The answer is no. Does physical therapy cause the tear to heal? The answer is no. But what they do is reduce the symptoms down to a tolerable level and by retraining the other muscles in the shoulder; most patients can go on with their lives. You have to remember that about 1 out of 3 individuals over the age of 70 has a rotator cuff tear and not everybody has pain. Because if you look at the population here in Bethlehem, if 1 out of 3 people over 70 had a painful rotator cuff, we’d have people lined up from here down to [inaudible] waiting for treatment of their shoulder. Even with a rotator cuff tear, surgery is usually the last resort. I myself have a small rotator cuff tear in my shoulder, bothers me once in a while. I take a little bit of anti-inflammatory, take it easy for a little bit, gets better, I go on about my daily activities. Let’s talk about the elbow. Basically the most common elbow problem in us more mature athletes are what are called epicondylitis. And that’s a fancy way of saying tendonitis which is a fancy way of saying irritation or inflammation of tendon. In medial epicondylitis, bump of the bone here on the elbow on the inner side, we call that golfer’s elbow. Quite honestly, in 25 years of practice, I think I’ve taken care of 2 patients with golfer’s elbow who actually played golf. Everybody else gets it from lifting weights, work related activities, whatever. Then there’s lateral epicondylitis, that’s the bump of the bone on the outer side of the elbow. That’s also a tendonitis. That’s usually called the tennis elbow. In 25 years of practice I think I’ve taken care of 3 tennis players who had tennis elbow. Everybody else gets it from a lot of computer work, or repetitive things like checkout ladies [inaudible] for 8 hours a day. Or patient comes in and says “I have a pain here.”

You determine they have tennis elbow. I’ll say “Any change in your activities?” “My husband and I were remodeling the house and it was my job to paint the trim and I did this for 8 hours a day.”  The treatments for either medial epicondylitis, golfer’s elbow, or lateral epicondylitis, tennis elbow, are the same. It’s medication. Things like Advil or Relieve. There’s now a really nice rub on version of anti-inflammatories called Voltaren Gel, I prescribe it probably by the 55 gallon drum. It’s really good because it doesn’t, although theoretically they have to use same warning labels, it does not get into the blood stream like the oral medicines do. And patients who are on Coumadin or Plavix, who are just not very healthy, I’m still very comfortable having them use that medication. So you can treat it with medication, you can treat it with physical therapy, you can treat it with a little band that goes around. We call that a counterforce brace. You can buy them over the counter or you can get a really good version here at Coordinated. Cortisone shot is sometimes temporary but often works very nicely. And last but not least, surgery. Some years ago I went to a conference on upper extremity problems and one of the lectures the title was “Is there anything new in tennis elbow’?” and the lecturer spent half an hour talking about tennis elbow and the conclusion was – no. The high shock wave stuff and plasmapheresis are not really proven to work for tennis elbow. The point of his lecture was that if you take a 100 patients with tennis elbow, and you treat them with medication, or injection, or therapy, or surgery, and you look at that same group of patients a year later, the same percentage have gotten better no matter what you had done.  The point is – don’t rush into surgery. I’ll talk briefly about the knee. Dr Rudolph covered that really nicely in depth. I’ll talk about the meniscus a little bit. You have to be careful in the older athlete because usually a torn meniscus or what we call meniscal pathology, coexists with arthritis. If the patient has mechanical symptoms like Dr Rudolph said, the locking or the catching, that might tend to [inaudible] surgically. The problem is that arthroscopy for the meniscal disease in the older athlete, 50, 60, 70, who also has arthritis; the success rate is only about 60%.

Success being defined as [inaudible] reduction in pain and getting back to your regular activities. I usually drag my feet about getting patient into surgery who has a meniscal tear and the arthritis. There’s other options to treat the arthritis. What are patellofemoral problems? The patellofemoral joint is in front of the knee, it’s between the knee cap and the thigh bone. Usually patients have pain in front of the knee. Their pain is worse going up and down stairs or getting u from a seated position. And even in the more mature population, the majority of patients who have patellofemoral pain are women. Why is that? I don’t need to tell you women are built a little differently than men, tend to be a little bit wider at the pelvis so you all tend to be knock-kneed, your knee cap instead of riding down the road straight wants to drive this way. 95% or more patients with front knee pain, patellofemoral pain, will respond to nonsurgical treatment. That’s’ another…if I tell you you have patellofemoral pain, I’m going to be kicking and screaming before you can drag me into the OR and operate on it because it doesn’t usually help. Therapy, medication, a good knee brace and the right kind of exercise is not the squats. Let’s talk about total joint replacement and sports participation. Definitely the top list of activities, definitely a no-no. Why is that? Because they all involve quick starts and stops, they involve repetitive impact. In the case of football, I believe it was Dion Sanders, there was a pro football player who had a total hip replacement and tried to go back into playing football and that was like…Bo Jackson? I’m sorry. Thank you. That was probably the craziest thing I’ve ever heard. Basketball, football, gymnastics, handball, singles tennis, jogging, volleyball and high impact aerobics. Again why? Remember your total joint is a mechanical product and like all machines it can wear out. Now yes, walking, swimming doubles tennis, golf and low impact aerobics. Why? Because again these are not repetitive heavy duty impact activities. Maybe if you’ve done these activities before joint replacement and you are reasonably proficient at them, then you might be able to go back to those activities after your joint replacement. That would be things like weight lifting, downhill skiing and skating. Now I’m a skier, if you can go back to downhill skiing, that means no moguls, you keep both skis on the ground. You know, don’t be crazy. This is Jerry Rice who at the age of I believe 42 played in his last professional football game. No it’s not 75 like a golfer but I can’t imagine at the age of 40 or 42 running down the football field with 10 guys who basically wanted to kill me. I have to say I think jerry Rice is my hero. Thank you.

J. E. Kooch:

I did my undergraduate degree at West Virginia University in exercise physiology. Then I went off to stormy Buffalo and I did 2 years of graduate school in biomechanics. Then I went out to cold, snowy Chicago and that’s where I did medical school. I’m an osteopath and then I went to Northwestern for my residency. That’s where I became what is called a physiatrist. Does anybody know what a physiatrist is? Anybody? What is it? It’s a rehab specialist, yes, but specifically the doctor of what is called physical medicine rehabilitation. We initially got training in things like stroke, spinal cord injury and brain injury and it’s really to deal with how to function on a day to day basis based on that impairment that you have. We also got a lot of expertise in musculoskeletal medicine. That’s kind of my area of expertise, obviously specializing in spine. The idea is that throughout my education a lot this is based on functioning and that kind of is the theme of this talk. It’s that functioning can be a lot of different things to a lot of different people. Your goals and aspirations are based on your functioning whether it is your activities of daily living, to try and make sure that you can wash the dishes or play Batman. Whatever that function is, that’s what we’re trying to restore. The exercise is the element that I’ve always used to try and be a means to the end. The idea is that, I’ll just start writing things down here. There are 5 lessons we’re going to go over. First lesson is anatomy. Let’s hand out some of these models here. I want you to kind of pass them around a little bit. This is the big one I’m just kind of show you briefly essentially what we’re looking at [inaudible] segments that I’ll pass out. The spine itself is a collection of bones that’s stacked on each other and these are the little bones’ segments. We are going to be talking primarily about the lower back cause it’s the most common area that we injure. The idea is that there are actually 3 joints in between every bone of your lower back or [inaudible]. The idea is that if you take things in cross sectional view and you start looking at them like this, you’re going to see a disk, it kind of looks like this, as being joint number one. It’s the most popular joint. Everybody’s like when you went to see Dr Kooch “How are your disks?” There’s more than just the disks but it’s a very important component. As we look here, this is the bone itself but the disk itself is in between that bone and that’s here. They key thing to that is you want to think of kind of like the jelly donut although it’s shaped kind of like the kidney bean. The jelly on inside helps out with compression. There’s two other joints that are pretty darn important also in the back part of the spine. These are little bones that you feel right on the middle line of your back. Right next to that on either side are two little hinge joints. They are called zygapophysial joints. I’ll quiz you later on that. But what we really do is we call them facets. And they are little hinge joints. They operate kind of like your knuckles.

There’s one on either side. This is a rudimentary drawing of your spine but the concept is that there are 3 joint here and they kind of form a triangle. The key component that is different in the spine than it is in any other quote unquote joint in your body is that it has another function that’s equally if not more important than any other joint in your body. And the fact that it houses and protects a very important nerve structure. It runs through this canal here. The spinal cord starts in your brain, runs down through the center of this canal and interestingly enough it ends just at or slightly above your belly button. Most people don’t realize that. The idea’s that from that point down is a series of nerves running through this canal here and these are the ones that exit the spine and head down south through your legs. Remember this model. That’s schematic. Our next question. Who can name lesson number two? Physics! Very good. This is tough, I know. The idea is physics is very important now to understand because we move. What happens to the spine when you move?  The idea is that we are a product of what we do and how we do things. And that’s essentially what is called biomechanics. No matter what area that I was studying in, everything kept going back to this thing called biomechanics. That’s really what we do and how we do things. The idea is that you can get very involved and I’ll talk briefly about what happens in spine, but there’s other areas of biomechanics that are equally important. The idea is that if this your spine as you are facing this direction, one of the key things to understand is that when you bend forward you are loading that front joint being at disk. You’re going to be putting more pressure, I’m exaggerating, but the idea is you’ll be putting more pressure towards the front where that disk lives. Increasing the pressure at that disk. When you extend back, you’re going to be loading those facet joints.

The idea is that that’s really important because when we talk about injuries to the spine and how the spine degenerates, again, it’s all about forces, so we go back in history where we find out what was happening at the time of the injury or what biomechanically happens and changes throughout life that can impact that spine. The other component though is all the things these guys are talking about. The additional injuries that occur, in particular when we’re talking about lower back with all the injuries and degenerative changes that we start having in our legs and feet and in our arms when we’re talking about neck. Case in point, the idea is that if you bring it down to the forces or when we’re talking physics, every time you put your foot on the ground, it generates ground reactive forces, it’s what they’re called. But in general it’s forces that come up through the foot, they come up through your calf, thigh and then go up to your spine. If everything is working great you’ve got great dampening forces .You decrease forces. As soon as your foot hits the ground your foot beautifully dampens those forces, your knee dampens those forces, your hips dampen the forces and then the forces that go through the spine inevitably are much less. The key component is, you start injuring these areas.