Cedars-Sinai Expands Orthopedic Services

By Kenton H. Fibel, MD

Pickleball is a popular recreational “racket sport” that combines elements of tennis, ping pong and badminton into one game that many people of varying ages and stages of athletic ability enjoy.

The most common pickleball injuries arise out of repetitive use and aren’t necessarily “acute” in nature as they happen over time.

In the wrist, injury can occur because of the repeated torque and twisting motion required to paddle the ball.

In the elbow, a phenomenon called "tennis elbow,” medically referred to as lateral epicondylitis, involves tendinitis and pain on the outside of the elbow resulting from repetitive use.

A calf strain can occur when explosively lunging forward for a low shot and can bring about pain that feels like a kick in the calf. Calf injuries should be monitored and evaluated to ensure they aren’t more serious, like an Achilles tendon rupture.

Additionally, hamstring strains can also occur with explosive court movements in pickleball, and depending on the degree of the strain, it may take longer to heal. For this reason, it is also vital to have the injury evaluated by a sports medicine doctor.

Of course, other types of bodily injury can arise from pickleball play, including shoulder strains, rotator cuff injuries, bursitis and impingement. In addition, knee injuries, such as meniscus and ACL tears and ankle injuries such as sprains, are also risks.

Awareness of the factors that can increase a person’s risk of injury while playing pickleball is crucial to knowing how to prevent those injuries. Some helpful steps every pickleball player can take include:

• Commit to always stretching while warming up before playing pickleball, and stretching while cooling down afterward. Regular stretching can help improve flexibility and reduce the risk of injury.
• Be diligent about the use of proper pickleball playing techniques. When available, take lessons from a qualified instructor to learn appropriate pickleball techniques.
• Avoid overuse injuries. Don’t play pickleball too often without giving your body enough time to rest.
• Use the right equipment. Wear proper shoes and use a paddle that is the right size and weight for you.

The sport of pickleball is an incredibly fun physical activity that people of all ages can enjoy. And while injuries can occur, knowing what they are and what causes them can go a long way toward preventing them from happening to you. If you have sustained an injury playing pickleball that hasn’t seemed to heal with conservative treatments such as rest and over-the-counter medication, be sure to see a sports medicine specialist.

By Natasha Trentacosta, MD

There are times when either heat or ice can be helpful in reducing pain and encouraging healing during the body’s recovery process from muscle pain or soreness. When it comes to the application of heat via heating pad, there are multiple health and safety considerations to make so that one can ensure they aren’t making the injury worse, prolonging recovery or introducing other bodily injury risks into the equation.

How does a heating pad work to help with sore muscles?

When muscles spasm and tighten, especially after an injury or vigorous exercise or activity, it closes or constricts the blood vessels. With delayed onset muscle soreness (DOMS) brought on by strenuous activity, the lactic acid produced gets further trapped by these constricted vessels. The application of heat in these cases, whether from a heating pad or hot bath, jacuzzi or shower, dilates the blood vessels in the area being warmed and increases blood flow, bringing cells to help heal the affected area. These blood cells get more oxygen and nutrients to the site and aid in eliminating the bad stuff (like lactic acid) from the affected area, which ultimately helps eliminate muscle pain and soreness. The application of heat can also facilitate the stretching and loosening of tight muscles, thereby helping to alleviate stiffness around joints. There is also a role that heat is believed to play in the gate theory of pain. Simply put, different nerves carry different messages (hot, cold, pressure, pain) from an area of the body to the brain. The brain puts all those messages together, and we then experience the sum of those messages as a sensation.

If heating pads can be helpful, what type is best?

Don’t get hurt! Heating pads can cause severe burns if they get too hot or stay on one body area too long. One of the safest heating pad types to consider is the disposable heating wrap or pad. These can be found in most drugstores and can be used for easy, convenient and safe heat therapy, which can be applied to almost any body region. Electric heating pads use household current to produce heat. Consider a heating pad that offers adjustable heat settings so you can start at a lower stage and increase as needed. Automatic shut-offs or preset timers are additional features to consider, especially if there is an undesirable chance of accidentally falling asleep with the heating pad on. Having a cover or some fabric between the device and your skin will also help to prevent burns. Moist heating pads use water to dampen the pad before placement on the skin. They can reach very high temperatures and are often used by physical therapists for heat therapy. It is best to avoid this type of heating pad for home use to not accidentally burn oneself.

Is it ever OK to fall asleep while using a heating pad?

Falling asleep while using a heating pad should always be avoided. Whether it’s heat or ice, there is no need to fall asleep with either on the skin as both can cause severe and disfiguring burns.

When applying a heating pad to any area of the body, how long is best?

Though there are no specific rules about the length of time to use a heating pad, it should stay on for about 10-30 minutes to be effective. If on for too short a time, the muscle or joint may not have an opportunity to warm up and experience pain-relieving benefits. Yet, leaving a heating pad on for too long can result in injury from burns and can potentially create a scenario of extreme inflammation. If using a heating pad with rest and over-the-counter medication isn’t alleviating your symptoms, be sure to see a sports medicine specialist.

By  Kenneth Jung, MD

From an anatomical standpoint, the Achilles tendon can be highly underappreciated until something goes wrong with it. This strong cord of fibrous tissue connects the muscles from the back of the calf to the heel bone in each leg, and it is used with every step you take.

Achilles tendon tears are most commonly seen in athletes – both professional and recreational, especially middle-aged weekend warriors. However, this is one orthopedic injury type that can happen to anyone.

Achilles tendon tears are classified into two categories – partial and complete. As these categories suggest, a partial Achilles tendon tear means that some tendon fibers have been damaged by injury. Still, the entirety of the tendon is not completely torn or separated from the undamaged portion. On the other hand, a complete tear means that the tendon has essentially “torn in two.” People who’ve experienced a complete tear usually experience more severe symptoms.

How long does it take to recover from a torn Achilles tendon?

The healing timeline for an Achilles tendon tear depends mainly upon the severity of the injury, the person’s age, and their overall fitness or activity level before the injury. In cases where the Achilles tendon was partially torn, and the intent is for the damage to heal itself, recovery can range from two to 12 weeks, during which there may be a need to wear a splint or boot. Physical therapy is typically prescribed during the recovery time.

In situations where the Achilles tendon was torn entirely, treatment options are nonoperative or operative. Achilles tendon surgery is usually performed as an outpatient procedure followed by several weeks in a walking boot or cast. Physical therapy is often initiated after surgery. Whether or not the tendon’s treatment was surgical, normal walking usually resumes in about three months. For those who play sports at an elite level, full recovery may range from six to 12 months. As is the case when fully recovering from any injury, patience is truly a virtue.

Can a person walk on a ruptured Achilles tendon? 

Again, the answer to this question can depend upon the severity of the injury. However, it is crucial to note that some people can still walk on a completely torn Achilles tendon. One notable example of this was Kobe Bryant, who walked to the free throw line, shot (and made) two free throws after tearing his Achilles. A qualified foot and ankle specialist should assess the injury, with specific examination protocols to diagnose an Achilles tendon tear and to assess its severity. Though some will walk on a torn Achilles, they will likely have extreme difficulty pushing off from the foot that is injured.

Can an Achilles tendon tear or rupture heal on its own?

The term “heal on its own” is a bit problematic in an Achilles tendon tear. While partial tears often “heal on their own,” a doctor should be consulted for diagnosis and guidance through rehabilitation.  Similarly, complete tears or ruptures should be evaluated and managed by a doctor. Whether nonoperative or operative treatment is selected for complete tears, a doctor will provide guidance and management throughout the rehabilitation process. So, while some Achilles tendon injuries can heal without surgical intervention, they all warrant proper medical care, ideally from a foot and ankle specialist.

By Jeffrey Zarin, MD

Osteoarthritis is a disease of the joints in the body whereby the cartilage in the affected joint degenerates or breaks down over time. Arthritis is narrowly defined as damage to the cartilage in the moving joints of the body that leads to mechanical and inflammatory symptoms. Of the many arthritis types that can affect the human body, osteoarthritis is the most common type and most frequently affects older people. Though the progression of osteoarthritis is often slow, it can be a painful and debilitating one for the people it affects. Fortunately, there are lifestyle alterations anyone can make right now that can slow its progression, so that people of all ages can maintain healthy and active lives.

The most common and clinically proven lifestyle approaches prescribed by doctors to slow the progression of osteoarthritis aim to decrease the inflammation created by the body in response to the damaged cartilage in the joints. Recommendations may include anti-inflammatory medications, ice, exercise, stretches, massage, diet, weight loss, acupuncture, herbal remedies, joint support and pain-relieving injections. Physical therapy is often prescribed to assist with implementing correct exercise techniques. Biologic injections, such as platelet-rich plasma (PRP) and stem cells, may also help to diminish the pain, swelling, stiffness and other symptoms of osteoarthritis inflammation, but their level of effectiveness has yet to be definitively proven.

Herbal remedies and supplements are intended to improve aspects of health that cannot be obtained through natural processes. Most supplements can be beneficial as long as they are used in moderation, but people should consider consulting with a doctor before self-prescribing. When supplements can help to diminish inflammation, then they can be of benefit. Studies show that glucosamine/chondroitin-containing supplements have anti-inflammatory characteristics similar to medications such as ibuprofen (NSAIDs) and are generally low risk. Anti-inflammatory products, such as cannabidiol (CBD) oils or herbal remedies (turmeric), have also been shown to diminish some of the symptoms of osteoarthritis. However, these supplements are often unregulated and can be unpredictable in how they affect each individual.

The two lifestyle factors that have repeatedly been shown to slow the progression of arthritis are interconnected: physical fitness and weight loss. I routinely encourage my patients to engage in regular low-impact exercises to help them maintain flexibility while strengthening the muscles around the affected joint. I also promote a healthy diet to keep excess weight off. Especially in patients who are obese, losing just a few pounds can take considerable force off the joints and improve the chances of slowing osteoarthritis progression.

Unfortunately, no current medications, injections or other lifestyle modifications will alter or change arthritis in a joint once it occurs. Certain injections, such as cortisone, have been shown in some studies to give short-term relief from symptoms but may increase the progression rate of arthritis.

It is often unpredictable how arthritis can affect a person’s quality of life. Some patients experience severe cartilage loss with bone erosion, deformity, bone spurs and mechanical symptoms, but have minimal inflammation and function quite well daily. Others have minimal joint damage but can have crippling inflammation severely compromising their ability to perform the simplest of tasks. I encourage patients to carefully consider how negatively they feel their quality of life is compromised related to their osteoarthritis symptoms. When patients believe that they have exhausted the nonsurgical treatments and are willing to undergo the process of surgery to replace the damaged cartilage in their arthritic joint, then they are usually extremely satisfied with the outcome of their surgery.

As an orthopedic surgeon, I aim to share in the decision-making process with my patients regarding surgery by listening carefully to their assessment of their current function, and quality of life compromise regarding their age and health. I educate them about osteoarthritis and explain the risks and benefits of joint replacement surgery related to their specific circumstances and health metrics. This process leads to good and meaningful decisions about surgery, which more frequently lead to excellent outcomes and, ultimately, healthier joints and happy patients.