Health & Wellness
Presented by Barnes Jewish Hospital & Washington University Physicians

With professional athletes as our biggest investment, it's important to have doctors and physicians we can count on. It's because of that principle that the Blues work with doctors from Washington University and Barnes Jewish Hospital. Below, you'll find video and articles from one of these physicians about common athlete injuries, how they can be treated and how well these injuries can heal. [ TEAM PHYSICIAN INDEX ]

  Robert Brophy, MD
Assistant Professor of Orthopaedic Surgery
Washington University School of Medicine

Dr. Brophy is a Washington University orthopedic surgeon who specializes in sports medicine, shoulder and knee surgery. A former soccer player, Brophy practices at Barnes-Jewish & the Washington University Outpatient Orthopedic Center in Chesterfield, Missouri as well as the Washington University Medical Center. He holds special interests in the prevention and treatment of injuries in soccer players and hosts the Annual St. Louis Soccer Conference.

VIDEO: Rotator Cuff Tears | Articular Cartilage Injuries in the Knee


MENISCUS REPAIR
The meniscus is the soft rubbery bumper cushion that sits between the thigh bone and the leg bone. There are two menisci in the knee; a medial (inside) and a lateral (outside) meniscus. These structures act as shock absorbers that decrease the stress seen by the articular cartilage found on the end of the thigh bone and leg bone. Meniscus injuries are quite common and occur in patients of all ages. An injury can occur as a result of squatting, turning or twisting during almost any activity. Once the meniscus is torn, symptoms like locking, clicking, and catching may occur due to the torn fragment. In addition, patients will frequently notice swelling in the knee. The pain will be localized along the joint line on the inside or the outside of the knee depending on the tear. The diagnosis is made based upon a history and physical exam and frequently special tests. X-rays are often normal. If there is some question regarding the diagnosis and MRI can be obtained to confirm a tear. Most tears remain symptomatic and will ultimately require treatment if they interfere with activities of daily living or sports and recreation activities.

Since the meniscus helps protect the knee from wear and tear, surgeons try to repair the meniscus whenever possible. However, most meniscus tears are not considered repairable. The meniscus has a limited blood supply, and tears in areas of little or no blood flow have a high risk of not healing. The pattern of the tear is also important. It is not always possible to predict whether a meniscus tear is repairable prior to surgery.
If a meniscus tear is considered appropriate for an attempt at repair, a number of techniques can be used. The surgery is primarily arthroscopic (minimally invasive) although additional small incisions, or cuts, may be necessary to perform the repair. A variety of devices or sutures can be used to perform a repair. If a patient has an ACL reconstruction at the same time as the repair of the meniscus, there is more blood present in the knee joint. As a result, the success rates of meniscus repair are higher when an ACL reconstruction is performed at the same time. Other methods can be used to improve the blood supply to a meniscus repair, for example using a portion of the patient’s own blood with a technique called platelet rich plasma (PRP).

The physical therapy following meniscal repair varies depending on a number of factors. Most patients can put weight on the knee soon after surgery, although a brace may be used. Running is usually delayed until 3-4 months after surgery while a full return to sports and squatting typically occurs after 4-6 months.


MICROFRACTURE
Articular cartilage covers the ends of bones in joints throughout the body. Normal cartilage is smooth allowing easy gliding of the joint. When the cartilage is injured, the smooth surface can become rough. On occasion, the cartilage injury exposes the underlying bone. Microfracture is a technique that can be used to treat an articular cartilage injury or defect that exposes bone. This is performed most often in the knee (it can be used in the elbow, hip, ankle and other joints as well). It is an arthroscopic procedure using a small sharp pick to create a network of holes in the bone at the base of the articular cartilage injury. These holes allow blood into the injured area to form a clot. Over time, this clot turns into organized tissue called fibrocartilage which fills in the injured area. This tissue functions similar to native cartilage to restore joint function and minimize symptoms such as pain and swelling.

The recommended rehabilitation following microfracture is a lengthy process. Depending on the location of the articular cartilage injury, patients often need to use crutches to keep all weight off the knee for 6 weeks. In some cases, patients can put weight on their knee, but must use a brace to keep the knee straight while walking for 6 weeks. The use of a machine to bend the knee (called a continuous passive motion or CPM machine) is recommended for 6-8 hours per day for 6 weeks after surgery. Return to sports is often delayed for 6 to 9 months after surgery.
Microfracture is a simple but cost effective method to treat smaller cartilage injuries. It is not usually used to treat large defects or defects with damage to the underlying bone. Like most procedures to treat articular cartilage injuries, it cannot be used to treat widespread arthritis in a joint. The tissue may not be as durable as the tissue generated by other techniques of cartilage restoration but patients do well in the short and mid-term. It is an excellent choice as an initial treatment of smaller articular cartilage injuries.


OSTEOCHONDRAL AUTOGRAFT AND ALLOGRAFT OF THE KNEE
Articular cartilage covers the ends of bones in joints throughout the body. Normal cartilage is smooth allowing easy gliding of the joint. When cartilage is injured, the smooth surface can become rough. On occasion, the cartilage injury exposes the underlying bone. Osteochondral grafting is a method of treating cartilage injuries that expose underlying bone. Osteochondral grafts replace both the articular cartilage on the surface and the underlying bone. The tissue can come from other parts of the patient’s body (called osteochondral autograft) or from a tissue donor (osteochondral allograft). These techniques are commonly used in the knee but can be used in other joints.

The injured area of cartilage is identified and a core of the injured cartilage and the underlying bone is removed in a method similar to coring an apple. A replacement core made up of cartilage and bone from another site in the knee (autograft) or a tissue donor knee (allograft) is then made to fit into the hole. The replacement core is gently tapped into place until it lines up with the surrounding tissue. No screws or other devices are typically needed to hold the replacement core in place since it fits tightly.

Patients can usually start to bear weight within 4-6 weeks of surgery. Activity is gradually increased with return to sport typically occurring after 6-9 months.

Patients often recover from both of these procedures. One advantage of these techniques is the ability to replace both cartilage and bone with similar tissue. There are limitations to the amount of tissue that can be taken from within a patient’s own knee so larger areas of cartilage loss may not be optimal for this approach. A potential concern with the use of donor tissue is the very low risk of disease transmission (like a blood transfusion). Although these techniques are too new to have data on how well patients recover in the long term, it is thought that tissue transfer has the potential to be very sustainable over time.


SLAP TEAR
In the shoulder there is a small bumper of tissue, called the labrum, which surrounds the socket. The labrum helps to keep the ball (humeral head) in its place within the socket. Superior labrum anterior to posterior (SLAP) tears are an injury to the top of the labrum on the socket. These tears are common in throwing athletes such as baseball pitchers but can occur in anyone after a traumatic injury to the shoulder. SLAP tears do not always need surgical treatment. The demands of the shoulder in a throwing athlete may make it difficult for these patients to return to their sport without surgery.

Surgical treatment is performed arthroscopically with the use of small anchors, typically made of absorbable plastic, placed along the rim of the shoulder socket. Sutures coming out of these anchors tie the labrum back to its proper location. Following surgery, the shoulder is held in a sling for up to 4 weeks with physical therapy to minimize the risk of shoulder stiffness. It usually takes 3-4 months of physical therapy to restore shoulder motion and strength following a SLAP repair.

Patients often have less pain and greater use of the shoulder following SLAP repair surgery. Return to sports, particularly for throwing athletes, varies widely from as low as 20% up to 84% depending on the study. Ongoing research is looking at ways of improving outcomes after SLAP repair, especially in throwing athletes.



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