sports medicine for primary care physicians dr. donald w. kucharzyk the orthopaedic, pediatric &...

“Sports Medicine for Primary Care Physician’s”

Dr. Donald W. Kucharzyk The Orthopaedic, Pediatric & Spine Institute Crown Point, Indiana


Pediatric Athletic Sports Related Injuries

Female Athletic Sports InjuriesPreventing Sports Injuries in Female

AthletesCOX-2 Specific Inhibitors: Emerging

Role in Sports Medicine


“Musculoskeletal Overuse Syndromes”


Increased Musculoskeletal stress is common in our young athletes recently

Reflects the escalating intensity of training and competition at younger ages

Athletes go from one sport to the next with prolonged seasons and little rest

Excessive use produces unresolved stresses on normal tissues that has yet to adapt and leads to failure and overuse


Overuse injuries occur at two particular times during training

First occurs when “underused” athletes who are partially conditioned are placed in demand situations: pre-season football and cross country

Second occurs in the extremely fit athlete who are participating in multiple sports resulting in depletion of tissue reserves

“Sports Medicine for Primary Care Physician’s”History is the best primary aid to the

diagnosis of overuse injuriesMechanical Pain that is produced by

activity and relieved by rest is the hallmark anatomic factor

Environmental factors such as playing surfaces and equipment play a role

The most significant factor though is the training program’s: sudden increases or changes


Overuse treatment protocol involves five phases:

Identify risk factorsModify offending factorsInstitute pain controlUndertake progressive rehabilitationContinue maintenance to prevent re-

injury


“Stress Fractures”Stanitski proposed the etiology to be the

result of highly concentrated eccentric and concentric muscle forces acting across specific bones and compounded by specific sports specific demands predispose the bone to failure

Loss of normal time frame for bone repair submaximal trauma produces the fracture


Muscle fatigue also plays a role in stress fractures

With fatigue of the muscle envelope, greater stress is absorbed by the underlying bone and predispose to stress fractures

Increased muscle force--change in remodeling rate--resorption and rarefaction--microfractures--stress fx

“Sports Medicine for Primary Care Physician’s”Standard radiographs are not helpful

because early phase stress fractures are radiographically silent

Bone Scan’s are extremely helpful but may not be positive till 12-15 days post injury

Locations involve primarily the tibia but also has been seen in the upper extremity such as the humerus and radius; and proximal femoral neck


Treatment regime involves immobilization via a pneumatic leg brace: this helps distribute the stress across the soft tissue envelope that will diminish stress across the fracture and allow healing to progress

Post healing rehabilitation is critical as well as evaluating the mechanics of the injury and training/conditioning and gait too.


“Stress Injuries of the Growth Plate”Must be aware that chronic stress injuries

can cause physeal damageRunner’s show this manifestation in the

distal femur and proximal tibia--attention to history, clinical exam, and xray evaluation important..confused with neoplasm

Area’s Affected Include: Proximal Humerus commonly seen in Pitcher’s


Gymnasts have the most common physeal stress fracture seen affecting the distal radius--will retard growth and produce an overgrowth of the ulna and wrist pain

Treatment is rest, immobilization, avoidance, rehabilitation, and conditioning

Treatment course involves at least 3 months of avoidance and then rehabilitation


“Little League Shoulder”Microtrauma and overuse to the upper

extremity localized to the proximal humerusMechanics of pitching produces stress

across the physis during the cocking phase, acceleration phase, and the follow-through-greatest stress on physis at this time

Radiographs reveal widening of the proximal humeral physis


Treatment is rest from throwing for the remainder of the season plus a vigorous preseason conditioning program the following year

Recommendation to the family involves the evaluation of the athletes throwing mechanics, in immature pitcher’s development of skill and control, then with maturity develop speed and velocity


“Little League Elbow”Medial elbow pain in tennis player’s,

javelin thrower’s, and football quarterback’s

Complex grouping of injuries involving medial epicondylar fractures, medial apophysitis, and ligamentous injuries

Pain is the most common complaintDuration of pain aides in the diagnosis


Short duration: must consider avulsion fxLonger duration: consider ligamentous

injury or medial apophysitisRadiographs lead to the diagnosis in

fractures, but normal variants must be understood especially medially

MRI gaining importance in use in these injuries as it gives great details of all the structures


Treatment is diagnosis specific: *Medial Apophysitis-medial pain,diminished

throwing effectiveness, and decreased distance: rest (4-6 weeks), NSAID, ice, gradual return to conditioning and resume throwing at about 8 weeks

*Medial Epicondylar Fractures-nondisplaced treat with cast and rehab; displaced 3mm or more treat with ORIF


*Medial Ligament Rupture-sudden onset of severe pain with instability; treatment is via direct surgical repair and if tenuous then supplement with a palmaris longus graft


“Panner’s Disease”Osteochondrosis of the capitellum (necrosis or

fragmentation followed by recalcification)Seen in children aged 7 to 12 years of ageDull,ache that is aggravated by activity

especially throwingPain always LATERALRadiographs reveal fragmentation and

irregularities of the capitellum


Treatment involves initially rest, avoidance of throwing, and splinting until pain and tenderness subsides

Rehabilitation and reconditioning of the upper extremity post recover important

Late deformity and collapse of the articular surface of the capitellun uncommon


“Iliac Apophysitis”Iliac crest tenderness on palpation and

muscular contraction seen primarily in adolescent long distant runner’s

No local trauma but history of extensive intensive training programs

Radiographs are normalTreatment is rest (4-6weeks), ice, NSAID,

progressive return to sports


“Osgood-Schlatter Disease”Classic presentation is seen in preteen or

early teenage children with activity related discomfort, swelling, and tibial tubercle tenderness

Bilateral occurrence in 20 to 30%Etiology is submaximal repetitive tensile

stresses acting on an immature patellar tendon-tibial tubercle junction


Muscle imbalance is commonly seen with weakness in the quadriceps sometimes significant

Treatment is avoidance of activity, rehabilitation of the weak quadriceps, hamstrings and flexibility training, and progressive return to sports

Family must understand that it can take from 12 to 18 months for all symptoms to subside


“Sinding-Larsen-Johansson Disease”Anterior knee pain at inferior pole of the

patellaSeen commonly in 10 to 12 year oldsTenderness seen at the inferior end of the

patella at the tendon-bone junctionMust evaluate for sleeve fracture or

patellar stress fractures if history of sudden onset


Treatment involves rest, ice, NSAID, and occassionally a knee sleeve for protection

Rehabilitation program to promote flexibility, quadriceps and hamstring conditioning, and return to normal activities to tolerance


“Slipped Capital Femoral Epiphysis”Most common hip disorder seen in adolescentSlippage of the proximal femoral epiphysisSeen in two body types: tall, slender, rapidly

growing or the short, obese childBilateral in 50%Common cause of anterior thigh or knee pain,

athlete’s with knee pain should have the hip evaluated too


Gait abnormality is the common initial presenting complaint with a limp seen

External rotational deformity of the hip seen (obligatory external rotation)

Pain can be seen: under 3 weeks (acute); over 3 weeks (chronic)

Treatment is immediate percutaneous hip pinning


“Patello-Femoral Malalignment”Common source of sports disability especially

in jumpers and those sports requiring rapid changes in direction

May be related to congenital, acquired such as in Down’s or Ehlers-Danlos syndrome, or acquired due to trauma

Can be seen in association with flexible flat footedness due to valgus thrust on the patella

“Sports Medicine for Primary Care Physician’s”Common symptoms include vague, localized

anterior knee discomfort Seen following prolonged sitting, stair accent

and descent, and with increase levels of activity

Clinically evaluate for mechanical alignment of the lower extremity, movement of the patella on flexion/extension, quadriceps function and size, hamstring function and overall flexibility


Gait analysis for femoral anteversion or tibial torsion should be studied as well as the evaluation for flexible flat footedness

Radiographic evaluation involves plain x-rays with Merchant view to see patellar alignment and position

Treatment is symptomatic via rest, NSAID, physical therapy and sometimes bracing


Rehabilitation is the key to preventing the reoccurrence of the condition

Failure to respond with prolonged symptoms and persistent subluxation with pain may benefit from arthroscopic lateral retinacular release

Long term sequlae may predispose the patient to the development of chondromalacia patella


“Osteochondritis Dissecans”Lesion of bone and articular cartilage of

uncertain etiology that results in delamination of subchondral bone with articular cartilage mantle involvement

Peak appearance is seen in early adolescence with male predominance 3:1

Seen in the knee but can also be seen in the ankle involving the talus and the patella


Clinically presents with vague knee pain that is aggravated with sports, intermittent swelling seen, and at times a feeling of the knee locking

Physical exam is nonspecificRadiographic evaluation includes x-ray's and

if indicated an MRIMost importantly, must differentiate acute

lesion’s from silent “chronic” lesions


Treatment geared to eliminate the pathologic process and clinical condition via repair or resection of the lesion

Chronic lesion’s loose bodies require removal arthroscopically and debridement of the bed

Acute lesion’s require drilling of the bed and fixation arthroscopically to allow the lesion to heal


Patellar osteochondritis is treated similar to that of femoral osteochondritis with arthroscopic evaluation and debridement and curettage of the lesion

Lesion commonly seen in the lower third of the patella and is due to increased patello-femoral contact force during flexion in the presence of weak quadriceps and minor trauma


“Ligamentous Injuries”Common in AthletesLoaded in tension to provide both static and

dynamic support to the kneeKnee has motion that occurs in three planes

and requires this static and dynamic supportKinematics of the Knee shows that any one

plane motion is always coupled with a second plane motion


Must Understand the Healing Process of the different ligaments

Collateral Ligaments have a rich blood supply from the surrounding tissue and heals well with conservative care

Cruciate Ligaments have a sparse blood supply from surrounding tissue and bone attachment and do not heal well with conservative care


Healing process begins with fibrin clot formation and then a local inflammatory response

First week post: local vascular and fibroblast proliferation

Second week post: fibroblasts become organized into a parallel network

Third week post: tensile strength increases


Eighth week post: normal appearing ligament is now present

Early range of motion critical to increasing the strength and energy-absorbing capacity of the ligament

Immobilization not favorable to healing and recover of the ligament


“Medial Collateral Ligament”Primary restraint to valgus stressCommonly injured by a direct blow to the

lateral side of the knee with the foot planted

Clinical signs reveal tenderness at the medial epicondyle with localized swelling

Pain on valgus stressing or laxity seen define the grade of injury


“Lateral Collateral Ligament”Primary restraint to varus stressCommonly injured with direct blow to the

medial side of the knee with the foot planted

Clinical signs reveal tenderness over the lateral epicondyle with localized swelling

Pain with varus stressing or laxity reveal the grade of injury


“Treatment of Collateral Injuries”Grade I do not require bracing, Grade II

and III require the use of a hinged ROM brace with motion limited at 10 to 75 deg. initially for the first three weeks

Early therapy important and include patellar mobilization, isometric quadriceps and hamstring exercises with modalities of whirlpool, E-Stim., and biofeedback


Bracing discontinued for Grade II and III at four weeks and achieving full ROM is now the goal

Once FULL ROM achieved then begin flexibility and strengthening program

Program includes: leg presses, mini-squats, resisted knee flexion, proprioceptive training and swimming leading to a sports- specific training program (return 2-8 wks)

“Sports Medicine for Primary Care Physician’s” “Anterior Cruciate Ligament”Primary stabilizer to anterior displacement

of the tibia on the femurSecondary role is in the control of rotation

of the tibia on the femur and to aide in varus-valgus stability

Common mechanism of injury is a twisting force to the knee accompanied by a varus, valgus, or hyperextension stress to the limb


Clinically feels a “pop” in the kneeInability to continue to play with a difficult

time putting weight on the limbGradual onset of swelling over the next 24

hours (acute swelling think chondral fx.)Examination reveals a positive Lachman Test,

positive Drawer sign, and Pivot-Shift signEvaluate for other associated injuries


“Non-Operative Treatment”Goal is functional stabilityInitially reduce pain and swelling with

NSAIDS, PT, and crutchesImmobilization not necessaryIntermediate rehabilitation involves

ROM, gait training, strengthening and proprioceptive training


Once effusion down and ROM full, then begin swimming and bicycling followed by light jogging

Late phase rehab includes functional trainingReturn to sports: 6 to 12 weeksMust attain 90% of the unaffected extremity

strength before return to sportsBracing is not absolutely indicated (no

evidence to support functional bracing)


“Anterior Cruciate Ligament”Isolated disruptions are unusual in childrenTwo types exist: nontraumatic cruciate

insufficiency and post traumatic cruciate insufficiency

Nontraumatic Insufficiency have inherent joint laxity of the knee as well as other joints


Positive anterior drawer sign but firm end point on Lachman test

Findings are seen bilaterallyAthletic participation should be

limitedMost will be asymptomatic with

activity modification


“Traumatic Anterior Cruciate Insufficiency”Can be seen in traumatic avulsions of the tibial

eminence with positive radiographic findingsLaxity is commonly seen with acute

hemarthrosis and often associated with damage to the supporting ligaments and meniscus

Treatment involves arthroscopic evaluation, reduction and internal fixation via bioabsorbable pins and casting


“Isolated Anterior Cruciate Ligament”Divided into two groups: those without

functional instability and those withIn those without limitations, conditioning and

participation in sports without limitations can occur

In those with limitations, thorough evaluation for other associated injuries must be undertaken MRI and Plain X-ray's


Arthroscopic evaluation is carried out to evaluate the site and magnitude of the ACL tear and if any peripheral meniscal lesions are seen then repair carried out

If avulsion from tibia or femur found then primary repair performed regardless of age

If midsubstance tear with growth left, conservative treatment undertaken

If no growth left evaluate sport situation


Conservative treatment involves rest for 7-10 days, progressive range of motion over next four weeks, quadriceps and hamstring conditioning exercises are begun

Maintenance program instituted and a functional brace provided and wait until skeletally mature for reconstruction

Skeletally mature and achieved goals of rehabilitation then return to sports without brace


If ACL torn and functionally impaired with little growth left, then reconstruction performed

Treatment geared to prevent further damage to the joint, meniscus, and articular cartilage

Surgical techniques multiple and center around the use of the patellar tendon or semitendinosus/tendon graft transfer


“Guidelines for ACL Treatment”Physiologically young person who remains

active in sports and will not modify activities, surgical intervention if not skeletally immature; if immature wait till maturity

Surgery for those with associated risk factors for instability such as collateral ligament tears or meniscal tears

Older athlete modify activity and conservative


“Female Sports Related Injuries”Shoulder InstabilityPreventing Knee InjuriesPatellofemoral Problems in WomenPreventing Exercise-Related injuries


“Shoulder Instability”Shoulder instability in the female athlete is a

difficult problem to identifyIdentifying the type of instability is the

biggest challenge facedTraumatic versus ligamentous laxityLigamentous Laxity is the more common and

seen with pain as the predominant complaint

“Sports Medicine for Primary Care Physician’s”Sex differences put the female athlete at risk for

shoulder injuriesWomen have shorter upper limbs relative to total

body length and thus upper girdle musculature and limbs work harder in certain sports ie. Swimming

Shorter limb and lever arm tends to promote capsular laxity compared to men and increases stresses on the shoulder girdle increases instability and capsular laxity

“Sports Medicine for Primary Care Physician’s”Identify Instability by the mechanism of

injury, by the degree of instability, direction of dislocation or subluxation, and type of onset

Types seen: Acute Dislocation,Recurrent Instability,Atraumatic Instability, and Repetitive Microtrauma

Most Common Type seen in the female athlete is the nontraumatic microinstability or subluxation injury due to capsular laxity


Acute Dislocation: due to trauma with anterior dislocation seen in 95% of the cases

Dislocations can cause anterior detachment of the labrum or capsule from the glenoid “Bankart Lesion”

Lesion associated with increased ligament laxity, stretching of the capsule, and loss of labrum-mediated stabilizing support


Recurrent Instability: due to repeated glenohumeral dislocations or subluxation that stretch the capsule and ligaments, leading to increased laxity and instability

Resultant Natural History of chronic dislocations with unhealed Bankart lesions

Secondary Etiology: Congenital Inherent Laxity of the shoulder joint (Genetic)


Atraumatic Instability: typically a micro-instability or a subluxation disability

Referred to at times as multi-directional instability due to the movement of the head abnormally in multiple planes

Generalized laxity of the capsule and ligaments seen with associated fraying of the glenoid labrum


Repetitive Microtrauma: commonly seen in athletes that participate in excessive overhead motions

Damages the anterior stabilizing structures of the shoulder joint

If associated with congenital joint laxity, then pain due to impingement of the rotator cuff is also seen


Clinical History will give clue to cause and the possible etiology

Physical examination evaluates passive and active motion, palpable pain location, instability signs such as inferior instability test, anterior-posterior instability test, apprehension test, anterior relocation test(Jobe),and axial load test

Imaging: X-ray's and MRI


“Treatment”Acute Dislocation: Reduction of the

dislocation followed by immobilization for three to four weeks and the rehabilitation

Emphasis placed on early and safe ROM for the first six weeks followed by strengthening of the dynamic stabilizers of the shoulder and capsule

Return to sports 12-20 weeks


Atraumatic Instability: cornerstone is rehabilitation with specific strengthening of the muscles that protect the shoulder joint from instability and discomfort

Sports specific rehabilitation is the KEYImportantly, restrict those motions that elicit

pain and promote those that do notFailure requires workup and possible shoulder

stabilization procedure (arthroscopic)


“Prevention”Essential Elements to Prevention:

strengthening the muscles of the shoulder girdle and structured pre-sport and sport specific strength training activities

Avoid weight training with the load above the shoulder as well as avoiding weight machines due to design, and evaluate technique of the athlete


“Preventing Knee Injuries in Female Athletes”20,000 injuries occur in female athletesDue to marked imbalance in hamstring and

quadriceps muscle strengthHighest incidence of injury in the “untrained”

athlete3.6 times more likely to have an injury than

the “trained” athlete


Strength training programs that include plyometrics, stretching, and strength training have decreased the imbalance and reduces injuries

These program should emphasize muscle balancing, muscle re-education, and sport specific training programs and in the long run turns out to be a simple and cost-effective means to reduce injury


“Patellofemoral Problems in Female Athletes”Anterior knee pain in our female athletes is a

frustrating problemAtraumatic knee pain is commonly due to soft

tissue overload and overuseOccurs when the demand overwhelms the

body’s ability to maintain homeostasisFactors influence: activity changes, training

errors, flexibility deficits, and weakness


Clinical History will determine if the patient’s problems are related to anterior pain only or instability

Anterior pain is commonly worse with prolonged flexion of the knee and sitting in one position, activity related pain always seen, and symptoms aggravated by walking up or down stairs


Patellofemoral instability is identified by the feeling of the knee “giving way” and the knee cap feeling like its “out of place”

Associated with activity but moreso full weight bearing activities that involve twisting motions

Low Energy injuries or the so called trivial injuries should alert one to the diagnosis of Patello-femoral instability


Clinical examination involves careful evaluation of the knee mechanics, muscle strength and size, palpation of the knee cap, and tracking of the patella

Evaluate alignment of the leg, shape, and size as well as flexibility of the limb

Evaluate patellofemoral alignmentEvaluate pain generator coming from the

patella


Imaging involves: x-rays including AP,Lateral and Obliques with Merchant view to see tracking of the patella

Treatment is usually non-operative and begins with activity modification

“Dye Envelope of Function” is a concept to achieve a balance between activity/work that a patient can do without leaving a state of homeostasis


Key Goal to treatment is to achieve a pain free envelope of function through avoidance of provocative activities until conditioning dictates a return

Strengthening should not stress the envelope and should be initially geared at the submaximal level until rehab sufficient

Specific exercises should be performed to enhance the deficient muscle groups


Quadriceps and Hamstring Balancing exercises and conditioning critical as well as VMO exercises

Stretching program is important as flexibility is key to rehab but moreso to prevention and re-education of the appropriate muscle groups

Taping beneficial during rehab but not long term…secondary deterioration of muscles


Surgical correction can be effective but after all conservative measures exhausted

Arthroscopic Lateral Releases work BEST initially but without proper re-education, will deteriorate after two-three years

Proximal or Distal Realignment procedures are then required with proximal muscle re-alignments better than boney procedures


“Pearls to Anterior Knee Pain”Detailed HistoryAccurate Physical ExaminationFocused Initial Rehabilitation ProgramDetailed Sports-Specific Conditioning ProgramUnderstanding of the Long-Term Need to

continue rehabilitationNO QUICK FIXES


“Recommendations for Preventing Exercise-Related Injuries in Females”Women are engaging in sports and fitness

activities with increasing numbersWomen participating in sports has grown from

300,000 three decades ago to 2.7 million today

Women represent 33% of college athletes and 37% of US Olympic athletes


37.4 million women now perform aerobic activity on average twice each week

Unfortunately, research on exercise-related injuries in women has not kept up and the true incidence and risk factors are not known

CDC evaluated military personnel for female related sports injuries


Injury rates among military females was 1.7 to 2.2 times higher than males

Female recruits were less fit upon entering the military service

Low aerobic fitness was found to be the greatest risk factor affecting female athletes

Increased aerobic fitness programs decreased the incidence of injuries in recruits when done early in basic training

“Sports Medicine for Primary Care Physician’s”Studies revealed that age was not a strong

risk factor for injuryOlder athletes modify there degree of

intensity of exercise and thus limit their risk of injury

Smoking did influence injury rates with 1.2 times higher rate of injury in smoker’s compared to non-smoker’s

Reason: delayed healing of microtrauma to tissue

“Sports Medicine for Primary Care Physician’s”Body composition also influenced injury rates

in femalesHigher Body Mass Index associated with

increased risk due to extra load placed on body

Low Body Mass Index also seen with higher risk due to lower proportion of muscle relative to body’s bone structure, thereby putting greater stress on the bones leading to injury


“Strategies for Injury Prevention”Women over 50 should consult their

physician before beginning an exercise program

Frequency, Duration, and Intensity of exercise should be customized

Watch for early warning signs such as increasing muscle soreness, bone and joint pain, fatigue, and decreased performance


When warning signs present, reduce frequency, duration, and intensity of exercise until symptoms diminish

If injury occurs, then sufficient time should be allowed for recovery and rehabilitation before resuming exercise activity

Women who smoke should stopMost importantly, set realistic goals


“COX-2 Specific Inhibitors: Improved

Advantages Over Traditional NSAIDs”


Role of NSAIDs in treating injuries has been based on their ability to inhibit inflammation and depress pain via inhibition of the enzyme: cyclooxygenase

Cyclooxygenase catalyzes the first two steps in the synthesis of prostaglandins

NSAIDs(COX-1) inhibit prostaglandins but also affect other important bodily functions ie. Gastric mucosal protection, platelet aggregation

“Sports Medicine for Primary Care Physician’s”Recent Studies revealed a second gene with

cyclooxygenase activity (COX-2)This gene primarily involved in the

inflammation and pain cycle whereas the COX-1 is moreso the housekeeping enzyme

Furthermore, COX-2 is inducible in most cells that is upgraded in inflamed tissue by cytokines and endotoxins to produce PG

COX-1 is a constitutive enzyme seen in all cells including monocytes and platelets


This specificity gives the COX-2 inhibitors a better and more selective effect on the inflammatory cycle without damaging the housekeeping effect needed from the COX-1

Comparative NSAIDs will influence bone and tissue metabolism through their effect on PG production and effect all aspects of healing both in fractures and injured tissue

COX-2 being inducible, will allow the normal cascade mechanism for healing to continue


Comparative NSAIDs will effect bone fracture healing, bone fusion in spinal fusion surgery, as well heterotopic ossification through effect on the COX-1 and overall effect on the constitutive enzyme needed for housekeeping

Even though COX-2 effect cytokines seen in inflammatory tissue and also the fracture model, being inducible, it will block those being produced and not those in the normal tissue cascade allowing the cycle to continue


Celebrex and Vioxx do not inhibit COX-1 and thereby do not affect the housekeeping functions of COX-1

Celebrex and Vioxx only affect COX-2 and does not disturb the COX-1 in the GI tract and thus preserves the effect on the gastric mucosal and the protective effect of prostaglandins in the GI tract


Benefits therefore of COX-2 show a higher safe GI profile

Improved effects on pain and inflammation

No effect on thromboxane synthesis and therefore no influence on platelet aggregation

No effect on post-operative bleeding


For Sports-Related Injuries it offers relief from pain and inflammation, rapid onset of action, improved quality of life and better dosing regimens

COX-2 inhibitors are effective in treating acute and chronic pain including muscle tenderness, strains, sprains, and even fractures (potentially no effect on new bone formation) excellent effect on pain control


Use in recent studies on minimally invasive orthopaedic procedures reveals positive results especially in ACL reconstructions

Regime proved effective was: Vioxx 50mg given the morning of surgery and then 50mg daily for 4 days, then decreased to 25mg daily there after


THANK YOU


Dr. George Alavanja Director, Section of Sports Medicine The Orthopaedic, Pediatric & Spine Institute Crown Point, Indiana


Role of COX-2 Inhibitors on influencing bone graft arthrodesis in spinal fusion surgery:

Kucharzyk,D and Cook,S. “In Vivo Controlled Animal Study on the Effect of COX-2 Inhibitors on Lumbar Spinal Fusion Surgery”

Tulane University Clinical Research Dept. The Orthopaedic, Pediatric & Spine Institute

sports medicine for primary care physicians dr. donald w. kucharzyk the orthopaedic, pediatric &...

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