JOI Rehabilitation Centers BEACHES Point Meadows Baptist Pharmacy Pavilion 1577 Roberts Drive, Suite 320 7740 Pt

Journal The official publication of Jacksonville Orthopaedic Institute Volume X Issue I

Autoimmune Diseases Delicious & Nutritious Smoothies Hit The Spot Synovial Chondromatosis: An Atypical Cause of Hip Pain in an Elite Cyclist Care of the Aging Knee: Baby Boomers May Need Lifestyle Changes Eating Vegetables is Food Smart The Perfect Swing

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BPC_1017_Network_Ad_JOIMag_v02.indd 1 4/19/11 11:44 AM Greetings from the Journal Chairman of JOI... Winter/Spring 2012 Baptist Health and Jacksonville Orthopaedic JACKSONVILLE ORTHOPAEDIC INSTITUTE Institute now offer Robot-Assisted Partial Knee 1325 San Marco Boulevard, Suite 701 Resurfacing to address the damaging effects of Jacksonville, FL 32207 osteoarthritis. For patients with limited damage, 904-858-7199 this new minimally invasive option offers a better R. Stephen Lucie, MD alternative to total knee replacement because Patrick A. Hinton, Executive Director Sports Medicine, Joint Replacement it is less invasive, has a shorter hospital stay, San Marco a quicker recovery time, and results in more natural knee function. The procedure is ideally suited for patients who The mission of the Jacksonville Orthopaedic Institute have early to mid-stage osteoarthritis in just one or two compartments of (JOI) is to provide high quality orthopaedic the knee, including younger patients who were precisely not considered health care for our patients good candidates for total knee replacements. JOI physicians who The MAKO RIO™ Robotic with musculoskeletal disorders. have been certified to date are Drs. Steven Crenshaw, Stephen Lucie and Arm Interactive Orthopedic Exclusive Sports Medicine Provider Carlos Tandron. System available at Baptist Medical Center Downtown Another exciting new piece of equipment JOI is pleased to showcase is the new AlterG “anti-gravity” treadmill located at JOI San Marco. This revolutionary approach to rehabilitation offers the ability to defy gravity and work toward increased function like never before. Some of the world’s best athletes and teams use this unit as part of their sports conditioning and rehabilitation programs. For post-operative and post-injury patients, the “unweighting” treadmill provides a safe way to treat the lower extremities, if you are approved by your physician Visit us on for at least 25% partial weight-bearing and are allowed to flex and extend your hip, knee and ankle through a limited range of motion. This conditioning provides a significant reduction in pain, and nearly 100% of patients who have tried it have facebook.com/myjoi AlterG “anti-gravity” treadmill said they like it because pain-free progress can be easily tracked Or point your smartphone’s browser to and charted, and you are soon restored to your natural gait, range of motion and have an improved www.joionline.net/m patient outcome. It’s also used to improve balance and confidence of those with prostheses.

With regard to sports medicine, JOI continues its leadership position as we are “on the field” serving JOI provides the needs of the NFL Jaguars, 2011 Arena Bowl XXIV Champions The Jacksonville Sharks, and JU, just to name a few. We offer a variety of FREE Sports Medicine Seminars at 1st Place Sports expertise in: locations – go to joionline.net for the community event schedule. Also, TEAM JOI Cycling, Running HAND and Walking Teams frequently participate in many of the region’s top events, including the GATE River Run – look for our employees and physicians on their bikes and on the pavement! FOOT & ANKLE JOINT REPLACEMENT This year, we are pleased to offer our annual continuing medical education programs for physicians, starting with the CME I presentation at the Museum of Science and History (MOSH) in SPINE the Planetarium. These events allow our physicians to communicate “how to” perform various SPORTS MEDICINE orthopaedic examinations, as well as give an update on orthopaedics to primary care physicians.

We are dedicated to fostering a personalized and We congratulate those who walked with TEAM PICERNO during the Juvenile Diabetes compassionate level of medical care for our patients. Research Foundation’s “Walk to Cure Diabetes Now” on March 24th, and the Arthritis Foundation’s “Touchdown To A Cure” Arthritis Walk, on Saturday, March 31st, at Metro Park with JOI’s Kevin Michael Kaplan, MD, Honorary Walk Chair. If you are a golfer, please The JOI Journal is designed & published by join JOI for the annual Florida State College Foundation’s “Golf Classic” on Monday, Custom Medical Design Group. April 30th at the Deerwood Country Club presented by JOI and Co-Chaired by Michael S. Scharf, www.CustomMedicalMagazine.com MD (floridastatecollegefoundation.org). Hope to see you “on the green!” To advertise in an upcoming issue please contact us at 800.246.1637. R. Stephen Lucie, MD Chairman, Jacksonville Orthopaedic Institute Medical

Medical PharmacyAd_JOIJournal2010_Layout 1 6/11/10 4:27 PM Page 1

JOI patients can go home with their prescriptions. For Getting Better, It Doesn’t Get Any Better! • Conveniently located When on the road to recovery, every stop on your journey • Full range of prescription is important. That’s why JOI offers its own first-rate and over-the-counter medications rehabilitation facilities. We find it is the best way to offer cohesive, streamlined care. As with every aspect of your • Most insurance plans accepted care, JOI will provide expert therapists, the best equipment and technology, and an outstanding environment to bring about the best results. All you need is the desire to improve. We will encourage you along the way to keep you motivated and thinking positive about your treatment. If for a particular reason you choose a non-JOI rehabilitation facility, we can work with other rehabilitation facilities as well. n

JOI Rehabilitation Centers BEACHES Point meadows Baptist Pharmacy Pavilion 1577 Roberts Drive, Suite 320 7740 Pt. Meadow Dr., Suite 1 & 2 Baptist Medical Center Downtown Jacksonville Beach, FL 32250 Jacksonville, FL 32210 Pavilion Medical Building, 836 Prudential Drive Phone: 904-247-3324 Phone: 904-564-9594 904.202.5288 Fax: 904-247-3926 Fax: 904-564-9687 Baptist Pharmacy Beaches Baptist Medical Center Beaches MANDARIN RIVERSIDE/WESTSIDE 1370 13th Avenue South, Jacksonville Beach 12276 San Jose Blvd., 4339 Roosevelt Blvd., Suite 600 904.241.0116 Suites 716 & 717 Jacksonville, FL 32210 Jacksonville, FL 32233 Phone: 904-389-8570 Baptist Pharmacy Nassau Phone: 904-288-9604 Fax: 904-389-8599 Baptist Medical Center Nassau Fax: 904-288-9643 1250 South 18th Street, Fernandina Beach SAN MARCO 904.261.3251 NORTH 1325 San Marco Blvd., Suite 102 12961 North Main Street Jacksonville, FL 32207 Baptist Pharmacy South Suite 201 & 202 Phone: 904-858-7045 Baptist Medical Center South Jacksonville, FL 32218 Fax: 904-858-7047 Medical Office Building, 14546 Old St. Augustine Road Phone: 904-757-2474 904.271.6690 Fax: 904-757-5541 SOUTH 14985 Old St. Augustine Road Baptist Pharmacy Children’s Orange park/Clay County Suite 106 (Durbin Crossing) Nemours Children’s Clinic, 807 Children’s Way 1845 Town Center Blvd., Suite 410 Jacksonville, FL 32258 904.697.3601 Fleming Island, FL 32003 Phone: 904-288-9491 Phone: 904-621-0396 Fax: 904-288-9698 Baptist Pharmacy San Marco Reid Medical Building, 1325 San Marco Boulevard Fax: 904-621-0397 904.202.5292 UNIVERSITY Baptist Pharmacy Lane Avenue 5737 Barnhill Drive, Suite 204 Baptist Primary Care, 810 Lane Avenue South Jacksonville, FL 32207 904.693.2389 Phone: 904-733-9948 Fax: 904-733-9984

4 joionline.net JOI Journal “First Coast Connect” with Melissa Ross presents Photo Credit: Hope Kinchen WEEKEND WARRIOR Every Friday at 9:50 am Weekly Guests Listed on www.joionline.net Sponsored by

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Jacksonville Orthopaedic Institute joionline.net 5 Autoimmune Diseases by Philip R. Hardy, MD Sports Medicine, Joint Replacement SAN MARCO

Philip R. Hardy, MD

he autoimmune diseases now currently recognized, number into the hundreds these days, and the extent to which they are responsible for multiple disorders is just beginning to be appreciated.

The classic autoimmune disease that presents with involvement of the musculoskeletal system is Rheumatoid Arthritis. This syndrome has several different manifestations, beginning with Juvenile Rheumatoid Arthritis in the youngest patients, and presenting as “Pauciarticular Rheumatoid Arthritis” in patients in their teens to thirties, and as the more widely recognized variety, which occurs commonly in the middle- aged to the elderly.

The one factor that all autoimmune diseases have in common, is that the body’s own defense mechanism -- its immune system -- starts to attack the body’s own tissues. Beginning with an inflammatory phase, which, if left unchecked, can lead to the overt destruction of joints and other tissues, leaving them mere scarred remnants of their previous forms. Awareness of autoimmune diseases is critically important because there are disease-modifying agents available today that can alter the course of these illnesses and provide the patient with enhanced quality of life, to levels that could never have been possible before these agents were discovered.

Two main groups of autoimmune diseases affect the musculoskeletal system. The ‘seropositive’ type, where the test for Rheumatoid Arthritis is positive, and the ‘seronegative’ types, commonly called ‘seronegative spondyloarthropathies’, where the test for Rheumatoid Arthritis is

6 joionline.net JOI Journal negative, and the areas involved include the spine and the Once the inflammatory process has started, there are several joints. There are some tests, such as the HLA-B27, which, ways of dealing with it. The typical “non-steroidal anti- although not diagnostic, are found to be present in a much inflammatory” agents, of which aspirin was the first, have been higher percentage of patients with Ankylosing Spondylitis than used extensively, as have steroid anti-inflammatory agents such in the normal population. as prednisone. Antimetabolic agents, such as methotrexate are also used, especially in Rheumatoid Arthritis. The new more Many well-known diseases, such as the skin disease specific agents, so called “anti-tumor necrosis factor alpha Psoriasis, have recently been appreciated as being agents,” such as Enbrel or Humira, are now being more widely autoimmune. It has been known for many years, however, used, and belong to the disease-modifying anti-rheumatic drugs that patients with Psoriasis can develop joint involvement, (DMARDs). DMARDs can really enhance the quality of life of often characterized by stiffness and ankylosis, that is, fibrous patients with these diseases. These agents are really antibodies or bony fusion. Other diseases, such as Inflammatory Bowel themselves that target the antibodies produced by the patient, disease, are also associated with arthritis, as are diseases such which are the ones causing the tissue destruction. The problem as Systemic Lupus Erythematosus (Lupus), Sjogren’s disease, of using one set of antibodies to tackle a different set is that, on Scleroderma, and Reiter’s disease. occasion, the body’s own immune system starts to produce even newer antibodies against the treatment antibodies, and thus the The cause of many of these disorders turns out to be a treating agents are unfortunately rendered ineffective. To add genetic predisposition, plus other environmental factors. even more confusion, there have been cases of patients being Reiter’s disease, for example is also called ‘Reactive Arthritis’ treated for Ankylosing Spondylitis with these agents who have and has been shown to be associated with a chronic infection developed Psoriasis as a side effect of the treatment. by an organism called Chlamydia. In common with many of these maladies, chronic infections start the immune system The bottom line is that if a patient has any autoimmune along the path toward the production of the patient’s own disease, he or she is more likely to get another, and the presence antibodies, and the genetic predisposition allows these of vague, multi-organ system symptoms characterized by antibodies to attack the patient’s own tissues. Very few other stiffness after periods of inactivity, along with a family history forms of autoimmune arthritis have had the initiating agent of any autoimmune disease, should immediately alert the determined, but the chances are that at some point in the physician to the possibility that the patient’s problem could future, these agents will be discovered. easily be another variety of such a disease. 

Jacksonville Orthopaedic Institute joionline.net 7 Homework first, then Olympic training.

The Bolles School ranks among the nation’s top in college preparatory. Students here discover the gifts and talents that lead them to richer accomplishments and higher academic capabilities.

From pre-kindergarten through high school graduation, our students gain the advantage from a faculty and staff leadership who are committed to a truly comprehensive and holistic instruction.

Your son or daughter may also benefit from our highly celebrated athletic programs, led by their passionate and dedicated coaches, trainers and instructors. Together, the Bolles Bulldogs’ teams are among the most awarded and accomplished in the country.

Plus, scores of Bolles student athletes graduate and become standout players on ranked college squads, compete in the Olympic Games and even play on professional sports teams in the NFL, NBA and MLB.

None, however, were allowed to compete or train without turning in their homework first.

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ruity, frozen fruit, such as strawberries, frothy blueberries, or a sliced banana. smoothies Then add low-fat or non-fat yogurt are ideal in plain, vanilla, or any fruit for breakfast flavor. If you wish, freeze a small or quick snacks, container of yogurt overnight for providing both great an extra frosty concoction. Fruit taste and nutrition. sorbets or soy-based yogurts can be Kids like them. substituted for dairy-based yogurts, Grownups love them, if desired. and you don’t have to heat up your kitchen to make them. Next, add fruit juice; orange, apple, Just toss some fruit in the blender, or cranberry are popular choices. add yogurt, juice, and voilà— If you prefer, stir in a small can instant perfection. of crushed pineapple with juice. Alternatively, you can pour in Not all smoothies are created equal. some low-fat milk or soymilk. As a Touted as healthy alternatives to finishing touch, toss a few ice cubes fat-laden milkshakes or ice cream, in the blender, hit “puree,” and some smoothies sold in commercial savor the results. outlets are actually higher in calories than some popular junk There’s no right or wrong way food commodities. to mix a smoothie. Proportions depend on your preferences— According to a CNN report in creamy or icy in texture? Sweet or 1997, beverages served up at a tart? Cool and refreshing, or cold Smoothie King in Atlanta contained enough to make a penguin shiver? an average of 460 calories— equivalent to a McDonald’s Quarter A good rule of thumb is to offset Pounder hamburger! Some drinks sweet fruits with tart ones. For sold at smoothie bars add in high- a thicker texture, use frozen fat ingredients such as chocolate fruits, such as blackberries. Not or peanut butter, raising calories to creamy enough? Just add some 700 or more. more yogurt, frozen yogurt, milk, soymilk, or sorbet. Fruit not ripe “If you are looking to watch your enough? Sweeten your smoothie Strawberry Delight Smoothie weight, I’d pay attention to the with a small amount of honey. Too nutritional analysis you can get at thick? Add ice or juice. Combine in blender: a restaurant or smoothie vendor and check to see what’s in it,” Smoothies packed with fruit are 1 banana, sliced registered dietitian Nancy Anderson naturally rich in Vitamin C and 5 or 6 frozen strawberries of Atlanta told CNN. antioxidants, while dairy products provide calcium. Some people like 1 cup orange juice Fortunately, it’s easy to create to further fortify their smoothies 1 small carton lowfat vanilla yogurt a low-fat smoothie without with extra ingredients to boost 3 or 4 ice cubes, if desired sacrificing taste or nutrition. nutritional content or add fiber. Start with a handful of fresh or Optional additives include wheat

Jacksonville Orthopaedic Institute joionline.net 9 germ, protein powder, blackstrap molasses for extra iron, spirulina for a vitamin boost, or 1/4 teaspoon of uncooked oatmeal.

In a mood for a luau? A nip of rum can transform a simple smoothie into a potent tropical delight.

Feeling truly decadent? Combine chocolate syrup, bananas, and some cappuccino-flavored yogurt for a sumptuous palate-pleaser.

True, smoothies have captured the hearts and appetites of adults. But smoothies are also great for kids with picky appetites, since it’s easy to hide those oh-so-good-for-you fresh ingredients in a blended drink that’s every bit as cool and refreshing as those Slushies and Slurpies so many of us guzzled when we were kids.

While smoothies are best served fresh, you can make them ahead of time and store your mixture in the freezer for up to three days. To freeze, pour into a freezer-safe container, leave room for expansion, and cover. Thaw at room temperature for an hour or so before serving—or defrost in your microwave for instant gratification.

Just how popular have smoothies become?

Smoothie bars such as Jamba Juice and Smoothie King have popped up across the nation over the past few years, turning up seemingly everywhere from airports to shopping malls. A search of one popular culinary website turned up no less than 16 different cookbooks devoted entirely to smoothies. Visit www.ekitchendepot.com/ smoothies.html to shop for smoothie cookbooks with such tantalizing titles Super Smoothies! Taste the Nectar of Life and Great American Smoothies: The Ultimate Blending Guide for Shakes, Slushes, Desserts & Thirst Quenchers. Americans everywhere are “chilling out” with cool, refreshing smoothies, it seems.

Want a smoothie to take to the beach or slurp down in the car? Stop by a grocery store and pick up the latest product to hit store shelves— Tropicana smoothies sold in bottles. Although not quite the same in flavor or texture as a fresh-from-the-blender smoothie, the Tropicana blends do contain real fruit juice, nonfat yogurt, and ample amounts of Vitamins C, E, calcium and fiber—all with just 240 calories.

For more information on smoothies check out Smoothie Central. You’ll find free smoothie recipes at www.recipezaar.com 

10 joionline.net JOI Journal Main St. C

Northeast Florida’s 5/G 4 6/I ® 2/A Most Respected Name in Orthopaedics F

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3/D Office Locations 1 Baptist Beaches 4 Riverside 1577 Roberts Dr., Suite 225 - Jacksonville Beach, FL 32250 2 Shircliff Way, DePaul Bldg, Suite 300 - Jacksonville, FL 32204 P: 904.241.1204 • F: 241.7331 P: 904.388.1400 • F: 388.9644 2 Baptist South 5 San Marco 14540 Old St. Augustine Rd., Suite 2201 - Jacksonville, FL 32258 1325 San Marco Blvd, Suite 200 - Jacksonville, FL 32207 P: 904.880.1260 • F: 880.1210 P: 904.346.3465 • F: 396.0388 3 Orange Park/Clay County 6 University 1845 Town Center Blvd., Suite 405 - Fleming Island, FL 32003 5737 Barnhill Dr., Suite 102 - Jacksonville, FL 32207 P: 904.276.5776 • F: 276.5958 P: 904.739.3319 • F: 448.1416

Rehabilitation Centers A Baptist Beaches F Riverside/Westside 1577 Roberts Dr., Suite 320 - Jacksonville Beach, FL 32250 4339 Roosevelt Blvd., Suite 600 - Jacksonville, FL 32210 P: 904.247.3324 • F: 247.3926 P: 904.389.8570 • F: 389.8599 B Mandarin G San Marco 12276 San Jose Blvd., Suite 716 & 717 - Jacksonville, FL 32223 1325 San Marco Blvd., Suite 102 - Jacksonville, FL 32207 P : 904.288.9604 • F: 288.9643 P: 904.858.7045 • F: 858.7047 C North H South 12961 North Main St., Suite 201 & 202 - Jacksonville, FL 32218 14985 Old St. Augustine Rd., Suite 106 - Jacksonville, FL 32258 P: 904.757.2474 • F: 757.5541 P: 904.288.9491 • F: 288.9698 D Orange Park/Clay County I University 5737 Barnhill Dr., Suite 204 - Jacksonville, FL 32207 1845 Town Center Blvd. Suite 410 - Fleming Island, FL 32003 P: 904.733.9948 • F: 733.9984 P: 904-621-0396 • F: 621.0397 E Point Meadows 7740 Point Meadows Dr., Suite 1 & 2 - Jacksonville, FL 32256 P: 904.564.9594 • F: 564.9687

Exclusive Sports Medicine Provider Here’s what the community has to say about JOI: Community Voices facebook.com/myjoi joionline.net/m www.joionline.net

11.1.2011

JOI 4 Page Brown.indd 1 10/12/11 10:27 AM Proven Leaders with the Highest Training and Experience

We offer 31 specialty-trained physicians, many with fellowships, Our mission is to provide the highest level of coordinated care who are dedicated to delivering comprehensive care for the so all aspects of recovery are seemlessly integrated from initial Gregory C. Keller, MD Garry S. Kitay, MD Robert J. Kleinhans, MD Steven J. Lancaster, MD muscles, bones and joints. Our diverse practice includes five diagnosis through rehabilitation. Spine; Joint Replacement Hand; Joint Replacement; Hand; Joint Replacement; Sports Medicine; Centers of Expertise: Sports Medicine Sports Medicine Sports Medicine Joint Replacement; Serving this region, we have six convenient office locations Baptist South & San Marco San Marco University Foot & Ankle; Hand Foot & Ankle and nine rehabilitation centers. JOI accepts more than 140 Baptist Beaches health plans, including Aetna, Blue Cross Blue Shield of Hand Florida, CIGNA, Medicare, Humana, United and workers’ compensation. We make every effort to work with our referring Joint Replacement Primary Care physicians to serve the needs of patients and their plan requirements. Spine Questions about our physicians, facilities or treatment Sports Medicine options? Call for an appointment today. Stanton L. Longenecker, MD R. Stephen Lucie, MD Jennifer L.M. Manuel, MD H. Lynn Norman, MD Joint Replacement; Sports Medicine; Hand Sports Medicine; Sports Medicine Joint Replacement Baptist South Joint Replacement Riverside San Marco Riverside

Stephen J. Augustine, DO Aaron Michael Bates, MD Hiram A. Carrasquillo, MD Steven M. Crenshaw, MD Richard A. Picerno II, MD William G. Pujadas, MD Robert G. Savarese, DO Michael S. Scharf, MD Sports Medicine; Sports Medicine; Foot & Ankle; Sports Medicine Sports Medicine; Sports Medicine; Joint Replacement; Spine; Physical Medicine & Spine; Joint Replacement Joint Replacement Joint Replacement San Marco Joint Replacement Joint Replacement Sports Medicine Rehabilitation - Spine Team San Marco Riverside Orange Park / Clay County San Marco Baptist South San Marco Baptist South & San Marco

Sunday U. Ero, MD Richard R. Grimsley, MD Philip R. Hardy, MD Gregory Solis, MD Maxwell W. Steel III, MD Bruce Steinberg, MD Carlos R. Tandron, MD David A. Doward, MD Spine Surgery Joint Replacement Sports Medicine; Foot & Ankle; Sports Medicine Sports Medicine; Foot & Ankle; Hand & Upper Extremity; Sports Medicine; Physical Medicine & Rehabilitation - Orange Park / Clay County Joint Replacement Baptist South Joint Replacement Joint Replacement; Joint Replacement Spine Team; Sports Medicine Orthopaedic Traumatology Riverside & Riverside San Marco University Sports Medicine San Marco San Marco Baptist South & San Marco

Timothy R. Hastings, MD Patrick M.J. Hutton, MD Brandon J. Kambach, MD Kevin Michael Kaplan, MD M. John Von Thron, MD Dale A. Whitaker, MD Edward D. Young, MD Sports Medicine; Joint Replacement Sports Medicine Spine Sports Medicine; Sports Medicine; Sports Medicine; Sports Medicine; Foot & Ankle; Spine; Hand Orange Park / Clay County Baptist South Joint Replacement Joint Replacement; Joint Replacement; Joint Replacement; Baptist Beaches San Marco Foot & Ankle; Hand Foot & Ankle; Hand Foot & Ankle; Hand Baptist Beaches Baptist Beaches Baptist Beaches

JOI 4 Page Brown.indd 2 10/12/11 10:27 AM Proven Leaders with the Highest Training and Experience

JOI 4 Page Brown.indd 2 10/12/11 10:27 AM Main St. C

Northeast Florida’s 5/G 4 6/I ® 2/A Most Respected Name in Orthopaedics F

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Exclusive Sports Medicine Provider Here’s what the community has to say about JOI: Community Voices facebook.com/myjoi joionline.net/m www.joionline.net

11.1.2011

JOI 4 Page Brown.indd 1 10/12/11 10:27 AM Synovial Chondromatosis: An Atypical Cause of Hip David A. Doward, MD Pain in an Elite Cyclist by David A. Doward, MD Physical Medicine and Rehabilitation – Spine Team, Sports Medicine San Marco

rimary synovial chondromatosis is a rare disorder that can present as chronic hip and groin pain. It is characterized by formation of nodules (made of bone and cartilage) which arise from the synovium (thin layer of tissue which lines the joint). We discovered an Olympic caliber cyclist, in her mid thirties, with primary synovial chondromatosis of the left hip. She presented with a 1-year history of progressive hip and groin pain that occasionally radiated to the front of her thigh. She complained of left hip tightness and described her pain as deep, dull and achy. Her symptoms initially began with running but then progressed to occur with walking, cycling and lying on the hip.

She was extensively examined and found to have decreased range of motion of the left hip. She complained of deep hip pain with external rotation. Provocative tests designed to localize pain to the hip joint were all positive. Next, a plain x-ray was ordered revealing slight narrowing of the left hip joint. This was followed by a magnetic resonance imaging arthrogram which showed a small anterior labral tear and many tiny abnormalities in the joint fluid. At this point, she was treated with a steroid injection to the left hip which was done via image- guidance with temporary relief of her pain. She was then enrolled in a formal physical therapy program but only received marginal improvement of her symptoms. She was

Jacksonville Orthopaedic Institute joionline.net 15 Fig 1. (A-D) Arthroscopic view of cartilaginous nodules in hip joint. Fig 2. Specimen consists of cartilage and vary in size ultimately sent for surgery which involved removal of the loose nodules (fig 1, 2) and the synovial lining of the hip joint. The diagnosis of primary synovial chondromatosis was confirmed by microscopic analysis (fig 3).

Evaluating a patient with chronic hip and groin pain can present a diagnostic and treatment challenge. It is essential to localize the area of abnormality. Pain may originate from the hip joint and its surrounding structures, as is seen with a labral tear or Fig 3. (A) Histology slide for microscopic analysis (B) Magnified stress fracture. It also may arise from the adductor muscles view - diagnostic of synovial chondromatosis where chronic muscle strain or tendinopathy occur. Injury to the pubic bones or abdominal muscles can be the cause of a patient’s symptoms. Likewise, the lower thoracic and lumbar 4. Davis RI, Hamilton A, Biggart JD. Primary synovial spine may refer pain to the groin. Other less common causes of chondromatosis (a clinicopathologic review and assessment pain in this region must also be considered. of malignant potential). Hum Pathol. 1998;29:683-688

Our patient had a fairly classic presentation of synovial 5. McKinney CD, Mills SE, Fechner RE. Intraarticular chrondromatosis. Most patients complain of a several-year synovial sarcoma. Am J Surg Pathol. 1992;16:1017-1020 history of joint pain, swelling, and loss of joint motion (signs of advanced disease) before diagnosis is made. Malignant 6. Lovell G. The diagnosis of chronic pain in athletes (a transformation has been reported in cases involving repeated review of 189 cases). Aust J Sci Med Sport. 1995;27:76-79 recurrence after treatment but is rare. Without intervention this disease can progress, the joint can deteriorate and secondary 7. Monu JU, Oka M. Synovial osteochondromatosis. osteoarthritis can occur. Early recognition and treatment are eMedicine. 2004;1-13 the keys to preventing this. We don’t know if our patient’s sport involvement played a role, but it is possible that the high-level 8. Pope TL, Keats TE, de Lange EE, Fechner RE, Harvey demands of cycling contributed to this condition. She did receive JW. Idiopathic synovial chondromatosis in two unusual the appropriate treatment and at follow-up was found to be pain sites (inferior radioulnar joint and ischial bursa). Skeletal free and able to return to her previous athletic activities.  Radiol. 1987;16:205-208.

References 9. Sviland L, Malcolm AJ. Synovial chondromatosis presenting as painless soft tissue mass - a re-port of 19 1. Mora R, Sodini F, Rashella F, paparella F, Belluati A, Basile cases. Histopathology. 1995;27:275-279 G. Primitive synovial chondromatosis of the hip. Ital J Orthop Traumatol. 1992; 18:231-239 10. Taconis WK, van der Heul RO, Taminiau AM. Synovial chondrosarcoma (report of a case and re-view of literature). 2. Coles MJ, Tara HH. Synovial chondromatosis (a case study Skeletal Radiol. 1997;26:682-685 and brief review). Am J Orthop. 1997; 26:37-40 11. Gille J, Kruger S, Aberle J, Boehm S, Ince A, Loehr JF. 3. Reichel PF. Chondromatose der Kniegelenkkapsel. Arch Synovial chondromatosis of the hip (a case report and Klien Chir. 1900;61:717-721 clinicopathologic study). Acta Orthop Belg. 2004;70:182-188

16 joionline.net JOI Journal

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Jacksonville Orthopaedic Institute joionline.net 17 Care of the Aging Knee: Baby Boomers May Need Lifestyle Changes

any people in the “baby boomer” generation highly active people may also develop OA if their knee are staying active as they age. This is healthy. suffered a significant injury. But playing team sports, jogging or doing other high impact activities that repeatedly • Diagnosis: See your doctor for diagnosis and treatment. pound, twist and turn the knees can stress aging The doctor will consider your comprehensive medical joints. Highly active, middle-aged patients may develop painful history, perform a physical examination and possibly order knees as a result of osteoarthritis (OA). This painful condition tests and/or imaging studies before recommending a course happens when the cartilage lining on the ends of bones gradually of treatment. wears away. It can affect one or both knees. Extending the Life of the Middle-Aged Knee • Symptoms: You may experience pain when standing or going up and down stairs. The knee may buckle and give Increasingly, baby boomers with OA of the knee are asking way, lock in place, or become stiff and swollen. for total knee replacement surgery. But first they should try making changes to their lifestyles. Mayo Clinic orthopaedic • Patients: Most people with OA of the knee are over age 55 surgeon Arlen D. Hanssen, MD presented a briefing on “Our and/or obese and/or have a family history of OA. Younger, Aging Population” at the 2002 Annual Meeting of the American

18 joionline.net JOI Journal Academy of Orthopaedic Surgeons stages, your doctor may recommend low (AAOS). He said many highly active impact activities and other non-operative patients in their 40s and 50s feel treatments that can delay or eliminate the inspired by advertising and news reports need for surgery. In some cases, activity about the success of knee replacement modification may be the only treatment surgeries. But often they refuse to a middle-aged patient needs. “In other change their lifestyles to extend the life cases when surgery is eventually needed, of their natural knees. the patient still has to modify activities first to preserve the replacement joint,” “They come in and say, -fix me,’” Dr. Hanssen advises. Hanssen explained, and they hope for a complete end to their symptoms Substitute Smooth, Low Impact without making any changes in their Activities activities. In reality, doctors use a complex medical process to determine Moderate physical activity lessens whether total knee replacement is joint pain and improves flexibility appropriate for a patient - considering and function. Baby boomer patients age, activity demands and other factors. with OA of the knee should continue Longterm results of joint replacement exercising, but change the forms of are less certain in younger patients. their activities:

For middle-aged people, the earlier a • Stop doing high impact activities doctor diagnoses OA of the knee, the that twist and turn the joints. more likely conservative treatment may This includes running, tennis, help. If OA of the knee is in its early racquetball, basketball, baseball, etc.

Jacksonville Orthopaedic Institute joionline.net 19 • Start doing smooth, low impact cartilage from degrading. (Note: and reduce pain. It may also help activities that are easier on the The U.S. Food and Drug to ice the affected joint for short joints. Recommended activities Administration does not test dietary periods, several times a day. include stretching, swimming, water supplements. These compounds aerobics, cycling, walking on a may cause negative interactions • Mechanical aids: You may need treadmill or outside, playing golf, etc. with other medications or excessive supportive or assistive devices such bleeding during surgery. Always as an elastic bandage, splint, brace, Other Conservative Options consult your doctor before taking cane, crutches or walker.  dietary supplements.) Other options that may extend the life of your natural knee include medications, • Injections: The doctor may inject steroid injections, physical therapy and the knee joint with strong anti- mechanical aids. inflammatory medications called corticosteroids. This can relieve pain • Medications: The doctor may and swelling for awhile. prescribe non-steroidal anti- inflammatory medications to help • Physical therapy: The doctor may reduce inflammation. Certain give you a balanced fitness program dietary supplements may also help. including physical/occupational Glucosamine stimulates formation therapy to improve joint flexibility, and repair of articular cartilage, increase range of motion, strengthen and chondroitin sulfate prevents muscle, bone and cartilage tissues

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Jacksonville Orthopaedic Institute joionline.net 21 Eating Vegetables is Food Smart by Charles Hudson

or generations, parents encouraged their children to “Eat your vegetables.” As it turns out, mom knew broccoli may have tasted awful, but was loaded with valuable nutrients.

Today, the inclusion of vegetables in your diet is one of the tried and true recommendations for a healthy lifestyle. No matter what diet fad is in fashion, no one can dispute the benefits of consuming vegetables.

Vegetables are rich in essential vitamins and minerals. Vegetables are low in calories, sodium, and fat and high in fiber, keeping hunger and weight down. There is compelling evidence that a diet rich in vegetables is linked to many health benefits, including lowered risk for certain cancers, stroke, heart disease, and high blood pressure. It is well known that cultures that follow diets high in vegetable content (like those found in Asia) have higher life expectancies and lower health risks than cultures with diets low in vegetable content.

Vegetables are rich sources of naturally protective substances called “phytochemicals” or “phytonutrients.” Phytonutrients are protective compounds found in plants that boost the body’s immune system and help the body prevent degenerative diseases within cellular structures.

Some familiar protective phytonutrients are: allicin in garlic; isoflavones in soybeans; lycopene in tomatoes; flavanoids in green and black teas; sulforaphane glucosinolate (SGS) in broccoli and broccoli sprouts; carotenoids in carrots; lignans in flax seed; and anthocyanin in blueberries.

Green, leafy vegetables seem particularly beneficial. Carotenoids are the pigments that color dark green and orange vegetables. Many are precursors to vitamin A and act as powerful antioxidants that can protect cells in the body from damage by free radicals, which is thought to lead to a number of health problems. Thus antioxidants may help protect against many diseases. nutrients only found in plants. The fiber and phytochemicals found in most vegetables prevent damage to blood vessels, Dark, leafy green vegetables are also rich in folate. Researchers decrease the risk of strokes, and can help the body eliminate have linked low blood levels of folate with an increased risk harmful carcinogens and toxins. of certain types of cancer and a high intake of folate with a lower risk. Even a small increase in the consumption of vegetables, or at least the addition of vegetable supplements, can improve health Consumption of vegetables is found to be extremely beneficial and overall well being and increase energy. So for once, your to heart health, as cardiovascular strength relies on certain mother was right. 

22 joionline.net JOI Journal Custom Publishing Design Group ® The Perfect Swing Jacksonville Orthopaedic Institute ground, facing target. over theball.Club’s shaftparalleltothe shoulder underneathchin.Head remains turned about90degrees clockwise.Left about 45degrees clockwise.Shoulders to therightofball.Right hip turned tensed kneesshouldbepointed slightly right foot. At thetopofswing, backswing. Weight almostfullyon cocking theclubneartopof maximum torque. Wrists hingeup, Arms extend completelytocreate to rightfoot. clockwise. Weight slowly transfers building tension. Hipstwist legs continuetwistingin place, begins rotatingtotheright while to follow smoothly. Upper body straight, forcingleftshoulder path ofthearms.Leftarmstays twist clockwise,following the while thekneesbegin to gently club backtotherightinanarc Arms slowly andsmoothlypullthe strong triangletothebody. angles outtoward theball. Arms forma almost straightdown totheclub,which backswing. Arms hangrelaxed left shoulderroomduringthe up fromchesttoallow the in centerofstance.Chin to target line.Balllocated hips andshouldersparallel shoulder width.Feet,knees, bent. Buttocksout.Feetsetat Back straight.Kneesslightly THE BACKSWING THE THE SETUP TAKE AWAY joionline.net after theshothasbeenhit. target. Headfinallyfollows bodywell on leftsideoffoot. Torso faces the behind head.Mostofthebodyweightis behind turnedleftshoulderandhigh the club’s follow-through. Handsfinish chin. Leftarmbendstoaccommodate fully around.Rightshoulderturnsunder shoulders follow untiltheclubextends to theclub,hipscontinueturn,and the target. Arms bothextend straight Club follows apathdirectlytoward address. at impact.Headinsamepositionas through theball,bothstraightandfirm perfectly squaretotheball. Wrists snap left armthroughtheball.Clubhead Right armslightlybent,pushingstraight weight shiftscompletelytoleftfoot. until justbeforeimpact. toward thetarget. Wrists remaincocked way totheball,itgains adirectplane swings down, abouttwo-thirds ofthe upper bodytofollow. As theclub release fromcoiledposition,forcing as bodyuncoilsfromthehips.Legs Hands dropslightlyfromfullextension THE FOLLOW THROUGH by BobbyArmstrong THE DOWNSWING Right footstartstoriseas straightening leftleg. front oftheball, Left hipwellin IMPACT 23 “The Ultimate In Comfort and Convenience!”

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