Very rarely can you repair the meniscus. If you put stitches into something that doesn’t have blood supply, it doesn’t heal. So it just tears again. So usually this is treated with a [inaudible]. Achilles rupture. Talked about this earlier. It’s very common in 20-40 year old athlete. Fancy way of saying it, eccentric force on a stressed tendon. Basically that Achilles tendon is taut, maybe just landed and if you go just a little bit too far, tendon can tear.  Usually it tears in that same [inaudible] where I mentioned there’s not a great blood supply. It’s the weaker part of your Achilles. Landing awkwardly after jumping, suddenly turning position or of course if you’re trying to run a first base while making the last out in the World Series. For you Phillie fans out there. And there it is. Last out of the World Series for you Phillie fans. That’s an Achilles rupture.

Symptoms: snapping, tearing sensation. Almost feels, people tell me they felt like they got shot in the calf. Significant weakness, can’t get up and walk. Inability to push off. Have to have your teammates carry you off the field while the other team is celebrating. Treatment. It is usually treated surgically. On occasion I treat these nonoperatively, somebody will be in a cast for 6-10 weeks but in general by far and large most orthopedic surgeons will treat this surgically with an incision, stitching the tendon together and getting going with physical therapy early. I think this is my last topic. It is a chronic ankle sprain. We all know what ankle sprain is but what I’ve seen in former and present athletes are repetitive sprains where you may have had just one really bad sprain that never healed or your ankle just keeps spraining. Eventually what happens is the ligaments on the outside of the ankle stretch out to the point where they just won’t snap back to where they belong. Most of the time after a bad sprain, 85% of the time, even with the worst sprain, those tendons will scar down to where they belong. But if ligaments become too stretched out you have a symptom of a chronic ankle sprain which means as you’re walking down the street you just hit a pebble and boom – your ankle turns and it can happen repetitively over and over. There’s a nice ankle sprain. A volleyball player. Symptoms: pain in the outside of your ankle, instability, feeling like the ankle is going to give out, can’t participate in the cutting activity, unable to walk on uneven surfaces [inaudible], notice every time you’re walking on  [inaudible] road the ankle rolls. This examination… anterior drawer sign is something that if you’ve ever had your ankle examined…basically I kind of stabilize your leg bone and pull on your heel bone and if there’s too much play there that means to me that ligament is chronically stretched out. X rays and MRI scans can help. Treatment. Nonoperative treatment for chronic ankle sprains doesn’t really help much. Those ligaments are so stretched out that even with all the therapy in the world, a kind of Arnold Schwarzenegger strength ankles, and that ligament is still too stretched out so it just buckles. Some folks they just don’t want to talk surgery. They don’t even want to think about it, you can put them in a brace that replaces the ligament but you’re in a brace all the time. Surgery is usually a two part procedure. First again through the arthroscope which is one of the really important tools. Look inside your ankle joint, clean out any scar tissue or any junk that’s built up and then go to step two which is tightening up the ligaments. Usually this is done by tightening up your own ligaments. Very rarely are those ligaments so stretched out that I can’t find them and bunch them together again. If that doesn’t work sometimes you have to get into a more complicated surgery where you try to create new ligaments from a host or different sources. That’s the end of my talk on the aging athlete. Hopefully nobody feels like this guy right now. We’ll have the questions after everybody else has talked. Thank you.

John Williams:

Aging has effects on all of the parts of musculoskeletal system. Muscle, the mass of the muscle and the strength of the muscle decrease with aging. If any of you have watched that commercial, I believe it’s for an insurer, they quote a number of 8% every 10 years over the age of 40. We are all headed in the wrong direction if you look at that. The effects of aging on muscle can be reduced by exercising. Now, effects of aging on bone. Bone density decreases after the age 35, particularly in women. In men it only decreases by half a percent per year. In women it’s 1.5% and after menopause it’s 3% per year. If we had time I could give you a separate lecture on osteoporosis but we’ll hold off of that. Bone loss can be reduced by weight bearing exercise and proper nutrition. What’s weight bearing exercise? Weight bearing exercise can be as simple as walking. It does not have to be running. Proper nutrition – calcium and vitamin D. How much calcium and how much vitamin D? Is there anybody in this room that really likes to drink a lot of milk? You’re going to see a few hands but in general, I used to say to patients “Only people on dairy farms drink a lot of milk” So I had a patient say to me “I run a dairy farm and I hate milk.” How much calcium and vitamin D you need to get? You need to get about 1500 mg of calcium and you need to get about 800 units of vitamin D. that’s a lot so we should all be on calcium supplements. Effect of aging on cartilage. Remember doctor Rudolph told you about cartilage. Cartilage is the covering end of the bone that makes up the joint. Basically it is a decreased elasticity. Wight bearing exercise is ok but not high impact aerobics or really high impact running. I’m not saying don’t run. I’m just saying in moderation. Ligaments. Remember the ligaments are the things that hold the bones together. It’s the thing that keeps your knee going this way instead of side to side or falling off. Like muscles, like cartilage, the ligaments can lose elasticity with aging. How can you get around that? Well, good stretching before activity. What’s good stretching? Good stretching is gradual stretch not what’s called a ballistic or bounce stretch. You do bounce stretch and you get to see Dr. Rudolph and me. Let’s talk about exercise. Particularly in our age group, the preparticipation evaluation is important. It’s a good idea not to have done high school athletics and then at the age of 50 or 60 or 70 say you know I really have to start exercising. Most of us at this age have medical issues whether it’s blood pressure or heart problems or diabetes and you should see your internist or family doctor to make sure that they say “Look, your heart is healthy enough to exercise.” Orthopedic issues. You know, we get less flexible as we get older. If you already have preexisting knee problems or ankle problems or shoulder problems, then there’s going to be certain exercise types that you should modify or stay away from. That’s why it’s important to, if you have an orthopedic or musculoskeletal problem, to talk to your orthopedic surgeon or your physiatrist about what kind of exercises can I do. Acute injuries. We older athletes have a lower incidence of what we call acute traumatic injuries. Which means “I fell down and broke it” or whatever. I think that is due to the wisdom of experience. Acute musculotendonous strains. Remember from Dr Rudolph’s picture, the tendon is the thing that connects the muscle to the bone. He talked about Achilles tendonitis. I agree with him, usually it’s surgical repair. Quad/patellar tendon tears.

Those tend happen more often as we pass the 35 marker, 35 years, and then get into 40s. A lot of tennis players, older tennis players, get it and that almost always needs to be fixed. If we want to talk about the upper extremity, you can rupture your biceps tendon and you can rupture it in two places, either at shoulder or the elbow. Most of the time if the biceps tendon ruptures at the shoulder you get a thing that looks like a Popeye muscle. I usually recommend patients that they do not get that repaired. Because surgery doesn’t really help to resolve all that much. It makes it look a little nicer but what you do is trade a scar for a Popeye muscle. And the few times that I’ve repaired acute traumatic injury, I’ve kind of been sorry cause the patient just, they want to be perfect, you know, “I was perfect before, why am I not perfect now?” Doesn’t work that way. Ruptures of the distal biceps tendon, that is the one at the elbow, unless you are very, very sedentary or you have medical issues, most of the time we recommend repairing those. Certainly, looking around the room here, looking at myself, I would say we are active enough where you really need that distal biceps tendon. And what does that tendon do? It helps you bend the arm, which is important. It also helps you turn the arm this way which is important if you like to do home repairs or if you play tennis. So most of the time we recommend fixing that. Chronic overuse injuries. That’s the most common injury in our age group. Cause remember now we’re smart enough not to get acute injuries and do really dumb things that maybe our children or grandchildren are doing but we maybe tend to do a little more than we should be doing and therefore most of the aging athlete injuries are of chronic overuse variety. Let’s talk a little more about the rotator cuff. Rotator cuff is a group of muscles inside your shoulder. I tell patients that it functions like a hinge on the door and that the big muscles are like a motor that opens the door, if we’re talking about that kind of door. One can get irritation or inflammation of the rotator cuff. How we get that? Doing too much of anything. We decided we were going to paint our ceiling, hanging wallpaper, trimming the hedges, playing tennis if we haven’t played in a long time.

That’s an overuse injury. Rotator cuff tendonitis almost always responds to what we call conservative care meaning nonsurgical care. Conservative care can include medication, it can include cortisone injection, almost always, at least in my patients, includes physical therapy. And what I tell my patients is once you’re done with the hard part of this, once you’re done with therapy, remember to do the exercises. Because what happens is, patients will get therapy, they’ll feel better, they’ll go home, they’ll say Dr Williams was really smart and then they come back 6 months later and then say “Wait a minute. My pain came back. Why?” And the first thing I say is “Are you doing your exercises?” And usually I get the sheepish look [inaudible]. Remember to do your exercises. There is a condition called impingement which is sort of associated with rotator cuff tendonitis. Impingement is when the space in rotator cuff is not quite exactly what it needs to be. And how do we treat impingement? I refer you back to rotator cuff tendonitis. We can treat it with cortisone shot, we can treat it with therapy, we can treat it with medication. If it doesn’t respond to treatment in, to quote Dr Rudolph, from lower extreme to the upper, in 12 months, then usually think about surgery. It can be done arthroscopically or open. Rotator cuff tears. There’s little tears and there’s massive tears and there’s tears in between. Usually we base our treatment of rotator cuff tears on the symptoms and their response to conservative nonsurgical treatment. Again, rotator cuff tear, just like tendonitis, you can treat it with cortisone shot, with therapy. Does the cortisone shot cause the tear to heal?