Search for tag: "ortho"

Interviewer: Maybe you have a bit of a bump on your foot, maybe it's painful, maybe it's just a little irritating, can't quite fit into the shoes that you used to wear. Is it a bunion, and what exactly is a bunion?

We're here with Dr. Devon Nixon, an orthopedic surgeon at the University of Utah Health, and he has an emphasis in lower extremity, foot, and ankle medicine.

Now, Dr. Nixon, what exactly is a bunion?

Dr. Nixon: Possibly one of the most common things that I see in practice. A bunion is more than just a bump that's forming on the outside of your big toe. What's actually happening is it's a complex change three-dimensionally in the alignment of the toe.

And sometimes it happens at a young age, so we see patients in their teenage to young adult years. And then sometimes it's acquired over time. So people in their fourth, fifth, and sixth decades of life begin to notice it gradually increasing. But it's not just a bump that's forming.

Interviewer: So what is it that causes a bunion?

Dr. Nixon: That's a great question and one that we don't have easy answers for. Probably the biggest component is genetic. We don't quite understand the genetics behind bunions, but they occur very commonly in families.

Historically, we used to put a lot of emphasis on people wearing tight shoes over the course of their lifetime. And that may or may not play a role. But my personal take is that it's not as big of a role as maybe we once put on it, that these are developing from factors that are somewhat patient-specific but largely outside of patients' control.

Interviewer: Since we understand that bunions have a genetic component to them, is there a particular population that is impacted more so you see it more commonly with?

Dr. Nixon: Certainly, bunions are more common in women than in men. They do occur in men, but certainly the heavy proportion is in favor of women.

And not all patients will have a strong family history, meaning that their mother or their grandmother, or other family members have had bunions, but certainly you hear that commonly.

But this is what we would describe in medicine is multifactorial. So there are many layers to this. Some of it is genetic, some of it is possibly shoe wear, but again, my take is that that's probably not as big of an emphasis as maybe it once was.

Interviewer: And for people that have, say, a bump on their foot, how do they know that it's a bunion and not, say, anything else that could be going on?

Dr. Nixon: I mean, certainly the easiest way to help make that distinction or determination is to come in and see someone with an orthopedic surgical focus on foot and ankle issues to help you better understand exactly what's happening.

Certainly, growths can form in your feet. But a bunion is really feeling like there's this strong bony contribution or strong bone prominence that's forming on the inside of the big toe, out by the joint. And at the same time, the big toe may be starting to drift towards the second and third toes.

So if those kinds of things are happening in concert, that's typically how a bunion looks and feels. There's a bump that's forming on the inside, but again, that's because the three-dimensional alignment of the toe is changing and not just growth that's happening at the bone level.

Interviewer: So what are some of the potential impacts that it can make on the foot on your day-to-day life if it's not treated?

Dr. Nixon: Certainly, bunions are a funny thing because they don't always bother all patients that have them. And so just because it may be a smaller "bunion" does not necessarily mean that it may not be symptomatic. So you don't necessarily have to wait until it's crossing over or underneath your second and third toes before you need to seek treatment.

The challenge is that we don't have a lot of in between options for treatment. So plenty of people try modifying their shoes to widen them so that they're more comfortable. They add some of these over-the-counter gel inserts that slide between the big toe and the second toe. And that certainly can make shoe wear and walking much more comfortable for people.

Unfortunately, doing those things does not change what we would describe as the natural history of a bunion, which is that it may slowly progress over time. And that's true for all forms of bunions.

Now, it doesn't mean that if it's progressing that it's going to be bothersome to you, but after those things no longer work, like modifying your shoes, adding in a toe spacer, if you continue to have pain and you're feeling like the bunion is limiting your quality of life, then that may be a reasonable time to start talking about what are the surgical options.

Now, bunions are extremely common. I see them many times in each clinic. Not all of them need surgery. But if you feel like you are at a position where modifying your shoes and adding some of these toe spacers is not the answer for you, then there are very reasonable things to think about from a surgical perspective, and many patients do really well from them.

Interviewer: So what exactly are growing pains, and are they normal? I'm here with Dr. Julia Rawlings, a non-operative sports medicine physician at University of Utah Health. And I just want to start out by asking what exactly are growing pains? Is it the legs actually growing? Or what causes these pains in kids?

Dr. Rawlings: Yeah, so the name growing pains is a little bit misleading. Children are growing, but that is not causing pain. There's no evidence that growth itself causes pain. What we think is actually happening is that when a child is just very active during the day, the muscles get a little tired and achy. And we'll see that kids get this achy, throbbing muscle pain that usually happens later in the afternoon or evening, or it can even wake the child up at night.

Interviewer: Geez. So it doesn't have anything to do with bones getting longer, muscles getting stretched. It's just them being active kids?

Dr. Rawlings: That's what we believe, yes.

Interviewer: When do kids usually start experiencing growing pains, if they do?

Dr. Rawlings: So there are two peaks that we typically see growing pains. It's usually the preschool age group, and then the preteen, so kind of 11, 12, maybe early teen, 13.

Interviewer: And it's normal, right? There's nothing . . .

Dr. Rawlings: Completely normal. It doesn't affect growth.

Interviewer: It's just a little uncomfortable?

Dr. Rawlings: Or quite uncomfortable. It can be pretty painful, yeah.

Interviewer: And let's say a kid is experiencing some severe pain in their legs, it's maybe keeping them up at night, etc. What are some ways that maybe you could treat it at home to give them a little bit of relief?

Dr. Rawlings: Yeah, so I think starting with just some massage, rubbing their legs is helpful. You can try a heating pad, or if they prefer it, you can even try ice. Sometimes just a dose of ibuprofen or Tylenol can be very helpful. And if they have this pain that comes up pretty frequently, you might even see if they'll be willing to stretch a little bit during the day and see if that helps at night.

Interviewer: Just running stretches, yoga stuff?

Dr. Rawlings: Yeah, yoga for kids, that's perfect.

Interviewer: Oh, fantastic.

Dr. Rawlings: Yeah, just some hamstring stretches probably is a good place to start.

Interviewer: Sure. And say a parent is listening right now. When can we expect these growing pains to stop?

Dr. Rawlings: Yeah, hopefully they'll stop after they leave those peak periods, so after they've left the preschool years or they enter their teen years. They can continue throughout the teenage years, but usually not through adulthood, into adulthood.

Interviewer: And until then, you've got stretches, ibuprofen, anything to help.

Interviewer: Now, if your child is complaining of leg pains, could it be growing pains, or is it something more serious?

Dr. Julia Rawlings is a nonoperative sports medicine physician here at University of Utah Health. And let's start with the type of leg pain I think just about every kid, at some point, experiences. One point or another, it seems pretty benign. What exactly is growing pain? What are growing pains, I guess?

Dr. Rawlings: Yeah. So growing pains, the name came kind of early in the 1930s and 1940s when people thought that growth was related to these pains that children get, usually later in the afternoon, evening, or maybe even wakes them up at night. But we know now that it's not related to growth, but it's more likely just related to children being very active during the day. So it's just these pains that come on later in the day or at night, mostly from kind of overuse of muscles.

Interviewer: But it's not like the bones are stretching or anything like that. It's just . . .

Dr. Rawlings: No, it doesn't have anything to do with growing. It does happen in children, but it doesn't affect their growth. It's not directly related to growing.

Interviewer: My understanding is it's pretty normal for kids to be having this and just as part of, like, I guess being active and running around.

Dr. Rawlings: It's very common. And the places where it's most common, usually it happens in the calf, the thigh, or the back of the knee. So those are some of the spots that we look at.

Interviewer: Okay. And it's like an aching or just like . . . I guess, how do we know that it's like that kind of pain?

Dr. Rawlings: Yeah, it's like an aching or a throbbing pain. Sometimes children will grab the back of their legs or grab their thighs or just be more cranky. It's usually at the end of the day. It can wake them up at night though.

Interviewer: And so your child's complaining of pain. I guess, as a parent, if you're worried, you know, what should you be on the lookout for to find out if it's something more than just typical growing pains?

Dr. Rawlings: Yeah. So growing pains usually happen intermittently. So it can happen every night, but that's a little less common. So growing pains typically are intermittent. They're usually in both legs, not necessarily at the same time. And the child usually wakes up in the morning completely fine and running around like there's nothing wrong. Those are all very typical for growing pains.

Interviewer: So say a kid is, you know, maybe continually complaining about leg pain or maybe they're getting it through the day. As a parent, what are some of the signs and symptoms that you should be on the lookout for to kind of let you know this isn't growing pains, it's something more serious?

Dr. Rawlings: Yeah, great question. So if your child is complaining of pain, particularly during the day, if they are complaining of pain in the same leg, if the pain stops them from participating in sports activities or from running with their friends, if they are limping with the pain during the day, or if you see anything else that seems abnormal, so swelling of the leg, redness of the leg, if they're getting fevers with it, all of that is something besides growing pains, and you should be seen for that.

Interviewer: And not to, say, worry parents, you know, prematurely, but what could be going on with their child?

Dr. Rawlings: So it could be something as simple as an overuse injury. Lots of times, in children that play sports, we see overuse injury at the growth plates actually. That's probably one of the more common things. If they're very active, say a teenager running, they could get a stress injury. They could just have tight muscles, and stretching could be helpful. All the way up to the more serious things that are very rare and uncommon, like childhood arthritis or bone cancer.

Interviewer: If your child is, say, showing some of these symptoms, what kind of doctor should you be going to, to, you know, treat the leg? Is it a primary care pediatrician? Is it a sports medicine specialist?

Dr. Rawlings: I think, initially, if your pain is kind of vague and you're not sure what's going on, starting with the pediatrician is a great place. If it's something more serious, like they're not limping, they can't get into the pediatrician, it is reasonable to go to an urgent care or the emergency department, particularly if they won't walk at all. We need to see what's happening. There are . . . sometimes toddlers will have a small fall and twist their leg, and they won't walk, and they'll have a little fracture that you won't even pick up on. And so that's one of the more common reasons we'll see toddlers stop walking, and that's something that can be taken care of either by a pediatrician, a nonoperative sports medicine provider, or in an urgent care emergency medicine setting.

Interviewer: And is there anything, maybe a home remedy, something they could try at home before they, say, take them into a doctor to maybe alleviate any of the pain that they're experiencing?

Dr. Rawlings: Yeah. So if they're experiencing more of these growing pains, kind of intermittent pains in the evening or at night, you can do things like massage the legs, massage the muscles. Warm packs, heating pads are helpful. If it's severe, you can try some acetaminophen, Tylenol, or ibuprofen. And sometimes if it's pretty frequent, you can have them do some stretching during the day and see if that helps as well.

Many kids, especially athletes, will complain that their feet hurt at some time. Heel pain is especially common and especially during growth spurts.

Heel pain in athletes who are growing actually has a name. It's called calcaneal apophysitis, otherwise known as Sever's disease. It is most common between the ages of 9 and 14 and is seen in athletes who do a lot of running and jumping. My teenage soccer player has this and actually so do several of his teammates, or the teammates of my younger son who will probably end up having this also. Basically, what it is, is inflammation of the growth plate of the heel bone. The bones, muscles, and tendons in that area all grow at different rates during puberty. And when they're out of sync, the muscles and tendons pull too hard on the growth plate and that causes the inflammation.

So what can your child do to help once the pain has started? Well, to be honest, the pain will improve most once your child is done with their growth spurt. Also, it's best to stop any activities that cause pain. But, of course, we know that's not going to happen, especially if your child is on a competitive or a school athletic team.

So other things that help include having an ice pack in a towel and icing the heel for 15 minutes every one to two hours during flare-ups. Have your child take an anti-inflammatory pain medicine, like ibuprofen or naproxen. But be sure to check with your child's pediatrician on dosing. Gel heel cups and shoes with good support are also helpful. They help put less pressure and less stress on the heel. Your child's pediatrician can also give you exercises that can help with stretching and which can help with the pain and help keep the condition from getting too bad.

If the pain continues, your child may be referred to a physical therapist. And if all else fails, then your child will be put into a walking boot and referred to an orthopedic specialist for management of severe cases. Eventually, Sever's disease gets better, but not really until your child has stopped growing and that growth plate closes. Until then, manage the pain and follow the advice your child's doctor gives them.

Interviewer: Yeah. So, if you have some elbow pain while you're pitching, there is something you can do about it and actually something you should do about it. And there's a new procedure that might be the thing that you need.

Dr. Peter Chalmers is an orthopedic surgeon. He's an elbow specialist. He's also the current team physician for University of Utah baseball and Salt Lake City Bees Triple-A baseball. So if somebody does have elbow pain while they're pitching, where do you start with that diagnosis, Dr. Chalmers?

Dr. Chalmers: Yeah. Absolutely. So elbow pain during pitching, it's not normal to have really, really a sore elbow with pitching. And there can be a couple of different causes, and some of them can be problematic for the future for a pitcher. So, definitely, I think it's worth, after a period of rest, if the pain doesn't go away, seeing someone to be fully evaluated with, you know, having someone take a look at the elbow, and then potentially getting an MRI to take a look at the cartilage and the ligaments within the elbow.

Interviewer: All right. And if the condition happens to be something called an ulnar collateral ligament injury, then there's a procedure that's been used for a long time called Tommy John surgery. Tell me a little bit about that, and then we're going to talk about the alternative, which could be better for some patients.

Dr. Chalmers: Yeah. Absolutely. So, for a long period of time, if you tore your ulnar collateral ligament, the ligament on the inside of the elbow that basically holds the upper arm and the lower bones together when you pitch a baseball, if you don't have that ligament, those bones try and fall apart, and it's basically not possible to pitch a baseball. If you tore that ligament, historically, then your career was just over.

And there was a pitcher named Tommy John, who had that injury, and he went to a surgeon who said, "Well, there's got to be something we can do," and they invented this procedure to reconstruct or rebuild the ligament using a tendon graft. And that actually works pretty well, but it has a very long recovery. It takes about a year to get back to play because the new tendon has to become a ligament over the top of the old ligament. And that process is very slow.

So that was the historic way that we would treat ulnar collateral ligament injuries, and the pitcher that first underwent it, his name was Tommy John. So they're commonly referred to as the Tommy John ligament or Tommy John surgery.

Interviewer: And now there's a new procedure. So I've heard that considered called reconstruction, and now there's a new procedure that actually just repairs the ligament and has some better outcomes. So tell me a little bit about that.

Dr. Chalmers: The good thing about many of these ligament tears is often the ligament is torn right off of either the upper arm bone or lower arm bone side. And the ligament itself is still good quality tissue. So, historically, we would replace that whole ligament with a new tendon graft.

The new procedure is to repair the patient's own ligament and allow their own ligament to serve as their ligament going forward. That has a much quicker recovery and can get pitchers back to play in six months. So that's been a huge advance in our treatment for this injury and has certainly, for a lot of our players, granted them ability to get back to another season or even sometimes to get two seasons in depending on the timing.

Interviewer: So, when you're working with a pitcher, how do you determine which one of these two that you're going to use?

Dr. Chalmers: So there's a number of factors that go into that. Certainly, the appearance of the ligament on the MRI and the location of the tear play a role, but often during surgery, we'll also assess the quality of the tissue. And if the tissue is robust enough, then we can use the patient's own tissue to do the repair.

Interviewer: If it is an option, then is it just as good as the Tommy John surgery? You said, definitely, you could get back to playing faster. Is it as a robust of a repair?

Dr. Chalmers: It may be better.

Interviewer: Oh.

Dr. Chalmers: Some of our early data suggests that the rates of return to play may be higher after repair than they are after reconstruction.

Interviewer: And I understand another advantage of the ligament repair is if you have a younger athlete, that this would be an option where Tommy John surgery would not be an option. Tell me about that.

Dr. Chalmers: Yeah. Definitely, younger athletes have the highest capacity for healing. And so, in a younger athlete, this surgery can work very, very well, and that's who it's been performed in mostly to date. But in someone who's really young, if they have open growth plates, you may be concerned about performing a surgery with a ligament graft, where we may have to drill tunnels in the bone that may disrupt the growth in the future. So this is a nice option for that patient population.

Interviewer: And what does the recovery look like then? You said that the recovery is faster. You know, Tommy John surgery could take up to a year. How fast is this recovery, and what's the rehabilitation process like?

Dr. Chalmers: So as early as two weeks out from surgery, the patient begins moving their elbow. About a month from surgery, they begin strengthening. And the whole goal here is that you have to start strengthening early because as early as three months out from surgery, the pitchers will start throwing again.

Interviewer: Wow.

Dr. Chalmers: And the goal then is to get back to full play with full velocity, pitching full games by six months.

Interviewer: That sounds pretty amazing. Is that pretty amazing from your perspective as an orthopedic surgeon?

Dr. Chalmers: It's a huge advance. It's a huge change over the year, sometimes 18-month recovery we saw historically with reconstruction surgery.

Interviewer: Are there downsides to this type of repair?

Dr. Chalmers: Well, it's a relatively new option, and so we don't have 5 or 10-year outcomes with it so far. But so far, it appears to have few downsides as compared to the reconstruction. There had been some concern that if you do this surgery, it may make another surgery in the future more difficult. And so far, those have not appeared to be true, but there have been very few of those performed because it works so well.

Interviewer: And it sounds like this is a very specialized procedure still at this point. What advice would you have for somebody choosing an orthopedic surgeon to do this type of procedure?

Dr. Chalmers: Well, I think that one of the most important things patients need to understand is that surgery itself is a technical skill, and it's important to find a surgeon that you feel like performs enough of those procedures to feel competent at it. So, as a result, I think when you look for a procedure that's less common like this, you need to find a surgeon that feels comfortable and performs enough of them, that they'll have already worked through the kinks and make sure that they're not going to have any problems performing this procedure for you.

That's one of the benefits of coming to a place like the University of Utah, where you have specialists in a large variety of areas. It allows each of us doctors to find a smaller niche and then, as a result, to be better at what we do.

Interviewer: I want to talk a little bit about this procedure. So what is, in your mind, the youngest patient that you would do this type of a procedure on?

Dr. Chalmers: One of the things that is unique about this area of the elbow is that right above the ligament is a growth plate. So for people who are skeletally immature, it's very rare to have the ligament be injured. And the vast majority of those that are skeletally immature, the growth plate itself sees most of the injury, if there is an injury. As a result, we very rarely perform this procedure for anyone under the age of 14 really.

Interviewer: Is there anything else about this procedure that you feel that a patient or a patient's parents would be interested in hearing that I missed?

Dr. Chalmers: One of the things that I think is really interesting about this procedure and really important for people to understand is that we've talked historically about the reconstruction and the tissue within the reconstruction as though we can make you a new ligament. But I will tell you that the tissue that we bring in from somewhere else is not the same as what you were born with. It doesn't have the same nerve fibers. It doesn't have the same pressure fibers.

And we demonstrated that actually pretty elegantly recently in a study we did with the Angels, where we looked at the changes in reconstructed ligaments as compared to non-reconstructed ligaments over the course of a single season or off-season on ultrasound, and found actually that the ligaments that had undergone a prior reconstruction respond differently to stress than native ligaments. And I think that's probably because they don't have all of their normal sensors within them.

So one of the big benefits of this procedure is that it preserves all that. It preserves all the normal pressure sensors and nerve fibers within your own ligament and allows it to respond normally to stress in the future. So that's a real benefit of this procedure over the reconstruction, and one reason why I think we're probably going to head more and more in this direction in probably a lot of areas of our field in the future.

Announcer: "Health Hacks" with Dr. Troy Madsen on The Scope.

Dr. Madsen: Today's health hack is an easy to do, homemade splint. So all of us have cardboard boxes around the house. So let's say you have something where you fall or a child falls, you look at their arm, and it looks like it's broken. It's obviously deformed, it's swollen, they're having lots of pain. You want to get them in to get some x-rays and get this checked out. But every time they're moving that arm, it hurts.

So if you take a cardboard box, you break it down, do a couple layers the length of their arm, you can then put one piece of that cardboard box on each side of their arm, so you've got two pieces total. And then wrap it around with something that's not too tight, maybe just use like a shirt, a couple shirts to tie it around there. This can stabilize their arm and help them to feel a lot more comfortable while they get into the ER to get an x-ray.

So you're wondering, "Well, why cardboard?" Well, it's easy to use. And a lot of EMTs, so if you call an ambulance, a lot of them have cardboard splints. They're just using the same thing. It's really a great tool to have. The advantage of it is if this arm's moving around while they're in the car, they're just going to hurt a lot. There's potential that the fracture could move out of place even further. And again, it's something you probably have around. It's simple enough to do. You can grab it, quickly put this in place, get them in to get some treatment.

Announcer: For more health hacks, check out thescoperadio.com. Produced by University of Utah Health.

Dr. Miller: You broke a bone and now it's painful? And maybe you're not walking on it correctly? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists, with Dr. Tom Miller, is on The Scope.

Dr. Miller: I'm here with Justin Haller. He's an orthopedic surgeon here at the University of Utah. Justin, tell me a little bit about what we call malunion or malalignment. And this occurs in patients who have had fractures and then subsequently develop pain or mechanical dysfunction because maybe the fracture just didn't heal right. Maybe they didn't have it set correctly, something like that. What does that mean?

Dr. Haller: So a malunion by definition is a bone that breaks and then heals in either a malaligned position or it's malrotated, so the bone itself is twisted and heals in that position.

Dr. Miller: What's the most common cause of that? I mean, obviously it's a fracture, but then is it because it didn't receive the right treatment or maybe they didn't follow instructions after they were casted?

Dr. Haller: The most common cause tends to be when patients are treated non-operatively with cast or something like that, in the United States, in the past.

Dr. Miller: So what do you do? How do you treat these? And then again, what are the most common fracture sites where malalignment occurs?

Dr. Haller: So most commonly symptomatic malalignment occurs in the lower extremities. So either the tibia or shin bone or femur or thigh bone. And what we do for those is first, to determine whether it's healed in a malaligned or malrotated position.

Dr. Miller: So you can see that on X-ray. So CT scan or MRI might show you that?

Dr. Haller: It starts with a full X-ray standing profile to see the mechanical axis of a patient's lower extremities and using a CT scan to see if there's any rotational component to that.

Dr. Miller: Do you see leg length discrepancy sometimes with these fractures if they've healed incorrectly?

Dr. Haller: Commonly you do see a leg length discrepancy with these, and that's picked up on the long standing X-ray.

Dr. Miller: What would somebody experience if one leg was a little bit shorter than the other after a fracture? And I gather they don't have to be that much shorter for them to develop symptoms, maybe if you're an athlete it's even more common.

Dr. Haller: Yeah, really, patients can become symptomatic for a couple centimeters of leg length discrepancy. And most commonly, the symptoms associated with that are back pain, hip pain, and if it's also, it can get some knee pain if it's in the tibia bone or shin bone.

Dr. Miller: So how do you treat that? I mean, obviously you don't put them on a rack and stretch out their leg. So how do you repair the leg and make the leg the right length?

Dr. Haller: Sure. So we typically will do an osteotomy, or we cut the bone or re-break the bone as people will typically say, and we'll realign it and fix it there with plate and screws or a rod down the middle of the bone.

Dr. Miller: How effective is that? Does that work pretty well?

Dr. Haller: It works very well so long as patients can heal the cut in the bone. Normally, patient symptoms are pretty much resolved.

Dr. Miller: Now, do you do the same thing for a malrotation, where the bone is twisted?

Dr. Haller: It's pretty similar. Again, you do an osteotomy or a cut or re-break the bone and you can rotate the bone and fix it with plate and screws or with a rod down the middle of the bone.

Dr. Miller: Well, final question. How would a patient find their way to you if they had symptoms? What would they look for and how would they know to come to you?

Dr. Haller: Most commonly people will present saying that their family members noticed that they have either a limb length discrepancy or they walk funny or one leg is rotated in or out. Normally it's family members that notice the most and will point the patient to either an orthopedic surgeon or general practitioner to take an X-ray. And then it can be pretty obvious that the bone is not quite the same as the other side.

Dr. Miller: Do you think going to a specialist is a good idea if you need to have this type of surgery, where you're going in and repairing a prior fracture that's been healed?

Dr. Haller: Absolutely. Orthopedic specialists, particularly orthopedic trauma surgeons, are the ones who are trained to fully evaluate and understand the malalignment that's present and then can fully correct what's going on.

Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there’s a pretty good chance you’ll find what you want to know. Check it out at TheScopeRadio.com.

updated: August 14, 2018
originally published: November 11, 2016

Interviewer: Dr. Travis Maak is a sports medicine expert and the Head Orthopedic Team Physician for the Utah Jazz. He says a majority of ski injuries happen in the late afternoon, and unfortunately it's during that last run, that one more run. How did you find this out?

Dr. Maak: Part of it was from personal experience, to be honest with you. So I actually was a sort of volunteer ski patroller in my high school days here when I was growing up. It's something that is known to all ski patrollers, that basically . . . ski patrol is in large part about 90% boredom, and that happens from the beginning of the day where you literally just go out and ski yourself because you're so bored, because there's nothing else going on, to about 10% of terror.

That always happens at the end of the day, and sometimes right after lunch. But usually it's from about 3:30 to 5:00 is when everything happens. That's where you basically put your gear on and get ready, because you are going out. It's not an 'if', it's a matter of 'when.'

The reason that happens is it most likely it has to do with two things. One is it's starting to cool down so from a temperature perspective the snow is starting to get a bit harder. It loosened up. It warmed up. It was a little bit softer. During the afternoon it starts to cool down, so it gets a little bit rockier, a little bit skied out, so the terrain itself is more difficult. That's the first thing that is most likely contributing.

But the other contributor is a personal and modifiable factor. You can't change the weather, but you can change yourself. We all want to get in as much as we can, the most bang for our buck. We bought that pass. It may seem a little overpriced, but when you do it, it's fantastic and you want to keep going and get the most out of it.

Basically, it has to do with a muscle fatigue. The ligaments are the structures that hold our joints together. The main injury that we see typically is either a broken bone or a ligament tear. In particular in skiing it's the ACL. The ACL seems to be unfortunately the skier's injury. Generally, the reason it happens is the knee joint has two predominant stabilizers, the muscles, the tendons as one unit, and then the ligaments. Those are separate. The ligaments are literally like ropes. They connect the two bones together.

The muscles are the dynamic stabilizers, so they fire when they're working and you make your knee bend and straighten, and it allows you to do those bumps and do those turns in a perfect fashion. But when muscle fatigue happens, then the muscles aren't working correctly. They aren't firing correctly and they start to get weak and tired. As they get weak and tired, your mind may want them to go, but it's not going to happen because, frankly, you just can't put forth the energy.

So where does that energy go? It doesn't disappear. It goes to the ligaments, and so the ligaments end up taking more energy than they're supposed to and they end up failing and tearing. That's most likely why this happens, because the energy which is dissipated by the muscles can't be because they're tired and fatigued, and so it goes to the next step in the chain.

Interviewer: Do you find that people that are a little bit more muscularly in shape are less likely to have this happen, or at that point in the day is pretty much everybody susceptible?

Dr. Maak: Muscularly in shape is a question that a lot of people take to mean the body builder, giant muscles, and frankly that actually has nothing to do with it. In fact, a lot of people who have those fast-twitch, big muscles end up getting tired quicker. If you look at endurance athletes or athletes that are training for a specific sport, the muscles themselves have become accommodated to a long-term type of energy expenditure.

Skiers, for instance, they train in both strength, the quads, the hams, the lower body strength, but also endurance. Ultimately, that's what we're talking about is endurance. It's the fatigue of the muscle, not the ability to jump really high one time or run a sprint. It's the ability to stay and produce that power and energy over a long period of time, hence the last run of the day.

At the end of the day, it's fatigue. It's training. It's the ability to generate that force required to ski throughout the day. When that ability to generate that force disappears, that's when the injuries happen.

Interviewer: So probably your casual skiers don't have that kind of muscular endurance.

Dr. Maak: They don't. Interestingly, here at the University we've actually produced a skier's program to provide people with sort of an ability to produce that type of power and endurance over a period of time pre-ski season, so that by the time they hit the ski season, they are ready. Their quads are ready. Their hams are ready, and it's a completely different muscle set than happens over the summer when you're out running, you're out doing the type of endurance summer activities, rock climbing, etc. It's totally different for skiing. It's a different muscle group, and if you don't [inaudible] and educate your body to those muscles, you're not going to be able to do it.

Interviewer: So what's your final advice? I mean, you've laid it out that the injuries are happening in the late afternoon. Do you just not do that last run? Do you just slow it down a little bit? What would you tell a skier?

Dr. Maak: At the end of the day there's always one last run. That's unavoidable. So the message that we try to get out here is make that one last run a fun one, and not a potentially serious or a safety issue run. The way to do that, let your body be your guide. You can do all of the things that we've talked about already, which is prepare yourself for the run. Prepare yourself for skiing. Get yourself in tip-top shape as best you can. But also listen to your body.

After lunch, you're going to be a little fatigued. You let things set in. You may slow down the runs. Don't go hit the double black run right after lunch. Instead, maybe start on blues, ramp it back up a little bit. But once 2:30, 3:00 starts setting in, look at your watch, listen to your legs, listen to your body, and instead of going and hitting the double black as the last run, maybe take a groomer. Take a nice, little, smooth one down. Enjoy yourself. You don't have to be a hero at the end of the day. At the end of the day, if you do it that way, you'll be able to come back the day after.

updated: December 14, 2022
originally published: February 17, 2016

Interviewer: Exercising outside in winter. I'm here with Dr. Russell Vinik, Internal Medicine at University of Utah Health Care. Dr. Vinik, should we exercise in the winter?

Dr. Vinik: Absolutely. Exercise is good for you, whether it's summer or winter. There's always a fear of going outside in winter. We worry about frostbite, but frostbite is very rare especially if you're dressed appropriately. There is some risk in people with heart conditions. It does create a little bit more work on your heart to exercise in the extremes of temperature, whether it be very hot or very cold. But for most of us, it will do us a lot of good.

And it's certainly not a good reason to stay at home and sit on the couch because you're worried about the temperature. People often dress very, very warmly, and there's actually a risk of overheating in the winter if you dress too warmly. So the most important thing you could do exercising in the winter is to wear layers that way, you can take off layers as you get too hot. But overall, it will do you a lot of good. You'll pump a lot of blood through your body and it'll help your cardiovascular health, as well as your mental health.

Interviewer: I heard you mention, it's probably people with heart conditions shouldn't exercise as much. That surprises me. It seems like people would be more worried about the cold air in their lungs, and the cold and dry air.

Dr. Vinik: Yeah. So even people with heart conditions can and should exercise because there's still benefit in doing that. I would just talk with the doctor before you do that. Now, obviously, we all feel that cold air in our lungs when we're exercising in the outside on cold days. That's not necessarily bad for you. If you have asthma, some people do have asthma that can worsen with cold and that's something to be cautious with, and even have an inhaler if you're going to run. One thing we worry about in Salt Lake City, though, is our inversion.

And when it gets cold outside the inversion settles in the valley, and that increases air pollution. And the two together can actually make things worse on your body than just one or the other. So the times to be very cautious are those days when the ozone is collected in the valley, we see a lot of particulate pollution, and it's cold. Especially if you have heart or lung problems, then you should probably consider staying indoors. But for the most part, getting outside is a good thing. It's hard to get enough exercise indoors. Some of us have the ability to do it easier than others, but it shouldn't be a good reason to sit on the couch.

Interviewer: So if we're middle-aged or younger, and pretty much healthy all the time, even when there's inversion, we shouldn't really worry about it, we should still go for that run?

Dr. Vinik: Absolutely. You could still easily go out for a run. The risk to your body is very, very low. In fact, the benefit to your body is a lot more than the risk associated with going out in cold weather or the inversion.

I think just getting out and working, and it doesn't have to be a huge amount of exercise, 20 minutes, three, four times a week would do a great deal for your heart/lungs, as well as your body, just weight and preventing obesity and all the bad things that come with a sedentary lifestyle

updated: December 29, 2021
originally published: January 7, 2016

Dr. Gellner: It's time for back to school and sports and that means it's time for ankle sprains. How to help with this frequent sports injury is today's topic on The Scope. I'm Dr. Cindy Gellner.

Announcer: Keep your kids healthy and happy. You are now entering the Healthy Kid Zone with Dr. Cindy Gellner on The Scope.

Dr. Gellner: We're seeing a lot of kids that are going to back to school training camps for football, soccer, all sorts of sports that can twist up the ankle really quickly. So what exactly is an ankle sprain? Well, it's an injury that causes a stretch or tear in one or more ligaments in the ankle joint. Ligaments are strong bands of tissue that connect bones to the joint. There are many ligaments in an ankle.

The most common type of sprain involves the ligaments on the outside part of the ankle. That's the lateral ankle sprain. Ligaments on the inside of the ankle may also be injured, those are medial ankle sprains, as well as ligaments that are high and in the middle of the ankle, those are called high ankle sprains. Again, a sprain is caused by twisting your ankle. Your foot usually turns in or underneath you as you're walking, running, jumping, but it may also turn to the outside as well.

Sprains can be mild, moderate, or severe, but they all hurt. Symptoms of a sprained ankle include anything from mild aching to sudden pain, swelling, and bruising, which may look quite severe. You may have pain in the ankle even when you are not putting any weight on it.

To diagnose a sprained ankle, your child's pediatrician will ask about your child's symptoms and how the injury occurred. So it's very important you know what happened at the time of the injury. That's very important to the pediatrician. They'll also examine your child's ankle and if needed, X-rays may be taken depending on the severity of the symptoms.

Treating a sprained ankle depends on how bad the sprain is. It can be remembered as the letters RICE, rest, ice, compression, and elevation. When your child first sprains their ankle, have them rest. Then, put an ice pack or package of frozen vegetables wrapped in a cloth on the area every three to four hours, for up to 20 minutes at a time. Raise the ankle with a pillow when sitting or lying down. And for compression, you can use an elastic bandage or even a brace that you can buy at your local store. Finally, keep your ankle elevated as much as you can for the first 72 hours.

If the sprain is severe, your child may need to use crutches until they can walk without pain. For the pain, your child can take an anti-inflammatory such as Ibuprofen or Naproxen, which is Aleve. Unless recommended by your pediatrician, do not take this pain medication for more than 10 days. Rarely, severe ankle sprains with complete tearing of the ligaments will need surgery. Your pediatrician will refer your child to an orthopedic doctor if that's the case. After surgery, your ankle will be in a cast for four to eight weeks.

Recovery time depends on many factors such as how old your child is, what kind of health they're in, if they've ever had a previous ankle injury, and the severity of the sprain. A mild ankle sprain may recover within a few weeks whereas the severe sprain may take six weeks or longer to recover even if it doesn't require surgery. Recovery also depends on which ligaments were torn. The lateral sprain, remember those outside ligaments, takes less time to recover than a medial sprain, the inside ligaments, or a high ankle sprain, the high middle ligaments.

We often get asked, "When can my child go back to playing sports?" Well, everyone recovers from an injury at different rates. Your child can return to the activities depending on how soon the ankle recovers, not by how many days or how many weeks it's been since the injury occurred. In general, the longer your child has symptoms before he starts getting treatment, the longer it will take to get better.

The goal is to return to his normal activities as soon and safely as possible. If your child returns too soon, they may worsen their injury. Your child may safely return to normal activities when they have a full range of motion in the injured ankle compared to the uninjured ankle. Also, they need to have full strength in the injured ankle compared to the not injured ankle and they need to be able to walk straight ahead without pain or limping.

For kids who are very active in sports, it's really important to try to remember how to prevent ankle sprains from happening in the first place. Be sure to have your child wear proper, well-fitting shoes, stretch before and after sports, avoid sharp turns and quick changes in direction, and consider taping their ankles or wearing an ankle brace during strenuous sports, especially if they've had a previous injury. If your child is a very athletic child, I can guarantee you they're going to have an ankle sprain. The most important thing is to address it right away, not wait, and let them recover before they get back out on the field.

Announcer: thescoperadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at thescoperadio.com.

Interviewer: It seems like unfortunately every year you hear a story about a student athlete, a young athlete getting heat stroke, getting really sick or dying at times. As a parent of, perhaps, a young athlete that's in a summer program or football training camp for the fall, even in August. What should you look for and what should you know, what would you want that person to know?

Dr. Madsen: That's a great question, you know kids in the summer, as you mentioned, are in a lot of sports camps and if you're a kid in a sports camp, the number one thing you want to do is impress the coach. That's what you're trying to do, you know. So you're getting out there and even if you're feeling lightheaded, you're still pushing yourself, you want to look like you're working hard and that's where kids really run into problems, and I think that's where you can really see some issues with heat stroke and heat exhaustion, are kids who are really trying hard, it's 100 degrees outside, they're playing football, they're in pads, whatever the situation is.

So the number one thing to watch for is let our kids know if they're feeling lightheaded, if they're feeling dizzy, to sit down and take a break because those are the first symptoms of heat exhaustion, as they start to feel nauseated, lightheaded. If they get to a point where they feel like they're passing out, if they look to you like they're just not responding well, that's when it becomes really serious and we get really concerned.

Interviewer: And hopefully a coach recognizes that as well and is not going, Madsen, man up.

Dr. Madsen: Exactly. Hopefully coaches are aware of it, but you've got to figure too, these coaches have 30, 40, 50 kids out there. They can't watch every one and know exactly what they're feeling so, yeah, hopefully they're aware, but definitely the kids, they need to let the coach know when they're just not feeling quite right.

Interviewer: Is there anything that would tell me that maybe my kid might be more or less susceptible to heat exhaustion, or heat stroke as somebody else, I mean, does it vary person to person?

Dr. Madsen: There's definitely some variability's. Certainly if you've got a little more weight, if you're a little heavier, that's going to increase your risk of heat exhaustion or heat stroke. If you've had problems in the past, that's something to be aware of as well. Obviously, depending on the type of sport the child is participating in and if they're wearing a lot of pads, exercising a lot, doing a lot of sprints, things like that where they're getting their body temperature up, those are situations where you need to keep a close eye on them as well.

Interviewer: All right, what do I do if I suspect heat exhaustion, maybe we should even say, what's the difference between heat exhaustion and heat stroke, and what should I do then?

Dr. Madsen: Yeah, so that's a great question. So that question often comes up, what is heat exhaustion mean, what is heat stroke? So heat exhaustion is when your body temperature gets up, I think we've all experienced that, you're lightheaded, a little big nauseated, just not feeling quite right. Heat stroke is when it gets dangerous, we're talking body temperatures of about 105 degrees and in that situation we're often times seeing people pass out, they're unresponsive. That's when they're at risk for organ failure and that's when it gets very serious, so once it gets to that point, just even the lightheadedness, dizziness, get in the shade, try and cool down, drink some water, try and get that person cooled down with a fan, something to try and get the body temperature down.

Interviewer: Pour water on their head, is that fine?

Dr. Madsen: Sure, absolutely. Pour water on their head, you know one thing you can do to really get the body temperature down quickly is with ice packs. Don't put ice directly on the skin but if you've got it in some sort of a pack you can put it in the arm pits, there's a lot of blood flow through there so you can get the body temperature to cool down fairly quickly, and if it's really serious where they're just not responding to you, if they're very confused, in that situation I'd get them to the hospital. Call 9-1-1 and make sure you get help for them.

Interviewer: It's nothing to mess around with at that point.

Dr. Madsen: Exactly. Once they're not responding or they're just not very responsive to you then it's much more serious.

Interviewer: Should you err on the side of caution if you have a question?

Dr. Madsen: Absolutely, err on the side of caution, you can always call the EMTs there, they can take a look, they may even check their body temperature, see how they're looking and maybe say, hey, he's okay, probably doesn't need to go to the hospital, but certainly, especially in sports camps, err on the side of caution.

updated: August 6, 2021
originally published: September 24, 2013