise physiology, and sports medicine. And they know how to get you back in the game!!!


For an article about treating athletes with quotes from our director, please see: http://news.todayinpt.com/apps/pbcs.dll/article?AID=/20080526/TODAYINPT0105/80523019

For more about what sets Elite Sports Physical Therapy apart from our competitors, please visit our website at: www.espt-ca.com. 

Your Doctor Is Important!!

First of all, thank you all for tuning into this blog. I hope that the information is helpful and allows people to become better informed consumers of our healthcare system.

What prompted me to begin this blog is a situation that I see occurring with greater frequency in today's healthcare system and economy. I see people that are not qualified medical professionals (personal trainers, yoga instructors, pilates instructors, massage therapists), providing medical advice. And the confusing thing to me is that people actually seek out these people for advice. It's true that some of them do have other credentials as a chiropractor, nurse, or physical therapist maybe, but most do not. I don't know if it is an accessibility issue because they can get information quickly or that they don't want to seek out their physician because of cost, but this raises a red flag for me.

What I observed was several people at the gym seeking out a personal trainer for advice on aches and pains they were having. The personal trainer then proceeded to provide them suggestions on exercises and stretching. One incident that was extremely disconcerting was a young soccer player that twisted her knee and the father was asking the personal trainer what to do. Instead of recommending that the father seek a medical professional for his daughter, the trainer proceeded to recommend exercises which included jumping and hopping without having looked at the girl's knee (Not that the trainer would have known what to look for even if they did).

What if the girl had a meniscus tear? Without a proper evaluation and assessment, what may have been a non-surgical condition could have progressed to a much more serious tear requiring surgery. These are things that a medical professional could have ruled out first and at that point the strengthening could have proceeded. Perhaps under the guidance of a physical therapist or someone else the doctor is comfortable with.

Doctors, chiropractors, physical therapists, athletic trainers and other certified medical professionals have 1000's of hours of experience at school and in the clinic. They pay for their education for a reason. They are armed with information the general population has not had access to, and their job is to share it for people's health benefits. Most fitness professionals have not had this type of training.

Seeing a doctor for aches and pains that happen is very important for another reason. Your doctor can order tests to rule out other medical issues as the cause of the pain. If the cause of pain is musculoskeletal, than exercises or stretching usually will help. But there are times when the pain is caused by a pinched nerve from a disc in the back or neck or another structure like a tumor. The aforementioned medical professionals have the skills to determine what warrants further medical care. They know how to prevent you, the patient, from making the condition worse. Fitness professionals do not!!

I'm just hoping that people learn that doctors are important. With the Internet, sometimes people may feel they don't want to wait for the doctor's appointment or pay the co-pay for the office visit, but doctors possess a wealth of knowledge and information to help people heal. They have access to cutting edge procedures and technology. They can provide referrals to other professionals to help. I know that it costs money to visit a physician, but tell me, would $20 for an office visit be too much if it prevented a $10,000 surgery?