Back in Action After a Pandemic

Welcome to the Unwind Audio Podcast, a joint production of the International Monetary Fund and the George Washington University Hospital. I'm your host, Dave Liss, IMF staff contributor. In this episode, we'll discuss sports injuries, including how to prevent, treat, and manage them. Today, we are joined by 3 sports physicians from GW Hospital in Washington, D.C. They are Dr. Mark Chodos, who specializes in foot and ankle injuries and conditions, Dr. Anthony Zimmer, who specializes in the shoulder and elbow, and Dr. Theresa Doeray. Dr. Doeray is GW Sports Medicine Lead and specializes in hip preservation and treating sports injuries. The doctors will now introduce themselves.

Hi, my name is Marc Chodas. I'm an orthopedic surgeon and an assistant professor of orthopedics at George Washington University. I specialize in foot and ankle orthopedic surgery. I went to medical school at UCLA, did my residency at Johns Hopkins Hospital, and then did an additional year of training in just foot and ankle orthopedics at Union Memorial Hospital in Baltimore. My interests include foot and ankle sports medicine, arthroscopy, tendon and ligament repair and reconstruction, and treatment of cartilage injuries and osteochondral defects. I also do quite a bit of foot and ankle reconstruction including complex deformity, limb salvage, and arthritis.

Hi, I'm Theresa Duret. I'm an orthopedic surgeon and assistant professor of orthopedic surgery at the George Washington University Hospital. I specialize in sports medicine and arthroscopic surgery including injuries of the shoulder, elbow, hip, and knee. I went to medical school at New York Medical College, did my residency at Albert Einstein Medical College of Medicine and Montefiore Medical Center. And then I completed a sports medicine fellowship at the University of Texas Houston, where I had the opportunity to work as an assistant team physician for the Houston Texans, Rockets, Astros, Dynamo, and University of Houston. My practice focuses on knee ligament reconstruction and cartilage restoration. My interests also include any arthroscopic surgery and the use of orthobiologics.

Hi, I'm Zachary Zimmer. I'm an orthopedic surgeon at the George Washington University Hospital. And an assistant professor of orthopedic surgery at the George Washington University School of Medicine and Health Sciences. I received my medical degree from Stony Brook University School of Medicine in New York. I then completed an orthopedic surgery residency at the University of Pennsylvania, followed by a shoulder and elbow fellowship at Massachusetts General Hospital in Boston. My surgical specialty focuses on conditions affecting the shoulder and elbow, including rotator cuff injuries, osteoarthritis, shoulder instability, biceps tendon injuries, and elbow tendinopathies. I perform procedures ranging from arthroscopic procedures to shoulder replacements to complex tendon transfers.

Welcome, doctors. Can you frame the physical health environment for people in the United States as it relates to your respective practice areas? And what percentage of Americans are suffering or will suffer in the future from conditions injuries that you treat?

Mark Chodas here. So sports-related injuries, if you look at sports, exercise, and recreational-type activities, extremely common. Going back before the pandemic to 2019, there were around 3.4 million emergency room encounters just for sports and recreational injuries, and that doesn't really include the medical care that people got, say, in the office or other environments, or things things that were self-treated. There's a very wide range in severity from very minor self-limiting problems all the way up to major injuries and death. If you look at sports, the main sports that account for injuries are basketball, cycling, and football. To some degree, that's related to the absolute number of people participating in those. So they're just very popular sports in this country. The highest rate of injury would be in cycling, which is almost double that of basketball and probably 5 times that of American football and soccer. I would say during the pandemic, we saw a drop in organized sporting injuries. And then with the release of the vaccination and people starting to come out again, there's been probably a pretty sizable increase in things that are related to inactivity and then sudden changes. So for instance, in a few-week period, I saw a whole bunch of Achilles tendon injuries as people started playing basketball again that weren't playing in leagues for the prior year. So it's been an interesting dynamic over the last few years.

How has the global pandemic exacerbated various health problems? Are there any overall trends?

This is Zach Zimmer. Unfortunately, as a result of the pandemic, there were certain conditions that had fewer patients being diagnosed because they were afraid to either go to the doctor or go to the hospital, including heart attacks, and cancer diagnoses, orthopedic conditions were not immune. Although most of the conditions will resolve over time and it didn't affect most of the patients, there are some conditions that require urgent treatment, or if they're gonna be treated surgically, they are much better treated in a more timely manner. For me, some patients who I've treated in the past few months had a surgical procedure that wound up being a little bit more complicated than it would have been. A patient of mine had a traumatic rotator cuff tear that became retracted and much more difficult to repair surgically 6 to 7 months after the initial injury, as opposed to if we had treated it 1 to 2 months after surgery.

Mark showed us here, I think also in orthopedics, there's an interesting dynamic between anatomy and environment. And with the pandemic and sheltering at home, there was a dramatic change in the environment for many people. At home, a lot of people walk around barefoot and normally don't spend all that much time in the scheme of things at home, but now you have people spending the entire day walking around on hardwood floors barefoot. And the things that I see a lot of related to that would be plantar fasciitis, foot pain, insertional Achilles problems that are related to the change in the angle of the foot, the way it's sitting without a shoe versus the elevation from a shoe. I think a lot of people think of the pandemic as a time where you stop exercising and you start eating and gain weight, but there was a large group of people that took it on themselves as a time to start exercising or to change what they were doing before. So maybe the gym's not open, but I'll start jump roping. And I saw a lot of injuries related to sudden changes and increase in activity, switching to higher impact things like jogging outdoors or sporting endeavors like jump rope that maybe was great when they were 13 years old, but at 55 didn't work out so well.

This is Theresa DeRay. I've noticed the same thing as well in regards to patients picking up activities that they didn't normally do. With COVID shutting down gyms, patients have begun doing activities like Marc said, which are higher impact and especially jogging. And so because of this, I saw an increase in runner's knee and patellofemoral pain, which is a very common non-operative injury that affects patients and involves pain in the front of the knee with patients jumping back into running and trying to increase at a rate that's a little bit faster than they should be. A lot of patients were affected by this. And so during the pandemic, I spent a decent amount of time counseling patients on symptomatic management for these types of injuries.

What are the most common conditions and injuries you treat surgically in your respective practices?

This is Theresa Duret. One of the most common injuries that I see patients for in my practice that I manage surgically are ACL tears. And along with ACL tears typically go meniscal injuries. This is usually an injury that's a non-contact injury, but around DC, I've seen all kinds of injuries ranging from non-contact injuries while playing sports such as volleyball, basketball, and football to injuries that are traumatic in nature and are related to motor vehicle accidents and also traumatic injuries such as falls. For young active patients and even patients who are older who are interested in staying active, we do recommend ACL reconstruction. And I often just have that discussion with patients about the risks and benefits of surgery and a discussion about what their goals are and what they'd like to return back to. So it's definitely one of the most common injuries that I see surgically in my practice.

Mark Chodas here. I would say in the foot and ankle world, if you look across all sports and the most common injury, it's going to be an ankle sprain or the associated constellation of things that look like ankle sprains. I get quite a few ankle sprains, some sports-related, some not, but we're seeing an increase in these as people are starting to get back outdoors again and do stuff. Many of these can be treated non-operatively and some are very self-limiting and require no care by a doctor or anyone else. And other injuries look maybe like an ankle sprain and are actually much worse and require surgery. I think it's important if you are having trouble bearing weight or severe swelling or bruising, having trouble moving the joint. If things are not getting better, it's really important to, to be evaluated and make sure that there's not something that needs more done. Sometimes even bracing, immobilization, or a bit of physical therapy will make all the difference, but there are some things that you don't want to miss that need to be taken care of surgically.

This is Zach Zimmer. In my shoulder and elbow practice, the most common pathology that I see has to do with the rotator cuff. Whether that is rotator cuff tendinitis or rotator cuff tear. Patients typically come into the office complaining of pain around the shoulder that is worse with overhead activities, pain with lifting objects, and also pain at night. Initially, for rotator cuff injuries, we treat this non-operatively with activity modification, physical therapy, anti-inflammatories, and cortisone injections. Oftentimes, patients can do quite well with these modalities. However, if patients continue to have pain or significant dysfunction despite these modalities, then it's time to consider getting an MRI. And if it shows a rotator cuff tear, then the patient and I have a discussion about possible surgery. Another important point that patients raise is, how often can I get a cortisone injection? And it's an important question because Although 1 or 2 cortisone injections spread out over a period of time really should not have much of a negative effect, multiple cortisone injections over a short period of time can have some negative effects to the quality of the rotator cuff tendon or other surrounding tissues. So it's important to take that into consideration when considering cortisone injections.

Could you speak to the growth of injuries from scooter riding? In the city?

Hi, this is Theresa Duree again. Yes, I think we can all agree that respectively in each of our practices, we've definitely seen an increase in injuries as a result of the scooters. I personally have tried them and also enjoy them and think they're fun and a great way to get around. But I do think it's important to exercise some caution with using these. They do go up to high speeds, and a lot of the injuries I have seen have involved the transition on uneven surfaces. I've seen CL tears, shoulder separations, shoulder dislocations, and all of us take call at George Washington University Hospital, which is a level 1 trauma center, and I know we've all seen our fair share of traumatic injuries and broken bones from the scooters as well. My message would just be to enjoy them, but be careful and just know that there are some risks involved with using them.

So, Mark Chodas here. From the foot and ankle perspective, one of the more common things I've seen from scooters are high ankle sprains or syndesmotic injuries. Unlike the average ankle sprain where your ankle goes inwards or your foot goes inwards, with these on the scooter, as people start to lose balance and go to put their foot down and they're still moving forward, they externally rotate around the foot and end up tearing the ligaments between the shin bone and the fibula bone on the outside. Most of that ends up being a surgical problem. My personal feeling is proceed with caution. There is definite risk. They're not as benign as many people think.

This is Zach Zimmer. I agree with Drs. Chodas and Doray. In terms of my practice, I've seen things from a shoulder sprain to complex proximal humerus fractures about the shoulder. So I echo Dr. Doray's comment of enjoy them, but definitely be careful.

What physical health problems and injuries or prospective injuries can be addressed through prevention? What is the role of exercise and sleep, diet, nutrition with regards to prevention and recovery?

Mark Schottis here. So I would say just in general, when you're talking about sports and exercise, there's a lot of basic things that can be done. It's really important depending on what the sport is to use sport-specific protective gear. So on a bicycle, for instance, using a helmet, roller skating, using pads. Most sports will have some type of a gear protective stuff that should be used. In the National Capital Region, especially during the heat and humidity of the summer, it's really important to stay well hydrated. If you're out there for a long time replenishing more than just water, you need to make sure that the salts and electrolytes that you're losing get replenished as well. I would say just general things in terms of the body. So the musculoskeletal system is very expensive to maintain for the body metabolically. So it's going to adjust the strength of the bones and the tendons and the ligaments relative to the forces that it sees. So if you make a sudden change in activity and don't give your body a chance to adjust to that new level, that's where you really set yourself up for some of these weekend warrior type injuries like Achilles tendon tears and such. I think the others can talk a little bit more about overuse injuries, but it's very important to build in rest days, cross-training in your regime, spending some time warming up, especially before a strenuous game or event. I think some sports, especially ones that are high risk for ankle or knee problems, there's pretty good evidence of prophylactic bracing can be helpful for preventing injury, especially if you've had prior injuries to that body part. Before.

Hi, this is Theresa DeRay, and I definitely want to piggyback off of Dr. Chodos' answers. I agree 100% with having diversity in workouts. I spend a lot of time encouraging patients to have diversification between high and low-impact exercise and to also cross-train and incorporate strength training into a part of their exercise routine. I think this definitely goes a long way in preventing injuries. Another thing that I counsel patients on often, especially coming off of an injury or if they're embarking on a new exercise program, is to just take things gradually, to build up, to give yourself rest days, and to just gradually increase what you're doing. If you try to jump into things too quickly, it can often lead to overuse injuries. But if you do things in a stepwise progression and you listen to your body as you're moving forward, You can definitely prevent a lot of overuse injuries by using some of this.

Hi, this is Zach Zimmer again. I agree with Drs. Troodos and Dorey. Just as important as preventing injuries is the prevention of recurrent injuries. And I think one of the best ways to do this, especially for those patients who have done a course of physical therapy, is to continue physical therapy by doing home exercises after your formal therapy has ended. I tell patients all the time that doing home exercises is analogous to getting a new car and routinely changing the oil. It's important to maintain the gains that you achieved in therapy to help prevent you from reinjuring yourself in the future.

How should people consider managing pain for their various conditions?

Hi, this is Theresa DeRay. When it comes to managing pain for musculoskeletal injuries, one of the things that we often recommend are the use of anti-inflammatory medications such as ibuprofen or naproxen. A common concern I hear from patients in the office is that they don't want to mask symptoms and risk making an injury worse. I think when it comes to using these medications, if you are experiencing some mild pain or you're symptomatic after having a longer workout and you're experiencing some soreness, I think using these medications for symptomatic relief, especially if it's causing discomfort that's keeping you up at night or soreness that's interfering with your day, using medication can be really helpful along with ice and rest. When it comes to treating pain, I think the important thing to keep in mind is if you're using it for symptomatic management, it can be helpful in the short term. But if you're having increasing pain or pain that's not resolving, that's really the time when you shouldn't be trying to cover up the symptoms anymore. So I think trying it in the short term and seeing if your symptoms are improving is definitely something that's not necessarily dangerous and can be helpful. For your comfort overall. But if you're having persistent pain or you're experiencing swelling around a joint, that's the time, you know, when it's important to see an orthopedic surgeon or sports medicine specialist.

What new technologies, treatments, or innovative surgical procedures are you most excited about related to your respective practice areas? And when do you think that the average person will be able to have access to these treatment modalities.

So, Mark Schottis here. I think in foot and ankle orthopedics, there's just a wealth of advancement going on all the time. Many of these things are already available for everyday use. We have much better fixation options, both for bony problems and also ligament and tendon issues. These things allow us, because the strength of our surgical repairs are so much better, we can get things moving a lot quicker and really speed up the recovery process. We have better ankle replacements now than we did before. It takes time to see how well these things work, but we're now on our fourth generation of ankle replacements, and we're seeing things that are starting to compare to some of the hip and knee literature. There's been a big push in the last few years on what we call MIS, or minimally invasive surgery in foot and ankle. So, Things that used to have to be done through sizable incisions can now be accomplished through small poke holes, and it leads to less pain and less scarring and quicker recovery. We're also seeing some advancements in cartilage grafting and taking care of cartilage problems. I think Dr. DeRay is going to talk a little bit more about that.

Thanks, Mark. This is Theresa DeRay again. Yes, cartilage restoration is a really exciting part of the field and something I really enjoy working with. With cartilage restoration, what we're usually discussing with patients, one, is when cartilage restoration is appropriate. And when we discuss this, what we're talking about are focal injuries to the cartilage inside the knee. When a condition including damage to the cartilage has already progressed to being very diffuse and throughout the entire joint, then it's usually too advanced for us to use cartilage restoration techniques. But if there's one or two areas inside the joint where there's been loss of cartilage, we can employ several techniques that include grafting cadaver or donor bone and cartilage. We can use a patient's own bone and cartilage from a non-weight-bearing area and transfer that to another area. And then we can even take a biopsy of cartilage and the cells can be grown in a lab, implanted in a membrane, and that can be transferred later for restoration of cartilage. One other area that's really exciting is the field of orthobiologics. There's a lot of excitement about this, and there are a lot of things on the market that people hear about, like platelet-rich plasma and stem cells. And what I think is really exciting about this is that it holds a lot of potential, but I think it's really important to have an honest conversation about what these biologics can accomplish and what are realistic expectations. So that's something that I have a discussion with patients about in the office in terms of understanding when they have a condition that's appropriate to use this for, what they can realistically expect to improve with this, and whether or not it's appropriate.

Hi, this is Zach Zimmer. One thing in the shoulder and elbow world that is quite exciting is the use of augmented reality in the settings of total shoulder replacements. The placement of the components during a total shoulder arthroplasty or a total shoulder replacement can be quite critical in maintaining the longevity of the prosthesis. And this is really critical for patients who are developing arthritis at a younger age. And what augmented reality allows us to do is to use a CT scan preoperatively of the patient and allows us during the time of surgery to put the components in the exact position that we think will give the patients the best chance of long-term implant survival. Because we want to allow these implants to last as long as possible and to reduce the risk of a revision surgery down the line. And this technology hopefully will become available within the next few years.

This is Mark Chodos. I'd like to also jump in on what Dr. Durai was discussing before with some of the biologics and ancillary things that are out there. Many of these things are not covered by insurance and are cash pay things. I agree, it's incredibly important to look at the literature and the evidence that supports their use and whether they are reasonable to use for that particular problem. It's not uncommon, unfortunately, for me to see people who are either in the process of having multiple different office procedure injections or like a high-energy or low-energy extracorporeal shockwave, various things that can be done in the office if you have the right equipment for a price. And sometimes those things are very reasonable, but there's Other times where it's, it's so far down the road, someone's just taking money that could not necessarily be needed for something like that. So I think you always have to have some question about the utility of these things and how that relates to the particular problem that it's being recommended for.

That is really great advice. If people know nothing else about your respective medical practice areas, managing, treating, and preventing their own physical injuries, what are the most important concepts that people should understand?

Mark Chodas here. I think probably across the board for all of us in the sports-related injury realm, it's really important to not be that weekend warrior. I think you really need to maintain and reach some level of fitness that's appropriate for what you're planning on doing. Going out there once a week or every few weeks and going all out is just a recipe for disaster. In terms of training, I think it's important to have a very planned, precise approach. I think it's important to sit down even with a calendar and write out what your goal is that's realistic and reasonable as you build up your activity and then stick to it and also be willing to modify that plan if you're starting to get aches and pains and your body needs a little bit of extra rest. From the foot and ankle standpoint, if I could give one piece of advice, it would always be to wear some type of shoe wear around the house. So the house is unfortunately an extremely dangerous place. I see tons of people that come in with toe fractures, toe dislocations where they're walking around barefoot and catch the toe on the threshold to the door or the side of the bed, and a lot of that stuff is preventable by having something on the foot, even a thick flip-flop, so that there's a little extra protection for those little toes out there.

This is Zack Zimmer. One message that I'd like to let patients know, especially those coming in with the common condition of shoulder pain related to the rotator cuff, is that even patients who have rotator cuff tears, this does not automatically mean surgery. For patients who come in with degenerative tears, which are tears that happen just due to regular wear and tear that accompanies us as we age. Very often patients can do well with activity modification, anti-inflammatories, and physical therapy. Only patients who fail these modalities are the ones that I then get an MRI on, and if an MRI shows a large tear, then we have a discussion for surgery. And again, even at that time, the decision for surgery is up to the patient after a thorough discussion of both the risks and the benefits. I often have patients come in for an initial visit who had an MRI ordered by their primary care physician and they see the diagnosis of a rotator cuff tear. And my job at that point is to tell them, no, you do not need surgery. Let's try the least invasive treatment first, which is always activity modification, physical therapy, and some anti-inflammatories.

I agree with both Dr. Zimmer and Dr. Chodos. This is Theresa Durey, and I want to piggyback off of some of the answers. I think one of the things I see that I want patients to understand is that not every injury is created equal. My example for this is meniscal tears. It's a very common injury. A lot of patients have it. But not every meniscus tear is created equal. There's a lot of things that influence our decision about how we treat meniscus injury. And that comes down to a discussion about what the patient's symptoms are, what their imaging looks like, and what their goals and objectives are. There are times where there are meniscus tears that should definitely be treated with repair. And in that case, the recovery is a lot longer. But by far, the more common thing in the US is that patients undergo treatment called meniscectomy where part of the meniscus is removed, and that has a very quick recovery. Sometimes when patients are talking about injuries with family members or people at work, everyone loves to compare stories and they get worried that they're not doing as well as someone else. I spend time counseling patients to let them know your injury is different. This is something that may require repair. It takes a longer time to recover and that's okay. And it's just an injury that has the same name, but comes in a lot of different flavors. And we, in medicine and in general, it's a dynamic field and we respond to what we see. I think that's really important for patients to understand about injuries is just that they're not all created equal. We just respond to the different challenges and the uniqueness of each patient's situation and expectations.

Thanks so much for your time and insight, Drs. Chodos, Zimmer, and Dore. This has been a great discussion, and it's a real privilege to have the opportunity to speak with all of you. Thank you to the audience for listening to this podcast, a joint production of the International Monetary Fund and the George Washington University Hospital. If you are listening and want to connect with the staff at GW Hospital, you can visit the hospital website at gwhospital.com or call 888-4-GWDOCS to make a virtual or in-person appointment. Again, I'm Dave Liss, wishing you well From our studio here in Washington, D.C. In Washington, D.C. In Washington, D.C. In Washington, D.C.