Knee Injuries

Knee Injuries

As the largest joint in the body, the knee is essential for competing in almost every sport, but it is also the most common site for injury in young athletes. Overall, knee injuries make up about 55% of all sports injuries.

An injury to the knee can cause an athlete to experience pain in many areas of the knee joint. The knee is formed by the convergence of three bones: the femur (upper leg bone), the tibia (lower leg bone) and the patella (kneecap). Two cartilage discs called menisci allow the bones to glide smoothly against each other, absorb shock and act as a cushion between the femur and the tibia. Fluid-filled sacs called bursa surround the outside of the knee. The knee joint is stabilized by muscles, tendons and four critical ligaments: the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), the medial collateral ligament (MCL), and the lateral collateral ligament (LCL).

The two major types of knee injuries that an athlete may face are acute injuries and overuse injuries.

How do athletes get knee injuries?

Acute injuries occur suddenly during an activity. In athletes, the most common acute injuries are ACL and MCL sprains. A sprain is the stretching or tearing of a ligament. An ACL injury can occur when an athlete changes direction quickly, stops suddenly, or lands from a jump. MCL injuries often occur in contact sports when the outside of the knee joint is struck.

Overuse injuries are caused by a repeated action or continuous pressure on the knee. Common overuse injuries include:

  • Bursitis — inflammation of the bursa
  • Patellar Tendinitis (jumper’s knee) — inflammation of the patellar tendon, the tendon that connects the patella to the quadriceps muscle
  • Patellofemoral Pain Syndrome (runner’s knee) — muscle weakness or minor softening of the cartilage under the kneecap that may cause an abnormality in the movement of the patella over the femur
  • Osgood-Schlatter disease — inflammation of the patellar tendon where it attaches to the tibia that occurs in growing adolescents

What types of athletes are more prone to knee injuries?

Knee injuries are common in most sports. Often, when a ligament is torn, other tears and strains accompany it. Athletes who play soccer, field hockey, gymnastics, lacrosse, skiing, snowboarding and volleyball are most susceptible to ACL injuries, while MCL injuries are commonly seen in hockey and wrestling. Other sports such as cycling, rugby, running, swimming and water polo are generally more affected by overuse injuries.

What are the common symptoms of knee injuries?

Depending on the location and severity of the injury, symptoms of a knee injury may vary. Symptoms that often coincide with knee pain include:

  • Swelling and stiffness
  • Warmth and redness
  • Limping or instability
  • Inability to fully straighten the knee
  • “Locking” of the knee

Symptoms of an ACL injury:

  • Loud popping sound and immediate pain when the ligament tears
  • Swelling occurs within an hour or two
  • Knee feels unstable and it is difficult to walk

Symptoms of an MCL injury:

  • Grade 1: Partial tear of the MCL. The symptoms are minimal, but athletes may feel pain when pressure is put on the MCL.
  • Grade 2: Incomplete tear of the MCL. Athletes may feel that their knee is unstable when they try to change direction or turn quickly. There is pain when pressure is put on the MCL.
  • Grade 3: Complete tear of the MCL. Patients are often unable to fully straighten their knee and there is substantial pain and swelling. The knee feels very unstable and may give out.

Symptoms of Bursitis:

  • Swelling in the front of the kneecap
  • Warmth and tenderness
  • Redness in the overlying area of the knee
  • Pain during activity

Symptoms of Patellar Tendinitis:

  • Pain and swelling around the patellar tendon
  • Pain with certain activities such as kneeling or jumping

Symptoms of Patellofemoral Syndrome:

  • Aching and discomfort in the front of the knee
  • Discomfort is worse going up or down stairs If symptoms are ignored, the quadriceps may lose strength, causing the knee to give out

Symptoms of Osgood-Schlatter disease:

  • Pain and swelling where the tibia attaches to the patellar tendon
  • Bony growth protruding in the front of the knee at the top of the tibia

What are the common recommended treatments for knee injuries?

ACL injury: Frequently, ACL tears require surgery to replace the ligament. Physical therapy is necessary to rehabilitate the knee and it is usually at least six to nine months before athletes can return to their normal activity level.

Learn about our new Functional Sports Assessment (FSA) for treating ACL injuries.

MCL injury: Fortunately, MCL tears do not usually require surgery. Treatment usually includes rest, anti-inflammatory pain medications and sometimes a brace is necessary to keep the knee from moving from side to side.

Patellar Tendinitis and Bursitis: Treatment for patellar tendinitis and bursitis normally includes rest, icing, and anti-inflammatory pain medications. However, physicians at Midwest Orthopaedics at Rush often treat bursitis with cortisone injections to the inflamed bursa, which is not recommended for patellar tendinitis.

Osgood-Schlatter disease: Osgood-Schlatter disease subsides when the patient is done growing and may be treated with ice and anti-inflammatory medications.

What are some strategies/exercises to help prevent knee injuries?

PDF Download the Knee Injury: Prevention Tips and Exercise Guide

Midwest Orthopaedics

Lindsey Vonn’s Return after ACL Repair

U.S. Olympic skier Lindsey Vonn recently won the Super-G in Cortina d’Ampezzo, Italy and broke the record of World Cup victories there with her total of 63 to date. Vonn’s accomplishment is even more remarkable considering her history of multiple knee injuries, including two ACL tears in 2013.

Vonn is just one example of an athlete who has returned from ACL injuries to compete at a high level. Dr. Brian Cole of Midwest Orthopaedics at Rush, a sports medicine surgeon who specializes in ACL reconstruction, points out that it can be done by working with a good surgeon and undergoing post-surgery therapy before jumping back into the game. He also recommends using some form of a functional sports assessment in order to evaluate the athlete’s strength, endurance and neuromuscular control.

The January/February 2015 issue of Sports Medicine Update included Brian J. Cole, M.D., M.B.A. an article by Dr. Cole, Dr. T. Sean Lynch and Dr. Christopher Ahmad called “The Role of Functional Sports Assessment in the Return to Sport after ACL Reconstruction.” The article explains that when athletes who have had ACL reconstruction are returning to their respective sports, the consensus regarding criteria for return to play is lacking.

Dr. Cole and his colleagues at Midwest Orthopaedics at Rush offer a Functional Sports Assessment (FSA) to their athlete-patients after ACL reconstruction. This process helps the physician and therapist determine the readiness of a patient’s safe return to sport.


Learn more about the Midwest Orthopaedics at Rush Functional Sports Assessment

The Role of Functional Sports Assessment in the Return to Sport After ACL Recontruction

PDF Download the January/February 2015 issue of Sports Medicine Update.


Human back muscle anatomyFrom the very beginning of the ancestral health movement, Paleo-inspired exercise plans have focused on strength training over cardio, with the rationale that lifting heavy weights effectively builds and maintains muscle mass, while jogging for hours actually destroys it. But this begs the question: what’s so special about muscle mass? Why would you want to have more of it?

The first obvious answer is “because it looks good:” especially for men, but increasingly also for women, the athletic look is in. Muscles make for a nice beach body, and they’re also attractive as an outer sign of positive personal qualities like self-control, discipline, and drive.

On top of their aesthetic appeal, muscles are useful. Even in a society saturated with every form of mechanical convenience we can dream up, we still occasionally have to move a couch, push a car, or carry a bike up a flight of stairs.

But most importantly, muscles play a vital role in supporting overall health and wellness, especially into old age. They aren’t just about looking good (although that’s a nice bonus), and they aren’t just about the occasional need to help your friends move; they’re a critical factor in metabolic health, body weight control, bone strength, and resilience to stress and disease.

Muscles Promote Insulin Sensitivity

One of the most important functions of muscles in metabolic health is their ability to store glucose (carbohydrates) as glycogen. They then use this stored glycogen as fuel every time you need to move. Muscle mass essentially acts as a glycogen reserve that you top up by eating carbohydrates, and deplete when you exercise.

This makes muscle a critical player in an overall healthy metabolism, because it allows you to use carbohydrate calories for what you want (energy and activity), and not what you want to avoid (storage as fat). In more scientific terms, it increases insulin sensitivity and protects against insulin resistance. In helping your body use carbohydrates this way, muscle mass is ultimately protective against metabolic syndrome and diabetes, which are really just diseases of inadequate carbohydrate metabolism (for more on this, see the full explanation here).

On the flip side of this, sarcopenia (the technical term for inadequate muscle mass or quality) is strongly associated with diabetes. So far studies have only established a correlation, not a causation, but the strength of the relationship is telling. One group of researchers studied 810 subjects in Korea, and divided them into two groups: diabetics and non-diabetics. 15.7% of the diabetics, but only 6.9% of the non-diabetics, were sarcopenic. And in American subjects, another group of researchers found a strong correlation between sarcopenia and impaired glucose metabolism independent of body fat. In other words, the less muscle you have, the more likely you are to develop insulin resistance, metabolic syndrome, and ultimately diabetes.

Muscles Protect Against Obesity

Diabetes, of course, usually comes along with an unwelcome co-morbidity: obesity. Diabetes and obesity are really just two sides of the same coin – diabetes is the inability to use carbohydrates productively, and obesity is the natural result when your body stores them as fat instead. Both are inflammatory; both are mediated by imbalances in the gut flora; both are closely connected to autoimmunity. Unsurprisingly, the muscle wasting of sarcopenia is also strongly associated with obesity, and the two problems react on each other in a vicious cycle.

This diagram (taken from this study) perfectly illustrates the vicious cycle of sarcopenic obesity:

Diagram of sarcopenic obesity

To explain the relationship very simply, obesity is inflammatory, and inflammation causes muscle breakdown throughout the whole body. Muscle loss makes it harder to move around, contributing to a sedentary lifestyle. Sitting all day accelerates weight gain and muscle loss, and the cycle continues.

Sarcopenic Obesity and Aging

The dangerous consequences of muscle loss and fat gain most obvious among the elderly, making muscle health especially important after middle age. Aging presents a perfect storm that greatly accelerates the rate of sarcopenia. As people get older, they generally stop exercising (if they ever did), and spend more time sitting still. But muscle, unfortunately, is a use-it-or-lose-it kind of tissue. For one thing, it takes a lot of energy to maintain, so if you want to keep it around, you have to use it regularly to show your body that it’s still worth the effort. Since an elderly person’s body already has enough to do without maintaining muscles for no reason, it breaks down the muscle proteins to spare energy and keep the heart and other organs functioning.

The elderly also don’t metabolize protein as efficiently as the young, so their protein requirements for maintaining muscle mass are higher at the time in their life when their actual protein intake is most likely to drop.

The result is a steady decrease in muscle size that really takes off around age 50 and accelerates with time. And it’s not only the amount of muscle tissue that’s affected; muscle quality also declines. Scans of elderly people’s muscles reveal much more intramuscular fat, or fat tissue that has penetrated into the muscle. Basically, the elderly are at a much greater risk of being “skinny-fat:” they aren’t noticeably underweight or under-muscled to the naked eye, but look a little closer and that “muscle mass” isn’t all muscle.

This diagram (from this study) summarizes the relationship between aging, weight gain, and muscle loss:

Diagram of sarcopenic obesity in the elderly

As you can see, it’s essentially an even more dangerous version of the sarcopenia/obesity cycle that occurs in non-elderly people.

All of these factors make old age an enormous risk factor for losing fat and gaining muscle, and as you might expect, the vast majority of sarcopenic obese patients are over 60. The consequences are severe. Sarcopenic elderly patients are more vulnerable to falls, and less able to recover from illness or hospitalization. Add obesity, and the story gets even worse; in one study, sarcopenic obese elderly patients fared dramatically worse than sarcopenic non-obese or obese nonsarcopenic patients in a test of their ability to carry out everyday activities (for example, bathing, dressing themselves, and cleaning the house). The extreme consequences of sarcopenic obesity in the elderly really highlight the crucial importance of muscle mass for maintaining a healthy spectrum of human activity.

Muscles, Diabetes, and Sarcopenic Obesity: Summing it Up

To summarize the previous three sections, muscle loss is a key player in the cycle of obesity and diabetes. Gain muscle, and you improve your metabolic function and reduce your risk of fat gain. (Although it’s not a magic bullet, it’s also worth mentioning that muscle in the resting state burns more calories than fat, so it does raise your metabolism slightly).

On the other hand, if you lose muscle, your body has a harder time maintaining a healthy weight and a normal degree of insulin sensitivity. And worse still, the cumulative effect of sarcopenia, diabetes, and obesity is far greater than the sum of their individual problems. All three of these conditions magnify each other and keep you trapped in a vicious cycle of poor health.

This all goes double if you’re over 60. The elderly, as the population most at risk for muscle loss and fat gain, are especially prone to sarcopenic obesity, and have the most to gain from taking care of their muscles. But it doesn’t just affect the retiree crowd: in people who don’t regularly exercise, muscle loss starts around age 20. Preventing insulin resistance and weight gain in middle age, and heading off sarcopenic obesity in old age, start in the gym when you’re young.

Muscles And Bone Density

Moving on from the metabolic advantages of having a healthy amount ofHealthy body composition muscle mass, strong muscles also help preserve and maintain healthy bone density. Especially for women and the elderly, bone density is important for preventing osteoporosis – and it’s not just about eating your calcium chews.

The connection might not seem obvious (how does more muscle mass make your bones stronger?), but the hidden link is in the concept of loading. The best way to build strong bones is to put them under a heavy load: lift, carry, drag, or otherwise move something with a substantial weight. And all the ways of doing this also result in stronger muscles. So it’s not the muscles themselves that make your bones stronger; it’s the exercise you use to build those muscles that also builds your bones.

Specifically, weight training with heavy weights has been proven again and again to increase bone density, even in the elderly. The literature on this subject is enormous; one comprehensive review found that the benefits of walking or light aerobics were debatable, but that strength training was both safe and effective for preventing bone density decay in older adults, especially when continued consistently for at least a year.

Just like building muscle to prevent sarcopenic obesity later in life, improving bone density through strength training is another benefit that it’s best to start working on while you’re young. If nothing else, it’s much easier to maintain a habit you already have than to take up deadlifting at 65. This review even found that exercise increased bone density in preadolescent children: as long as the exercise is done at an age-appropriate intensity, there really is no age limit on the benefits.

Muscles Improve Disease Recovery

Another health benefit of muscles is their ability to create a “safety net” of protein that your body can draw on at times of increased need. Protein is one of the most important structural components in your entire body, and muscles play a key role in regulating protein availability. They absorb protein from the diet, store it, and distribute it to the heart, liver, and other organs as needed. In the absence of dietary protein, your body will break down your muscles to keep feeding your organs.

In healthy people under normal lifestyle conditions, the intake of protein from food balances out the demands from the organs, and muscle mass is preserved. In bodybuilders, the intake of protein from food exceeds the demands from the organs, and muscle mass is increased. Under the stress of any kind of illness or injury, though, your body’s protein needs increase significantly because all your organs need more support to help them fight the stressor. Patients with severe burns, for example, can require up to 3-4 grams of protein per kilogram of bodyweight (compare that to .8-1 grams/kg in healthy people).

Diet can rarely deliver this level of protein, especially diets of the hospital food that you’re likely to be stuck with if you have such a severe injury. From an evolutionary perspective, it’s also unlikely that humans could regularly get that much protein while severely injured and unable to hunt. Fortunately, your muscles can take up the slack – if you have an adequate reserve of muscle to start with. Muscle is your body’s “safety net” against the increased protein demands of illness.

If you don’t have that safety net, you’re in trouble. For example, muscle mass is an independent predictor of survival rates for patients with all kinds of cancers, even after accounting for sex, age, and stage of cancer. Compared to patients with normal muscle mass, patients with sarcopenia find chemotherapy harder to endure. They experience symptoms of overdose at lower levels of drugs, they require more rehabilitative care, they suffer from infections and complications more frequently, and they simply die more often.

From the numerous disadvantages of people who don’t have adequate muscle mass, it’s clear that skeletal muscle is an important stockpile that the body can draw on for extra nutrients when it needs them. So building up a healthy reserve of muscle is an excellent form of health insurance just in case life happens and you find yourself in the hospital with a serious problem.

Building Healthy Muscles

After all that description of the benefits of muscle mass, it’s time to get Healthy exercisedown to the details: how can you increase the size and quality of your own muscle tissue?

First of all, it’s important to note that not everyone has to be a bodybuilder in order to get these benefits. The studies linked above, that resistance training substantially improves bone density in elderly women, weren’t turning little old ladies into she-hulks with a steady diet of whey powder and creatine. To get the benefits of healthy muscle mass, you don’t have to go anywhere above the musculature that most people find attractive (unless, of course, you want to).

That said, the nitty-gritty of building muscles is actually fairly simple. First, eat adequate protein (20-25% of calories is a good ballpark number for putting on muscle) and adequate calories. If you’re losing fat, your body can build muscle mass on a slight calorie deficit because it will just take energy from body fat to make up for what you’re not putting in your mouth. On the other hand, an extreme calorie deficit is completely counterproductive and will actually destroy muscle mass you already have, since starvation produces the same kind of muscle-wasting stress response as injury or illness. 1,200 calories a day is not enough for an adult human of any size, especially if she’s also working out.

If you aren’t losing fat, you’ll need to eat a slight surplus in order to gain muscle: you can’t build any kind of mass without raw materials over and above what your body needs just to function. The bigger your surplus, the faster you’ll put on muscle, but many people prefer the “slow and steady” route since very fast muscle gain is usually accompanied by a significant amount of fat.

On the exercise front, easily the best muscle-builder around is strength training. This can be bodyweight exercises (push-ups, pull-ups, and planks, for example), or free weight training (squats, deadlifts, and presses). This article goes into a little more detail on your strength-building options, but for beginners almost any kind of exercise program will get results so don’t spend too long agonizing over which to choose.

Of course, if it were all that simple, there wouldn’t be entire forums full of amateur bodybuilders and powerlifters eagerly debating the best timing of their post-workout meals and the most effective protein powder. There’s an infinite amount of complexity out there if you’re willing to take the time to get into it. But starting off with a solid diet and a basic strength training routine will already get you a lot further than almost everyone around you. And by the time a beginner program stops giving you results, you’ll have the background knowledge to make a more informed decision about plunging into the details.

Women and Muscles

Strength training and building strong muscles are especially important for women, who tend to have less muscle to start with, and who are also more prone to osteoporosis and bone density problems. But when it comes to building muscles, women are often skeptical. Even though the benefits are significant, they’re afraid of getting “bulky,” and shy away from heavy weights in favor of extremely light dumbbells.

CrossFit has started to make a dent in this attitude, but it’s still very prevalent, and it’s time to put it to rest: lifting weights will not make you look like a bodybuilder unless you also take massive amounts of steroids, eat thousands of calories at every meal, and devote endless hours to your biceps. Figure competitors and female bodybuilders dedicate an unbelievable amount of time and effort to looking that way; unless you’re willing to imitate their regimen, it’s not going to happen to you.

That isn’t to say that weightlifting won’t change your body. But for the vast majority of women, those changes are positive: a leaner physique, arms they love showing off in T-shirts, and toned, shapely legs. So there’s absolutely no need to fear the free weights, and plenty of reasons to embrace them.

Muscles and Human Health: Conclusion

Muscles aren’t just for bodybuilders. They’re for everyone. Human beings are physiologically designed to have a fair amount of muscle mass built through regular exercise, muscle mass that allows us to metabolize carbohydrates efficiently, recover from injury or illness, and maintain our resilience and health into old age.

As a consequence of the sedentary modern lifestyle, we’re seeing all the dangers of muscle atrophy: osteoporosis, diabetes, obesity, fragile bones, and difficulty recovering from stress. These problems are not normal, and they don’t have to be inevitable parts of life. While muscle alone isn’t a miracle cure, building healthy muscle mass and maintaining it past middle age is one way to preserve good health and prevent the diseases of the modern environment.

Contributed by: Paleo Leap | Paleo diet Recipes & Tips


Girl’s 10 Years of Knee Pain Ended after Surgery at Midwest Orthopaedics at Rush

By age 18, Annie Hendricks’ knee was operated on eight different times, and it still wasn’t getting any better.  Hendricks first injured cartilage in her knee at age 8. She then developed a staph infection, leading to seven more operations over the next 10 years to repair the damage.

“Eventually all my cartilage in a couple of spots was gone because of the other surgeries,” Hendricks said. “It was bone-on-bone.” 

Hendricks wasn’t able to walk up stairs or ride a bike without pain by the time she came to see Dr. Brian Cole at Midwest Orthopaedics at Rush. Cole, who was recommended to Hendricks by former Denver Broncos team physician Ted Schlagel, is well-known for his research with Rush University Medical Center on cartilage transplantation. After examining Hendricks, he thought she was an excellent candidate for a donor allograft (using tissue from a cadaver) procedure on her knee.

“He really changed my life and made everything better,” Hendricks said. 

About a year after the surgery, Hendricks, now 19, is able to take stairs and ride a bike without pain. She is now working toward a goal she would not have been able to achieve before coming to Midwest Orthopaedics at Rush. “I am becoming a volunteer firefighter and can do every physical task I need to do for it,” she said. “There are so many things I’m doing now that I never even thought about doing before.”

– Annie Hendricks

877 MD BONES (877.632.6637)


The Advanced 7-Minute Workout

Ever since the magazine published the Scientific 7-Minute Workout in May last year, readers have been writing and tweeting their requests for an updated, more advanced version. For them, the workout became too easy or humdrum, as tends to happen when exercises are repeated without variation. So here it is: a new, more technically demanding regimen, one that requires a couple of dumbbells but still takes only seven minutes.

To come up with the workout, I turned to Mark Verstegen, the founder and president of the Phoenix-based EXOS, a company that focuses on health and athletic performance. He and his colleagues train, among others, N.F.L. players and the German national soccer team, which won the World Cup this year. EXOS also develops in-house fitness and nutritional programs for corporations, so Mr. Verstegen has experience working with those of us who don’t already have bowling-ball biceps and vast reservoirs of endurance and gritty resolve. He and his colleagues, Mr. Verstegen says, know how difficult it can be to find the time and motivation to work out as often as we know we should. Hence a routine that can be completed in just minutes and without much space — no more than a hotel room or an office, for example.

<strong>Go to <a href=""></a> on your phone to try our new Web application. </strong>Taken together, the exercises stress and strengthen muscle groups throughout the upper body, lower body and torso. The full workout (see step-by-step instructions) also provides a compressed but intense interval-style endurance workout. Anyone who completes multiple push-up-to-row-to-burpee movements in 60 seconds (Exercise 3) will raise his or her heart rate substantially. The subsequent 30 seconds of side bridges (Exercise 4) provide a brief aerobic respite before the aerobically demanding Exercise 5 (single-leg Romanian dead lift to curl to press). Go to on your phone to try our new Web application.

There’s a lot of scientific support for the benefits of this sort of high-intensity interval training. In recent months, articles have reported that even a few minutes of interval-style exercise increase endurance, squelch appetite and improve metabolic and cardiovascular health in sedentary adults more effectively than traditional prolonged-endurance exercise. In other words, seven minutes or so of relatively punishing training may produce greater gains than an hour or more of gentler exercise. What’s more, study subjects who did a combination of prolonged exercises (like running or cycling) and high-intensity interval workouts typically reported preferring the intervals.

Interval programs based on cycling, walking and running come with a downside, however: They improve overall fitness and health but do little to improve muscular strength other than in the legs. By contrast, the New Scientific 7-Minute Workout does more than build the large, obvious muscles that most of us can name-check, as Mr. Verstegen puts it — the quads and glutes, for example; its exercises also engage smaller, often overlooked muscles in the back, abdomen, shoulders and hips that, when neglected and weak, contribute to back, neck and knee pain.

The workout should combat a desk job’s “aches, pain and fatigue,” Mr. Verstegen says, as well as teach “clean and efficient movement patterns,” even to those of us who tend to be clumsy. The exercises demand precision and, over time, should instill graceful, athletic coordination. Done correctly, they should make you healthier, stronger, less prone to injury and athletically more capable.

As a whole, the routine is also “extremely scalable,” Mr. Verstegen says. People who are out of shape today may be able to complete only one or two reverse lunges with rotation during the 30 seconds of Exercise 1. But after several weeks of practice, they may be able to perform five or more repetitions, he says, and can continue to intensify the routine’s physical demands by adding as many repetitions as possible in the time allotted.

It should be noted that the 7-Minute Workouts, the original and the advanced versions, are not meant to be your sole exercise. “Any routine, if that’s all you do, will become monotonous and demotivating,” Mr. Verstegen says. So mix up your workouts. Perhaps alternate the old and the new seven-minute regimens over days or weeks. Go for a run at lunch. Join an over-40 rugby league. Buy a bike or a Speedo — use them together in a triathlon.

“The idea is to develop a relationship and routine with your body,” Mr. Verstegen says, “so that it feels strong and healthy and you feel energized and excited to be up and moving.”

The New York Times is now offering a free mobile app for the popular Scientific 7-Minute Workout and the new Advanced 7-Minute Workout. The app offers a step-by-step guide to both 7-minute workouts, offering animated illustrations of the exercises, as well as a timer and audio cues to help you get the most out of your seven minutes. Go to on your phone, tablet or other device to try our new Web app. For more information on installing the app, which can be used on an iOS, Android or other device, visit “For a 7-minute Workout, Download Our New App.”

CTi Wakeskate Team Rider George Daniels shows his skills!

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By Marc Safran, M.D., Professor of Orthopedic Surgery, Stanford University and Dev Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • FAI surgery is sometimes necessary to return the athlete to sports participation
  • Results from FAI surgery are generally excellent, with 95% of athletes returning to sport at about 4-6 months after surgery

Last week we wrote about a condition called “femoroacetabular impingement”, commonly referred to as “FAI”. The hip is a ball-and-socket type of joint. FAI is a condition where the femoral head (the ball), acetabulum (the socket), or both do not fit normally in place due to an alteration in the shape of the femoral head or rim of the acetabulum. The result is increased contact (impingement) as the hip is placed through a range of motion. ch1_image_020

Patients with FAI often complain of pain in the groin with sports activity, after prolonged sitting or even with walking. Many athletes often describe pain in the groin with deep flexion or rotation of the hip during activity. Occasionally, a popping or clicking in the front of the hip is described.

We diagnose FAI through a careful evaluation of your description of the pain, an examination of the hip and pelvis, along with an assessment of your sports participation. Imaging studies typically begin with x-rays, which are very useful to look at the shape of the bone and any bone spurs. We will usually also do a special type of MRI scan called an “arthrogram MRI” in which some dye is injected into the hip joint to highlight the soft tissue structures.

The first step in treating the problem is usually done without surgery. Rest from the sport or activity causing the pain combined with anti-inflammatory treatment can get the pain under better control. Physical therapy to correct weakness or imbalance in the hip and core musculature is done. The nonsurgical approach can be successful in some cases.

But in many cases where the bone overgrowth is simply too much, the impingement will continue to cause pain when the young athlete attempts to return to sports. In those cases, arthroscopic surgery can be done.

The emphasis with arthroscopic surgery is to tailor the procedure to the exact type of problem in each hip. For young athletes we have a strong preference for performing the most conservative procedure that results in restoration of as close to normal anatomy as possible. This typically includes removal of the impinging bone spurs to restore the natural shape of the ball and socket, repairing the ring of tissue around the socket (called the labrum), and tightening loose ligaments.

The surgery is done as a come-and-go procedure, meaning that there is no overnight stay in the hospital. The specific recovery will be different for each person depending on the type of repair, but for the typical FAI surgery you can expect to be on crutches and in a hip brace for two weeks after surgery. We recommend that physical therapy start early (as early as week 1) and generally continue through week 12 – 24.

A review of our results from FAI surgery across all age groups showed that 95% of athletes (all levels – including recreational, high school, college, and professional / Olympic) successfully returned to sports with excellent pain relief, function, and performance. The physical therapist or performance specialist will have the athlete go through a series of tests to determine readiness for return to sport, and return can be expected at 4 to 6 months after surgery, depending on the type of sport.



By Dev Mishra, M.D., President, Sideline Sports Doc, Clinical Assistant Professor of Orthopedic Surgery, Stanford University And Marc Safran, M.D., Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Muscle strains are the most common hip and groin injuries in young athletes and will typically improve with simple measures
  • An “avulsion fracture” can occur in the growing athlete, and can also result in excellent healing without surgery
  • Femoroacetabular impingement (FAI) can be a source of hip pain in older adolescents and teenagers. This condition often requires surgery, with typically excellent outcomes.

Hip and groin injuries are fairly common in young athletes, and the type of injury is often influenced by the age of the young athlete. In the very young player, hip and groin injuries tend to be mild tendon or muscle strains. In the 11-17 year old age group a large percentage will also be tendon or muscle strains but a type of fracture through one of the growth plates around the hip and pelvis can also occur. In older players, stress fractures, athletic pubalgia (also known as sports hernia or core muscle injury), FAI, and hamstring tears can happen. 7050567_orig

Muscle strains can happen in any of the muscles crossing the hip joint but we tend to see the highest number of muscle strains in the group of muscles in front of the hip called the “hip flexors”. A hip flexor can be strained when it contracts forcefully, especially when the leg is fully extended or prevented from moving. Kicking and sprinting are the most common movements that cause strained hip flexors.

The athlete will typically feel soreness or pain in the front of the hip along with a sense of weakness. If pain is significant or you are having difficulty putting weight on the leg see a sports medicine physician soon. For most mild strains, there will generally be a good recovery with initial rest and ice, followed by stretching and strengthening, and eventually gradual return to sports. Some athletes find that a compression wrap is helpful in recovery.

A more serious injury sometimes confused with a hip flexor strain is called an “avulsion fracture”. In the young athlete the bones are growing through areas called growth plates. The growth plates are a site of weakness and occasionally a tendon attaching to the growth plate can pull off a piece of bone attached to the tendon. This injury is typically accompanied by a “pop” at the time of injury, can be quite painful, and can be very difficult to put weight on the leg. If you experienced a “pop” and are having a lot of pain and difficulty walking on that leg, then we recommend you see your pediatrician or a sports medicine physician quickly for proper evaluation. These injuries will usually have a full recovery without surgery if they are treated correctly from the start.

We are becoming more aware of a condition called “femoroacetabular impingement”, sometimes simply referred to as “FAI”. FAI typically affects the older adolescent or teenage athlete. FAI is a condition in which abnormal bone growth on the femur (the large bone in the upper leg) and / or the acetabulum (the socket part of the pelvis) repetitively contacts each other.

Sports involving forceful rotation place the athlete at risk of developing pain from FAI. Golf, football, baseball, volleyball, soccer, hockey, lacrosse, field hockey, martial arts, and tennis are the sports most likely to aggravate the FAI.

For reasons not completely understood, some people develop excessive bone growth at the top of the femur and/or around the edge of the hip socket. These people are not born with FAI but it appears to develop early in life with growth. The movement that aggravates FAI is deep bending, or a forceful rotation of the core, including the hips. The longer that repetitive rotational movement occurs over a period of years, the more irritated the area becomes, the more pain can be felt because of bone bumping into bone, leading to damage of other, non-bony, tissues.

FAI requires careful evaluation by a sports medicine specialist with expertise in hip injuries. The pain may decrease with a period of rest and rehabilitation but unfortunately surgery is often needed for return to sports. The good news is that arthroscopic surgery for FAI is becoming much more common, and with very high success rates. In next week’s post we will outline the basics of FAI surgery.



By Dev K. Mishra, M.D., President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Lack of binding release is correlated with knee injury in most age groups
  • Bindings must be professionally adjusted at the minimum at the start of the ski season, and more often if you are a high-frequency skier
  • Get yourself in good skiing condition prior to the start of your ski season

In Northern California mountains it is snowing, ski resorts are open for business, and this week we started seeing the first real flow of patients with skiing related injuries in the office. We revisit an important topic today: skiers, check your bindings for proper release to reduce your knee injury risk. warren-miller-fall-2007-film-tour-schedule

Skis, boots, and bindings have changed dramatically over the last 40 years. It was believed that the main injury risk for skiers were fractures of the leg or ankle, and over time the design of skis, boots, and bindings has evolved to significantly reduce the risk of equipment related fractures. But an interesting thing then happened: as the risk of fractures went down the risk of knee ligament injuries went up. ACL tears in particular are estimated to occur in 70,000 skiers per year. There are several factors that lead up to the “why” but I would anecdotally say that in the clinic I do hear some common themes in the injured patient. It was an end of day run with less than ideal conditions, and the patient’s legs were fatigued. And from the equipment standpoint we often hear that the bindings didn’t release.

Like most medical issues, the exact causes for knee injury in skiers is not black and white. For the scientifically inclined amongst you I would recommend you have a look at this excellent review study in the open source Orthopedic Journal of Sports Medicine. You can view the full text here. There are a few nice take-aways from the article. Younger skiers (less than 20 years old) reported that their binding did release at time of injury in 53.7% of the injuries but across all age groups the bindings released in only about 24.6% of all injuries. This study along with several others does not prove that the lack of binding release caused the knee injury but certainly it suggests a correlation. Furthermore, the lack of binding release seems to be more dangerous in some injury mechanisms like the “phantom foot” (happens when the skier falls backwards).

The experience from our orthopedic sports medicine clinic might be a bit different in other parts of the country but at least from what we are seeing I can suggest some simple tactics to reduce your chance of injuries this ski season.

  • Get yourself into good skiing shape! My bias especially for young athletes is to avoid heavy weights and focus on power, core strength, and coordination. Click here for a simple set of exercises that utilizes body weight activities and can be done indoors or out. These are good for all age groups up to adults.
  • Absolutely make sure your bindings are professionally adjusted, for novice skiers at the start of the ski season and for high-frequency skiers at a minimum a monthly check. You might also consider the Knee Binding, a new type of binding that allows for a binding release prior to the theoretic strain point leading to ACL tears.
  • Finally, know your conditions! Resist the temptation to ski in bad snow, especially slush. You’re just asking for trouble.


Why to Eat More (Healthy) Fat in 2015

As we enter the New Near, resolutions are on many people’s mind, with losing weight and adopting a healthier lifestyle topping the list. In 2015, my resolution revolves around eating more healthy fat. Let me explain….

Fat is a macronutrient, and one that was vilified by many for years, sustaine in part by studies that showed a correlation between heart disease and high-fat diets. This fueled the low-fat craze of the 80s, which had us eating a lot of processed foods that were loaded with sugar (to make them taste batter due to the lack of fat)! Fast-forward 20 years, and we are rediscovering the benefits of certain kinds of fat; namely omega-3 and omega-6 fatty acids, which are polyunsaturated fatty acids that also happen to be essential nutrients for health, and MCTs, which are medium-chain fatty acids that boost metabolism. Here are 3 ways unsaturated fats can improve your health:

Feeling Full & Satisfied

It’s actually a myth that fat in our diet automatically equates to fat on our bodies. Just as fat can cause weight gain, especially when you combine high intakes of fried food and a sedentary lifestyle – consuming fat can also be beneficial for weight loss or maintenance. When you eat fat in the form of healthy omega-3’s, you experience a lasting full feeling, which will make you less apt to overeat. (Notice how that doesn’t happen when your diet is filled with processed carbohydrates!) To achieve satiety, you’ll need to focus on eating healthy high-fat foods such as flaxseeds, nuts, and nut butters. And you don’t need much of it to experience the benefits. A single ounce of almonds, for example, has about 14 grams of fat and 163 calories. That serving size is enough to keep your stomach from growling for several hours.

Energy Reserve & Metabolism Boost

The typical Western diet is largely composed of long chain triglycerides (LCTs), typically consumed in processed vegetable oils such as canola, soy, and safflower. In excess, LCTs act as the building blocks of stubborn body fat.

But there is a specific kind of plant-based fat called medium-chain triglycerides – commonly referred to as MCTs – that is shown in multiple studies1 published in the American Journal of Clinical Nutrition to not only increase metabolism, but literally keep fat off your body. Unlike LCTs, shorter length MCTs are primarily used for energy production and rarely ever stored as fat.

Derived from palm kernel oil and coconut oil, MCTs provide you with cleaner and more rapidly utilized energy. This is because MCTs are not stored in the body in the same way traditional fats are stored. Instead of landing in problem areas of your belly, hips, and thighs, MCT oil does the opposite. MCTs promote ketone bodies-compounds created by the body when it burns fat stores for energy. When you eat a diet low in carbs and high in healthful fat like MCTs, your body responds to the reduced levels of blood sugar by switching to an alternative power source and converts fatty acids in the liver to ketones. Ketones then become the main energy source. Instead of your body burning carbs, it burns fat! This usually starts to occur 20 minutes into an exercise session.

Vitamin Transport & Whole-Body Benefits

Vitamins A, D, E and K are fat-soluble vitamins, which rely on fat for storage and transportation throughout the body. Vitamin A helps with vision, vitamin D helps with bone strength, vitamin E boosts the immune system and vitamin K promotes blood clotting. Fatty acids synthesize hormones and molecules involved with immune function and cell signaling.

Because your brain is actually comprised of 2/3 fat, eating unsaturated fat helps promote cognitive health. The same goes for your nervous system, as the protective covering surrounding nerves is comprised of 70% fat. Fat provides the structural components not only of cell membranes in the brain, but also of myelin, the fatty insulating sheath that surrounds each nerve fiber, enabling it to carry messages faster. Finally, fatty acids are important for hair and skin health.

Here are my favorite healthy fats:

  • Avocado
  • Olive oil
  • Coconut oil
  • MCT oil
  • Flaxseed
  • Nuts and seeds (almonds, walnuts, pine nuts, pumpkin seeds, sunflower seeds)
  • Tahini
  • Salmon
  • Sardines
  • Tuna

Try adding a tablespoon of coconut oil or MCT oil to your morning smoothie, or a tablespoon of ground flaxseed along with fresh berries to your Greek yogurt in the morning. Or, try of mixing your tuna with avocado instead of mayo as the creamy binder. Make a salad dressing mixed with tahini and olive oil. Bring a bag of fresh almonds or toasted pumpkin seeds into the office for a snack instead of hitting the vending machine. There are so many easy ways to incorporate healthy fats into your diet!

You will see a lot of these foods in my upcoming 14-day Transformational Whole Foods Winter Cleanse, as winter is a time that favors having more fat in your diet. So if you’re looking for guidance to help your body get in tune with what it needs right now as you head into 2015 with aspirations of becoming your best self, don’t delay. Click here to sign up today. This 14 Day Transformation kicks off next Monday and I’d love to have you along for the ride!

Click here to buy pharmaceutical grade MCT oil from MCT Lean

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