What To Know About Victor Oladipo’s Quad Injury

Indiana Pacers guard Victor Oladipo suffered a torn quadriceps tendon in his right knee and will miss the remainder of the NBA season, the team announced Thursday. Surgery will be required to repair the tendon.

Dr. Adam Yanke, a sports medicine orthopedic surgeon from Midwest Orthopaedics at Rush, and head team physician for the Windy City Bulls answers three questions about the injury and expected recovery.


Q: What exactly is a ruptured quadriceps tendon?

A: The quadriceps tendon attaches the entire quad muscle to the kneecap or the patella and allows you to straighten your leg. This tendon can commonly have inflammation in it that causes pain but it can occasionally also rupture. This injury is more common in individuals over 50 years of age but can happen in younger, athletic patients as well. Typically this happens from the tendon being overloaded but can also be due to some underlying tendon disease that weakens the tissue before injury.

Q: How do you repair a torn quadriceps tendon?

A: There are multiple ways to fix a quadriceps tendon tear with regards to specific surgical technique. Regardless of the specifics, they all involve an open approach to directly visualize the tendon. Once you can see the tear directly sutures are placed through the tendon and they are either brought through drill tunnels or anchors in the patella to perform the repair. Typically the soft tissue adjacent to the tendon called the retinaculum is also torn and this requires repair as well.

Q: What is the rehab and recovery process?

A: The recovery after quadriceps tendon repair typically involves a period of immobilization in a brace for 4-6 weeks. After this time, we work aggressively on range of motion try to eliminate any stiffness. There is always a balance between healing and motion and it is important to have both be successful for return to play. Some patients do get back to full activity without pain or restrictions, however there is a subset that still have discomfort in that area or have issues with building up muscle strength. In general its a successful procedure with good outcomes but can take up to 6 months for complete recovery.


Dr. Adam Yanke’s clinical interests include advanced arthroscopy, shoulderImage replacement, and a special focus on patellofemoral dysfunction and cartilage restoration. Dr. Yanke is a team physician for the Chicago Bulls, Windy City Bulls, Chicago White Sox and DePaul Blue Demons.

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Concussions in Cheerleaders: Symptoms and Treatment

By Tara Hackney, PT, DPT, OCS, KTTP for Athletico Physical Therapy

Cheerleaders are commonly seen on the sidelines of school and professional sporting events, but the sport is no longer reserved for the sidelines. Cheerleaders have their own competitions where they are in the spotlight. Competitive cheerleading participation is on the rise with teams ranging in age from 5 years old through college.

All-Star cheerleading is the name used to refer to cheer groups created for competition and not associated with any school or team. Competitive cheerleading is divided into groups according to age and each group has different levels according to experience. Cheerleaders perform tumbling, stunting and pyramids as part of their routines. As with any sport, injuries can occur.

Did you know that the most common injury in competitive cheerleading is concussions? The overall injury rate in cheerleading is low; however of those injuries, concussions account for 31.1 percent.1 You may be thinking this high rate of concussions would be from cheerleaders falling and landing on their heads. However, the cheerleading position that suffers the most concussions are the bases, the athletes who support the flyers in the air by holding them up and catching them. This position is at risk for concussions as a flyer may fall on top of them, or from a foot or elbow hitting them in the head as the flyer comes down from a stunt. In fact, it is more likely in cheerleading for a concussion to occur after contact with another athlete than with contact with the floor.

Concussion Symptoms

Any one or more of the following signs and symptoms may indicate a head injury:

  • Headache
  • Nausea or vomiting
  • Dizziness
  • Coordination or balance issues
  • Blurred or double vision
  • Light and noise sensitivity
  • Feelings of sluggishness
  • Memory or concentration problems
  • Altered sleep patterns

Signs observed by coaches or other team members that may indicate a concussion has occurred:

  • Stunned or confused appearance
  • Forgets arm motions or cheers
  • Confused about formations in routines
  • Unsure of surroundings
  • Moves clumsily
  • Loss of consciousness (long or short)
  • Personality or behavior changes
  • Forgets events right before or after a blow to the head

If a head injury or concussion is suspected, the athlete should not return to play prior to 24 hours after the initial incident and should be cleared by a physician prior to returning to sport.

Concussion Management

Concussion management is evolving through research. There is strong evidence to support an active approach to rehabilitation of concussions. Physical therapy is one way to help manage the symptoms following a concussion. Physical therapy can include management of neck pain and headaches, balance exercises, progression of exercise tolerance and cardiovascular activities, and vision training. Ideally, an athlete will complete a graded exposure program that starts with symptom limited activity, progress through light aerobic activity, and transition to sport-specific incremental intensity training. Finally, the athlete will be cleared to practice prior to being cleared to compete.

Speed of recovery after concussion is individualistic for each athlete and may be affected by severity of trauma, area of the brain injured, age, gender, past medical history, and previous history of concussions.

Please visit our Concussion Page to learn more about our services.

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Exercise for the Prevention and Treatment of Hypertension – Implications and Application

3 Key Points:

  • Regular aerobic exercise results in reductions in blood pressure of 5-7 mmHg among individuals with hypertension and these reductions translate to a reduced risk of CVD of 20-30%.
  • Emerging research suggests that dynamic resistance exercise may also serve as an efficacious strategy to lower blood pressure to levels similar to aerobic exercise.
  • Special consideration should be given to signs/symptoms or presence of disease, concomitant drug therapy, and other comorbidities in order to optimize CVD risk reduction and improve overall health. The goal of preparticipation screening should be to risk classify individuals at risk for an adverse or life threatening response to exercise while decreasing barriers to physical activity participation.

Cardiovascular disease (CVD) is the leading cause of death in the United States (U.S.) and accounts for 1 out of every 3 deaths in U.S. adults. High blood pressure (BP) or hypertension is the most common, costly, but modifiable major risk factor for the development of CVD and premature mortality, affecting nearly half (46%) of U.S. adult population (PMID: 30700139).

Hypertension is the most common, costly, and modifiable CVD risk factor.

In 2017, The American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines released new guidelines, which now define ‘hypertension’ as:

  • having a resting systolic BP (top number) of 130 mmHg or greater
  • having a resting diastolic BP (bottom number) of 80 mmHg or greater
  • taking antihypertensive medication
  • being told by a physician or health professional on at least two occasions that one has high BP
  • or any combination of these criteria

Blood Pressure Guidelines Zaleski

The ACSM recommends that individuals with hypertension engage in moderate intensity, aerobic exercise 5-7 d/wk, supplemented by resistance exercise 2-3 d/wk and flexibility exercise ≥2-3 d/wk.

Participation in regular exercise is a key modifiable determinant of hypertension and is recognized as a cornerstone therapy for the primary prevention, treatment, and control of high BP. On average, regular aerobic exercise lowers resting systolic BP 5-7 mmHg, while resistance exercise lowers resting systolic BP 2-3 mmHg among individuals with hypertension. These BP reductions follow the “law of initial values” such that individuals with higher baseline BP values experience even greater reductions in BP from exercise training. In other words, exercise works best in those who can stand to benefit the most.

BP reductions of this magnitude lower overall CVD risk by 20-30%. For these reasons all major public health organizations universally recommend aerobic exercise for the primary prevention and treatment of hypertension. Similar to a drug prescription, individuals can be “prescribed” an exercise prescription for the prevention, treatment, and control of high BP following the FITT principle:

Frequency: How often?

Intensity: How hard?

Time: How long?

Type: What kind?

Specifically, the ACSM recommends the following exercise prescription for individuals with hypertension:

Frequency:

For aerobic exercise, 5-7 d/wk, supplemented by resistance exercise 2-3 d/wk and flexibility exercise ≥2-3 d/wk.

The frequency of aerobic exercise is slightly greater than those with normal BP (i.e., 3-5 d/wk). In fact, individuals with hypertension are encouraged to engage in greater frequencies of aerobic exercise than those with normal BP because we know that a single bout of aerobic exercise results in immediate reductions in BP of 5-7 mmHg, that persist for up to 24 hr (i.e., postexercise hypotension). For this reason, individuals with hypertension are encouraged to exercise on most days of the week in order to benefit from the acute effects of aerobic exercise on BP.

Intensity:

Moderate [i.e., 40-<60% VO2R or 11-14 on a scale of 6 (no exertion) to 20 (maximal exertion) level of physical exertion or an intensity that causes noticeable increases in heart rate and breathing] for aerobic exercise; moderate to vigorous (60-80% 1RM) for resistance; and stretch to the point of feeling tightness or slight discomfort for flexibility.

New and emerging evidence suggest that the magnitude of the BP reductions that result from aerobic exercise occur as a direct function of intensity, such that the more vigorous the intensity, the greater the resultant BP reductions (PMID: 26423529). Individuals who are willing and able may consider progressing to more vigorous intensities, however, the risk-to-benefit ratio has not yet been established.

Time:

For aerobic exercise, a minimum of 30 min or up to 60 min/d for continuous or accumulated aerobic exercise. If intermittent, begin with a minimum of 10 min bouts.

New and emerging research has shown that short bouts of exercise (3-10 min) interspersed throughout the day may elicit BP reductions similar in magnitude to one continuous bout of exercise and may be a viable antihypertensive lifestyle strategy for individuals with limited time.

Type:

For aerobic exercise, emphasis should be placed on prolonged, rhythmic activities using large muscle groups such as walking, cycling, or swimming. Resistance training may supplement aerobic training and should consist of 2-4 sets of 8-12 repetitions for each of the major muscle groups. For flexibility, hold each muscle 10-30 s for 2-4 repetitions per muscle group. Balance training (neuromotor) exercise training is also recommended in individuals at high risk for fall (i.e., older adults) and is likely to benefit younger adults as well.

Blood pressure reductions appear to occur in a dose-response manner such that greater volumes of exercise elicit greater reductions in blood pressure. Progression to the Ex Rx should be gradual, avoiding large increases in any of the FITT components of the Ex Rx, especially intensity for most individuals with hypertension.

A recent meta-analysis demonstrated dynamic resistance exercise training to result in BP reductions similar in magnitude to aerobic exercise training (PMID: 27680663). These results suggest that the antihypertensive benefits of resistance exercise training may have been largely underestimated and warrant reappraisal in the near future. Note that, inhaling and breath-holding while engaging in the actual lifting of a weight (i.e., Valsalva maneuver) can result in extremely high BP responses, dizziness, and even fainting and should be avoided during resistance training.

Practical Applications

Accurate BP assessment is critical for a) the initial diagnosis of hypertension and b) to establish a baseline BP to properly evaluate the influence of lifestyle intervention strategies across time. Proper patient positioning and preparation are critical for ensuring accuracy of BP values. Caffeine, exercise, and smoking should be avoided at least 24 hr before BP assessment. Prior to the first reading, the patient should be:

  • seated quietly and not talking for at least 5 min prior to or during the measurements
  • legs uncrossed and flat on the floor
  • bladder empty
  • back supported upright
  • arm supported at heart level
  • with an appropriate sized cuff

American Heart Association standards state that BP should be measured three times in each arm, separated by at least 1 min, and averaged. This is particularly important given that the first reading is often the highest reading. Preferably, the same exercise professional should measure BP on the same patient and using the same BP monitoring device. Approximately ~25% of patients experience “white-coat hypertension” such that BP readings obtained in the presence of a healthcare provider appear elevated, however, home or ambulatory BP values are within normal ranges. Patients with suspected white-coat hypertension may be referred to their healthcare provider for proper evaluation.

Appropriate preparticipation health screening should be implemented to identify at-risk individuals who may require medical clearance before they begin an exercise program (PMID: 2647375). Although exercise is safe for most individuals, there is a small risk of cardiovascular complications in certain susceptible individuals, particularly among sedentary adults with known or underlying CVD who perform vigorous-intensity exercise they do not usually engage in. The ACSM preparticipation guidelines emphasize the public health message that exercise is important for all individuals and largely triages individuals on the basis of current physical activity levels, desired exercise intensity, and the presence of known or underlying CVD, metabolic, and/or renal disease.

As such, individuals with hypertension cleared to exercise (by the preparticipation algorithm or healthcare provider) should be encouraged to progress gradually, avoiding large increases in any of the components of the FITT. Progression should begin by increasing exercise duration over the first 4-6 wk, followed by an increase in frequency and intensity to achieve the recommended volume of 150 min/wk or 700-2000 kcal/wk over the next 4-8 mo. Progression may be individualized based on tolerance and preference in a conservative manner.

Lifestyle modifications, such as regular aerobic exercise, are fundamental for the prevention, treatment, and control of hypertension. When lifestyle interventions are not effective in achieving treatment BP goals, antihypertensive therapy may be required to optimize CVD risk reduction. Whenever possible, an interdisciplinary, collaborative approach involving the patient, healthcare provider(s), and exercise professional will largely improve lifestyle and pharmaceutical adherence, translating to greater BP control and overall health, which is the ultimate goal in the treatment of hypertension.


Author: Amanda Zaleski, PhD is an American Heart Association Postdoctoral Fellow in Amanda Zaleski PhDthe Department of Kinesiology at the University of Connecticut. She is also a Project Manager and Evidence-Based Credentialed Analyst for the forthcoming ACSM Hypertension Position Stand Update and Co-Chair of the Communications Committee for New England ACSM.


Recommended Reading: New Blood Pressure Guidelines, Preparticipation Screening

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Shoulder Instability Surgery- Reliable Results For Most Athletes

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

Key Points:

  • Many young athletes with a shoulder dislocation from sports activity will choose to have shoulder stabilization surgery
  • Modern arthroscopic surgery techniques generally result in extremely stable shoulders for 90% of athletes and high satisfaction

I wrote last week about improvements in ACL surgery over the last 25 years and this week I’d like to explore improved results from another commonly performed sports medicine surgery- stabilization surgery for the dislocating shoulder. The results here mirror those of ACL surgery in many ways.

Many young athletes dislocate a shoulder from trauma, typically a dive with the arm outstretched overhead. This can happen in any sport involving that kind of motion, and any contact sport.

Most surgeries were performed through a large “open” incision 25 years ago, but nowadays can be performed arthroscopically in most cases. For uncomplicated stabilization of shoulders that have had a small number of dislocations from trauma, we should expect 90% of shoulders to remain stable and satisfaction rates upwards of 80% out to about 5 years with current methods, for recreational athletes.

Early Open Surgery Methods- Very Good At Stabilizing, Not So Good At Retaining Motion

Historically, the open surgery was for an unstable shoulder was reported in the early 1900s. A surgeon named “Bankart” first described the essential anatomy of the torn ligament and labrum stabilizing the shoulder in 1923, and for the most part we still generically refer to a shoulder stabilization as a “Bankart repair”.

Over the decades as additional knowledge was gained, modifications to the original procedures were developed. A key component surrounded understanding why surgeries on shoulders with many dislocations tended to do poorly compared to ones with only a few dislocations. While there are many factors, restoring bone loss that resulted from the dislocations was a major advancement.

As it turned out, open stabilization was extremely effective at providing excellent stabilization, with low re-dislocation rates.  But it came at a price. The rehabilitation was difficult and often resulted in permanent motion loss. Some techniques had unacceptably high rates of early arthrits. The end result was that many folks ended up with a stable shoulder but were unhappy about the result.

Arthroscopic Stabilization- Much Better At Retaining Motion With Excellent Stability

 “Arthroscopy” involves small incisions, with the surgeon visualizing and performing repairs through the small incisions. There are numerous advantages over open surgery.  Arthroscopy avoids some complications of open incisions, is generally faster, has minimal blood loss, is more comfortable after surgery, and generally leads to a faster return to sports with excllent joint motion.

And yet, in its earliest years, arthroscopic stabilization had a higher dislocation rate than open surgery. As it has been with ACL reconstruction surgery, arthroscopic shoulder stabilization has improved substantially over the years. Better surgical technique, improved surgical implants, and cutting-edge rehabilitation all play a role.

Measuring the ultimate outcome from arthroscopic shoulder stabilization surgery can involve many factors. Is there another dislocation after surgery? How is the range of motion? What’s the patient’s level of sport activity? How does the patient feel about their result?

If you’re a young athlete with an unstable shoulder, and you have a strong desire to resume a contact or collision sport you’ll likely want to consider shoulder stabilization surgery. Find an experienced shoulder surgeon and have a thorough discussion. You’ll have to work hard on your rehab and be patient but you should generally end up with an excellent result.

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