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If you’re an athlete in your late teens to…
Date Recorded
September 27, 2021 Service Line
Destination Care, Orthopaedics
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Dr. Travis Maak talks about his medical…
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An injury to a young athlete can be a serious…
Date Recorded
December 06, 2016 Health Topics (The Scope Radio)
Bone Health Transcription
Dr. Miller: You've torn your ACL. Is that a game changer for the young athlete? 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: Hi, I'm Dr. Tom Miller, and I'm here with Dr. Travis Maak. Travis is a professor of orthopedic surgery in the Department of Orthopedics here at the University of Utah. Travis, got a young athlete who's playing football, hears a pop, falls down the ground, torn his ACL. Is that it, you no longer play football, or what can you do?
Dr. Maak: Absolutely not. I think, obviously, no one wants to get injured at any point in their sporting career and it is extremely psychologically impactful for the athlete when they injure themselves. And the first gut reaction is, "I'm never going to get up. I'm never going to play sports. I'm never going to be the athlete I was before."
Dr. Miller: Pretty traumatic emotionally for the young and talented athlete, I'm sure.
Dr. Maak: It absolutely is and, in fact, as an area of expertise, sports psychology is a growing area, because it really is a hard thing to recover from.
Dr. Miller: Let's talk about the first piece of this, which would be the diagnosis of an ACL tear. How do you do that and how are you assured that the patient actually has an ACL tear?
Dr. Maak: The way to differentiate between an ACL and everything else is fairly straightforward. If you fall, you twist, you feel a pop, and your knee swells right away, and you can't walk off the field...
Dr. Miller: You know you got it. Something's going on.
Dr. Maak: It's a good chance.
Dr. Miller: Well, how do you definitively diagnose that? Is that the coach on the sideline or the trainer, or do you think that that belongs to a specialist, such as yourself in sports medicine?
Dr. Maak: Well, I'll tell you, actually, trainers are fairly good for the most part. There's an example, the Lachman exam, where you test the knee instability. That being said, right out of the gates, when the knee is extremely swollen, the athlete's in pain, it's really hard to diagnose it. So generally speaking, if there's a concern of any sort that there might be an ACL, a referral to a specialist is probably the best answer.
Dr. Miller: Now, treatment or therapy doesn't begin until that swelling is reduced or is eliminated. Is that correct?
Dr. Maak: That is correct.
Dr. Miller: We think the first thing, athletes, they want to get it repaired right away, and the assumption is that, "I've got to go to the ED," and then the surgeon comes down and operates on him, like as if it's a terrible fracture. But that's not true. You want things to cool down.
Dr. Maak: You're 100% right. In fact, we know now that operating for an ACL when a knee is extremely swollen and stiff, all it does is make the knee continue to be swollen and stiff. And so we let things calm down with therapy. And once the knee is back to moving appropriately, that's when you fix it.
Dr. Miller: Well, the million-dollar question and the question that I've been asked by patients is, do we have to have the ACL repaired? Do I have to have the ACL repaired once we know that it's torn?
Dr. Maak: It is 100% the million-dollar question. Fortunately, we have some statistics behind this. So looking at all of these different types of repairs, reconstructions that we've done, we've learned the following things. Number one is if you're extremely young, and by that, I mean under the age of 18, you cannot have a kid do activity modification.
No matter what you do to try, they are going to run, they are going to jump, and you can try, even if you're a parent, you know quickly it's not going to happen. So in those patients, they actually have a higher risk of other injuries to their knee if they don't have an ACL because they will not modify their activity. So in the 18 and younger, most of us will recommend surgery for them almost across the board.
When you get above that, in the 20, 30, 40-year old range, the question then becomes, can you modify your activities, and do you need an ACL at all? And actually, there's fairly good evidence to suggest that a third of patients actually don't need an ACL.
Dr. Miller: How would you determine if a patient didn't actually need their ACL for the types of activities they're interested in doing, such as running, tennis? I imagine if they're going to play basketball or running sports like soccer, they probably would need their ACL in almost all cases. But maybe, that's wrong.
Dr. Maak: Sure. So, Tom, that's a really good question. If we could do that, if we could identify who the individual was that didn't need their ACL, we would be winning the game. And unfortunately, we can't. So a third of people don't need it to do anything, including rotational activities. So I saw one of the players who actually used to be on the women's national Olympic soccer team for the US and she actually was diagnosed as having no ACL, and the reason it was diagnosed is they got an MRI because her knee hurt.
Dr. Miller: No ACL.
Dr. Maak: No ACL. And she actually had to see four separate orthopedic surgeons, all of whom had to tell her she did not need her ACL fixed before she could return to playing high-level soccer, at that level. That being said, she'd torn it years ago, and her knee was totally stable. So there are some people, it's about a third, that don't need it. A third of people need it to do rotational activities. So to your point, that's soccer, that's pivoting sports like tennis, especially singles, you can run without an ACL, that's generally fine if you're in that group. Then there is a third of people that need it for everything, and that is walking down the stairs and saying hi to your friend. That is turning, stepping.
Dr. Miller: Walking, stepping off a curb, get away, we fall down.
Dr. Maak: Basically, exactly. And those people need it for everything. To answer your question, can you figure it out for yourself? The answer is yes. And generally speaking, if you're tending towards saying, "Hey, you know what, I'm okay giving up these activities," and this is what I tell my patients. If you take those numbers, about two-thirds of people need it, if they're not going to modify their activities. So if they're going to go back to playing basketball, tennis, bump skiing, things like that, there are good odds you're going to need your ACL.
Dr. Miller: Well, that begs the question. So you let the swelling recover, you let that inflammation calm down, and then, do you allow them to go back and play their sport to see if they can manage it without the ACL, or do you recommend that they proceed with surgery?
Dr. Maak: For me, it is very patient dependent. So in terms of the statistics, what I would tell you is, and what I tell my patients, is if there is a good chance they're going to retry to return to rotational activities, and they're somewhere between the ages of 20 and 50, then my recommendation is unless they're absolutely against surgery, they probably fix it.
Because if you don't fix your ACL and you return to rotational activities and you need it, what you end up doing is risking further injury to your knee, and that is mainly the meniscus. We know that if you tear your meniscus, your risk of arthritis down the road is much higher than if you didn’t, and we're not talking about the ACL, we're talking about the meniscus.
Dr. Miller: So for the patient who rips that ACL, now you've repaired it, what is the time to return to activities? Is it a month, is it two months, is it six months, is it a year?
Dr. Maak: Sure.
Dr. Miller: I mean, some time ago, I believe, it was like a year before you can get back on the field. Things have changed since then.
Dr. Maak: Well, to some degree. So the devil's in the details, actually. And I think what you mean by return to activity, it can vary depending on the person. So you can walk within two to three weeks. If that's, if your activity is walking your dog around the block, number one, you probably shouldn't get your ACL fixed if that's all you want to do, but number two, you can definitely do that. If you're talking about rotational activities like basketball, football, baseball, high-level tennis, anything of that nature, you're looking about six to nine months.
Dr. Miller: Now, let's say that this individual has heard that pop, they had swelling in the knee, where do they go first to have that evaluated? Should they come and see an orthopedic surgeon? Should they go to a sports physician? Should they just end up going to their family practitioner? What do you recommend?
Dr. Maak: I would say all three of those, yes. The truth of the matter is, at this point, the vast majority of individuals, number one, should have a family practitioner as a doctor. So if you don't have a doctor, my plug here is please go get one. That being said, if someone you are familiar with, go ahead and get evaluated. I would say just about everyone is comfortable diagnosing an ACL.
Dr. Miller: To summarize, then, if you have that pop, and you have swelling, you might have pulled, ripped out that ACL, a chance of that. Secondly, if you're about 18 years old or under, you recommend that that be repaired surgically. If you're older, it might depend. You said a third of the people that have complete ACL tears may not actually need that ACL and time will tell. And it also depends on the type of activity that they're going to engage in as well. And then, finally, once you have the surgery, it depends on what you plan to do with that knee again in terms of how quickly you'll get back into that activity. Would that be fair?
Dr. Maak: That is fair. And the other thing I would say is one of the hardest things about tearing your ACL is the idea that you'll never return to what you wanted to do the way you were before. And I can, fortunately, say that there's very good evidence, that in fact, you will be able to do that. And the idea and the reason that I do the job that I do is to get people back doing all of the high-level activities at the level they were training in before as quickly as we can. So your life is not over, your career is not over, you will be fine.
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.
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Your coach says you might have a pulled groin…
Date Recorded
March 09, 2022 Health Topics (The Scope Radio)
Bone Health
Sports Medicine Transcription
Dr. Miller: Your coach tells you you have a groin pull. Is that really what it is? We're going to talk about that next on Scope Radio.
I'm Dr. Tom Miller and I'm here with Dr. Travis Maak, an orthopedic surgeon here at the University of Utah and he's in the Department of Orthopedics. Travis specializes in sports medicine. Travis, talk a little bit about that whole issue around groin pain. Is there such a thing as a pulled groin muscle or is that something else?
Groin Pulls & FAI
Dr. Maak: It could be and many athletes are very used to this type of injury and being told by their trainer or their coach that you bent down or you were running and just kind of exploded off the blocks if you're a running athlete. And all of a sudden, you have pain in your groin and you're told you pulled your groin and you need to take a little bit of time off, stretch it, out walk it off, take some anti-inflammatories like Aleve, ibuprofen, Advil and when the pain goes away, you get back doing what you were doing.
Yes, there are muscles, to your point, that you can literally pull in your groin. Those are called the adductor muscles. They are on the inside of your hip. Frankly, multiple groin pulls are not common.
Dr. Miller: They're not common?
Dr. Maak: They're not common.
Dr. Miller: Contrary to what everybody hears.
Dr. Maak: That is true.
Dr. Miller: We always talk about a groin pull. For the audience, I think that a groin pull is pain on the inside of your upper leg towards the pelvis, right?
Dr. Maak: That is correct.
Dr. Miller: If it's not a pulled muscle, then what is it?
Dr. Maak: Well, a person who's prone to groin pulls and has a history of playing sports from their childhood and being told they pulled their groin, they pulled their groin, they pulled their groin and it never seems to get . . . it will go away temporarily, but then it comes back. One of the other diagnoses, which can cause this, is something called femoral acetabular impingement or FAI.
Femoral Acetabular Impingement
Dr. Miller: That's a big word. What does it mean? What does that look like?
Dr. Maak: So the femur, that's the thigh bone
Dr. Miller: That's the big bone in the thigh?
Dr. Maak: That's the big hole in the thigh. Acetabulum, that's the socket or the ball and the socket of the joint. So the ball is the femur, the socket is the acetabulum. Just the two bones of the hip joint. And then impingement is a fancy word for the two bones hit together.
Dr. Miller: They rub?
Dr. Maak: They rub.
Dr. Miller: When they rub, they cause pain.
Dr. Maak: That's exactly right.
Dr. Miller: Are certain people predisposed to this problem?
Dr. Maak: They are. It tends to be a Northern European type of injury or at least the way the bones are shaped. Although it can happen in any type of ethnicity or group of population. Interestingly, we also have some evidence that specific sports put people at risk for this.
Which Sports Can Lead to FAI?
Dr. Miller: Do tell, which ones?
Dr. Maak: Lacrosse tends to be a fairly high incidence of sport, football, hockey.
Dr. Miller: Now, why lacrosse as opposed to basketball or soccer?
Dr. Maak: Interesting question. We believe it has to do with the rotation with the stick. Part of this, there's a current theory that this has to do with the growth plate of the hip and small growth plate injuries that occur over time can make your hip shaped a little differently.
Diagnosing a Pulled Groin or FAI
Dr. Miller: So if this happens, you have this pain, this discomfort. How is one reliably to separate this out from actually a pulled muscle or tendon versus you know this is a problem with the hip joint.
Dr. Maak: Sure. So the history is actually fairly classic here. So while the initial acute stabbing pain of a pulled groin can happen quickly, particularly when you're exploding off the blocks or you twister you get tackled, and then it goes away within a few days and basically you return to normal. With FAI, there's typically a subtle, continued discomfort, particularly when you sit for long periods of time. If you find yourself going to the weight gym and your coach says, get down, get deep and squat this weight and every time you find yourself not going . . .
Dr. Miller: Get discomfort.
Dr. Maak: Right.
Treatments for FAI
Dr. Miller: What do you do then? What are the treatments?
Dr. Maak: Well, the first treatment is physical therapy so athletic trainers are very good at this. Many physical therapists are as well. As long as you have the diagnosis, going and learning how to lift a little bit differently, avoiding deep squatting exercises and strengthening the muscles around the hip as well as a little an-inflammatory, like Aleve, ibuprofen, Advil can help you. When those fail, sometimes other interventions can help you.
Dr. Miller: How often is this a game changer for the young athlete?
Dr. Maak: So I can tell you is if this ultimately gets diagnosed in the athlete finds himself limiting their athletic participation because they're groin hurts when it's treated, the beautiful thing, while no one wants to get surgery, if it ends up getting surgery . . . and the surgery is basically to make the ball of the hip round again, it's done with a camera. It's minimally invasive and three little, tiny poke holes. And you go in and basically reshape the ball to make it round again. It's curative, it does not return and effectively, they return to their sports at a higher level without pain.
Dr. Miller: One of the things you started out with is the potential to have this problem misdiagnosed. So what would be your recommendation be to an athlete that has groin pain?
Dr. Maak: The first thing is probably to not worry about it initially. If it's a first time you're told by your trainer that you have a groin pull, odds are you probably did. That being said, if it continues to happen and you have a one or two or three or even four groin pulls that keep happening, my recommendation would be to go get an X-ray of your hip. It's nothing fancier than a simple X-ray of your hip and you can diagnose this problem.
Dr. Miller: They could very well do that through their primary care physician?
Dr. Maak: Absolutely.
Dr. Miller: So, in summary, this groin pain may not actually be a groin pain, it could be an impingement in the actual hip joint itself and that that ought to be checked out if you have repetitive groin pains.
Dr. Maak: That's exactly right.
updated: March 9, 2022
originally published: August 9, 2016 MetaDescription
The differences between a pulled groin and femoral acetabular impingement.
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Travis Maak, MD, used to volunteer on the ski…
Date Recorded
December 14, 2022 Health Topics (The Scope Radio)
Sports Medicine Transcription
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.'
Common Causes of Ski Injuries
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.
Who is Most At-risk of Ski Injuries?
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.
How to Avoid Last-run Ski Injuries
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 MetaDescription
Every day after 3:30 pm is when the ski injuries start happening. But what makes 3:30 pm different than 10 am? Is it conditions or conditioning, or a bit of both? Learn how to identify the factors that contribute to those late-in-the-day, last-run injuries, and avoid ending the day in a bad way.
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