NEWS

ISSUE 05 I WINTER 2011 Welcome Message Winter is here and with that comes a long line of winter sports. The cold weather and early snow O rTHOSPORTS Locations brings skiing and snowboarding to mind, to prepare for the ski season Drs Sher and Bruce gave > Concord 02 9744 2666 lectures to the ski patrol in readiness for the busy season of snow sport injuries. > Hurstville 02 9580 6066 Winter also means Rugby, Netball, Hockey, AFL, Soccer and many other sports that bring with > Olympic Park 02 9735 3637 them a vast array of knee, ankle, shoulder, foot, hip and general orthopaedic traumas. > Penrith 02 4721 1865 Leading on from the completion of our knee examination series, we commence our shoulder > Randwick 02 9399 5333 examination series on page 3. > Sydney 02 9735 3637 We hope you enjoy this issue of Orthosports News. The Team at Orthosports Or visit our website www.orthosports.com.au The Young Patient who Dislocates their Who Are We? Orthosports is a professional Shoulder for the First Time association of Orthopaedic Surgeons based in Sydney. This is one of the most controversial topics in orthopaedics. The literature has established We specialise in joint replacement, that the younger the patient, the higher the risk arthroscopic and reconstructive of recurrence (up to 90% in persons under 20 surgery. years). With each instability episode, increasing Orthosports also includes a team damage is done to the articular cartilage and of Sport & Exercise Medicine other structures of the shoulder. One can Physicians who are dedicated to extrapolate from that, that the more frequent Fig 3. X-ray showing Fig 4. MRI showing promoting excellence in the treatment the number of dislocations, the higher the risk bony Bankart lesion torn anterior labrum of musculoskeletal disorders in of developing Glenohumeral arthritis. and Hill Sachs lesion both adults and children. When a patient dislocates the shoulder the Our team of surgeons has particular labrum can tear (a bankart lesion), the capsule the shoulder is strong, usually at about 6 to 8 expertise in hip and knee is stretched and bony damage can occur to the weeks after the injury, the patient is generally replacement, ACL Reconstruction, Humeral head (a Hill Sachs lesion) or Glenoid allowed back to full activity. If the dislocation knee and shoulder arthroscopy, (a bony bankart lesion). recurs then surgery is recommended. open shoulder surgery, trauma, In these active young patients, if there is a foot and ankle surgery, fracture large labral tear then arthroscopic surgery is management, paediatrics and recommended to repair the labrum and reduce many subspecialist procedures. the risk of recurrent dislocations. The surgery All of our practices are conveniently carries a 4 to 6 month rehabilitation period and located next to physiotherapy, x-ray the success rate is approximately 90%. and imaging facilities. Our mission is to have the facilities to offer everything our Fig 1. Arthroscopic Fig 2. Arthroscopic patients may need but also to be picture of torn Anterior picture of Hill Sachs small enough to look after the little Labrum lesion details that make all the difference to patient care. When there is a large labral tear or significant bony damage, the risk of recurrence and more Fig 5. Arthroscopic Fig 6. Diagram of labral Our website is subsequent damage to the joint is very high. This risk is amplified if the patient is young, photo of labral repair repair using anchors your Orthopaedic active and plays contact sports. Resource If there is significant bony damage then a A general approach to the first time dislocator If you haven’t visited our website larger and more complicated procedure is is to initially perform a thorough history and recently, please take the time to visit required to compensate for the bone loss examination. A plain x-ray will assess the bony and take a look around. It contains which involves transferring the coracoid damage. If it is possible to arrange an MRI descriptions of many common surgical process into the defect. conditions and procedures as well as with intra articular contrast, this will give a lectures, animations and videos of good view of the labrum. In summary, a dislocated shoulder is not a benign injury and can do significant structural damage lectures given by our surgeons and If the MRI reveals no bony or labral damage, to the joint. This damage can be minimised by sports physicians over recent years. commence physiotherapy immediately. There early surgery in the high risk individual. www.orthosports.com.au is no evidence in the literature to suggest that sling immobilisation is of any benefit. Once Dr Jerome Goldberg www.orthosports.com.au 1 Management of Treatment of Bunions Acute Ankle Sprains The term “bunion” is commonly used to describe any enlargement or deformity around the great toe. The origin of the term “bunion” is Acute ankle sprains are an extremely common injury in both sport and the general from the latin word bunio, meaning turnip. The most common cause of a community. The ‘garden variety’ ankle sprain bunion deformity is due to hallux valgus, where there is lateral deviation involves the lateral ligament complex. It of the great toe, and a medial eminence. generally occurs in a position of plantar flexion and inversion, where the foot ‘rolls Aetiology to establish the diagnosis and dictate under’ the ankle. Clinical assessment of the Studies have shown that painful hallux appropriate treatment. ankle is very important as it should not be valgus is a problem of the shoe wearing assumed that all ankle sprains are lateral Treatment population, occurring in up to 33% of ligament sprains. Important conditions to Non-operative management usually people as compared to 2% of the unshod exclude are: alleviates symptoms associated with persons. The fact that hallux valgus hallux valgus. Patients are encouraged 1. Syndesmosis does not occur in everyone wearing to use wide shoes with a wide toe box. sprains – This injury shoes, or does occur in the unshod Shoes can be stretched by a shoemaker is a disruption of the population suggests that there is an to relieve pressure points over the inferior tibiofibula underlying hereditary component that ligaments. It is bunion. Podiatric care, with the use of may predispose to this condition. important to bunion pads, night splints, or bunion differentiate this The first metatarso-phalangeal joint is posts, have been shown to be effective injury as it runs a subjected to a number of deforming in relieving symptoms. These products more protracted time forces. When the toe is straight, these have not been effective at preventing the course (roughly twice forces are balanced and do not cause progression of the deformity. as long as a lateral a deformity. Once hallux valgus occurs, When conservative management has ligament sprain)and the pull of tendons around the joint failed to relieve symptoms, operative External rotation test occasionally requires becomes imbalanced, allowing for further management is considered. Proper surgery. On history worsening of the deformity. Pressure correction of the deformity involves a the patient describes a dorsiflexion and on the medial eminence from shoes, external rotation mechanism, which is quite rebalancing of the forces around the and altered pressure on the great toe different to the plantar flexion inversion first metatarsophalangeal joint. I have commonly causes pain. mechanism of a lateral ligament injury. had excellent results with a procedure Clinically pain is felt with forced external Painful hallux valgus occurs far more known as the SCARF osteotomy. The rotation of the foot with the ankle in a commonly in females than males. While first metatarsal is cut and the bone neutral position. deformities may first arise in the teenage shifted laterally to re-align the bony 2. Fractures – The common fractures population, patients usually seek treatment deformity. This procedure, popularised by accompanying an ankle sprain include either for this condition around the sixth decade a French surgeon, Louis Barouk, allows medial or lateral malleoli, the base of 5th of life due to worsening of the deformity, for correction of large deformities, and metatarsal or one of the midfoot bones, such difficulty with shoe wear, and pain and patients are allowed to immediately bear as the navicular. Imaging guidelines known deformity in the great toe or lessor toes. weight on the operated foot. Surgery can as the Ottawa ankle rules provide guidelines be done on both feet simultaneously. for when to x-ray an injured ankle and have Diagnosis been shown to reduce radiology requirements The majority of patients report pain over for emergency departments by 30%. the medial eminence of the great toe. 3. Peroneal tendon Up to half of patients will report pain subluxation – The underneath the second metatarsal head, peroneal tendons are usually due to transfer of weight bearing held in place by the to this part of the foot as the deformed peroneal retinaculum, first ray is unable to share load. which may be ruptured in an acute Pain can be present all of the time, but Before After ankle sprain. This patients usually report worsening of pain Above: the most common cause of a bunion leads to instability of with shoe wear and improvement of pain is Hallux valgus. With the scarf osteotomy these tendons. with open toed shoes or thongs. procedure, the first metatarsal is cut and the Clinically this may be I prefer to order standing or weight diagnosed by asking bone shifted laterally to realign the bony deformity. the patient to actively bearing radiographs as they better Stirrup brace demonstrate the true deformity. The dorsiflex and externally Keypoints rotate the foot, whilst palpating for the tendons presence or absence of arthritis and snapping from posterior to anterior over the the anatomic structure of the foot  • Bunions are mainly due to hallux valgus, malleolus. This may require surgical repair. demonstrated on radiographs will help a deformity of the great toe MTP joint. If these conditions are excluded, then almost  • Pain from the deformity can be controlled by wider shoes and podiatric care. all ankle sprains may be treated with Would you prefer to receive this functional rehabilitation. This may include newsletter via email?  • Hallux valgus may progress over time, partial immobilization in a stirrup brace, and may cause symptoms in the weight-bearing as tolerated, anti- Please send your email address to lessor toes. [email protected] with inflammatory measures (ice, compression,  • Surgery is considered when non- NSAIDS) and physiotherapy which has both your name and we will send you this operative treatments have failed to a ‘hands-on’ and an exercise component. newsletter via email. control symptoms. Dr Paul Annett Convenient, eco-friendly and cost saving! Dr Todd Gothelf 2 www.orthosports.com.au From left: internal Key rotation, forward elevation, and Examination external rotation. Points Shoulder Examination Series supraspinatus being the most commonly with subacromial bursitis with a tear Shoulder pain is common and can be injured muscle. of the rotator cuff often has objective difficult to diagnose accurately. It is helpful rotator cuff weakness caused by pain to remember that certain diagnoses are Inspection when the arm is positioned in the arc of more common in certain age groups. The shoulders and arms should be impingement, however the rest of the Across the board, impingement is by far properly exposed to look for swelling, rotator cuff examination may be normal. the most common diagnosis but in the asymmetry, muscle atrophy, scars and The supraspinatus can be tested by younger age groups (20-40) one should bruising. Loss of shoulder roundness may having the patient abduct the shoulders consider instability both as it’s own be from a dislocation or chronic muscle to 90 degrees in forward flexion with the diagnosis and as a cause for secondary wasting. Scapular winging and poor thumbs pointing downward. The patient impingement. In the 30-50 year age group scapulothoracic rhythm can indicate then attempts to elevate the arms against remember adhesive Capsulitis (which a nerve injury or be the cause of secondary examiner resistance. This is often referred unfortunately is overdiagnosed) as well impingement. Wasting of the supraspinatus to as the “empty can” test. as impingment; and in the 50+ age group or infraspinatus makes you suspicious of Next, with the patient’s arms at the add arthritis to the list above. a rotator cuff tear, suprascapular nerve entrapment or neuropathy. sides, the patient flexes both elbows to As with all joints a thorough history is 90 degrees while the examiner provides required to appropriately direct your P alpATION resistance against external rotation. clinical examination. Ask about the Palpation should include examination of Weakness of external rotation almost patient’s age, hand dominance, sport and the acromioclavicular and sternoclavicular always indicates a rotator cuff tear. work activities. Does the injury prevent or joints, the cervical spine and the biceps Subscapularis function is assessed interfere with work, hobbies and sport? tendon. The glenohumeral joint, coracoid with the lift-off test. The patient rests The location and nature of the pain, process, acromion and scapula should the dorsum of the hand on the back in instability, stiffness, locking, catching also be palpated for any tenderness the lumbar area. Inability to move the and swelling are all critical questions. and deformity. hand off the back by further internal Pain from the shoulder is often felt in the rotation of the arm suggests injury to upper arm and night pain is common. Range-of-Motion Testing the subscapularis muscle. A modified Stiffness or loss of motion is seen with Always compare the two shoulders with version of the lift-off test is useful in a adhesive capsulitis, arthritis and posterior both active and passive range of motion. patient who cannot place the hand behind glenohumeral dislocation. Pain or inability Forward elevation, external and internal the back. In this version, the patient to throw suggests anterior glenohumeral rotation and abduction are the most places the hand of the affected arm on instability. Pain at the top of the shoulder useful movements. A difference in active the abdomen and resists the examiner’s may be AC joint arthritis. A history of a and passive motion is usually caused by attempts to externally rotate the arm. fall, or pain with lifting, may indicate a a rotator cuff tear. Loss of some motion rotator cuff tear and may be associated Injections can be used for diagnosis and can be caused by impingement, calcific with bruising in the upper arm (which treatment. If a subacromial injection tendonitis and chronic instability. A global could also indicate a fracture). relieves pain and restores motion loss of motion is caused by arthritis, and strength the patient usually has Clinical examination requires inspection, chronic dislocations, fractures and impingment rather than a rotator cuff tear. palpation, evaluation of range of motion massive rotator cuff tears. AC joint injections are useful to deal with and provocative testing. Always remember superior shoulder pain (please refer to the to check the neck and elbow and look for Strength testing “Teaching” Section of our website and go neurological problems. Bones, muscles When testing the rotator cuff be to “Injection Techniques”). and soft tissue structures can all be sure to compare the painful side to injured around the shoulder. The rotator the unaffected side to detect subtle The next newsletters will deal with further cuff is made up of 4 muscles: differences in strength and motion. True clinical examination specific to rotator cuff the supraspinatus, infraspinatus, teres weakness should be distinguished from tears and instability. minor and subscapularis, with the weakness that is due to pain. A patient Dr Doron Sher

Spotlight on Dr John Negrine Dr. Negrine specialises exclusively in conditions of the Adult Foot and Ankle covering all aspects of sports injuries, arthritis and foot deformity. Dr. Negrine is the Immediate Past President of the Australian Orthopaedic Foot and Ankle Society (2008-2010) as well as a member of the Australian, A sub-group of Orthosports, American and European Foot and Ankle Societies. He also has numerous The Sydney Shoulder Clinic is local and international presentations and publications to his name. a specialist shoulder service providing clinical care in Dr. Negrine graduated from the University of Sydney in 1984. He completed his physiotherapy, sport & exercise residency at Royal North Shore Hospital Sydney. In 1989 he was selected as Commonwealth medicine and orthopaedic surgery. Orthopaedic Registrar, Royal National Orthopaedic Hospital London. In 1990 Dr Negrine commenced the Sydney Orthopaedic training scheme which he completed in 1993 gaining the Fellowship of the www.sydneyshoulderclinic.com.au Royal Australasian College of Surgeons (Orthopaedic). In 1994/5 he was the Accredited Foot and Ankle Fellow at Baylor University Medical Center, Dallas Texas where he studied and worked under the world renowned Foot Surgeon Dr. James W. Brodsky. www.orthosports.com.au 3 Orthopaedic Surgeons and their Interests

LOCATION SURGEON SPECIALTY

Concord Dr Todd Gothelf Shoulder, Foot & Ankle 47-49 Burwood Road, Dr John Negrine Foot & Ankle (Adult) Concord NSW 2137 Dr Rodney Pattinson Paediatrics and General Orthopaedics Tel: 02 9744 2666 Dr Doron Sher Knee, Shoulder and Elbow

Hurstville Prof. Warwick Bruce Hip and Knee 2 Pearl Street, Dr Jerome Goldberg Shoulder Hurstville NSW 2220 Dr Todd Gothelf Shoulder, Foot & Ankle Tel: 02 9580 6066 Dr Andreas Loefler Spine, Trauma, Hip and Knee Dr John Negrine Foot & Ankle (Adult) Dr Rodney Pattinson Paediatrics and General Orthopaedics Dr Ivan Popoff Shoulder, Knee and Elbow Dr Allen Turnbull Hip and Knee

OLYMPIC PARK Prof. Warwick Bruce Hip and Knee Retail 4, 8 Australia Ave Sydney Olympic Park NSW 2127 Dr John Trantalis Shoulder and Elbow Dr Peter Walker Hip and Knee Tel: 02 9735 3637

Penrith Level 3, 1a Barber Avenue, Dr Todd Gothelf Shoulder, Foot & Ankle Kingswood NSW 2747 Tel: 02 4721 1865

Randwick Dr Jerome Goldberg Shoulder 160 Belmore Road, Dr Todd Gothelf Shoulder, Foot & Ankle Randwick NSW 2031 Dr Andreas Loefler Spine, Trauma, Hip and Knee Tel: 02 9399 5333 Dr John Negrine Foot & Ankle (Adult) Dr Rodney Pattinson Paediatrics and General Orthopaedics Dr Ivan Popoff Shoulder, Knee and Elbow Dr Doron Sher Knee, Shoulder and Elbow Dr John Trantalis Shoulder and Elbow

SYDNEY Level 3, 187 Macquarie Street, Dr Peter Walker Hip and Knee Sydney NSW 2000 Tel: 02 9735 3637

Sport & Exercise Medicine Physicians

Physician LOCATION Physician LOCATION Dr Paul Annett Hurstville Dr Mel Cusi Concord | Hurstville | Randwick Dr John Best Randwick

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ARTHROSCOPY I JOINT REPLACEMENT I LIGAMENT RECONSTRUCTION I PHYSIOTHERAPY I SPORT & EXERCISE MEDICINE

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