Search for tag: "orthopedics"

Interviewer: You hurt your back. What can you do on your own, and when should you go see a doctor? Dr. Andrew Joyce is a physical medicine and rehabilitation specialist. He's also an expert at helping patients manage neck and back pain.

Dr. Joyce, I was shocked to find out that low back pain is the number two reason Americans see their healthcare provider. Is it for this kind of acute back pain that we're talking about that they're usually seeing their doctor for?

Dr. Joyce: In most cases, yes. I think a lot of people have chronic low back pain as well, but I think most of us tend to see a lot of acute low back pain, and particularly my primary care colleagues see tons of it.

Interviewer: And we're talking in this particular Q&A that we're doing together about acute back pain, which is back pain that you were just doing something and you hurt yourself, right? Is that kind of what we're talking about there?

Dr. Joyce: Yeah. And it doesn't even have to be doing anything in particular, but you wake up, you have back pain, and you don't know where it came from. Or you were lifting something and tweaked something, threw out their back is a common phrase that people will use, all of those count as what we're talking about today.

Interviewer: And technically, when you say "acute back pain," that's back pain that lasts less than four weeks, right, four weeks or less?

Dr. Joyce: Depending on which guidelines you use, some people say four weeks, some people say less than six weeks, but somewhere in that range.

Interviewer: All right. So, but if I hurt my back like one day, I don't know how long it's going to last. So is there a better way to kind of determine what type of back pain I have? I suppose if I was doing something, it's pretty obvious that, oh, well, I tweaked my back doing that. But like this wake up scenario, how could I tell that maybe that isn't a symptom of something bigger? Because a lot of times back pain is a symptom of other things, isn't it, you've got to kind of rule out?

Dr. Joyce: Yeah. Yeah. And so that's when we start looking at kind of these what we call red flags. So it's very common that people will hurt their back, and oftentimes the pain can be very severe and debilitating. Severity doesn't always correspond with something being necessarily worse. There's actually set of red flags that we look for to kind of try to triage and look for people who might be at risk for having other sources of back pain that warrant further investigation.

Interviewer: All right. So before we kind of get to then acute back pain, I think it's really important to hit those kind of red flags to somebody can make an informed decision that they need to see their healthcare provider sooner than later, or trying to take care over themselves. What are those red flags?

Dr. Joyce: Big ones are trauma. Obviously, if you were like in a car accident, that would factor in. If you have new fevers, numbness, tingling, weakness in your legs. If you have a history of cancer, if you're having any bowel or bladder changes, you use any blood thinners, have cancer, have IV drug use, all these things could put potentially be risk factors. And those were reasons that we'd want you to be evaluated more soon.

Interviewer: And if a patient doesn't believe that that's the case, if they truly just believe, oh, I must have slept funny, or I did something, what can a patient do on their own for acute back pain before they need to see a doctor? What are some recommendations you would have?

Dr. Joyce: Yeah. So the first thing we actually recommend is that you avoid bed rest. Fifty years ago, everyone got recommended, "Oh, just stay in bed, let yourself heal." And what we found is that we were actually giving people a lot of bad advice.

What we recommend now is actually that you try to stay as active as you can tolerate. For most people when they're having an acute back pain flare, they're pretty uncomfortable. So even simple things like getting up, showering, cooking a meal, eating can be somewhat uncomfortable, but our recommendations are to actually try to stay active because recovery is faster when you do that.

Interviewer: And is that because you're getting more blood to the area? What's going on there? Do we know?

Dr. Joyce: I'm not sure if we have exact answers on that. Some of it is that we're probably reducing some of the stiffness. When people have a lot of back pain, they don't move their muscles, they get really stiff and that can cause more pain.

I think we're also testing it. Some people with back pain are really afraid that they're going to do damage and so they don't do anything. And so then their muscles start getting weaker. Within a week, you can lose a large percentage of your overall muscle mass just by not moving and staying in bed. And so by keeping your muscle strong and keeping you moving, you help stretch and strengthen those muscles and help your body on the way to recovery.

Interviewer: And this extra moving, you're not going to hurt yourself most of the time. Is that correct?

Dr. Joyce: As long as you don't have one of those red flags, in most cases, you are able to go out and do whatever you need to do, knowing that there may still be some pain due to this flare-up. But it's safe to go out and be active. In fact, it's kind of the treatment of choice at that early stage.

Interviewer: All right. So get active or just be active as much as you can tolerate. What are some other things that a person could do before they go see a doctor?

Dr. Joyce: They can try over-the-counter medications. So nowadays, we have the Salonpas patches or other lidocaine patches that people can use. There are a variety of topical creams. There's Tylenol. There's oral anti-inflammatories that people can take. All of those are over-the-counter and are medications that patients can try out.

Additionally, this somewhat depends on your insurance plan, but sometimes you can get direct access to physical therapy without even needing to see a doctor in certain cases. And so that's often a reasonable place to start.

Interviewer: And then what amount of time doing those types of things should a patient wait until they start to see some relief or start to be concerned that, "Oh, maybe this isn't acute"?

Dr. Joyce: Yeah. So I would give it at least two weeks and see how you're feeling at that point. If at that point you're not getting better, that might be a good time to at least start scheduling an appointment with your doctor. Most patients with back pain will recover within two weeks.

The next set will kind of get better over the course of six weeks. And definitely if it's been over six weeks, it's probably worth seeing a physician to evaluate you.

Interviewer: And then when you come into your physician, you could go to a primary care physician, or could you come to an expert such as yourself at that point? What would you recommend there?

Dr. Joyce: If you have a good, established care with a primary care physician, I think that's a great place to start, and they will often be able to help you. If you have any concerns, or if for some reason you're not able to get in, or you don't have a primary care physician, we're always happy to see people and get people in from the ground up and make sure that they're getting treated appropriately.

Interviewer: All right. And then what types of things would you do at that point for a patient that has gone two to four weeks not necessarily seeing the kind of recovery that they'd like? What are you looking for at that point?

Dr. Joyce: Yeah. So, at that point, we likely would get some imaging, probably starting with an X-ray, just to check to see that the bony structures are intact and there's no new issues. And sometimes there are things on the X-rays that can clue us into other potential sources of pain that we might not otherwise be able to see just from our physical examination.

We'd prefer a full history and a physical examination to really get a better picture of the back pain and understand how it fits in with your other medical conditions and if there's any other rarer conditions that we really need to be looking at.

At that point, then we make a decision, based on everything, on what the next treatment plan should be, whether it be a formal referral to physical therapy, whether it be more advanced imaging in preparation for certain procedures, and considering different injections.

Interviewer: What about surgery at that point, or when does that come into play?

Dr. Joyce: Most patients don't need surgery. And that's one of the great things. The natural history of these, which means how people do if we do nothing and just let people live their lives, is that most people recover with it over time. It just can be very debilitating during that time.

And so, in most cases, surgery isn't recommended. If you do have one of those red flags, I think it's worthwhile to get evaluated, and then we can see whether surgery makes sense. But in most cases, there's nonsurgical options that we will try first and see if we can help get this under control or get your pain better before having you meet with the surgeons.

Interviewer: And then how about you using opioid medications for back pain? Is that ever a good idea?

Dr. Joyce: In most cases, I would say probably not. There are always exceptions to the rule, so I don't want to say never. But in general, opioids aren't really a first-line treatment for back pain. And if you look at the CDC or you look at other organizations, such as the American Academy of Family Medicine, they don't recommend opioids. And part of the reason is that they've been shown to have higher risks, which we all know through the opioid epidemic, but also no significant benefit when compared to other over-the-counter medications. So Tylenol and Advil versus opioids, the studies show that they're roughly equal in terms of controlling the pain and the opioids carry a much greater risk. So, in most cases, we try our best to avoid opioids because we don't want to risk our patient's health.

Interviewer: And when you're talking about over-the-counter painkillers for back pain, do you just follow the directions on the boxes to what your dosage should be, or generally do you recommend to your patients a higher dosage?

Dr. Joyce: It depends on the medication, but, in general, I probably will recommend for Tylenol, you can take up to two Extra Strength Tylenols, and you can do that three times a day as kind of a high-level dose of Tylenol.

And then for the anti-inflammatories, the low doses of the medication tend to be more pain relievers. And at the higher doses, they tend to have a little bit more anti-inflammatory effect. And so sometimes, for a medication like Advil, we can recommend up to three tablets of regular Advil three times a day.

Any more than that, you should probably be seeing a doctor or checking in with them to make sure you're not using too much medication because that can have other side effects.

Interviewer: So maybe you or a loved one has a bony protrusion on your foot. It's maybe painful, maybe not. It's a bunion. How exactly does one treat a bunion and what kind of results can one expect from the treatment options?

We're here with Dr. Devon Nixon. He is an orthopedic surgeon at University of Utah Health, with an emphasis on lower extremity, foot, and ankle medicine.

Now, Dr. Nixon, before we kind of go into treatments, let's just start real basic. What is a bunion exactly?

Dr. Nixon: A bunion is an interesting thing that we see really commonly in clinic. It's more than just a bump that's forming on the inside part of the big toe. What's actually happening is there's a complex three-dimensional change that's occurring where one portion of the toe is beginning to move towards the inside, which then drives the big toe part towards the second and third toe. And it may begin to even cross over under those second and third toes.

Interviewer: And is there any way to, say, prevent them?

Dr. Nixon: I wish there was a way to prevent them. They're very common, and certainly not everyone with a bunion needs surgery. And so there are plenty of things to do to try to make them more comfortable, like modifying your shoes or adding a toe spacer. But unfortunately, those options don't necessarily change the long-term progression, which is that the bunion may slowly increase over time.

Interviewer: So let's go back a little bit with that. When you're talking about treatments, you said it's not necessarily surgery. If we're not doing surgery, what are the other options available, and what are you actually treating with those?

Dr. Nixon: Like most things in my practice and in most orthopedic practices, there are nonsurgical and surgical treatments. And the nonsurgical things that many patients choose to do are to add some modifications to their shoes. So they get them in wider forms to help reduce some of the irritation on the inside part of the big toe, which, for many patients, is one of their biggest pain drivers.

Another thing is they can add over-the-counter gel inserts that slide between the big toe and the second toe to help push the toe a little bit out of the way to make it more comfortable.

And those are all driven based on symptoms. So the choice of whether or not to move forward with surgery is a patient-driven choice. It's certainly not one that I will make for them. My goal is to help them have the information they need to make the right choice.

But the options after modifying your shoes and adding an insert, there's not a lot of in-between. So, unfortunately, the conversation may then move towards, "What are my surgical options?" which are to help get the toes straighter and to help remove the bump.

Interviewer: So let's move on to those surgical options. As an orthopedic surgeon, any time a patient hears the word "surgery," there's a little bit of anxiety. There's a little bit of weighing the risks and benefits. Kind of walk us through the surgery. Not necessarily the nuts and bolts of everything, but as a patient, is this an outpatient procedure? How long can I expect to recover, etc.?

Dr. Nixon: Absolutely. I mean, I'm a surgeon, but I'm extremely sensitive to the fact that no one wants to go through surgery. And my job will never be to sell anyone on the surgery. It's the patient coming in to tell me that this is what they think is the best option for them. They feel like they've tried these other things.

And then the different technical options for surgery vary from patient to patient. So it's driven by a lot of factors, some of them clinical, some of them on the X-ray, some of them very patient-specific.

But largely, what we're doing is we're trying to correct the bunion by straining the big toe. And you can do that by either cutting the bone and shifting it. We call that an osteotomy.

You can fuse certain joints around the big toe. So one of them is fusing a joint closer to the middle of the foot, and we call that a Lapidus procedure.

And then another procedure is, depending on the patient, if they have some arthritis that's developed, you can fuse the actual big toe joint itself.

But a lot of these decisions of what to do from a surgical perspective are not uniform to everyone. So that's a conversation that we all have in clinic. If patients feel like they're at a surgical level, I look at the X-rays, I talk to them, get a good history, understand their activity level, what are their goals, and if there's any arthritis present, and then we talk about, "What are these varying treatment options?"

Interviewer: So a surgery like this, how long can someone expect to be undergoing treatment? How long does the procedure last and how long is recovery?

Dr. Nixon: Yeah. The surgery is an outpatient procedure. You go home the same day. The main goal is that . . . Depending on which type of surgery to do, it doesn't really change the fact that for the first four to six weeks, we're going to be keeping you off of your foot in terms of full weight out at the big toe.

If we're cutting the bone, doing what we described as an osteotomy, we need that bone to heal. And if we're trying to get joints to fuse, then we need those bones to heal together too. And so there is a form of protected weight-bearing, which can be challenging if it's your right foot because it's going to limit your driving.

But the first two weeks, you have sutures in. They get removed at two weeks. And then between Weeks 2 to 6, you're kind of protecting your foot, and then usually get X-rays around the six-week mark. Depending on the type of surgery you had, we may begin to advance your weight-bearing so that you're putting more full weight on the big toe.

Interviewer: Now, is there much physical therapy or anything involved with this particular procedure?

Dr. Nixon: Physical therapy is certainly a very reasonable thing to consider. And for some patients, they think that it's helped them considerably. Some of that depends on the type of surgery and the surgeon's specific decision-making. Not all bunions need physical therapy afterwards, but certainly plenty of patients that I operate on benefit greatly from physical therapy.

Interviewer: And what is the success rate for a procedure like this?

Dr. Nixon: It depends a little bit on the operation you do. So one of the things that we're trying to address if you have both a bunion and arthritis, if you have the big toe joint fused, and if that goes on to fusion, which can occur in about 90% or so of patients, then those are some of our happiest patients. They do quite well. They can remain very active.

The downsides to a fusion are that it does limit the motion in the big toe. So getting back into high heels is challenging. Getting back into certain types of activities, like certain yoga poses, the toe just won't let you do that. So that is one of the downsides, but it certainly is a very powerful and successful operation.

If we are preserving the joint and we are cutting the bones, then patient satisfaction is usually in the 80% to 90% range. Patients do quite well from those operations.

Whichever one you choose, they do require some level of recovery. And I would be lying to you if I said that it's a fast recovery. Some patients recover faster than others, but the first couple of weeks, there's going to be some swelling involved, so it's really important to keep it elevated. But as you begin to progress your recovery, you'll begin to get that swelling down and hopefully be able to quickly transition back into regular shoes, as we allow you to, once we get X-rays that confirm that everything has healed up well.

Interviewer: What is something that you as a surgeon would tell to give that last bit of kind of confidence to someone who's considering bunion surgery?

Dr. Nixon: I think what's really important is that the decision-making is all by the patient. My job or any of my partners' jobs is just to make sure that you have the right information to make the decision.

And at the end of the day, patients can get a lot of good pain relief and a lot of satisfaction and a lot of improvement from having their bunion corrected, whichever method you choose.

And like most things in life and in medicine, they all have some form of a pro and con weighing, a pro and con assessment, but whichever one you choose, patients do quite well from these operations. There is a recovery involved, but ultimately, patients do quite well.

Dr. Miller: Strains, sprains and fractures. How do you tell which is which? We're going to talk about that next on Scope Radio.

Hi, I'm Dr. Tom Miller and I'm here with Dr. Emily Harold. Emily is a Professor of Sports Medicine here at the University of Utah in the department of Orthopaedics. Emily, tell me the difference between . . . well, what do we do? What do we start with? Is there a difference between strains and sprains and . . .

Dr. Harold: Yeah, there is a difference. So, typically, when we talk about a sprain, we're talking about an injury to a ligament. A ligament is a structure that connects one bone to another bone. When we talk about a strain, we're talking about an injury to a muscle. So they vary in terms of what we're describing and they also vary a little bit in terms of treatment.

Dr. Miller: So ligaments are the tough, fibrous tissues that connect joints together? Would that be fair?

Dr. Harold: Yes, that's fair.

Dr. Miller: So you have them in your ankles, your knees, your hips, any major joint?

Dr. Harold: Any major joint. It's a tough, fibrous tissue that connects the two bones together.

Dr. Miller: And yet a sprain is a problem between the tendon and the muscle?

Dr. Harold: Exactly. So, typically, sprains can either be located at where the tendon and the muscle connect, or sometimes they'll be within the muscle themselves.

Dr. Miller: Which is more common, sprain or strain? And also, why is it important to know the difference between the two? Is that something that the general audience should be familiar with or is that more something that a physician needs to know?

Dr. Harold: I think that it's important to know the difference because when we talk about an ankle sprain we're talking about injury to a ligament that connects the two bones. And therefore, the recovery and the treatment for that injury is going to be a little bit different than when we're talking about a hamstring sprain, which is an injury to the muscle itself.

Dr. Miller: Treatments are different?

Dr. Harold: Treatments are different. When we talk about an ankle sprain or ligament sprain, we grade those one through three, with one being just a very mild injury to the ligament and three being a complete tear in the ligament.

Dr. Miller: So, obviously, a complete tear would result in a lack of function or a severe impairment of function.

Dr. Harold: Exactly, and depending on the joint, the treatment is a little bit different. So when you hear of an ACL sprain, a complete tear of the ACL, which would be a grade three sprain, typically results in a surgical intervention.

Dr. Miller: How about the minor stage one and stage two? Are those treated with physical therapy, typically?

Dr. Harold: Typically, those are treated more with physical therapy to help get the joint moving again. Ice, anti-inflammatories. And they take about two to four weeks to recover, whereas a grade three sprain can take up to six weeks to recover.

Dr. Miller: So you're a sports medicine physician. You treat a lot of athletes and also weekend warriors, I imagine. Tell me a little bit about what are the major sprains that you see, and then later on the major strains.

Dr. Harold: So the major sprains I see would be an ankle sprain, as well as, a lot of times, knee sprain. So MCL, different ligaments in the knee that can get sprained. The major strains I see are rotator cuff, which are the muscles in the shoulder, and then I also see a lot of calf and hamstring.

Dr. Miller: So let's take a sprained ankle. That's a fairly common injury, I would think, among athletes and just people who are exercising on a day-to-day basis, and step off a curb incorrectly. Do you always need an x-ray of that? I mean, how does one proceed? Let's say they have swelling, they have pain, does that need to be evaluated by a physician? And how would they know?

Dr. Harold: That's a good question. So there is a set of rules called the Ottawa Ankle Rules, that came out of Canada, where they looked at a lot of patients who had an ankle sprain and they tried to determine which ones were at risk for a fracture and which ones were at risk just for a ligament injury. And so there are some rules you can follow. One is if you can walk on your ankle right after the injury, that's a good sign.

Dr. Miller: Bear weight and walk.

Dr. Harold: Bear weight, exactly. The other is we look for tenderness on either side of the ankle on the bony prominences, both on the inside and the outside of the ankle, as well as if anyone has tenderness on the outside or the lateral part of their foot.

Dr. Miller: And if you have either of those debilities, what next?

Dr. Harold: Then you should come in and get an x-ray, just to make sure that you don't have a fracture with the injury.

Dr. Miller: So you could go to an urgent care clinic, you could go to your primary care physician or even a sports medicine physician?

Dr. Harold: Yeah, all three would be able to handle that with an x-ray and let you know if it's a fracture or just a sprain.

Dr. Miller: So sometimes, there's this difficulty in distinguishing whether it's a fracture or whether it's actually just a sprain?

Dr. Harold: Yes.

Dr. Miller: Okay. Other joints that are concerning for either fracture or strain? I think of ankle, most commonly, and then knee is one where . . .

Dr. Harold: Ankle, knee, I think wrist.

Dr. Miller: Wrist?

Dr. Harold: I'll see some people who fall on their wrist and there's concern whether it's a fracture, or whether it's a sprain or a strain. And that doesn't have a set of rules to guide x-ray so, typically I'd say if it's really swollen and if you have limited movement, those are the times that I would get an x-ray.

Dr. Miller: So if you're lacking function in that hand because of swelling and pain, that needs to be checked out, especially if it goes on any longer than maybe a day. Or if it just hurts incredibly, it needs to be checked out. Okay. So let's talk about strains. You've mentioned hamstring.

Dr. Harold: Yes.

Dr. Miller: And is that the most common that you're familiar with or that you deal with on a day-to-day basis?

Dr. Harold: Because I treat a lot of the younger athletes, I see that probably most commonly.

Dr. Miller: And what do you do to rehabilitate that? What's the main treatment there?

Dr. Harold: The main treatment there is to keep from over-stressing it when it's still injured. So usually, we start with some gentle stretching, usually some physical therapy. Avoid any kind of sprinting or any kind of activity that really stresses it until it slowly heals with time, and that can take up to a month.

Dr. Miller: I imagine you work very closely with physical therapists?

Dr. Harold: Yes.

Dr. Miller: And so a person with either a sprain or strain would end up maybe going to a physical therapist if it was a non-operative injury?

Dr. Harold: Yeah, absolutely, and I would say at least 90 to 95% of all of them are non-operative.

Dr. Miller: That's great to know.

Dr. Harold: So most injuries require physical therapy, some time off from the activity that really bothers it, but very few ever go on to require surgery.

Dr. Miller: Emily, you mentioned something earlier, talking about non-steroidals. Could you talk about that and what a non-steroidal is?

Dr. Harold: Yeah, a non-steroidal is a drug that helps with inflammation. If you get them over the counter, brand names like ibuprofen, Aleve, or naproxen, Advil, those are medicines that people take to help with inflammation. Now, I think it's worth noting that it hasn't been shown to heal anything quicker, it's more of a pain alleviator.

Dr. Miller: Should they go to the drug store and pick up ibuprofen or Naprosyn, common non-steroidals that are available without a prescription? Or do you have a certain way that you prescribe them or tell them how to use them so that they don't overuse those types of medicines? Because they do have side effects.

Dr. Harold: Yeah. I typically tell my patients that if they have a lot of pain, they should take the dose that is written on the over-the-counter bottle and take that for pain only. And once their pain starts to get better, they should stop the medication as they tolerate it. There are some doctors who will tell people to take it constantly for one or two weeks. Again, I don't think there's any data behind either option. I think it's more of a physician and patient preference.

Dr. Miller: So, Emily, we just talked about sprains, strains and fractures. Could you just summarize what we said? And we said quite a bit but I think, for the audience, a little bit of a recap would be good.

Dr. Harold: Absolutely. So a sprain is an injury to a ligament, which is a piece of tissue that connects a bone to a bone. A strain is an injury to where the muscle and tendon are connected. And a fracture is any break in the bone, regardless of how many pieces it is in or how big it is. All of these are treated a little bit differently, and . . .

Dr. Miller: I think, as you said, 90% of them . . .

Dr. Harold: . . . most of them are non-operative.

Dr. Miller: . . . that don't require procedure and operation to heal.

updated: December 21, 2022
originally published: October 4, 2016