Search for tag: "orthopedic"

Interviewer: As technology and practices have improved, more people than ever are receiving joint implants. In fact, "The Journal of Rheumatology" projects as many as 600,000 joint replacements in the U.S. by the year 2030.

With more folks receiving an implant, how do you take care of it and ensure that it lasts as long as possible? To answer those questions, today, we are joined by Dr. Mike Archibeck. He is an associate professor with the Division of Adult Reconstruction at University of Utah Health.

Now, Dr. Archibeck, for someone who has just barely received a replacement joint, whether it be a knee or a hip or something like that, what do they need to know about taking care of it for, say, the first year after surgery?

Dr. Archibeck: Yeah. So I think I'm primarily going to talk about total knees and total hip replacements. That's kind of the purview of the Adult Reconstruction Division in the Department of Orthopedics. So we do total knees and total hips as well as revision total knees and total hips.

And so there are a few things that are generic in regards to how to maximize your recovery early after surgery. Most would consider the first year as kind of the recovery period. It's been shown that both hips and knees generally do improve over that year, even though the vast majority of the improvement is in the first few months.

And during that first year, there are a few things you can do to kind of maximize the outcome and protect it from the dangers. Early after surgery, one of the most common complications is a blood clot in the leg or something that we call a deep venous thrombosis. So, usually, patients are prescribed some form of blood thinner. It could be aspirin. It could be something stronger. So being sure to do bed exercise during the day, get up about every hour or so, and go for a short walk.

You also want to be sure that the wound heals. So one of the concerns early after surgery is infection. Try not to overdo it such that the knee or hip area becomes too swollen, that can slow or compromise wound healing, and being sure to avoid any other types of infections that you might get early after surgery, like a urinary tract infection or a skin infection.

So if any of those things develop, or dental issues, you want to touch base with your surgeon and be sure those are treated so they don't potentially get into the bloodstream and make it to the hip or knee replacement.

And then recovery-wise, some patients participate in formal physical therapy. And more commonly now, more and more patients are doing kind of directed physical therapy, but working on whatever the tasks might be that the therapists direct you to do.

So with a knee, early after surgery, one of the high priorities is working on range of motion. A hip, less of a concern range of motion, but with both, starting to work on gait training initially with a walker, and then subsequently, weaning to a cane, and gradually off. Usually, that process is coached by the therapist or the surgeon and his team.

And trying to avoid overdoing it. Like I mentioned, you can really set yourself back if you do too much too soon. You can get swollen, wound healing can be slower, and it can just be more painful and kind of slow the recovery process.

So, again, the main things to be careful about are watch for the signs of blood clot, which would be significant swelling in that leg that does not respond to elevation, protecting the wound from infection, and just being an active participant in your recovery and physical therapy.

Interviewer: For someone who has received a joint replacement or is about to have joint replacement surgery, the recovery takes anywhere from 10 months to a year. So when will they see the most improvement? I mean, when will they start walking again?

Dr. Archibeck: Yeah. So, with both, you'll really be walking the day of surgery, obviously to a limited degree, and you'll be using a walker typically. But with both, you're generally able to place as much weight on that implant or that extremity as you want.

But like you mentioned, the first few months, the improvement is very rapid. So week to week, you see a significant improvement.

The improvement after those first few months is a little more subtle. So you may not notice dramatic changes like you do early after surgery, but it will continue to improve, and you gain more confidence in it, and you think about it less as time goes by.

But most people kind of describe the first six weeks as the majority of the recovery, so that's really the time frame when the focus is on avoidance of complications. So blood clot, infection, things like that.

Interviewer: Wow. So after the first year, the body is healed up, we've made sure that the wounds are not getting infected, we're not getting clots, etc., but now we have a piece of hardware in our body. What do we have to do to make sure that we're taking care of the implant and make sure that we get as long of a use out of that implant as possible?

Dr. Archibeck: There are several things that are important to know. So one is how do these things fail? And there's a little bit of a difference with knee replacement and hip replacement, but in general, they can still fail by infection. So, obviously, that's a life-altering event if it occurs.

And generally, it's felt that that is caused by a remote infection that then enters the bloodstream and finds its way to the joint replacement. So, unfortunately, a chunk of metal like a hip and knee replacement is always more susceptible to infection than a native healthy joint.

So you just want to take generally good care of yourself. Keep your dental work up to date. That can be a potential source of infection.

Interviewer: Really? Dental work?

Dr. Archibeck: Yeah. In the past, they used to recommend antibiotics prior to any dental work, and that still is a bit of a controversial topic, but that's not felt to be absolutely necessary unless you're high risk or have multiple joint replacements. But again, that's a topic you'll get different opinions about.

Any other bacterial infections, so common ones would include urinary tract infection, skin infections on that leg or other areas, obviously sinusitis, pneumonia. As you typically would if those things develop, you just want to be diligent about getting them looked at and treated, and more so if you have prosthetic joints.

I mean, obviously, we're talking about hip and knee, but there are elbow replacements, ankle replacements, and others. So any bacterial infection can potentially go to those areas. So just kind of taking good care of yourself like you generally would.

Implants can wear out. So, luckily, hip and knee replacements, the materials that we use have significantly improved over time over the last couple of decades. And so, even at 20 years, most are still functioning well, but they do wear and tear.

So a few things you can do in that regard. It's generally recommended that you avoid repetitive, high-impact activities, such as running, for exercise or aggressive cutting and pivoting sports. Things like walking, hiking, biking, swimming, golfing, dancing, most people feel like skiing is fine, are all activities that are absolutely fine to do and don't need to be limited at all. You can do as much as you want.

Then there are those in-betweeners, like tennis, pickleball, skiing, where some of those the risk is more the risk of a fall. But generally speaking, those activities are felt to be okay too, just avoiding the really high-intensity cutting and pivoting type things.

The other thing that can help add to the longevity of an implant is maintaining a good body weight. So it's been shown that the risk of wear and tear . . . and by that, I mean the plastic can wear or parts can loosen. The risk of those issues arising increase a bit as your BMI, or body mass index, increases. So trying to maintain a good body weight is helpful. Avoiding high-impact activities.

And then another rare cause of failure would be an injury of some type. So the implants themselves are very durable. But obviously, the bone adjacent to the implant can be susceptible to fracture or injury.

Especially as you get into your advanced years, being careful to avoid situations that might put you at risk for a fall or an injury, making sure your home is safe in regards to no obstacles on the floor or edges of rugs, and just kind of doing your best to minimize the risk of a fall. A fracture around an implant obviously is considered a failure and typically requires surgery to correct.

With that being said, though, like I mentioned, when patients ask, "How long do these things last?" we give a relatively simple answer, like, "Hopefully 15 to 20 years." But to be honest, even at those intervals of time, the vast majority are still functioning well. Yeah, they're pretty durable implants.

Interviewer: What I'm hearing is after you get your joint replacement, if you take care of your body, your health, your weight, and so on, that your implant can last as long as 15 to 20 years?

Dr. Archibeck: Yeah, I think that's fair to say. The other thing that I should mention is that even if a joint replacement is functioning well, it's wise to see your physician. And recommendations vary, but I would say probably about every five years.

So the first year, there's a regimen of post-op visits. Usually two weeks, six weeks, maybe three months, a year. After that, though, we usually let patients go for a while. And it's wise, though, to return and get an X-ray and be evaluated, I would say, anywhere from every five to ten years.

The reason being is that there are things that can occur with the hip replacement or knee replacement that aren't always painful. So if you get a little bit of plastic wear, that might be something that we would be able to see on X-ray, but may not be a painful problem.

And sometimes, if caught early enough, the solution to that issue is relatively simple. If caught late, when it's maybe resulted in loosening of an implant, it can be a much more problematic issue to correct.

So routine follow-up, even after that first year, is wise. Especially as you get to the 15- to 20-year interval of time since surgery, then it becomes even more important because that's about when our concern kind of increases a little bit in regards to the risk of some of these wear-and-tear type mechanisms of failure.

The other thing that's worth mentioning is beyond just having it last a long time, obviously all patients want it to be as comfortable and functional as possible. And it's true that a hip replacement and a knee replacement probably will never feel like a totally normal joint, but the closer we can get it to that, the better.

And typically, hip replacements, for whatever reason, seem to approximate a normal hip more closely than a knee replacement. In other words, it's much more common to have some residual symptoms with a knee replacement.

But the most common reasons we see patients back who maybe had a knee replacement or a hip replacement five years ago, 10 years ago, and just somehow, again, feel concerned that it's not as comfortable as possible, or as they were hoping it would be, include weakness.

So that early post-op time frame, like we mentioned, it's important to work on strengthening. Maintaining that strength is equally as important to allow that hip or knee to function as good as it possibly can.

Again, maintaining a good body weight. It's been shown that if your BMI kind of creeps up a little bit, sometimes the patient's satisfaction level with their replacement decreases. So even though it's not intuitive that that would be the case, maintain a good body weight, maintain good strength.

And obviously, if it really seems like something is wrong, if it's painful and it seems to be not resolving or worsening, then you definitely want to see your physician to kind of rule out any concerning findings.

But again, continuing with those strengthening exercises, maintaining a good body weight, those things can help the joint replacement function most effectively for a long period of time.

Interviewer: Now, going back to that idea of satisfaction, if a patient gets a replacement and is able to take care of it for those 15, 20, or more years, what kind of improvements in quality of life can they expect after receiving a joint replacement?

Dr. Archibeck: That's a good question. The good news is that the vast majority of patients, even though they may have some residual symptoms, feel as though they're dramatically improved when compared to their status preoperatively.

So like I mentioned, it's often the younger patients that maybe notice the limitations or the shortcomings of joint replacement because of maybe their demands of it or their expectations of it.

Because they're just by nature more active, they may notice those limitations a little more than a very elderly patient that maybe isn't as active. Those patients often feel like, "Hey, this does feel pretty normal to me," whereas, maybe the younger, more active patient feels that they're still a little limited by it.

But like I mentioned, most patients, younger or older, generally feel significantly improved after surgery.

And as I mentioned earlier, they should expect to be able to participate in those activities that I mentioned without significant pain: walking, hiking, biking, swimming, things like that. The more demanding activity is, so things like stairs, squatting, walking up or downhill, long hikes, it's not uncommon to still maybe develop a little fatigue or a little ache in the joint. And those things, unfortunately, may persist.

So, with knee replacement, it's been estimated that about 15% to 20% of patients continue to have some degree of what they describe as pain, even though most patients are still very satisfied. Hip replacements, it's a little less. So maybe 5% to 10% of patients still have occasional pain. So, yeah, unfortunately, not a totally normal joint, but definitely typically a significant improvement.

Although the things that I mentioned, like infection or injury, are extremely scary and worrisome, they are very, very rare. And most people do very well after hip or knee replacement in regards to a significant improvement in their quality of life, both in regards to the level of pain that they have as well as their level of function and the activities that they're able to participate in.

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: 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.

Interviewer: Are you working out from home with exercise bands? Well, you might want to watch out for this injury.

Dr. Troy Madsen is an Emergency Room physician at University of Utah Health. And a lot of us are trying to get in some exercise at home, and we might reach for those exercise bands. But, Dr. Madsen, I understand that there could be some risk working out with those exercise bands. Tell me more about that.

Dr. Madsen: You know, Scot, I have used exercise bands, and this is a risk I've never really considered, but apparently there is an increase in risk and injury to the eye that has been something that's been noted since the pandemic started. So what we're seeing, I think, more and more people are not going to the gym, they're working out from home, and a great tool is a resistance band. If you've ever used this, it's like a giant elastic band. You know, these things are huge. You put it around your foot, and then maybe you're leaning back or doing something with your leg, all kinds of different things, stretching, strengthening.

Well, at the University of Miami, they actually published their experience with seeing multiple patients come to the Emergency Department with injuries to their eyes from these resistance bands. So the title of this article is "Ocular Trauma Secondary to Exercise Resistance Bands During the COVID-19 Pandemic," published in the "American Journal of Emergency Medicine."

And you can imagine how this can happen. I don't know if this has ever happened to you, but let's say you wrap it around your foot, and you're stretching your leg out, and that thing is really tight. And then, maybe you've got socks on or something, and it slips off your foot and flips back and hits you in the eye.

Interviewer: Oh. Ow. Oh.

Dr. Madsen: Yeah, sounds miserable. Sounds absolutely miserable.

So they reported their experience in the "American Journal of Emergency Medicine," and they talked about 11 patients they had seen, and these were not minor injuries to the eye. So they said 11 patients, 14 eyes, so that means several of these patients had both eyes injured. Eighty-two percent of these patients had a hyphema.

So a hyphema is a pretty big deal. That's where you get blood behind the cornea. And, you know, if you ever look in the mirror, you see the cornea, you see your iris, the colored part of your eye. The cornea is the clear part over the top of that. And if you ever see blood there, it just looks like just this red line that's filling up behind there, that's a pretty big deal. That's a serious injury.

And then, vitreous hemorrhage in 36% of these patients. That's blood back behind the iris, back in kind of the main part of the eye. That can really affect your vision. Potentially, if it causes enough damage, potentially have long-term effects. Same thing with a hyphema if it's not treated.

So these are not minor injuries, but they saw a number of these, and just given the number they've seen, they reported on it in the "American Journal of Emergency Medicine" to make people aware that things are happening with resistance bands.

Interviewer: All right. So not happening to, necessarily, a large number of people that we know of, but is in the realm of possibility of happening apparently.

Dr. Madsen: Exactly. And I think the reason they published this and their conclusion was, if you're using a resistance band, wear glasses or consider wearing goggles. I mean, it may seem like overkill. It is something that emergency departments are seeing. This is one emergency department's experience. I'm sure it's happening elsewhere. I have to be honest. I have not seen this in the ER yet, but if we talk to some of our ophthalmologists, my guess is that they probably have. So it's out there, it's happening. You know, takeaway, be aware of it and consider wearing some glasses or goggles if you're using a resistance band.

Interviewer: Yeah, or consider just making sure that you're looking at how you're using it, and "If it was to slip right now, would it slip back and snap me in the eye?" And is there an adjustment you can do in your form that would, you know, prevent that from happening?

Dr. Madsen: Yeah, exactly.

Interviewer: Travis Nolan is an athletic trainer that works for the University of Utah Health Orthopedic Center and also works with high school athletes here in the valley. And the question today is if an athlete gets a fracture, should you always go get that x-rayed? Now, I threw on a trick word there, Travis. I said "always," right?

Travis: Yes, yeah, yeah.

Interviewer: So maybe not always. But first of all, you were saying that you've got stories of people who got a fracture, didn't get it x-rayed, didn't get it taken care of, and then it really impacted them later in their life. Give me an example of how that might happen.

Travis: I ended up coming in over this summer just to do some check-up on the school I work at and things like that, and this athlete pops in my room. And he wasn't really thinking about it much. He was doing some lifting and just experiencing some slight pain in his wrist. And he's like, "Hey, man. Is this normal? I took a little follow-on a couple of weeks ago." He actually did ended up going to see somebody. He was instructed to come back in if it wasn't getting better, and the athlete didn't do that. And so after evaluating it, I was pretty concerned for a fracture still present in his wrist.

And so we sent him back in. And I guess, long story short, since that second referral, getting him back into a doctor again, he has actually had four different surgeries on his wrist trying to restore normal function and trying to properly heal the bone that broke. And so he ended up breaking his scaphoid bone. And for those that have broken it or know about that bone, I'm sure they know the complications that can come from breaking that bone, and then it not healing properly because that bone can lose blood supply. And when that happens, it's called necrosis. And so part of that bone can sort of die off. He, to this day, still has trouble playing athletics. It has affected him in class, in school, writing, typing, so many aspects of his life, carrying things, lifting a backpack. And so he is definitely one of my big advocates when I have to tell other athletes to go get an x-ray, and he'll back me on that a lot of the time, so yeah.

Interviewer: So, for young high school athletes, are there some fractures that tend to occur more often that if it does occur, that is definitely a reason you want to go see somebody, ask for an x-ray? What are those kind of common fractures that could really give you problems down the road if you don't take care of them almost immediately?

Travis: Yeah, the ankle. So whether or not it's from twisting your ankle, getting it caught up in a pile, or if you're a basketball athlete, very common to come down on top of somebody's foot after you jump up into the air, and then any kind of fracture around the ankle bone. So whether it's a small chip off your tibia or fibula, those are sort of common when it comes to spraining your ankle. And most of the time, why doctors recommend x-rays for ankle sprain is because you can get . . . whether it's a small piece of your ligament sort of pulls off a little piece of bone, that's a common area to fracture as well.

The other area of the body that is another big one to go get checked out is called the base of your fifth metatarsal. So that's on the outside of your foot there. And that's a special bone because it's sort of just like the one on our wrist where if we don't catch it in time, it can also go through that sort of necrosis. And it's called a dancer's fracture, actually, because it happens in dance quite frequently. And so that's one of those areas where if you do have pain on the outside of your foot sort of near the . . . we call it the base of our fifth metatarsal. If you have pain in that location, that's a very important one to go get evaluated and x-rayed because it can go through that necrosis process.

And then also, they actually are seen quite often in the military. They're called marcher's fracture. So it's at second or third metatarsal in your foot, and that's the same thing. It's going to be those repetitive stress motions. So whether it's marching, running, jumping, that's another very common area in athletics or the sports world to see a fracture in.

Interviewer: So I noticed that these common fractures in athletics that you believe should be x-rayed seem to be around the wrists, ankles, and the feet, the smaller bone.

Travis: Yeah.

Interviewer: Yeah. So those are the ones that if you don't get them looked at, x-rayed, follow your doctor's instructions can really kind of mess things up in the future for you not only in athletics, but in regular life as well. And I'd imagine a lot of those you don't even know that there's a fracture. You probably . . . just pain. You thought maybe just strained something or sprained something. Is that accurate?

Travis: When athletes have a bigger emotional response, it's pretty easy to convince someone, like, "Hey, we should go get an x-ray on this," like, "You're in a lot of pain right now." It's more time those athletes that they're able to tolerate it. They're sort of pushing through it, they're playing with it still, or they come in and they're, like, "Dude, this is something I can deal with." And you have to have that conversation and you have to educate them on, "Hey, look. It's not about you missing a couple of games." This is about your long-term health, especially for those important areas, whether it's the scaphoid, the base of the fifth. There are some areas in your body where if you don't get them checked out and treated properly, they will cause long-term complications. You will have to get multiple surgeries on them in order to try restore normal function in your body.

Interviewer: And if the athlete is experiencing that, how much time do they have to go get the x-ray? Now, I know at University of Utah Health, we have a walk-in orthopedic center, which is great because you could just walk in, tell somebody what's going on, and they could do an x-ray right there. If they need to have a couple of days in order to arrange that, did you have a couple of days to do that or you really want to get it checked sooner than later?

Travis: Yeah. So can you wait overnight? Sure. Should you wait the entire weekend and then maybe go get it checked out on Monday? Those are some things that I probably wouldn't recommend unless you've been advised and it's already been evaluated by somebody, but make sure you're getting evaluated by a professional that can give you recommendations on, "Hey, this is one of those high-risk areas and this is why I would go get an x-ray tonight instead of waiting over the weekend."

updated: December 8, 2022
originally published: March 3, 2021

Interviewer: How to handle a knee injury. Dr. Julia Rawlings practices primary care sports medicine and also pediatric emergency medicine, and she is one of the physicians that you would find at the walk-in orthopedic clinic at University of Utah Health. I wanted to talk about knee injuries and young athletes actually. What are some common ways that young athletes can injure their knees? What specific sports or activities do you see?

Dr. Rawlings: Yeah. So it's really common to have a knee injury when you're playing sports, particularly contact sports. But severe injuries, including the ACL, don't always have to be from contact. So we typically see knee injuries that are acute, meaning they happen from a trauma, when you're doing an activity where there's either contact or you change directions quickly, so you're pivoting, you're shifting, you're changing your weight, and the knee can kind of buckle on you and get injured. In people that do more endurance-type sports, like cross country runners, we tend to see more chronic knee pain just from overuse.

Interviewer: Got you. So you kind of covered some of the common injuries to the knee. What could be handled at home without a clinic visit? And then we'll get to when you should perhaps consider coming in.

Dr. Rawlings: Yeah. So starting with an acute injury, meaning that's something you were out doing your sport, you were doing something, and all of a sudden you felt the knee pop, or you twisted it, or something happened. A couple of clues that I would give to go ahead and come in to be seen is, one, if you're having a hard time walking on your leg, then we would really like you to be seen sooner rather than later. We'd like to get X-rays and make sure there's nothing that's broken and then do a good examine and check out the ligaments and the meniscus of the knee.

Another clue is if your knee gets pretty swollen, then that means that there's something significant going on in your knee that should be seen sooner rather than later. Two more other clues, things that I like to ask people about and look for. If your knee feels like it's buckling under you, it's giving out when you walk, then there's the potential that every time it buckles, that we're doing more damage. And in that case, we'd like to get you on crutches and get you into a knee brace. Or if the knee is getting stuck or locked, meaning you can't bend it or you can't straighten it very well without kind of forcing it, those are all things that we'd want to see you sooner rather than later for.

Interviewer: And then when somebody comes into the clinic with some of those more serious symptoms, as you said, what does the clinic do?

Dr. Rawlings: Yeah. So if you have, say, a big swollen knee and we're worried about bigger injuries to the ACL or to the meniscus, something like that, what we would generally do is start off with X-rays, make sure there's nothing that's broken, and then we would do our exam, get a feel for what we think is going on, and then generally get you set up in a knee brace that's appropriate for the injury you have, plus or minus crutches. And then often, patients with significant injuries we'll get set up for an MRI to check out the soft tissue structures, which we can't see on X-ray, and get a definitive diagnosis. And then depending on what we see on our exam, we'll either get you set up with one of the non-operative sports medicine providers for follow-up or our sports medicine surgeons. My practice myself is I typically just let people know what their MRI shows, and then depending on what they need done, I'll then schedule the appointment with the appropriate follow-up person.

Interviewer: And when people come in, how often would you say that they could just come into the clinic and that's kind of it? It's just going to take a little bit of rest, and they're going to recover from their injury.

Dr. Rawlings: You know, it depends a little bit, I think, on the age demographic. So we do see a fair amount of people that come in with an acute knee injury that have just flared arthritis, and they don't actually have an injury to the ligament or something that we would need to do an MRI or surgery for. And those patients we really treat with physical therapy, maybe a steroid injection, and kind of getting them back to functioning, hopefully, so that we can prolong the longevity of their knee. In those cases, then, yeah, all they need really is just that visit in the orthopedic injury clinic and then a follow-up appointment down the road with a primary care sports medicine person or a sports medicine surgeon.

Interviewer: Are there any final thoughts you would want a listener to know about the clinic, or knee injuries, and how to handle that or take care of it?

Dr. Rawlings: I think definitely when in doubt, especially when it's an injury that's happened within the last day or two, come on in. We'll be happy to take a look at it. And if you're getting a chronic injury from training for a marathon, or in kids, they can often get growth plate injuries, again, if they've happened in the last three months, we're happy to see you in injury clinic for more of a chronic developing problem as well.

Interviewer: When should you consider University of Utah Health's Orthopaedic Injury Clinic over perhaps a visit to the ER or urgent care, or is it something you can handle on your own? That's what we want to find out today.

Dr. Julia Rawlings is a primary care sports medicine and also practices pediatric emergency medicine, but it's that sports medicine doctor that we really want to talk to today. So the first thing I want to find out is what are some of the common orthopedic injuries a person should consider using the Orthopaedic Clinic versus an ER or urgent care?

Dr. Rawlings: The Orthopaedic Injury Clinic is a great place to go if you have an acute injury, meaning that you have had an injury that you've sustained recently. We're actually willing to see people that have had an injury anytime in the last three months, but preferably not something that's chronic and going on. We'd rather you go ahead and make an appointment with a regular physician during regular hours, although it can be at the Orthopaedic Center.

Specifically, things that are good for the Injury Clinic. So we see a lot of injuries from the ski slopes. We see people that have been playing different sports, or running, biking. We see some football injuries. Anything that's kind of acute. Anything that could go to an urgent care can go to the Orthopaedic Injury Clinic if it's a musculoskeletal injury.

A couple of things we don't see at the Injury Clinic. We don't do stitches there. So if you're bleeding and you think you need stitches, an urgent care or the emergency department would be more appropriate. Also, if your bone is pretty crooked, it's probably a better idea to go to the emergency room. We can do some local numbing medicine to set some easy broken bones, fingers, and things like that, but larger fractures would need to be seen in the Emergency Department for sedation.

Interviewer: And what kind of diagnostic tools do you have there that kind of makes you the choice for some of these as opposed to perhaps an emergency room or an urgent care?

Dr. Rawlings: Yeah. So the Injury Clinic is fantastic because we have access to x-ray on-site, and we can see those images back as soon as they are done. And depending on the time of the day, we actually can often get the reads back from a musculoskeletal radiologist within a few hours. Sometimes those reads don't come back until the next day. We don't have the capability to do CT scans at the Injury Clinic. We do have access to scheduling MRIs in the building, but that's not done the same time as the visit.

So one great thing about the Injury Clinic is you get kind of a full package. So you get your x-rays. You could get an MRI set up. We have all of the braces and everything that you would need, crutches, things like that. And then, we can get you set up with a specialist, whether that's a sports medicine surgeon, foot and ankle surgeon, or one of our non-operative primary care sports medicine physicians. We will actually make that appointment for you while you're there for follow-up.

Interviewer: So the clinic, it sounds like a better option than perhaps making an appointment. It can be difficult to get in sometimes with an orthopedic doctor at times. So this clinic, it's primarily walk-in, is that how it works, or do you have to make an appointment?

Dr. Rawlings: It is walk-in. It's a little bit tricky right now with coronavirus going on, but, typically, it is walk-in. They are switching to appointments during this period of time, but that's going to be very temporary. Generally, it is walk-in, first come, first served.

Interviewer: How can a person decide if an injury is something that they can treat at home or they can just try to see if it's going to get better versus coming into the clinic or seeing a professional?

Dr. Rawlings: Yeah. So we're always happy to check anything out if you're not sure. A couple of tips that just come to my mind. One is if you have an injury that's bad enough you can't really walk on it or bear weight on it, that's something that should be seen, probably get an x-ray, make sure you haven't broken a bone. Or if you really can't move your shoulder or can't move your arm in some way. If you twist your ankle, and you're walking on it okay, and it gets a little bit swollen, that's something that you could probably wait on at home and see how you do. But, yeah, if you have a hard time moving a body part, that's a good time to go in.

Interviewer: All right. Are there some injuries that really you do want to have looked at, otherwise it could affect you and your mobility in the future?

Dr. Rawlings: Yeah. So there are definitely, particularly injuries that involve the joints. We often like to get a sooner look at what's going on rather than a later look, just because things can happen down the road that can lead to arthritis if they're not treated early. That being said, a lot of musculoskeletal injuries aren't emergencies. Meaning, even if you get something like a torn ACL, which is considered a pretty big injury in the sports world, if you're diagnosed several days after that happens, in general, that's okay. It's not something that absolutely needs to go to the emergency department or into the Injury Clinic even the same day you have it. You'd really be okay to get yourself a pair of crutches from the garage and come in a couple of days later.

Interviewer: For the particularly injury-prone that might have some crutches?

Dr. Rawlings: Exactly. There are a lot of people with crutches in their garage from siblings, so.

Interviewer: Any final thoughts that you have when it comes to the walk-in Orthopaedic Clinic? It's such a great resource. I was able to utilize it. I had a shoulder injury. I'm not even going to go into how that happened because it was not cool, it was not athletic. But it was great because I could go in, they were able to look at it, make sure that I didn't, you know, do any permanent damage, which I didn't, and then, you know, gave me a reference to go to a physical therapist to do some exercises to rehabilitate it, so.

Dr. Rawlings: I think it's a fantastic clinic. I mean, it's staffed by people that are trained in musculoskeletal medicine, so we have a little bit of an advantage over lots of the urgent cares that are more kind of general medicine, that we treat a lot of musculoskeletal injuries. We can get you set up with physical therapy pretty easily. And one or two days of the week, we actually have a physical therapist with us in-clinic. So if your injury is appropriate for that, we can even get you started on physical therapy the night that you come in. So I think it's a fantastic resource.