O Rthopaedic Digest

O rthopaedic DigestA Publication of the Orthopaedic Clinic of Daytona Beach, P.A. Volume 2

Inside This Issue�� Osteoporosis

�� The BIRMINGHAM HIP™ Resurfacing System

�� Tears of the Meniscus in Athletes

�� Shoulder Pain

�� Surgery

�� Arthritis

�� Joint Disease

�� Hand Disorders

�� Carpal Tunnel

�� Birmingham Hip Resurfacing

�� Shoulder Problems

�� Reconstructive Surgery

�� Total Joint Replacement

�� Unicondylar Knee Replacement

�� Foot Disorders

�� Spine Surgery

�� Kyphoplasty

�� Osteoporosis

�� Fractures

�� Back & Neck Pain

�� Soft Tissue Injuries

�� Sprains

�� Bone Density Studies

�� Second Opinions

�� Physical Therapy and

Rehabilitation

Learn about Minimally Invasive Surgeries, General

Problems, Child and Adult Orthopaedics, Pain

Management and much more with our articles, videos and interactive virtual joint replacement surgeries

Visit us online at

www.ORTHODB.com

WelcomeOrthopaedic Clinic of Daytona Beach - Total Orthopaedic Care Since 1961

General Orthopaedic & Spine Care Sports & Adult Reconstruction Specialists Providing Surgical & Non-Surgical Treatment. Radiology Services Available at All Locations.Main Office:

1075 Mason Ave.Daytona Beach, Florida

(386) 255-4596•

Physical Therapy:(386) 252-5534

•Palm Coast Office

4 Office Park Dr., Pod #1Palm Coast, Florida

(386) 255-4596•


•Twin Lakes Office

1890 LPGA Blvd., Suite 240

Daytona Beach, Florida(386) 255-4596

•Physical Therapy:

(386) 274-1244•

Port Orange Office1165 Dunlawton Ave.,

Ste. 102Port Orange, Florida

(386) 255-4596•


•Our Physicians:

Dr. Thurman Gillespy, Jr.

Dr. Gilbert A. Martin, Jr.

Dr. Albert W. Gillespy

Dr. Mark C. Gillespy

Dr. Malcolm D. Gottlich

Dr. James M. Bryan

Dr. Brian R. Hatten

Dr. Jeffrey W. Martin Dr. Todd A. McCall

Orthopaedic Clinic of Daytona Beach’s Magazine is designed and published by Custom Medical Design Group, Inc. To advertise in an upcoming issue please contact us at: 800.246.1637 or visit us online at www.CustomMedicalMagazine.com This publication may not be repro-duced in part or whole without the express written consent of Custom Medical Design Group, Inc.

Osteoporosis ........................................................................................................................................................................... 5

The BIRMINGHAM HIP™ Resurfacing System: ............................................................................................................. 7

The Rewards and Risks of Total Hip Replacement .................................................................................................... 8

Tears of the Meniscus in Athletes ................................................................................................................................... 10

Meet the Physicians ............................................................................................................................................................. 12

Physical Therapy .................................................................................................................................................................... 14

The Five Rules of FITNESS .................................................................................................................................................. 15

Knee Injuries ............................................................................................................................................................................ 18

Hip Fractures In The Elderly .............................................................................................................................................. 20

Shoulder Pain ......................................................................................................................................................................... 22

Contents

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Daytona Beach1320 Mason Ave.Daytona Beach, FL 32117386-258-0401

Orange City938 Saxon Blvd., Suite 103Orange City, FL 32763386-775-1266e-mail: [email protected]

The Insurance Specialist for all of your Commercial,

Employee Benefits, and Personal Needs.

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Fax: (386) 760-8949Lic/Cert: #130471000 Medicaid, Medicare120 Beds/Units

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steoporosis is a silent disease until it is complicated by fractures – fractures that can occur following minimal trauma. Fractures and their complications are the relevant clinical sequelae of osteoporosis. The most common fractures are those of the vertebra (spine),

proximal femur (hip), and distal forearm (wrist). However, most fractures in older adults are due in part to low bone mass, even when they result from considerable trauma.

Osteoporosis-related fractures create a heavy economic burden, causing more than 432,000 hospital admissions, almost 2.5 million medical office visits, and about 180,000 nursing home admissions annually in the United States. The cost to the health care system associated with osteoporosis-related fractures has been estimated at $17 billion dollars for 2005; hip fractures account for 14 percent of incident fractures and 72 percent of fracture cost.

Osteoporosis can be prevented and can be diagnosed

and treated before any fractures occur. Importantly, even after the first fracture has occurred, there are effective treatments to decrease the risk of further fractures. Prevention, detection, and treatment of osteoporosis is imperative for all patients to lead long, productive and healthy life.

The National Osteoporosis Foundation has the following recommendations for the evaluation and management of osteoporosis. Recommendations apply to post-menopausal women and men age 50 and older.

�� Counsel on the risk of osteoporosis and related fractures.

�� Check for secondary causes.

�� Advise on adequate amounts of calcium (1200 mg. to 1500 mg. per day) and vitamin D (800 to 2000 IU’s per day), including supplements if necessary for individuals age 50 and older.

osteoporosisby Albert W. Gillespy, M.D.


�� Recommend regular weight-bearing and muscle-strengthening exercise to reduce the risk of falls and fractures.

�� Advise avoidance of tobacco smoking and excessivealcohol intake.

�� In women age 65 and older and men age 70 and older, recommend bone mineral density (BMD) testing.

�� In post-menopausal women and men age 50 to 69, recommend BMD testing when there is concern based on the risk factor profile.

�� Recommend BMD testing to those who have had a fracture, to determine degree of disease severity.

�� Initiate treatment in those with hip or vertebral (clinical or morphometric) fractures.

�� Initiate therapy in those with BMD T-scores less thanor equal to -2.5 at the femoral neck or spine by dual-energy X-ray absorptiometry (DXA), after appropriate evaluation.

�� Initiate treatment in post-menopausal women and men age 50 and older with low bone mass (T-score between -1.0 and -2.5, osteopenia) at the femoral neck or spine and a 10-year hip fracture probability of greater than or equal to 3 percent or a 10-year major osteoporosis-related fracture probability of greater than or equal to 20 percent based on the US-adapted WHO absolute fracture risk model (FRAX).

�� Current FDA-approved pharmacologic options for osteoporosis prevention and/or treatment are bisphosphonates (alendronate, ibandronate, risedronate and zoledronic acid), calcitonin, estrogens and/or hormone therapy, parathyroid hormone (teriparatide) and estrogen agonist/antagonist (raloxifene).

�� BMD testing performed in DXA centers using accepted quality assurance measures is appropriate for monitoring bone loss. For patients on pharmacotherapy,

it is typically performed two years after initiating therapy and every two years thereafter; however, more frequent testing may be warranted in certain clinical situations.

Osteoporosis is the most common bone disease in humans, and it represents a major public health concern. It is characterized by low bone mass, deterioration of bone tissue and disruption of bone architecture, compromised bone strength, and an increase in the risk of fracture. According to the WHO diagnostic classification, osteoporosis is defined by BMD at the hip or spine that is less than or equal to 2.5 standard deviations below the young normal mean reference population. Osteoporosis is an intermediate outcome for fractures and is a risk factor for fracture just as hypertension is for stroke. The majority of fractures, however, occur in patients with low bone mass rather than osteoporosis. Osteoporosis affects an enormous number of people, of both sexes and of all races, and its prevalence will increase as the population ages. The National Osteoporosis Foundation estimates that more than 10 million Americans have osteoporosis, an additional 33.6 million have low-density of the hip. About one out of every two Caucasian women will experience an osteoporosis-related fracture at some time in her lifetime, as approximately one in five men. Although osteoporosis is less frequent in African Americans, those with osteoporosis have the same elevated risk factors as Caucasians.


the BirmiNGhAm hip™ resurfAciNG system:

by Mark C. Gillespy, M.D.

ctive adults suffering from difficult hip pain now have access to the world’s leading treatment technology for their condition. Called the BIRMINGHAM HIP™ Resurfacing (BHR) System,

this implant is an alternative to total hip replacement that may last longer and enable a more active lifestyle than traditional total hip implants.

Rather than replacing the entire hip joint, as in a total hip replacement, the BHR hip simply shaves and caps a few centimeters of bone within the joint.

The bone-conserving approach of the BHR hip preserves more of the patient’s natural bone structures and stability, covering the joint’s surfaces with an all-metal implant that more closely resembles a tooth cap than a hip implant. This approach reduces the post-operative risks of dislocation and inaccurate leg length, and be-cause the all-metal implant is made from tough, smooth cobalt chrome, it has the potential to last longer than some traditional hip implants.

The BHR hip has been implanted more than 100,000 times since being introduced in Europe in 1997. And outside of the US, approximately 1 in 10 hip replacement candidates receive a hip resurfacing device. In the US, the number is smaller – approximately 3 out of 100 – because the procedure is still relatively new.

The Food and Drug Administration approved the BHR hip for use in the US in 2006, and it now represents more than 80% of all hip resurfacings performed in this country every year.

For patients concerned they may need follow-up surgery later in life because of their relative youth, data from a respected British registry of patients indicates that 10 years after surgery, 95.4% of the BHR hips studied are still performing as designed. And according to the definitive Australian Orthopaedic Society’s registry of patients, hip resurfacing procedures actually last longer that total hip replacement in male patients under the age of 65. And in that same British registry, patients scored their experience with the BHR hip as “pleased” or “extremely pleased” in 98.6% of cases.

The BHR hip is not for everyone. The Australian registry also indicates that 90% of hip resurfacing patients are under the age of 65, and 73% are male. This is due in large part to the fact that men tend to have greater bone density than women, and that bone density decreases as you age—and the BHR hip works best when implanted in patients with good bone

stock. X-rays and examination may help to determine if it is right for you.

The Birmingham Hip implant is intended for patients suffering from hip pain due to osteoarthritis, dysplasia or avascular necrosis, and for whom total hip replacement may not be appropriate due to their increased level of physical activity. The BHR hip may not be appropriate for people with impaired kidney function or for women who are or may become pregnant.


the reWArds ANd risks of totAl hip replAcemeNt

by Brian R. Hatten, M.D.

he hip joint is one of the largest joints in your body.

Unfortunately, it is also one of the most easily injured—and not all at once. Osteoarthritis (known as ‘wear-and-tear arthritis’) can set in gradually

and can cause not only stiffness but also excruciating pain.

What causes the hip to deteriorate to the point where it needs replacement? Sometimes Osteoarthritis is the culprit, and it may be that genetics play a role in this. In other cases, the ball of the hip joint (called the femoral head) loses its blood and simply dies, leading to degeneration.

At first, the discomfort might be noticed only when bending or when putting pressure on the hip joint. This commonly occurs, for example, when walking up and down stairs. Eventually, the pain can become nearly constant. In time, the pain may affect the sufferer’s ability to enjoy a full and active life. A measure of relief may come through medication and walking aids, but sometimes these remedies are short-lived. For long-term treatment, the solution might be total hip replacement. Hip replacement surgery is becoming

Many of us go about our activities blissfully unaware of the importance of our hip. Until it erupts in severe pain, that is. If you are a sufferer, you are not alone.


more and more common as the population of the world begins to age. Hip replacement surgery has a very high success rate and provides reproducible results.

The hip joint is composed of two parts: The ball and the socket. During surgery, the two parts are removed and replaced with artificial surfaces. The ball is usually made of metal or ceramic, while the socket is usually composed of plastic. Ask your orthopedist about newer “alternative bearing” options that may be available. The option of hip replacement is completely up to the sufferer. It is a function and lifestyle matter. Your orthopaedic surgeon will have recommendations, based on such factors as your medical history, weight, health status, and hip condition. After considering non-operative options, some decide that the benefits of total hip replacement far outweigh the risks and complications.

True, the very idea of hip surgery may seem daunting. But new developments—mainly over the past few decades—are changing the face of hip replacement for the better. For example, a procedure known as minimally invasive total hip replacement now allows surgery to be performed with less trauma to the soft tissues of the hip. It uses the same implants that are employed in traditional surgery. But one major difference is in the incision. Whereas traditional surgery requires a 12-inch or longer cut, the incision made with the muscle-sparing technique is much smaller. It helps speed up recovery and helps the patient return sooner to normal activities.

What are some of the risks of hip replacement surgery? There are several important ones to be aware of, including: Deep Venous Thrombosis - DVT (when blood clots in the large veins of the leg), infection, dislocation (when the ball comes out of the socket), loosening of the joint, or the legs

having unequal lengths. A thorough discussion of the risks and benefits of hip replacement surgery will be completed with your doctor prior to deciding on surgical management.

When total hip replacement is recommended, the outcome can be positive. A total hip replacement will provide complete or nearly complete pain relief in 90 to 95 percent of patients. It will allow patients to carry out many normal activities of daily living. The artificial hip may allow you to return to sports or work

under your doctor’s instructions. Most patients with stiff hips before surgery will regain much of their motion, and nearly all have improved pain levels. Talk to your orthopaedic surgeon if you have hip pain and find out your options.


teArs of the meNiscus

iN Athletesby Jeff W. Martin, M.D.

enisci are crescent shaped fibrocartilage structures that are triangular in cross section. There is both medial (inside) and lateral (outside) meniscus. These C-shaped cartilage structures which deepen the articular surfaces aid in shock absorption, stability, lubrication and nutrition. In younger athletes meniscus

tears usually occur with a traumatic event, typically involving twisting and compression. It is also more common in younger athletes to see ligament injuries in association with meniscus tears. Older athletes, because the meniscus degenerates with age, may tear a meniscus with trivial trauma such as squatting or twisting. It is

also more common to see arthritis in combination with a meniscus tear in the older athlete.

When the meniscus tears, it creates a rough surface irritating the knee joint causing swelling, pain, stiffness, and frequently catching

and popping. Some meniscus tears can “lock” the knee if large enough. Orthopedic surgeons, by taking a good history and performing a physical examination, usually can make the diagnosis. At times Magnetic Resonance Imaging (MRI) may be needed for a diagnosis.

It is important that a diagnosis is made promptly as some tears can increase in size making treatment more difficult or lead to additional damage inside the knee. Treatment of a meniscus tear depends on the location and shape of the tear.

Arthroscopy, which involves looking inside the knee joint with a small scope, allows the surgeon to characterize and treat the tear appropriately. The “Scope” requires small incisions and anesthesia but usually can be done to allow going home the same day.

With only the peripheral 20 to 30 % of the menisci vascularized, most tears are located in a position that lacks a blood supply. These degenerative tears usually occur in older patients and can have an insidious onset. Treatment typically involves removal of the torn piece so that the rough edge no longer irritates the knee joint. As little tissue as possible is removed in order to preserve the function of the remaining meniscus. Tears in the meniscus near the outer edge have the ability to heal and can be relocated by suturing or tacking with biodegradable anchors. Holding the meniscus in place may allow for healing to occur thereby preserving the function of the entire meniscus. This type of arthroscopic surgery is technically more demanding on the surgeon and has a slower recovery. Healing of repaired meniscus tears is not 100%. The medial meniscus is torn three times more frequently than the lateral meniscus.

In conclusion, tears of the meniscus are common amongst athletic individuals. The medial meniscus tears more often than its lateral counterpart. Most often a meniscus tear is symptomatic and requires arthroscopic treatment. Though removal of a torn piece of meniscus remains the most common intervention, we are continually investigating methods to preserve the entire meniscus and normal knee function.

Meniscal (Cartilage) Tear


orthopAedic cliNicof dAytoNA BeAch, p.A.

1890 LPGA Blvd., Suite 240Daytona Beach, Florida

(386) 255-4596

Physical Therapy: (386) 274-1244

1075 Mason AvenueDaytona Beach, Florida(386) 255-4596


Palm Coast Office

4 Office Park Dr., Pod #1Palm Coast, Florida(386) 255-4596


Twin Lakes Office

Main Office - Daytona Beach

1165 Dunlawton Ave., Ste. 102Port Orange, Florida

(386) 255-4596


Port Orange Office

meet the physiciANs of orthopAedic cliNic of dAytoNA BeAch, p.A.Dr. Thurman Gillespy, Jr., M.D., F.A.B.O.S., F.A.A.O.S. Dr. Gillespy is a board certified orthopaedic surgeon. In 1961 he founded the Orthopaedic Clinic of Daytona Beach, P.A. Dr. Thurman Gillespy practices general orthopaedic surgery, non surgical treatment of deformities, diseases and injuries to the bones, joints, ligaments, muscles, tendons and other soft tissues, nerves and related structures of the human body. He has specialized in total joint replacements since 1970 when he became one of the first surgeons in Florida to perform these surgeries. Dr. Gillespy has performed more than 4,000 total joint surgeries. He actively participates in the Jesus Clinic and the physician residency program at Halifax Medical Center. Twenty-five years ago he initiated the spinal screening program for detecting scoliosis and other spinal deformities. Annually, the surgeons from the Orthopaedic Clinic of Daytona Beach, PA examine students at all of the middle schools in the Halifax area. Dr. Gillespy has also actively participated in the Childrens’ Medical Services Clinic (formerly Florida Crippled Childrens’ Commission) and has served as team physician for many high schools athletic programs. Dr. Gillespy has been a clinical instructor for the Department of Orthopaedic Surgery at the University of Florida in Gainesville for more than forty (40) years. Dr. Gillespy is a member of the Presidents Council of the University of Florida. Dr. Gillespy recently had The Gillespy Orthopaedic Residents Education Commons named in his honor at the University of Florida. Dr. Gillespy and his Wife, Elaine, have six children, three of whom are physicians. Two of his sons, Albert and Mark, joined him in practice at the Orthopaedic Clinic of Daytona Beach, P.A.

Dr. Gilbert A. Martin, Jr., M.D., F.A.B.O.S., F.A.A.O.S. Dr. Martin is a board certified orthopaedic surgeon. Dr. Martin has practiced general orthopaedic surgery including treatment of diseases and injuries to the joints, ligaments, bones, tendons, muscles, fractures and related structures of the human body in addition to joint replacement and spine surgery. He received appointments as Chief of the Department of Surgery and served two terms as Chief of the Department of Orthopaedic Surgery at Halifax Medical Center. Dr. Martin currently has a non-surgical orthopaedic practice and has hospital privileges at Halifax Medical Center. He has office hours daily Monday through Friday at the Mason Avenue Office. During his years of practice in Daytona Beach, Dr. Martin has participated in and volunteered his services to the Halifax Dunn Clinic (formerly Keech Street Clinic), scoliosis screening in the Volusia County middle schools, Childrens’ Medical Services Clinic (formerly Florida Crippled Children’s Commission) and team physician for local high school athletic programs. In additional, he is a supporter of the Work Oriented Rehabilitation Center for young physically and mentally

challenged adults. Dr. Martin and his Wife, Kit, who is a retired physical therapist, are the parents of five grown children.

Dr. Albert W. Gillespy, M.D., F.A.B.O.S., F.A.A.O.S. Dr. Gillespy is a board-certified orthopaedic surgeon and long-time resident of the Daytona Beach area. He practices general orthopaedic surgery with special interest in spine. His orthopaedic practice includes surgical and non-surgical treatment, spinal disorders, neck and back pain, arthritis, joint disease, total joint replacement, out-patient unicondylar knee replacement, arthroscopic knee surgery, shoulder problems, shoulder rotator cuff tendon repair surgery, hand disorders, carpal tunnel syndrome, foot disorders, bunion surgery, fractures, and osteoporosis. He performs surgery at Twin Lakes Ambulatory Surgery Center, Halifax Medical Center, and Florida Hospital Memorial Medical Center. Over the years, Dr. Gillespy has been involved in many community projects including the Halifax Dunn Clinic, scoliosis screening in the middle schools, physician residency program at Halifax Medical Center, and physical and occupational therapy training programs through the University of St. Augustine, St. Augustine, FL. He also served as the orthopaedic surgeon on call and on site for the Daytona International Speedway from 1989 through 2004. Dr. Gillespy and his wife, Doreen, have two teenage daughters. He coaches his daughters’ basketball team at St. James Episcopal School.

Dr. Mark C. Gillespy, M.D., F.A.B.O.S., F.A.A.O.S. Dr. Gillespy is board certified orthopaedic surgeon commonly is consulted for many musculoskeletal conditions including fractures, muscle, ligament and joint injuries, and nerve entrapments. He specializes in spinal, hip, and knee surgeries. He performs cervical, thoracic, and low back spinal operations using minimally invasive techniques. In addition, he performs arthroscopic surgery of the knee, minimally invasive partial and full knee replacements, and minimally invasive total hip replacements. He has developed and perfected less invasive approaches to management of spinal disc conditions, spinal fractures and spinal fusion surgeries. Improved patient outcome generates his philosophy that these approaches have become the standard of care in our community. Following his training at the University of Florida, he returned to his hometown, Daytona Beach in 1992 to join the Orthopaedic Clinic of Daytona Beach, P.A. He performs surgery at Twin Lakes Medical Center, Halifax Medical Center, and Florida Hospital Memorial Medical Center. He maintains a courtesy affiliate professorship with the Department of Orthopaedics at the University of Florida since 1995.

meet the physiciANs of orthopAedic cliNic of dAytoNA BeAch, p.A.Dr. Malcolm D. Gottlich, M.D., F.A.B.O.S., F.A.A.O.S. Dr. Gottlich is a fellowship trained Orthopaedic Surgeon with a specialty interest in adult reconstruction. Although being born in Brooklyn, New York he has grown up in the Daytona Beach area graduating from Spruce Creek High School. He completed his undergraduate education at Duke University and went on to complete Medical School, Orthopaedic Residency and Orthopaedic Fellowship at the University of Florida in Gainesville. Dr. Gottlich has completed a fellowship in adult reconstruction at the University of Florida emphasizing not only total knee and total hip arthroplasty, but revisions of the above procedures. He is also interested in sports medicine with arthroscopic procedures as well as care of multi-trauma patients and routine orthopaedic fractures. Dr. Gottlich joined the Orthopaedic Clinic of Daytona Beach on August 1, 1994 and provides care in and around Volusia County including Daytona Beach, Ormond Beach, Port Orange and Palm Coast.

Dr. James M. Bryan, M.D., F.A.B.O.S., F.A.A.O.S. Dr. James Bryan is a fellowship trained orthopaedic surgeon with subspecialty interests in shoulder and sports medicine surgery. Dr. Bryan has been recognized by the American Board of Orthopaedic Surgery for subspecialty certification in Orthopaedic Sports Medicine. He provides care for a wide variety of bone, joint, ligament and tendon disorders. He performs both simple and complex arthroscopic procedures of the knee, shoulder, elbow, ankle and hip joints including anterior cruciate ligament reconstruction, partial menisectomy, chondroplasty, arthroscopic rotator cuff repair, arthroscopic bankart repair and multiple other mini-invasive procedures. He also brings a sports medicine perspective to reconstructive procedures like total knee, hip and shoulder replacements. By using a less invasive technique the patient, hopefully, will experience less discomfort and a quicker recovery. Dr. Bryan obtained his undergraduate education at Wake Forest University in Winston-Salem N.C. He completed both medical school and orthopaedic residency at the prestigious Rush University in Chicago, IL. Dr. Bryan completed an Orthopaedic Sports Medicine Fellowship at the University of Florida, Shands Hospital, Gainesville, FL.

Dr. Brian R. Hatten, M.D., F.A.B.O.S., F.A.A.O.S. Dr. Brian Hatten is a board certified orthopaedic surgeon with special interests in total joint replacements, arthroscopic management of athletic injuries and complex fracture management. Dr. Hatten was born and raised in Long Island, New York. He pursued his academic schooling at Cornell University followed by medical school at New York University. He achieved distinction as a member of the Alpha Omega Alpha Medical Honor Society and graduated among the top of his class. He further pursued surgical training at the University of Miami. Dr. Hatten joined the Orthopaedic Clinic of Daytona Beach in 2004 and practices general orthopaedics including surgical and nonsurgical management. He provides advanced surgical management for a wide variety of bone, joint, ligament and tendon disorders. He employs minimally invasive surgical techniques to improve patient outcomes. Dr. Hatten is involved in a variety of local community medical activities and currently serves as the Chief of Orthopaedic Surgery at Halifax Medical Center and is on the Executive Committee of the Volusia County Medical Society.

Dr. Jeffrey W. Martin, M.D., F.A.B.O.S., F.A.A.O.S. Dr. Jeffrey Martin is a board certified orthopaedic surgeon who in addition is fellowship trained in sports medicine. He performs arthroscopic and reconstructive surgery of the hip, knee, shoulder, elbow and ankle. His interests include arthroscopic ACL and PCL reconstruction (anterior and posterior cruciate ligament), meniscal repair and cartilage resurfacing techniques. Dr. Martin has also dedicated and focused his practice on arthroscopic and minimally invasive treatment of rotator cuff tears, impingement syndrome and shoulder instability. Dr. Martin also provides orthopaedic care for arthritis, fractures, joint replacements and various musculoskeletal conditions. He emphasizes supervised physical therapy and rehabilitation for optimal outcomes in his patients. Dr. Martin participated in the 2005 NFL combine selection, on behalf of the San Francisco 49ers as well as participating as team physician for the San Francisco 49ers and Stanford Athletic Department. Dr. Martin joined the Orthopaedic Clinic of Daytona Beach, P.A. in August of 2005. He provides care to patients in and around Volusia County including Daytona Beach, Ormond Beach, Port Orange and Palm Coast and performs surgery at Twin Lakes Medical Center, Halifax Medical Center and Florida Hospital Memorial Medical Center.

Dr. Todd A. McCall, M.D., F.A.B.O.S. Dr. Todd McCall is a board certified orthopaedic surgeon with special interests and training in orthopaedic trauma, complex fracture management, non-unions, and total hip replacement. Dr. McCall was born and raised in southern Illinois. He obtained his undergraduate degree at the University of Illinois and graduated with highest university honors. He then completed medical school at Southern Illinois University. After medical school, he completed his surgical internship and orthopaedic residency at the University of Florida, and remains an avid Florida Gator fan. After completion of his residency, he completed his sub-specialty orthopaedic trauma fellowship at OrthoIndy in Indianapolis IN. His fellowship focused on complex fracture and trauma care including peri-articular, pelvic, and acetabular fractures at Methodist Hospital, one of the busiest Level 1 Trauma centers in the United States. Dr. McCall joined the Orthopaedic Clinic of Daytona Beach in 2007 and is the only surgeon specializing in Orthopaedic Trauma in Volusia County. He currently practices out of the office at Mason Avenue and performs surgeries at Halifax Medical Center, Florida Hospital Memorial and Twin Lakes Surgery Center. He focuses his practice on fracture care, traumatic injuries, and hip reconstruction.

physicAl therApye offer Physical Therapy Services at our Mason Avenue, Twin Lakes Medical Center, and Palm Coast offices.

State of the art facilities and licensed staff promote full orthopaedic rehabilitation care. Our staff works hand in hand with your doctor to develop a personalized rehab program for our patient’s specific needs.

Paul Gulliksen, RPT is a graduate of Marquette University and has owned and operated outpatient orthopaedic clinics for over 31 years. A member of the American Physical Therapy Association, he has been with the Orthopaedic Clinic of Daytona Beach since 1993 and is the Director of Physical Therapy.

Keith Stose, MPT is a graduate of the University of St. Augustine for Health Sciences. He is a member of the American Physical Therapy Association, Orthopaedic Section. He has been with the Orthopaedic Clinic since 1996.

Suzanne Danch, MPT received her undergraduate degree from Bowling Green State University in Bowling Green, Ohio. She earned her masters degree in Physical Therapy from The Medical College of Ohio at Toledo in 2005. She has been with the Orthopaedic Clinic since 2008 and is a member of the American Physical Therapy Association.

Richard Keys RPT is a graduate of the University of Ulster at Jordanstown on the north coast of Ireland. He graduated with a BSc (hons) in Physiotherapy in 1993. Richard immigrated to the United States in 1997 and has since worked solely in an orthopaedic setting.

Justin Gordon, DPT received his undergraduate degree at Oakwood University in Alabama and then went on to obtain his Doctorate Degree in Physical Therapy from Shenandoah University in Virginia in August, 2009. He has been with The Orthopaedic Clinic since October, 2009. He is also a member of the American Physical Therapy Association.

Paul Gulliksen, RPT, Director of Physical Therapy Keith Stose, MPT, Twin Lakes Office Justin Gordon, DPT

Suzanne Danch, MPT, Port Orange Office

Richard Keys RPT, Palm Coast Office

the five rules of fitNessby Jeff W. Martin, M.D.

ll things complex have simple beginnings. The decision to improve the condition of your body seems simple enough at first, but the complexities have derailed many a determined soul. Before you suffer information overload, build a foundation. In fitness, you will find that all improvements come from certain basics.

These are the five ground rules that anyone serious about personal health should employ in order to continually improve himself or herself.

RULE ONE is that you need a goal. Deciding to “get in shape” is like deciding to “buy low and sell high” on the stock market; you need to be a bit more specific. The good news is that fitness goals are easy to quantify. For example, losing 3 percent body fat and gaining 15 pounds of strength on the leg press machine in a month is a legitimate goal; it’s realistic and measurable.

RULE TWO is that you must pursue your goal with intensity; you must train hard. If you don’t push your body past its everyday level of exertion, you won’t improve beyond your current condition. If 15 years of little or no exertion hasn’t gotten you the body you want, what makes you think that going to the gym and not exerting yourself will? Remember, the process of muscle conditioning starts with the muscle being broken down. A muscle, if allowed to heal properly, will make itself stronger than it was before. It is true that you will experience some degree of soreness. Relish the ache as a reminder of a workout well done.

RULE THREE is that you employ a variety of techniques in your training. If you want a day away from the weights, try rock climbing. If it’s the treadmill you despise, then try running stadium stairs. As long as you change your workout on a regular basis, your muscles


Justin Gordon, DPT

Suzanne Danch, MPT, Port Orange Office

Richard Keys RPT, Palm Coast Office


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800.330.0890www.southeastmedical.com

P.O. Box 57613 Jacksonville, FL 32241

(904) 571-3974 Fax (904) 739-5649

e-mail: [email protected]

will always be confused, and a confused muscle is forced to adapt and become better conditioned.

RULE FOUR is that you must eat specific foods in specific portions to elicit the desired response from your body. When used properly, food can have an enormously positive effect upon your body. The portions of macronutrients (protein, carbohydrate, fat) you need from different foods is complex, to say the least. Many nutritionists have been recommending low-carbohydrate diets for years. If counting carbohydrates, fat, and protein is not realistic for you, then simply try to take in a moderate portion of each macronutrient at every

meal. A moderate portion of protein and carbohydrates each would be roughly the size of your fist. A moderate fat portion might be one-fifth of that. A sample meal might be the following: scrambled egg beaters (protein), cheese (fat), and strawberries (carbohydrates).

Once you gain an understanding of which foods have which macronutrients

in them, you can further improve your diet by committing yourself to eating several small- to medium-sized meals each day instead of the standard two or three. This steady flow of food cranks up your body’s fuel furnace. The result is higher, more stable energy levels. On the other hand, if you fast for long periods between large meals, you are sabotaging your healthy eating habits. A large meal requires a large quantity of blood to be diverted to your stomach to aid in digestion, leaving you listless and out of energy. To make matters worse, you have taken in considerably more calories than your body can use at that point. (Think about trying to force twenty gallons of gas into a car

with a ten gallon tank.) Those excess calories have to go somewhere, so they often are stored as fat. At some point during your bloated fast, your body will begin to worry that food had become scarce, and will engage its self-preservation mechanism. Your metabolism will slow so that you burn fewer calories, making it easier to store the extra calories as, you guessed it, fat. You also may have guessed that a slow metabolism burns fewer calories and supplies less energy, thereby rendering you tired, weak and overweight.

You can further fine tune your diet by eliminating as much of your sugar intake as possible. Sugar causes a release on insulin, the storage hormone. Excessive insulin causes calories to be stored as fat regardless of whether they were protein, carbohydrate, or fat calories originally. As if nutrition weren’t complex enough, now you find out that even if you don’t take in any dietary fat, you still can gain body fat. Fried foods also should be on the hit list. Most fried foods are dangerously high in saturated (bad) fat. “Good” (unsaturated) fat is found in such things as nuts, fish and avocados.

RULE FIVE, the final rule, is that you must be consistent in your training, nutrition, and positive mental approach to fitness and life. As cliché as it may sound, it remains true that where the mind goes, the body will follow.

lthough every amputee we see and every surgery is different there is one thing that each patient we see at American Ortho-Tech demands from their prosthesis. Comfort. No matter what kind of knee, foot, or cosmetics that we use when we fabricate a prosthesis for someone, if the socket is not comfortable the prosthesis will be

unacceptable. The socket is also the one portion of the limb that is common to all amputees. The socket is the custom made portion of the socket that provides the interface between the patient and all of the components of the prosthesis.

One of the best ways we have found to provide maximum comfort and increase the health of patient’s residual limbs is by using vacuum technology to create an elevated negative pressure environment within the socket. Using this technology allows us to increase socket comfort by reducing movement within the prosthesis and therefore reducing the sheer forces in the socket that cause soreness, abrasions and blisters. Our ability to reduce movement in the socket leads to increased proprioception and allows patient’s to feel what is happening at their foot and walk more safely and confidently. The elevated negative pressure increases oxygen to the tissues in the residual limb and improves blood flow. It is this increased blood flow that helps maintain the volume of the residual limb throughout the day and increases comfort and a person’s activity level.

When making a socket using negative pressure patient’s have a cast made of their residual limb under vacuum in order to have a custom liner made for them. Do to the precise fit of this type of socket and the individuality of each person this will be done to obtain the best results. After the custom liner is made we take a second cast, but this time over the liner for the fabrication of the socket. Initially a clear socket or check socket will be made so the prosthetist can see the residual limb and evaluate the fit. After the correct fit is achieved the foot and other components will be attached and the patient will begin their walking trails.

After both the patient and the prosthetist are satisfied with the fit and function of the prosthesis a definitive limb will be made. All prosthetics in our practice are made using high strength carbon fibers, fiberglass braids and laminated using epoxy acrylic resins to provide a

light weight yet extremely strong product. Many of our patients wish to personalize their sockets and can do so with various fabrics that we incorpo-rate into the socket.

American Ortho-Tech has two locations in Volusia County at 1320 Mason Ave in Daytona Beach and 938 Saxon Blvd. #103 in Orange City. Please call either one of our offices at (386)258-0401 or (386)775-1266 for a free evaluation.



kNee iNjuriesby Paul Gilliksen, RPT

nee injuries account for more than 1.2 million visits

to doctor’s offices every year and an estimated 200,000 to 250,000 of those injuries

involve the anterior cruciate ligament or ACL.

There is a misconception that these injuries are specific to only athletes but can involve the athlete and non-athlete alike and are usually non-contact in nature. Activities which involve jumping, cutting and pivoting can promote excessive stresses to the knee and possible injury to the ACL. Some sport activities such as basketball, football (flag & tackle), soccer, volleyball, tennis and skiing have higher incidents of ACL injuries due to the extreme forces placed on the knee joint. What are ligaments?Ligaments are structures which connect bone to bone and act like stronger rubber bands which have a slight “give” to them but will usually return to their normal length once pressure is taken off of them. With stronger and more forceful stresses, enough force can be placed on these structures to stretch, partially or even complete-ly tear these structures. What is the ACL? The ACL crosses in the center of the knee with the posterior cruciate ligament (PCL). The ACL inhibits forward movement of the lower leg (tibia) in relation to the upper thigh bone (femur) and also limits rotation of the knee. Most ligament injuries of the knee will involve the ACL.

Injuries to the ACL may also involve trauma to other structures of the knee such as the meniscus (shock absorbers between the tibia and femur), medical collateral ligament (ligament on inside portion of the knee to stabilize inside movement of the joint) or even damage to the joint surface (osteochondral defects). Injuries of this magnitude almost always require surgery. Recent studies indicate that female athletes are 2 to 4 times more likely to sustain an injury to the ACL than male athletes and that females will account for 2/3 of all ACL injuries. There are varying opinions on why the incidence of this injury is higher in females than in males. Some theories suggest that the female ACL is smaller than the male ACL. It is also suggested that the high estrogen levels in females can promote weakening of the ACL. Most recent studies have indicated that the structure of the knee where the ACL attaches to the tibia (lower leg bone) and femur (upper thigh bone) is usu-ally smaller in females than in males and that the excessive contraction of the quadriceps muscles (muscles which straighten the knee) during jumping and cutting activities place excessive stress on the ligament and promote trauma. Programs have been developed to train female athletes to improve on their jumping and running techniques and to increase recruitment of other muscle groups so as to counteract the excessive contraction of the quadriceps muscles. There is evidence that these types of programs are affective in reduc-ing ACL injuries. If surgery is indicated, the surgeon will discuss options with the patient regard-ing the type of procedures available to the patient. If the ACL is completely torn, the body is unable to heal or repair this structure. The best clinical option is to have the torn ligament removed and surgically reconstructed. There are many techniques used to reconstruct the ACL. Some involve taking tissue from the patient which is

called an autograft procedure. Some areas of the body where the graft can come from are the patellar tendon of the knee or advancing one of the hamstring tendons. Another technique is to take tissue from a tissue bank (usually the Achilles or posterior tibialis tendon) which is called an allograft procedure. The surgeon can then take the tissue and prepare the graft to the length and size they desire. The patient and surgeon will discuss what type of technique will be most suitable for their reconstruction.

In our office, physical therapy is usually initiated 2-3 days following surgery. Rehabilitation protocols are very specific and the main goal is to protect and not stress the graft. We usually see our pa-tients in the office 3 days per week and the patient is provided exercises which are to be performed daily at home. The patient is progressed from their crutches and protective brace working towards increasing range of motion and strength while maintaining orthopedic specific precautions and strict therapy protocols.

One of the biggest hurdles for the patient is to “trust” the surgical knee.

Patients are sometimes hesitant to bear or shift weight onto the surgical knee. The physical therapist is not only responsible for the patient regaining their motion and strength but also the confidence that their knee is “healthy”.

Length of supervised therapy can be anywhere from 2 to 4 months but the patient is advised and instructed in exercise activities that need to be continued on a regular and consistent basis after supervised therapy is completed. Patients are slowly returned to running, jumping and cutting activities and are usually cleared to return to sport specific activities in 9-12 months after surgery. Sometimes their surgeon will order a special brace for the patient to wear while participating in sports. In any case, serious knee injuries are becoming more common, particularly involving the anterior cruciate ligament. These injuries require proper evaluation and treatment and many times surgery. Specialized therapy protocols are essential in returning the patient to prior activities and function.


Partial Hip Replacement

hip frActures iN the elderly

by Todd A. McCall, M.D.

ach year, more than 300,000 people in the U.S.

are hospitalized with hip fractures. The vast majority of

hip fractures (90%) occur in persons over age 65. Women are two to three times more

likely than men to sustain a hip fracture. Of women who reach 90 years of age, nearly 50% will have suffered a hip fracture at some point in their life. Others at high-risk for hip fracture include smokers, heavy drinkers, those with low calcium intake, unsteady balance, and poor eyesight. Because of the aging population, it is expected that by the year 2050 the yearly number of hip fractures will rise to more than 650,000.

Most hip fractures occur as the result of a fall. It has well been observed that among the elderly a hip fracture is more than a broken bone; it is a potentially life-threatening event. This can be especially true if the person lives alone and cannot get

help after a fall. Hours may elapse before an injured elderly person is found which can result in other serious medical problems.

According to the American Academy of Orthopaedic Surgeons, the diagnosis of hip fracture accounts for more hospital stays than any other musculoskeletal injury. Nearly 44 percent of hospital days due to fractures are due to hip fractures.

The Hip—an Owner’s GuideThe hip is a true ball-and-socket joint. It is made up of a deep cup called the acetabulum (socket) that surrounds the femoral head (ball). The femoral neck attaches the femoral head to the rest of the femur (thigh bone). Articular cartilage covers the surface of the femoral head and the inside of the hip socket. The cartilage reduces friction and allows the joint surfaces to slide against one another. Arthritis results as a thinning or “wearing out” of the cartilage.

Sometimes weakened bone— perhaps the result of a condition such as osteoporosis—can lead to a fracture when too much stress is put across the neck of the femur. Those who have a family history of fracture in later life are more susceptible to develop the same problem.

Symptoms and DiagnosisA hip fracture usually lands the patient in a hospital emergency room. There, the attending physician will examine the patient and obtain the patient’s medical history. It is important to know the patient’s overall condition, as this will enable the doctor to determine which mode of treatment to recommend.

X-rays are usually taken to confirm the presence of a fracture. However, if the X-ray does not indicate that a break in the bone has occurred and the patient still feels pain, an MRI or CT scan may detect a fracture that was missed by the X-ray.


Surgical Repair of a Femoral Neck Fracture Surgical Repair of a Intertrochanteric Femur Fracture


When it comes to hip fractures, an early and accurate diagnosis is essential. Non-displaced fractures may become displaced by walking on a fractured hip. A non-displaced fracture is easier to treat and has fewer complications than a displaced fracture.

TreatmentThere are several different types of hip fractures based on the anatomic location of the fracture. The most common hip fractures are femoral neck fractures and intertrochanteric fractures. Treatment of hip fractures is based on the location of the fracture as well as the amount of displacement of the fracture. They can be treated with the use of screws, a metal plate or rod with screws, or by replacing the broken femoral head with an artificial implant (called a hemiarthroplasty). Occasionally a total hip replacement (replacing the ball and the socket) is preferred if the patient has significant arthritis.

Before proceeding with treatment, an orthopaedic surgeon will determine if the fracture is displaced or non-displaced, and if it is stable or unstable. A non-displaced and stable fracture can sometimes be treated without surgery. However, most non-displaced and minimally displaced hip fractures are treated with screws to hold the two parts of bone together while the fracture heals. The problem with non-surgical treatment is that there is a significant risk of the fracture displacing. Non-operative treatment is also associated with more activity restrictions and less mobility. Experience has shown that this lack of mobility can be dangerous, especially for the elderly. Prolonged confinement can lead to serious complications, including blood clots, pressure ulcers (bedsores), and mental confusion. Considering the physical and psychological effects of being incapacitated, it is easy to see why doctors recommend that patients get up and moving as soon as possible after surgery. The goal of any surgical procedure for hip fractures is to allow the patient to get out of bed as soon as possible.

Hemi-arthroplasty (replacing the ball) is preferred when fracture is displaced. When the fracture is displaced, there is a higher likelihood that the blood supply to the ball has been damaged, which can cause avascular necrosis. Avascular necrosis is when an area of bone has no blood supply and the bone tissue dies. This can cause significant pain and arthritis and lead to need for further surgery (hip replacement).

RecoveryThe prognosis for recovery is good when the fracture is treat-ed promptly. Most hip fracture patients who previously lived independently will require some assistance from their family or home nursing care. The American Academy of Orthopaedic Surgeons (AAOS) reports these sobering statistics:

�� only 25% of hip fracture patients will make a full return to pre-injury activity level

�� 40% will require nursing home care�� 50% will need a cane or walker;�� 24% of those over age 50 will die within 12 months

With hip fractures, the surgeon and the patient is therefore faced with a greater obstacle than mending a broken bone. The real challenge is dealing with the complications that can set in after surgery.

The situation is made even more critical by the fact that elderly patients are more likely to suffer from mental confusion following hip surgery. Being in a strange environment, losing a degree of independence, taking medication, and becoming immobile can spiral the elderly patient into symptoms of dementia. For this reason, it is crucial for the patient to receive regular visits of family and friends.

PreventionConsidering the critical effects that a hip fracture can have on the elderly, education in accident prevention cannot be overstressed. An inspection of the home can uncover a few dangers that previously may have been unnoticed. For exam-ple: Are there slippery tiles or loose throw rugs in the home? Is the lighting sufficient? Are any of the rooms cluttered, per-haps including small objects that are left lying on the floor?

Besides looking around the home, it’s good for the elderly to regularly have their vision checked. Medications should be evaluated for possible side effects, such as dizziness. Regular exercise will help improve balance and promote overall health. Bone density testing should be done to detect bone loss (osteoporosis or osteopenia) in patients with risk factors. Treatment of osteoporosis has been shown to decrease the risk of fractures. Preventive measures can go a long way in keeping the elderly in their place (at home) and where they belong (on their feet).

houlder pain can occur in anyone at any age from a variety of different causes. The Shoulder is composed of three bones:

the collar bone (clavicle), the shoulder blade (scapula) and the upper arm bone (humerus). The bones are supported by ligaments, tendons and muscles which allows movement at the joints where the bones meet. Shoulder motion occurs at three different locations: at the ball and socket joint (glenohumeral joint), between the collar bone and the shoulder blade (acromioclavicular joint) and between the shoulder blade and the back of the chest wall (scapulothoracic motion). Pain can occur at any of these locations.

Reasons for painShoulder pain can arise from many different reasons. Most of the causes fall into three major categories:

�� Acute Injury/Instability�� Chronic Inflammation/Degeneration �� Arthritis

Often times the reason for the pain is a combination of more than one category.

Discovering the cause of the painThe first step in determining the cause of pain is obtaining a detailed medical history including the history of the shoulder symptoms. The next step is a thorough physical examination including observation, palpation, measuring range of motion, ligamentous testing, and strength testing and special provocative tests. Usually x –rays are obtained to understand the

shoulder pAiN


by James M. Bryan, M.D.


bony anatomy. Sometime special imaging studies like CAT scans or MRI scans are required to more fully understand the anatomy. The diagnosis is determined by combining the history, physical examination and the imaging studies.

Treatment by diagnosisAcute InjuriesThe treatment for acute injuries like deep bruises (contusions), fractures and dislocation of the shoulder usually progresses from a period of immobilization through a progressive motion based supervised therapy program. Anti-inflammatory medications are often used to help control the pain. Sometimes surgery is required for more unstable fractures and ligamentous injuries.

Chronic Inflammation and Rotator Cuff TearsThe treatment for chronic bursitis and rotator cuff tears is based on the severity of the symptoms. Usually simple stretching exercises and therapeutic exercise will significantly improve an individual’s symptoms. Oftentimes anti-inflammatory medications and corticosteroid injections are required. Ultimately if conservative management fails, then arthroscopic or open shoulder surgery may be required.

Frozen ShoulderThe treatment for frozen shoulder (adhesive capsulitis) is based on slowly progressive improvement in range of motion. This condition is probably the most frustrating shoulder diagnosis and treatment must be tempered with a significant amount of patience.

ArthritisMany types of arthritic conditions exist: osteoarthritis, rheumatoid arthritis, post-traumatic arthritis, rotator cuff arthritis and others. The treatment

generally involves activity modification (avoiding overhead activities and heavy lifting). However, movement with the arm at the side is helpful to the shoulder and decreases shoulder pain. The best example is swinging the arms while walking. For patients with balance disorders, swing the arms at the side in the sitting position is a good alternative. Some patients require long term anti-inflammatory medications to help control the pain. Some patients are provided pain relief with intra-

articular corticosteroid injections. These injections can be repeated every three to four months if needed for pain control. Ultimately, total shoulder arthroplasty (shoulder replacement) or reverse shoulder arthroplasty may be required to alleviate the painful symptoms. The decision for surgery should be based on how symptoms affect the patient’s quality of life. With realistic goals in mind, the patient and surgeon both provide input regarding the decision for surgery.

Torn Labrum Labrum Following Repair

After RepairTorn Rotator Cuff

Shoulder X-Ray Before Surgery Shoulder X-Ray After Surgery

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O Rthopaedic Digest