Meet Victoria

Victoria_RC.JPGIt’s National Athletic Training Month!

Meet our Athletic Trainer Victoria Stanislawski.

Victoria received her undergraduate degree in Athletic Training/Health Education from Kean University and her master’s degree from the University of South Carolina. As a graduate assistant, she worked as a Certified Athletic Trainer for the USC cheerleading and equestrian teams. She also served as a physician extender to two of USC Sports Medicine’s orthopaedic surgeons.

Victoria completed The Steadman Clinic’s Athletic Training Fellowship program in 2013. She is a board-certified orthopaedic technologist and licensed surgical assistant. She enjoys hiking, cycling, snowboarding and volunteering with the US Ski and Snowboard Association.

Why does she love what she does?

“My workday is never the same!  I’m able to evaluate patients clinically, assist in their surgical intervention and watch them progress in their rehabilitation, ultimately returning to sport.  The human body is an amazing machine and I continue to learn clinically and within surgery with Dr. Cunningham’s guidance.  I’m able to enhance my skills through continuing education, utilizing evidence-based practice centered on current medical and scientific research.  This career allows me to connect with amazing people.  The moments of heartfelt appreciation from patients who are able to return to century rides, climb Mt. Everest, ski 500,000 vertical feet or simply return to their weekly yoga routine because of the efforts of our team makes the late nights, early mornings and long days worth it.  These are the moments that make me love being an Athletic Trainer!”

 

 

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Meet Matt!

It’s National Athletic Training month and a great time to shine the spotlight on our terrific athlematt vinnaltic trainers. Today, you’ll meet Matt Vinnal.

Matt earned his undergraduate degree in Athletic Training from Rowan University in Glassboro, NJ, and his master’s degree in Advanced Athletic Training from the University of Hawaii at Manoa in Honolulu. He moved to Colorado in 2010 and participated in a physician extender fellowship. He later moved to Michigan and helped a sports medicine physician start his practice. Wanting to return to the mountains, he moved back in 2013 to work with us. We’re glad he did. Thanks, Matt for all you do!

First published in Summit Daily

IT BAND

Q: I am a runner and I think I have IT band tendonitis. What can I do for it?

Iliotibial band (IT) syndrome is a common cause of pain on the outside or lateral side of the knee. I see it commonly in my patients who are runners and cyclists or in athletes doing a sport where the knee undergoes repetitive flexion and extension.

The IT band is a dense fibrous band of connective tissue that runs all the way from the lateral side of the pelvis down to the lateral side of the knee. The IT band acts to either extend or flex the knee depending on what angle the knee is positioned in, while also providing some added stability to the knee.

With sports such as cycling or running where there is repetitive flexion and extension of the knee, there can be friction between the IT band and a bony bump off of the side of the knee called the lateral epicondyle. This friction phenomenon causes inflammation of the IT band at this location. When the knee is at about 30 degrees of flexion, the impingement of the IT band on the lateral epicondyle is most severe, and not surprisingly, this is the position the knee is usually in when most runners experience sharp pain. In a runner, the knee typically comes into this position just after their foot contacts the ground. Cyclists typically spend less time in this impingement zone than do runners. Thus, this condition is more common in runners than cyclists.

As for risk factors, runners who run uphill, downhill and at a slower pace spend more time in this impingement zone and can therefore be more symptomatic. Excessive stride length and running longer distances can also make the condition worse. Someone who is bowlegged or flat footed or has weak hip abductors is also more prone to develop this condition as all of this leads to increased resting tension in the IT band.

In the office, patients with IT band tendonitis have pain over the lateral side of their knee just above their joint line. Oftentimes, I can feel some crepitus or “creaking” as I palpate this area and move the knee. Usually there is a significant contracture of the IT band on physical exam. The quadriceps are often tight as well.

In the office, I obtain a radiograph of the knee to be sure there is no knee arthritis or other conditions that could be contributing to the lateral-sided knee pain. An MRI is usually unnecessary but in cases where I have them to review, they typically show thickening of the IT band with a fluid collection deep to it.

As for treatment, I am a big fan of an IT band foam roller. This is a good way of stretching out and mobilizing the IT band. Rolling out the gluteal muscles is also helpful. I also send patients to physical therapy. Runners are naturally more dominant in their quadriceps and hip flexor musculature, so it is critical when not running to have these athletes strengthen the opposing muscle groups, namely the gluteal and hamstring muscles and also core musculature. Occasionally, I will inject a steroid medication around the IT band for recalcitrant cases or to get an athlete through a big upcoming event such as a marathon. Utilizing a running coach for a few sessions can also be helpful. In some refractory cases, surgery may be required to eliminate the condition.

Dr. Rick Cunningham is a Knee and Shoulder Sports Medicine Specialist with Vail-Summit Orthopaedics. He is a Physician for the U.S. Ski Team and Chief of Surgery at Vail Valley Medical Center. 

coffee_rc

Does caffeine increase athletic performance? Caffeine is a stimulant, after all. And yes, according to a recent study by The American College of Sports Medicine, moderate doses of caffeine do in fact increase athletes’ performance.

Interestingly, the Olympics do not ban caffeine but student athletes may be disqualified by the National Collegiate Athletic Association (NCAA) if their urine contains more than 15 mcg/mi of caffeine. To put that into perspective,  one would have to consume 17 caffeinated soft drinks to reach that level. That’s a lot of caffeine!

More about the study 

 

Fit and function of your knee brace is important. Learn how to properly install and operate your brace after surgery.

Watch the video

knee brace overview

There are certain injuries that differ between male and female.  In my office, I tend to see more women with shoulder instability or shoulder subluxations. For example, a young female athlete such as a volleyball player may come in with a shoulder that can slide partially out of the socket, which is called subluxation. Generally, they have not had a major injury to cause the condition. In contrast, I probably see more males who dislocate their shoulders but this is due to a traumatic injury such as a major fall in the terrain park.

Dr. Cunningham with knee patientAnother notable difference is with ACL tears. Women are more at risk for an ACL tear. This is due to several factors but mostly neuromuscular. When landing, women tend to land in a knockneed alignment. They also land with their center of gravity behind their knee (“landing in the back seat”). These positions can place greater force on the ACL and cause it to tear. Women’s ACLs are also generally smaller in diameter than males and their tissues are generally more lax creating a predisposition to tearing the ACL. And finally, the intercondylar notch at the end of a female femur is narrower and can more easily pinch the ACL in sports and predispose it to tear. Some question whether there are hormonal factors at play but this is unproven.

Tibial Plateau Fractures

Tibial plateau fractures are common ski injuries. On a given winter weekend of taking orthopedic emergency room call, I will see several of these on average. Patients usually describe a sudden twisting type force to the knee while skiing and may also report hearing or feeling a pop, and having swelling and pain.

Tibial plateau fractures are fractures of the top part of the tibia or lower leg bone. The knee joint is made up of the bottom end of the femur gliding on the top part of the tibial plateau. The top of the tibia and the bottom of the femur are covered in white, articular cartilage, much like the cartilage on the end of a chicken bone. When one fractures the tibial plateau, they not only break the bone of the tibia but also crack this white coating cartilage. This is what makes these injuries more severe than simply breaking the mid shaft of the tibia or a so called “boot top fracture.”

Depending on the amount of energy that caused the fracture and the age of the patient and relative density of one’s bone, the tibial plateau can break as one clean split, or in worse cases, the cartilage and bone can be splintered into many small pieces. I typically see split fractures of the tibial plateau in young patients, whereas in older patients, the bone and cartilage are typically more depressed and in multiple fragments. However, it is not uncommon to see a young person suffer a terribly depressed and multi-part fracture of the tibial plateau from landing a big jump “flat” in the terrain park. In these cases, patients can fracture both the medial and lateral tibial plateaus. In these high energy fractures, there can be severe associated soft tissue, nerve and even blood vessel damage and some of these injuries are limb threatening.

In the emergency room, we obtain xrays but once the diagnosis of a tibial plateau fracture is made, then a thin cut 3D CT scan of the knee is obtained. This shows in detail all the fracture lines and the amount of displacement of the bone fragments.

If there is not too much soft tissue swelling, these fractures can be surgically repaired right after the injury. In surgery, an incision is made over the fracture site and the fractured fragments of bone and cartilage are re-aligned as best as possible and are then held in place with a low profile, anatomically contoured metal plate and screws that lock into the plate at fixed angles. There is typically voids left in the bone due to the bone being compressed and then lifted back up into place in surgery and these bone voids are filled with cadaver bone which provides a latticework over which the patients bone can grow. Patients can have associated meniscal tears that are also repaired at the time of surgery.

Patients are usually in the hospital for a few days for pain control, nursing care, and physical therapy. In most cases, the patient cannot put any weight on the knee for at 8-12 weeks or else the bone and cartilage fragments might be pushed back down and displace once again. During the first 8 weeks, physical therapy is critical in order to start knee range of motion and prevent stiffness in the knee. Patients are also placed on a blood thinner medicine to prevent blood clots from forming after surgery.

Long term, patients can do reasonably well but there is an increased risk for having some residual stiffness in the knee. Some patients with more severe fractures may develop posttraumatic arthritis and associated pain and swelling. However, many patients are able to resume many of the activities that they enjoy once they heal their tibial plateau fracture and get their strength back.

platelets

Many of my athlete patients are asking me about PRP injections and whether they work. Platelet rich plasma (PRP) has been used to treat dermatologic and maxillofacial conditions since the 1950’s, but only recently has it been used to treat orthopedic conditions.

What is PRP?

PRP is a sample of ones own blood where the concentration of platelets is above baseline amounts. Platelets are cells found in our blood which work with coagulation factors to stop bleeding. When a sample of ones blood is placed in a test tube and then centrifuged, the liquid and solid components of blood separate. The plasma and platelets are separated from the heavier red blood cells and white blood cells. The platelet and plasma portion is then isolated. This mixture contains higher concentrations of growth factors such as platelet derived growth factor, endothelial cell growth factor, and other growth factors. Investigators have postulated that by concentrating and injecting these growth factors into injured tissue, that the healing potential of that tissue will be improved.

There are dozens of commercial systems available to physicians to prepare PRP. However, the final platelet concentration depends on many factors, including the commercial system used, the initial volume of whole blood used, and patient age to name a few. Moreover, a higher number of platelets does not necessarily lead to improved tissue healing. The phase of healing and the timing of PRP administration are also important predictors of success. Because no two samples of PRP are exactly the same, it is difficult to study PRP and compare results in one study to results in another study on PRP. This muddies the water a bit when trying to draw conclusions about the effectiveness of PRP on tissue healing.

Is it effective? 

In the office, I commonly see patients with various degrees of knee or shoulder arthritis. Some patients ask me if PRP injections will help reverse their arthritis or at least reduce their pain levels. Most studies show no additional benefit of injecting PRP over giving hyaluronic acid injections for the treatment of knee arthritis. Furthermore, it is important to remember that most insurance plans cover hyaluronate injections whereas they do not cover PRP injections in an office setting. Thus, patients are often stuck paying thousands of dollars for PRP injections when the data would suggest that there may be no added benefit over HA injections. Furthermore, the American Academy of Orthopedic Surgeons recently came out with a position statement which states that they are “unable to recommend for or against growth factor injections and/or platelet rich plasma for patients with symptomatic osteoarthritis of the knee.”

In the lab, PRP has been shown to promote bone healing and bone growth. However, the results of PRP in treating patients where bone growth is desired have been less successful. For example, spine surgeons have tried to use PRP to help increase their spinal fusion rates, but PRP does not seem to confer any benefit in spine fusion rates.

PRP does seem to have a role in the treatment of some patients with chronic tendonitis. Studies comparing PRP to steroid injections for tennis elbow have shown that patients injected with PRP have more sustained and added benefit. Studies looking at injecting PRP for achilles tendonitis did not show the same added benefit.

PRP has been studied in patients undergoing rotator cuff repair in the shoulder. The thought is that PRP may improve healing rates of the rotator cuff tendon back to bone. The results of studies are mixed, but most studies have shown no difference in healing rates when PRP is added. The same findings have been shown in patients undergoing Achilles tendon repair, with no significant improvement in healing seen in patients injected with PRP after undergoing an Achilles tendon repair.

Enhancing tissue healing with PRP and concentrated growth factors is an exciting area of clinical research. However, the current indications for PRP injections are limited with questions remaining about its efficacy and also concerns for cost to the patient.