SPORTS MEDICINE MAGAZINE

SPORTS MEDICINE MAGAZINE

SPORTS MEDICINE MAGAZINE

SPORTS MEDICINE MAGAZINE

SPORTS MEDICINE MAGAZINE

Get SkiReady:with Snehal C. Dalal, MD Tim Simmons, MHA, ATC, LAT & Gary A. Levengood, MD

Gwinnett Gladiators – An Athlete’s Success Story with Brian Morgan, MD

Preventing Knee Injuries in Female Athletes with Mark C. Cullen, MD

WINTER 2012

WINTER SPORTSISSUE

Keeping the Georgia Force On Trackwith Brian Struck, ATC, LAT

on the coverNorcross Women’s Basketball teamgears up for another great seasonphotographs by Jackie Reedy

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Publisher | Kandace Walker-BundaLead Designer | Robert Walker-BundaMarketing/Advertising Sales | Sherri CloudContributing Photographers | Tim Song, Jackie ReedyCopy Editor | Megan GreerPrinting | Protech Printing and Graphics

>Editor’s Note /// Gary A. Levengood, MD /// 3>Diagnosing & Treating Skier’s Thumb /// By: Snehal C. Dalal, MD /// 5>Snow Sport Related Injury /// Tim Simmons, MHA, ATC, LAT /// 6-7 ///Gary A. Levengood, MD /// 8>Preventing Knee Injuries in Female Athletes

/// By: Mark C. Cullen, MD /// 10-11>Gwinnett Gladiators – An Athlete’s Success Story

/// By: Brian Morgan, MD /// 12-13>Keeping the Georgia Force On Track

/// By: Brian Struck, ATC, LAT /// 14>Eddie: The Athletic Trainer /// By: Eddie Knox, ATC, LAT /// 15>Rehabilitation of the Back Pain Patient

/// By: Curt Bazemore, PT, ATC, LAT /// 16>Multidirectional Shoulder Instability /// By: Stephanie H. Hsu, MD /// 17>The Right Way to Make Weight for Wrestlers

/// By: Ann Dunaway Teh, MS, RD, LD /// 18-19>Skin Infections in Wrestling /// By: J. Stephen Kroll, MD /// 20>Radiologist’s Role in Sports Medicine Imaging /// By: Val Phillips, MD /// 22

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Letter from the EditorGary A. Levengood, MD

Gwinnett Sports Medicine Magazine’s first issue debuted this fall and was distributed among the medical community at the beginning of this past

September. We were humbled by the level of support and enthusiasm the community presented towards GSMM’s de-but. The collaboration and contributions from the member’s of our Gwinnett Sports Medicine committee will enable this magazine to continually produce resourceful information for medical reference. As a team of Gwinnett Sports Medicine doctors, it is our goal for each issue to assist practitioners and the rest of the medical community as they work towards diag-nosing, treating, and preventing future sports injuries.As temperatures drop and the football season comes to a halt, we begin to turn our focus to the new season - winter sports. Basketball, swimming, wrestling, hockey, and skiing are all extremely popular among the sporting community and each require a high level of athletic performance by its participants. Like any event where strength, speed, and agility are required, athletes of winter sports yield themselves to common sports related injuries. This issue of GSMM features articles on a diverse set of winter related sports injuries and provides a number of precautions an athlete should take when properly preparing for their respective sport. To enhance the GSMM magazine, there are several specialized articles including a Nutritionist Corner, Rehabilitation Spotlight, and A Day in the Life..of an ATCAs always, we look forward to this issue of Gwinnett Sports Medicine Magazine being a quality resource that you can turn to when seeking assistance with sports related injuries. Over-all, our goal, in collaboration with family practitioners, is to keep our athletes educated, safe, and ultimately healthy so that they can perform at the highest level. Now and in the future, please give us your feedback so that we can further tailor the magazine to continually fit your needs.

GSMM

If you would like to submit an article or are interested in advertising opportunities in GSMM please contact Sherri Cloud atsherricloud@windstream.net or 6789072912

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GSMM 3

Kaylee RosenbergerContributing Editor

phone: 770-237-3475 ext. 113fax: 678-689-2940

krosenberger@sportsmedsouth.com

You really w o u l d not be-lieve the i m p o r -

tance of your thumb until you injured it. The thumb allows the move-ment of opposition – the thumb pressed against your other fingers – which allows the ability to pinch or grip with your hand. If you lose this function, you lose the basic skill to perform ev-

eryday activities such as holding a pen, an eating utensil, or undoing buttons on your shirt. Thumb injuries can comprise up to 5-15% of all injuries sustained from alpine snow skiing. Skier’s Thumb (injury to the ulnar collateral ligament) is the number one thumb in-jury amongst skiers. The mechanism of injury is that most skiers hold the ski pole in the palm of their hands. The skier may also use the pole strap to secure around their wrist so they do not lose the pole when they fall. Unfortunately, when the skier does fall, the pole held in the palm acts as a lever against the MCP joint of the thumb, forcing it into abduction and radial deviation. Alternatively, when a skier plants the pole into the snow, the pole can become stuck or the skier does not move the pole in time as they move forward, resulting in a similar force against the thumb. This outward force results in damage to the UCL. This mechanism of injury has greatly diminished in the recent years as pole handles have become consider-ably smaller, making them less likely to cause this injury. As with most other injuries, the clue to the diagnosis is in the history of what happened. On examination, there is localised tenderness at the base of the thumb over the MCP joint, specifically over the UCL. There may be asso-ciated swelling and bruising. An x-ray is often taken to ex-clude the presence of an associated fracture (sometimes as the ligament gets pulled with force, it pulls off a small piece of bone as well - known as an “avulsion fracture”). The injury may be soft tissue only, where no fracture is evident on radiographs. Sometimes you may see vo-lar subluxation of the proximal phalanx in relation to the metacarpal head if there is significant capsular injury. You may even see abnormal widening of the joint space on the ulnar aspect of the joint. If the injury involves a bony avulsion of the ligament, you will see a fracture at the medial base of the proximal phalanx.

In case of fracture, you can determine where the distal UCL lies. If in close proximity, you may treat the injury conserva-tively with a thumb spica cast or splint for 4 weeks and then a brace for an additional 4 weeks. If displaced, you may sus-pect a Stener Lesion and refer to an orthopedic surgeon for possible surgical repair. In the absence of a fracture, the stability of the UCL can be tested by holding the thumb metacarpal steady in one hand whilst with the other hand try to abduct the MCP joint. Ideally this should be done with the thumb fully extended and also in 30 degrees of flexion. If the injury is very sore, some local anaesthetic can be injected in first to make it all go nice and numb. Physical examination becomes even more important in the case where there is no fracture seen on xrays. The thumb MCP joint can be stressed in full extension and at 30 degrees of flexion. Even in a normal thumb, there is a degree of give felt when stressing the MCP joint this, but it should not be excessive. Depending on the amount of give detected in the injured ligament (and this can be compared to the thumb on unaffected hand) the ligament injury can be graded as 1, 2 or 3 in increasing degrees of severity.Grade 1 – No Laxity (‘give’) in the ligament when stressed. Few ligament fibers are torn.Grade 2 – Some laxity in the ligament but a definite endpoint is present. Some but not all of the ligament fibers are torn.Grade 3 – Complete give in the ligament. All ligament fibers are torn. If there is a firm endpoint and angulation is normal, the thumb can be treated in a splint for 4 weeks. If angulations is >35 degrees or >15 degrees compared to the unaffected side or if there is not firm endpoint, an MRI is recommended. At this point the patient should be referred to an orthopedist for pos-sible surgical fixation. To complicate things still further, the UCL itself lies under-neath a sheath of fibrous tissue called the adductor aponeu-rosis. On occasions, when the ligament ruptures, one end of the torn ligament folds back and the aponeurosis falls be-tween the torn ligament and its insertion point. This makes it impossible for the end of the ligament to come back down to the bone and heal naturally. This is called a Stener lesion and its presence makes surgical fixation necessary. Although the presence of a Stener lesion on MRI requires surgery, the lack of a Stener lesion does not necessarily mean conservative treatment. Recent studies suggest that a grossly unstable joint without a Stener lesion still may need surgical fixation. If surgery is chosen, the thumb should be immobilized in a thumb spica cast for 4 weeks with transition to a brace for an additional 4 weeks. How can we prevent Skier’s Thumb? A simple answer is to not use poles or at least the pole straps. More modern, smaller handles have resulted in a lower incidence of this type of injury. If the straps are worn, make sure the hand comes through the loop from underneath before grabbing the pole handle. The strap will then sit on the wrist rather than over the 1st web space. When the pole is let go, the pole will sim-ply fall out of the hand and hand around the wrist rather than becoming entangled around the thumb. Now you can recognize, treat, and most importantly pre-vent this common thumb injury – so click on those skies, grab those poles and enjoy the slopes this winter!

Diagnosing & Treating Skier’s Thumb/// By: Snehal C. Dalal, MD

GSMM 5

GetSKI Ready!with articles fromGwinnett Sports Medicine’sSnehal C. Dalal, MD,Tim Simmons, MHA, ATC, LAT,and Gary A. Levengood, MD

Snow sports are one of the most popu-lar winter activities

worldwide, with around 200 million skiers and 70 mil-lion snowboarders joined by snowbladers, and cross-country skiers. The inci-dence of adult injuries in skiing has recently declined due to rapid advances in equipment technology, while the incidence of ski trauma in children and adolescents remains high. The highest percentage of injuries occurs from ages 6 to 15 years.

Many studies show high injury rates in winter sports with skiing most commonly affecting thumb and knee while snowboard injuries

ReferencesHansom, D., & Sutherland, A. (2010).Injury prevention strategies in skiers and snowboarders.Current Sports Medicine Reports, 9(3), 169-175. Retrieved from EBSCOhost.Verhagen, E. M., van Stralen, M. M., & van Mechelen, W. (2010). Behaviour, the Key Factor for Sports Injury Prevention.Sports Medicine, 40(11), 899-906. Retrieved from EBSCOhost.Meyers, M., Laurent, C., Higgins, R., & Skelly, W. (2010).Downhill Ski Injuries in Children and Adolescents.Sports Medicine, 37(6), 485-499. Retrieved from EBSCOhost.Schwager, T. (2011). DON’T BE A VICTIM OF WINTER WIPEOUT. American Fitness, 27(1), 40.Retrieved from EBSCOhost.

• 49,000 ice-skating• 74,000 sledding, tubing and tobogganing• 35,483 snowmobiling• 143,990 snowboarding related problems• 144,379 snow skiing

Top seven reasons for high injury rates in skiing include:

• Musculoskeletal immaturity• Fatigue & deconditioning • Experience level• Equipment type and use• Collisions and falls• Risky behavior• Gender

most commonly occur in the foot, ankle, and wrist. Injury rates now range between 3.9 and 9.1 injuries per 1000 skier days, and there has been a well-documented increase in the number of trauma cases and fatalities associated with this sport. Head and neck injuries are considered the primary cause of fa-tal injuries and constitute 11–20 percent of total injuries among children and adolescents. Cranial trauma is responsible for up to 5 percent of total hospital injuries and 67 percent of all fatalities, whereas abdominal and spine injuries comprise 4–10 percent of fatalities. The most common injury in children and adolescents are those to the lower extremity, with knee sprains and anterior cruciate liga-ment tears accounting for up to 47 percent of total injuries. Knee sprains and significant ligament trauma associated with lower leg fractures account for 39–77% of ski injuries in youth populations.Downhill skiing injuries among children and adolescents are caused by a number of factors, including musculoskeletal imma-turity, risky behavior, excessive fatigue, age, level of experience, and inappropriate or improperly adjusted equipment.

Snow Sport Related Injury/// By: Tim Simmons, MHA, ATC, LAT

Here are some top tips to help prevent or lessen the severity of common ski-related injuries:1. Take time to learn techniques for moving, stopping, and falling from a professional instructor, rather than just relying on hap hazard tips from friends—and pick an easy, starter slope that is designed for learning how to ski.2. Check to ensure that your ski binding is working properly prior to your vacation and then perform a self-release test at the start of each day. Check with ski shop personnel if you are uncertain of proper settings. 3. Wear a helmet to help protect against head injuries, which are the most common cause of death in ski related accidents.4. Learn how to crash. Drop your ski pole when you fall to avoid thumb and hand injuries.5. Avoid alcohol and other drugs, including stimulants, which can interfere with your performance, slow response times, or make you jittery or nervous.6. Condition and prepare for your skiing trip.

If ski fitness has a magic bullet, it’s training the core. A great tool for core fitness is the Physioball. Many elite skiers use the physioball by standing on it while a partner tosses a medicine ball. Start with an easier version by standing on a flat-bottomed Bosu ball, but get into a skiing pose and maintain that position while your partner throws a medicine ball. Catch it, and then twist to the side, alternate as throws progress. You’ll work your balance, quads, glutes, and abdominal area. This core exercise regimen will better prepare you when added to basic training activities such as weight training, biking, walking, jogging, and swimming.

According to the 2010 report by the U.S. Consumer Product Safety Commission, visits to emergency rooms, doctor’s offices, and clinics for winter sports- related injuries, snow skiing was in the top five of winter sports – it was number five with over 144,000 injuries reported: ADVERTISEMENT

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maximum heart rate to be sustained for at least 30 minutes. To compute this use the following formula: 220 – age x 65 percent = target heart rate. This should be repeated at least three times a week. It is important to start off slow and in-crease the length and intensity of your work out as you get closer to your vacation. Once you get to the ski slope a few words of advice. If you own your equipment make sure it is in good shape and the binding settings are proper for the level of you ability and ski conditions. This can easily be done at a ski shop at home or in a few minutes as a ski shop at home at the mountain. If you are renting equipment be sure to let the person adjusting your bindings know your true level of ability. If you overesti-mate and the bindings are set too tight your skis may not re-lease and injury to your legs or knees is assured. Additionally, if you are a beginner or have never skied before, then a ski lesson by a trained ski teacher is money well spent and can increase your enjoyment as well as prevent injury. Should you suffer an injury while skiing have the ski patrol assist you down the slope and get prompt medical atten-tion. There is usually a ski area clinic at the base of most ski resorts. Some injuries, such as a broken bone penetrating the skin or an injury to a blood vessel demand immediate treatment. If the injury is confined to your knee ligaments, there is no danger in waiting several days and recent studies have shown improved results when surgery is delayed until swelled is resolved and range of motion is regained prior to knee ligament (ACL) reconstruction. There is certainly time to fly home and obtain a second opinion or undergo surgery where family support is available. There are two additional considerations that also need to be addressed before your ski vacation. First, if you are heading to a high altitude i.e. > 10,000 feet above sea level, then the medicine acetolamide (Diamox) taken the day prior to your trip can greatly decrease your chance of getting acute mountain sickness (AMS). Ask your doctor id this is right for you. Secondly, make sure you have the proper clothes, gloves and eyewear, as frostbite and snow blindness will surely camp your vacation plans. Skiing is one of the most exhilarating sports known to man. It can be a fun and safe undertaking if you properly prepare and use common sense. Good luck preparing and I’ll see you on the slopes.

Ski season is fast approaching and with it the thrill of an exhilarating run down the slopes on your skis or an equally exhilarating ride, but it’s not nearly as fun going

down the slope on a ski patrol. Which scenario you end up in is decided in large part by how you prepare for your ski vacation. The biggest cause of ski inju-ries is lack of conditioning for this demanding sport. If you have that vacation planned for February or March now is the time to get into condition for skiing. Proper muscular conditioning involved all the components of fitness, i.e. flexibility, strength and endurance. The muscles most involved in skiing are the knee. If you have not started previously, now is the good time to begin a stretching program. Stretch all the muscles around the hip including the hip abduc-tors, flexors, extensors and groin muscles. Once you place your muscles in a position of stretch, hold them for a count of 30, and remember do not bounce. Then proceed to stretch the quadri-ceps and hamstring muscles again holding for 30 seconds. Finally, give the calf muscle a good stretch. These stretches should be done at least once a day or more frequently if your muscles are tight. Always stretch prior to your workout and defi-nitely before heading down the slopes. Strength training specific for skiing involves the hip abductors, quadriceps and hamstrings. Weight training with free weights or exercise machines which emphasize these muscles groups can be equally beneficial. Additionally, for the quadriceps, per-form a wall squat. Place your back firmly against the wall with your feet two feet in front of you. Slide down until your thighs are parallel with the floor. Hold this position until you feel he burn. Try to increase the length of time in this position with each session. For the hip abductors, lie on your side and curl your lower leg up, keep your upper leg straight and lift your upper leg two-three feet off the floor,. Start with three sets of 10 and increase the number of sets as this becomes easier. A two-pound weight can be attached to your ankle for added difficulty. Endurance training is also important. If you ski out Wresting you will probably be in elevation greater than 8,000 feet above sea level. This puts incredible demands on your cardiovascular system. To build endurance, participate in some aerobic activ-ity. These can include walking, jogging, biking, aerobics and swimming. To get at aerobic benefit the activity you choose must increase your heart rate to 60– 70 percent of your

ski conditionings/// By: Gary A. Levengood, MD

ACL tears in female athletes are occurring at an alarming rate. Fe-male athletes are four to six times more likely to sustain an anterior cruciate ligament (ACL) injury than male athletes. Since the enact-ment of Title IX, female participation in jumping and cutting sports has increased 10-fold. The elevated risk of ACL injury, coupled with a dramatic rise in participation has led to an increase in ACL tears in female athletes.

Girls are up to six times more likely to injure their ACL than boys playing similar sports. As many as 1 in 20 collegiate-level and 1 in 50 to 100 high school-level female athletes sustain an ACL tear during any given year of varsity sports. Over 50,000 ACL injuries likely occur in female athletes at the high school and intercollegiate varsity levels during an aver-age year. So imagine a hypothetical high-school soccer team of 20 girls, statistics predict that 1 player year will experience an ACL tear. Over the course of four years, 4 out of the 20 girls on that team will tear their ACL.

ACL injuries in female athletes are so wide-spread that coaches of high school and college teams expect at least one player to be sidelined by an ACL injury every season. Extensive research has been performed to study this epidemic in female athletes. Before puberty boys and girls have similar athletic characteristics. They run, sprint, jump, and land in similar ways. After puberty, noticeable gender differences are ob-served in their motor skills.

Women tend to land from a jump with: 1) with straighter legs (i.e., no bend in the knees/hips), which is often termed a ‘stiff’ landing 2) have greater knee valgus, where the knees buckle inwards, when landing from a jump 3) stop or change directions using one large step 4) activate the quadriceps prior to the hamstrings during changes in direction and when landing from a jump

These four characteristic have been identified as key mechanisms in the etiology for non-contact ACL injuries in female athletes. Fortunately, neuromuscular training can help young women alter faulty movement patterns reduce their risk serious knee injuries.Research on ACL injury prevention in female athletes has focused on altering specific aspects of jumping, landing, and changing direction.

The most common techniques are to: 1) change ‘stiff’ landings into ‘soft’ landings by having athletes bend their hips and knees upon landing from a jump2) make athletes consciously aware of maintaining proper knee alignment upon landing from double leg and single leg landings 3) replace the one-step stop or change in direction with multiple, small steps

Sportsmetrics is a neuromuscular training program designed and scientifically verified to prevent knee injuries in female ath-letes. It was developed through research at Cincinnati Sports Medicine and Orthopaedic Center. It has been scientifically proven to decrease the risk of serious knee injuries by 70%. The Sportsmetrics employs a number of drills to encourage proper form for jumping and landing during athletic participation. Jumping drills are used to teach the athlete to preposition the entire body safely when accelerating (jumping) or decelerating (landing). The selection and progression of these exercises are designed for neuromuscular retraining proceeding from simple jumping drills (to instill correct form) to multi-directional, single-foot hops and plyometrics with an emphasis on quick turnover (to add sport-like movements). Doctor Cullen utilized this program during his sports medicine fellowship and has promoted the program as part of his sports medicine practice. He has trained several physical therapists, coaches and athletic trainers in the program in order to increase its use in Gwinnett County. He has tried to educate parents on the importance of ACL injury prevent so that they may be proac-tive and request the program as part of their daughters training programs. Sportsmetric should be an integral part of training of all female athletes to minimize their risk of ACL tears.

Preventing Knee Injuries in Female Athletes /// By: Mark C. Cullen, MD Sportsmetrics can:

• Reduce the risk of serious knee injury, including non-contact ACL tears• Increase vertical jump height up to four inches• Improve leg strength from hamstrings to quadriceps• Improve symmetry in right-to-left leg power• Improve landing mechanics• Reduce side-to-side movements at the knee

///Check out before and after pictures to the left from a Sportsmetric participant.

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10 GSMM

GwinnettGladiatorsI

ce hockey is a full contact game that is rapidly gaining in popularity in the US. It is one of the leading causes of sports medicine injuries for winter sports. Most hockey injuries are relatively minor and include contusions, lacerations, and mild sprains. However, some of the more serious injuries include concussions, shoulder injuries, and knee injuries.

Phil Youngclaus is a professional hockey player who grew up and learned to play in Mas-sachusetts. He played for the University of Ver-mont from 2002-2006. He then played for sev-eral teams in different leagues prior to joining the Gwinnett Gladiators during the 2008-2009 season as a defenseman. Early in the season, he injured his left knee in a home game against Charlotte. On-ice scuf-fles are a frequent occurrence in minor league hockey, and Phil became involved in one. As the team physician for the Gladiators, I was present and witnessed the injury. His knee appeared to give way suddenly, and he immediately came off the ice. I met him in the training room to ex-amine the knee. He stated that his knee buck-led and he felt a pop. On exam, there was im-mediate swelling, tenderness, decreased range of motion, and laxity with ligamentous examina-tion. Lachman’s and anterior drawer tests were positive, indicating a likely injury to the Anterior Cruciate Ligament (ACL). It was obvious that he would not be able to return to play that night. We placed him in a hinged brace and gave him crutches. MRI scan the next day confirmed the sus-pected diagnosis, a complete rupture of the ACL. Because the ACL is a critical structure for stability of the knee during agility sports, it is a major knee injury that usually requires sur-gery. Luckily for him, the meniscus cartilage and other ligaments were spared. I met him in the office to review the treatment for this injury. Unfortunately, it meant that he would miss most of the remaining season, but there was a good chance that he would be able to return to play prior to the playoffs, so that gave him a goal to try to achieve.

After a brief course of physical therapy to regain his range of motion, surgery was performed to reconstruct the ACL. Since it is not possible to repair the injured ligament primarily, it is necessary to make a new ligament out of a tendon. In this case, I used a portion of his patellar tendon, with a bone plug on each end, from the tibia and patella, to make a new ACL. The ACL graft was harvested and then placed through bone tunnels in the tibia and femur, and secured there using interference screws. The majority of the procedure is performed arthroscopically, which is less invasive, and allows for a very thorough examination of all of the intra-articular structures. He did well during surgery and was discharged home shortly after waking up in the recovery room. With newer surgical techniques and improved physical therapy protocols, the rehabilitation for an ACL reconstruc-tion usually takes an average of 4-6 months. This includes physical therapy and home exercise programs to regain the range of motion, strength, proprioception, and balance needed to return to competitive sports. The rehab protocol progresses through different stages designed to allow for a speedy recovery, but also to protect the ACL graft as it

heals and strengthens. The implanted tendon actually becomes revascularized and undergoes a process called ligamentization, in which it gradually changes properties to assume its new role a ligament. In Phil’s case, he rapidly progressed through his reha-bilitation program. Within a few weeks, he had full range of motion. Approximately two months after surgery, he re-turned to skating. One month later, he began to participate in non-contact drills and puck handling. When he was four months postoperative, he underwent a “functional ACL test” to determine if he was strong enough to return to play. He passed the test with flying colors and was re-turned to full contact hockey. He was able to finish the season as he had hoped. Phil continued to work hard throughout the end of the season and offseason in 2009 and returned to play an-other successful season with the Gwinnett Gladiators in 2009-2010 before moving on to other teams in the ECHL and later, an Australian league. Without surgical recon-struction of the ACL, his career would have ended and he would never have been able to return to the sport that he loves.

Gwinnett Gladiators – An Athlete’s Success Story/// By: Brian Morgan, MD

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NCAA Bowl Games and the Super Bowl are right around the cor-ner, marking the end to both College and NFL seasons, and con-versely, marking the start for preparation for the Arena Football season. The Georgia Force schedule has been released, and it is

now time for the medical staff to prepare for pre-participation sports physicals. With Gary Levengood, MD as the Team Physician and Brian Struck, ATC, LAT as the Head Athletic Trainer, the team has an advantage many teams do not. The majority of the medical care is done at Sport Medicine South and Gwinnett Medical Center. The GA Force began prepping for the season by getting team sports physicals done around the middle of February. Sports Medicine South‘s team of physicians, physician assistants, certified athletic trainers, physical therapists, and medical assistants provided the GA Force’s comprehensive pre-participation sports physicals. The sports physicals consist of two groups of 45 to 50 Georgia Force players who all receive in-depth medical evaluations. The players range from 22 to 35 years of age, with a variety of experience. The physical process includes ortho-pedic evaluations, EKG’s, imaging of prior injuries, and general medical evalua-tions. Yearly sports physicals are vital to the teams overall “prep” in order to rule out any pre-existing injuries or medical conditions, including injuries occurring within the previous year. With the orthopedic evaluations and imaging, courtesy of Dr. Levengood and his staff, the physical includes a comprehensive inspec-tion of the remaining medical history. The team’s future relies strongly on the health of the team athletes. It is crucial that not only evaluations are completed thoroughly, but furthermore that there is a proper level of communication from the Orthopaedic Specialist down to the team’s Family Medicine practitioner. The family medicine practitioner plays an important role and functions as a key member of the sports medicine support for the Georgia Force who plays an active role throughout the season. Having a family medicine practitioner at hand allows the team to function at the advanced level expected and ensures that athletes never miss a day on the field. Ad-ditionally, the family medicine practitioner gives way to expedited evaluation care and access to needed services quickly. Their ability to expe-dite care to the team players ensures consistency and maintains the tight timeline associated with the athlete’s arrival-to-field requirements. Among many responsibilities, a team’s family medicine practitioner assists the medical team with controlling team illnesses before spreading among players, medical problems from the player’s history, or any additional health issue that may arise throughout our season. The team’s family medicine practitioner dedicates a lot of time to the team, and is normally requested to be on the sidelines of our home games - even making themselves available after hours. The level of commitment given by the easily allows for the players to develop a personal relation-ship with physician which often translates into opportunities to take care of the player’s and coach’s family medical needs as well. Another key member of the pre-season medical support is the team’s personal Athletic Trainer. It is the responsibility of the ATC to be a liaison between the team’s head coach, the Orthopedic Specialist, and the Family Medicine Practitioner. The team’s ATC also has many responsibilities outside of assisting with medical support to the players. To ensure proper pre-season prep, an ATC must perform a com-prehensive list of duties including: taking current inventory, ordering medical supplies, prepping for the team’s travels, coordinating with the hospital’s emergency services, etc. The team’s athletic trainer’s efforts towards pre-season prep helps to not only ensure a well prepared team, but also allows for lower injury risks and higher levels of performance out of the players. The quality of care given by the team of Orthopaedic Specialists, Family Medicine Practitioners, and Athletic Trainers, as well as Physical Therapist and Licensed Massage Therapists, is crucial in keeping the Georgia Force healthy and successful at the highest level. It is the expertise of these professionals that allows players to step on the field – ready to go, on the season opener. The first game of the 2012 season for the Georgia Force will be on Monday, March 12th against the Cleveland Gladiators at The Arena at the Gwinnett Center. Check out the full Georgia Force schedule at georgiaforce.com or learn more about our sports medicine program at gwinnettsportsmed.com.

Keeping the Georgia Force On Track/// By: Brian Struck, ATC, LAT

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Eddie Knox spends anywhere from 40-50 hours a week at Mountain View. His mornings, filled with charts, greetings and evaluations. Eddie usually starts his day around 8:30 a.m., where he helps Dr. Gary A. Levengood M.D. and staff with patient care. Whether it is interviewing a patient, per-forming an evaluation or giving “doc” a quick thirty second run-down, he is helping to make the odds, evens. By late afternoon, he rushes out and leads way up to the high school where he will finish out his day. Its 2:00 p.m., more than five hours before kickoff and the American-past time of football starts. Upon walking in doors, there is quietness, a focus of attention that could even make a hair rise on a bald head. Eddie Knox walks into his train-ing room and starts his day with addressing coaches and appropriate staff the game plan for tonight’s game and how injuries will be managed. Afterwards, he preps his water so-lution and starts his first session of treatments. Shortly, more student-athletes pour in to get a quick rub, taping, rehabilita-tion or even just a “hello”. Soon-after, 4:30 p.m. arrives, and treatment session two is under way. This session includes a pre-game routine consisting of stretching, taping, preventa-tive techniques and bracing. Next, splint bags, emergency equipment, water bottles and athletic training kits are ready to be loaded on the big cheese. Its now, where game mental-ity sets in and coaches, athletes, athletic trainers and helpers wait patiently for what unfolds at kickoff. Playing sports especially collision ones is inherently risky. There is an assumption of risk students and parents claim when they sign their name on the list. Athletic Trainers can give the athlete prompt attention and follow with appropri-ate care. Continuum of care is the key to the athletic trainer role at the high school level or any other adjacent level ap-plicable. Individuals such as Eddie are not only team players, but integral leaders in the communities they serve. They set the example and bleed commitment, dedication and loyalty to their community. The value of an athletic trainer is unparal-leled. The athletic trainer is the real deal.

As student-athletes compete younger and train harder, the need for athletic trainers has grown ex-ponentially. Traditionally, athletic trainers were not

known readily. In fact, there is still moderate vagueness con-cerning what exactly athletic trainers do and who they are. In part, this is what actually makes the athletic trainer a one of a kind medical professional. Athletic trainers are trained in a wide variety of treatment of care and additional domains. The “Trainer” helps prevent and treat injuries, more commonly muscle and bone injuries, not only for young athletes, but also for professional athletes and the weekend warrior. Providing “appropriate” and quality medical care for high school athletes goes beyond having an ambulance pres-ent at football games or student managers handing out ice packs. Interestingly, there is an estimation of about seven million athletes who will participate in school athletics each year. Ironically, only about 42 percent of high schools in the United States employ athletic trainers. Majority of which are only part time employees. Gwinnett Medical Center and private practices such as Sports Medicine South play a significant role in providing care for local high schools and communities in Gwinnett County. Eddie Knox, 24 year old athletic trainer, provides care full-time for Mountain View High School while working as a clinician at Sports Medicine South. On Friday Nights, you might seemingly notice him on the sidelines with arms crossed, much like a sentry. On his waist, a medical kit, prepared for any uncanny situation which may arise. Minor bumps or bruises, a fracture, or torn ACL are just some of the injuries he will manage and if he is lucky, he will just enjoy a great game. However, bruised egos are the respon-sibility of coaches. Alongside Eddie, Sports Medicine South new arrival Dr. Stephanie Hsu, watches the field carefully, keeping her fingers crossed, hoping no catastrophic injuries occur. Coaches, administrators, parents and students are content in their knowledge Mountain View Athletes have a certified athletic trainer at attention for any situation.

Eddie: The Athletic Trainer /// By: Eddie Knox, ATC, LAT

Multidirectional Shoulder Instability/// By: Stephanie H. Hsu, MD

In recent years, the number of young athletes engaged in sport focused and year round training has continued to increase. Overhead sports, such as swimming, throwing, and racquet sports place significant demands on the shoulder and can lead to MDI, or multidirectional shoulder instability. This is especially prevalent in young athletes, where developing anatomy and char-acteristic soft tissue laxity both contribute to the risk of instability. MDI was described by Neer and Foster in 1980 and is characterized as involuntary subluxation in any combination of anterior, inferior, and poste-rior directions. The etiology of MDI may be due to a number of factors, including repetitive overhead activities, traumatic and recurrent dislocations, ligamentous laxity, muscular imbalance and weakness, or scapulothoracic

dyskinesia. Most often, repetitive overhead activities, such as the wide extreme mo-tions in swimming, cause micro-damage to the static stabilizers of the shoulder, leading to MDI. This is differentiated from acute, traumatic shoulder dislocations which have a extremely high recurrence rate in immature patients. Glenohumeral joint stability is sup-ported by bony anatomy, the joint capsule, labrum, glenohumeral ligaments, long head of the biceps, the rotator cuff, and periscapular muscles.

Patients with multidirectional instability often complain of vague pain and are able to describe positions of apprehension or subluxation. They may note numbness or tingling in the affected arm reproduced with certain activities, such as carry a heavy load or sport specific motions, such as a butterfly stroke. MDI can occur bilaterally, and both shoulders of athletes should always be examined for comparison. Up to 75% of MDI patients have generalized ligamentous laxity that is noted with signs such as hyperextension of the elbows and knees, hyperextension of the MCP joints, and the ability to abduct the thumb to forearm. A careful history and focused, specific physical exam are essential to make the correct diagnosis and determine the most effective treatment. The majority of atraumatic MDI can be treated non-operatively. Emphasis is placed on initial pain control and moves to activ-ity modification and rehabilitation. A well coordinated physical therapy program consisting of shoulder proprioception, rotator cuff and periscapular strengthening, and scapulothoracic synchrony is critical to return an MDI athlete back to their sport with shoulder stability and confidence. If an athlete with MDI fails 6 months of non-operative management or has more severe instability affecting daily activities, surgi-cal management may become necessary to attain the level of shoulder stability necessary for sport.

Back pain patients have been able to be classified in three main syndrome categories. Postural SyndromeThe postural syndrome is a mechanical deformation of postural origin causing pain of a strictly intermittent nature, which appears when the soft tissues surrounding the lumbar segments are placed on prolonged stretch. A frequently-seen poor sitting posture includes a forward head, rounded shoulders, and a flexed low back. With the postural syndrome the patient is taught how the poor postural posi-tions cause discomfort and then are taught correct posture. Dysfunction SyndromeDeveloped as a result of poor postural habit, spondylosis, trauma or derangement, the dysfunction syndrome is the condition in which adaptive shortening and resultant loss of mobility causes pain before achievement of full normal end range movement. Essentially, the condition arises because movement is performed inadequately at a time when shortening of soft tissues is taking place. The dysfunc-tion is named by the motion which is lost or restricted. For example, a flexion dysfunction would limit the ability of an individual to bend forward in that area of the spine. Pain appears during test movements at end range and abolishes as soon as the patient’s soft tissues are off stretch. The changes in the patient’s symptoms are not sustained and his condition is neither better nor worse following test movements. The patient is given instructions in how to stretch out the tight tissue along with what is good posture and how to avoid creating tightness in these structures. Derangement SyndromeDerangement syndrome is the situation in which the normal resting position of the articular surfaces of two adjacent vertebrae is disturbed as a result of a change in the position of the fluid nucleus between these surfaces. The alteration in the position of the nucleus may also disturb annular material. This change within the joint will affect the ability of the joint surfaces to move in their normal relative pathways and departures from these pathways are frequently seen. This condition becomes painful when the disk wall or nucleus deformation intrudes on adjacent pain sensitive soft tissues. This pattern of pain increases and peripheralizes as the tissues become more deformed or as nerve root irritation becomes a factor. Symptoms tend to centralize and eventually diminish as the displaced disk material is relocated and the deformity of surrounding tissues is reduced. The effects of test movements on symptoms usually occur during the movement rather than at end range and tend to be sustained. Once a patient has been classified, a treatment program is begun consisting of education of self-treatment techniques along with postural correction and protection of the injured area. The patients are able to understand how typically, the forward movements of their trunk produces their symptoms and neutral positions or trunk extensions tend to reduce their symptoms. They are instructed to avoid the forward movements, maintain their lordotic lumbar positioning and to perform the extension movement that has shown to reduce or centralize their discomfort. The patients learn how to manage their back long term and how to prevent or self correct any future onsets.

Rehabilitation of the Back Pain Patient/// By: Curt Bazemore, PT, ATC, LAT

Low back pain (LBP) affects at least 80% of us some time

in our lives, perhaps 20-30% of us at any given time. It is the fifth most common reason for all physician visits in the

U.S. It is usually recurrent, and subsequent episodes tend to increase in severity. It is common in individuals who lead sed-entary lives and in those who engage in manual labor. It can occur at any age but is most prevalent during the third to sixth decades of life. LBP has been and is currently treated with almost every mo-dality known to man including prolonged bed rest, narcotics, surgery, heat, cold, exercise, immobilization, flexion, exten-sion, traction, massage, manipulation, mobilization, muscle relaxants, etc., etc. LBP is a self-limiting disease which means that in time most patients recover regardless of treatment; 80-90% of patients with acute LBP recover in about six weeks, and nearly 60% of LBP patients return to work within one week. Since LBP is usually self-limiting and recurrent about 90% of the time, we should teach patients how to avoid LBP and how to self-treat.

Robin McKenzie is a physical therapist in New Zealand who recog-nized over 40 years ago that many of his back pain patients demon-strated a predictable pattern of worsening or improving symptoms, depending on the direction of trunk movement. From these obser-vations developed a system of classification and treatment that has proved reliable and most effective in helping the patient learn to self-treat and manage. This approach can be effectively introduced at the primary care physician level!The McKenzie approach to treatment emphasizes the following concepts:1. Education of the patient to make him self-reliant; as independent of the practitioner as possible. Therapists’ hands-on-techniques are judiciously applied only after self treatment has ceased to produce improvement in the patient’s condition. 2. Close, nearly continuous interaction of the therapist and patient during treatment sessions to monitor the effects of movement and position on symptoms. When, during testing or treatment, are symp-toms experienced and how is their intensity and location affected? The phenomena of “centralization of symptoms” is especially impor-tant here as a barometer of treatment success.3. The use of movement and position to treat soft tissue dysfunction and to reduce spinal segment derangement.4. The significance of posture in regard to the production of symptoms and pathology, and its importance in treating all mechanical LBP.5. Preparing the patient for full participation in the activities of life following successful treatment.

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Times have changed for wrestling. There are more stringent regula-tions in place to discourage dangerous measures to lose weight that have plagued the sport in the past. For the 2011-2012 school year, more weight classes were introduced at the high school level. In the state of

Georgia, there are now 14 weight classes ranging from 106 pounds to 285 pounds. Furthermore, the Georgia High School Association (GSHA) has instituted a manda-tory weight management program for the 2011-2012 school year (1). While this is welcome news, nutrition guidelines for safe weight loss are not covered and should be tailored to the individual athlete. A mandatory assessment at an assigned Regional Assessment Site to establish a wrestler’s weight class must be conducted before competition begins that in-cludes height, weight, urinary hydration test and body fat percentage test. These measures are then put into a calculator to determine the minimum competition weight for the wrestler. For the hydration test, a gravity of 1.025 g/ml or less is

required. The minimum body fat percentage allowed for boys is 7% and for girls is 12%. If a wrestler’s body fat percentage falls below these standards then the athlete’s physician may provide written clearance for competition attesting that the wrestler is naturally thin and is growing normally for his/her growth curve (2). As part of the assessment, a weight loss plan is generated for the athletes where only a maximum of 1.5% of body weight may be lost per week. The plan also stipulates the allowable competition weight class on a weekly basis during the season as the athlete loses weight (2). The mandatory weight management program though does not provide guidelines on how to lose the weight. GSHA, however, does specifically prohibit practices such as crash dieting, taking diuretics or other weight loss drugs, using devices such as a sweat box or other heating devices, including vinyl or plastic clothing or bags, to induce weight loss (1). It is important for wrestlers needing to lose weight to do so by starting early enough before competition begins by following a balanced diet, focusing on lean protein, fruits, vegetables and whole grains. During the competition season, it is even more important to maintain a balanced diet as there is a fine line between providing your body with enough nutrients to still perform at its best and restricting too much so that performance is hampered. A balanced diet includes eating regular meals and snacks that provide a good source of carbohydrates, protein and healthy fats. The main source of carbohydrates should be from fruits, vegetables and whole grains. Carbohydrates are the body’s pre-ferred fuel source in sports such as wrestling that requires short bursts of high intensity energy as well as aero-bic endurance so that muscle glycogen stores are maximized. In addition, if a wrestler is restricting calories then even more carbohydrates as a proportion of the daily diet (up to 65%) may be needed to provide needed energy for the muscles in training and competition (3). Muscle strength and power are para-mount for wrestlers. Protein is essen-tial in the diet to maintain strength and power. It has been recommended that wrestlers consume 1.2 to 1.7 grams of protein per kilogram of body weight. No benefits are associated with intakes above 2 grams of protein per kilogram per day (3). Total caloric intake and carbohy-drate intake, however, must be sufficient for protein to be used properly by the body to synthesize muscles and repair damage as a result of training. Good sources of protein include eggs, beans, soy, poultry, fish and lean red meat.

References:Georgia High School Association. Wrestling Rules and Procedures. Available at: http://www.ghsa.net/wrestling-rules-and-procedures. Accessed November 10, 2011. Georgia High School Association. 2011-2012 Wrestling Weight Management Program: Coaches Handbook. Available at: http://www.ghsa.net/files/documents/wrestling/2011-2012_GHSA_Wrestling_Weight_Management_Program-Coaches_Manual.pdf. Accessed November 10, 2011. Jonnalagadda S and Skinner R. Nutrition for weight- and body-focused sports. In: Dunford M, ed. Sports Nutrition: A Practice Manual for Professionals. Chicago, IL: American Dietetic Association; 2006:460-485. Reedy J, Krebs-Smith SM. Dietary sources of energy, solid fats, and added sugars among children and adolescents in the United States. J Am Diet Assoc 2010;110(10):1477—84.Galli N. Signs of Body Image Disturbance, Disordered Eating, and Eating Disorders in Physically Active Adolescents. Association for Applied Sport Psychology. Available at: http://www.appliedsportpsych.org/Resource-Center/Parents/articles/body-image. Accessed November 11, 2011.

While body fat is preferably lower in wrestlers and is not a pri-mary source of energy during this type of exercise, dietary fat in the range of 20% to 35% of total calories is still needed. Di-etary fat is necessary for optimal health as it is used to produce essential fatty acids, aid in absorption of fat-soluble vitamins and hormone production. The focus of dietary fats should be on those that are monounsaturated, polyunsaturated and omega-3 fats. Nuts, seeds, olive oil, canola oil, avocados and fatty fish such as salmon are all good sources of these types of fats. Eating often throughout the day such as every three to four hours keeps energy levels more stable. If the time between meals is longer than four hours, then a snack containing car-bohydrate, protein and healthy fats is warranted. Examples include an apple and peanut butter, yogurt with fresh fruit, or hummus and carrots. Sensible snacking and eating regular meals can be accomplished while trying to lose weight as long as portion sizes are reasonable. Information found at http://choosemyplate.gov can help an athlete determine appropriate portion sizes for his/her particular needs. Of course proper hydration is extremely important as well, as even slight dehydration can have a negative impact on performance. An athlete should have at least one urination a day that is clear to pale yellow in color. Water is the preferred beverage as it is the optimal way to hydrate and provides no calories. Recent data has shown that soda is the number one source of calories for adolescents between the ages of 14 and 18 (4). Cutting soda consumption and other sugar-sweetened beverages is one strategy in helping an athlete achieve his/her weight loss goals.

Nutrition advice should be tailored on an individual basis to each athlete as each athlete is unique. What works for one athlete may not work for another. A reg-istered dietitian specializing in sports nu-trition should be consulted to accurately determine energy needs and ensure that an athlete is meeting his/her specific sport dietary needs while also achieving neces-sary weight goals. While the sport of wrestling has come a long way in protecting its athletes from dan-gerous behaviors to achieve the desired

weight for competition, it is still important to monitor for signs of disordered eating. Athletes in sports that focus on weight are at higher risk of engaging in disordered eating to satisfy the demands of the sport. Some signs of disordered eating that health care providers, coaches and parents should look out for include (5): - Preoccupation with bodily appearance such as making con-stant comments about body size, excessive weighing behav-iors, or spending an unusual amount of time in front of the mirror. - Strange eating behaviors such as extreme changes in eating patterns, stringent dietary “rules,” skipping meals, eating ex-cessive amounts, over-reliance on supplements or meticulous calorie counting.- Drastic changes in appearance such as sudden weight changes, hair loss and pale skin - Drastic changes in personality such as atypical mood chang-es, aggravation or fatigue- New priorities where losing weight or sport overrides other things that were once important to the person such as spend-ing less time with friends and turning down opportunities for social events previously enjoyed Nutrition is key for optimal sports performance, particularly in sports where weight is a focus such as wrestling. Safe tech-niques for losing weight must be followed in order for the ath-lete to achieve his/her weight while maintaining performance goals. All members of the medical and athletic team should be aware of general nutrition guidelines and watchful for practices that could be detrimental to the athlete’s health and in turn per-formance such as supplement abuse, crash dieting and dehy-dration practices to achieve desired weight loss.

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It’s important to have a strong relationship with a bank that understands the needs of your practice.

With United Community Bank you’ll have a partnership with a bank that’s both small enough to provide outstanding customer service and large enough to have the resources and expertise you need to support and grow your practice. We invite you to contact one of our Gwinnett area Physician’s Banking Specialists, Alexandra, Casey or Valerie, to see how we can help you reach your goals.

With a strong relationship – your practice will be stronger than ever.

Alexandra Simmer-AbadPhysician’s Banking SpecialistO�ce: 770-723-7073Cell: 770-771-1115alexandra_abad@ucbi.com

Casey BrogdonPhysician’s Banking SpecialistO�ce: 770-338-7664Cell: 404-803-7577casey_brogdon@ucbi.com

Valerie McNaughtonPhysician’s Banking SpecialistO�ce: 678-957-5657Cell: 678-897-7423valerie_mcnaughton@ucbi.com

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The Right Way to Make Weight for Wrestlers/// By: Ann Dunaway Teh, MS, RD, LD

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As a parent, coach, or player it is important to recognize possible transmittable skin infection in athletes, es-pecially wrestlers. Opponents in wrestling have pro-longed close body contact when skin infections may be transmitted easily from the infected wrestler to the op-ponent. It is important that possible skin infections are also quickly treated. Tinea corporis (ringworm), MRSA (Methacillin Resistant Staph Areus), and herpes sim-plex virus (HSV) infection (herpes gladiatorum) are a

few of the most common wrestling skin infections. These infections are predominantly transmitted as a result of skin-to-skin contact. Many case reports of outbreaks of her-pes simplex, MRSA, and tinea corporis have been published in the literature as a direct result of exposures in wrestling.

It is very common and natural for wrestlers to have apprehension about possible skin infections. They know that any skin infection may lead to loss of practice or competition time. Although this is true, it is important to communicate to the athlete that treatment for a minor infection quickly may help reduce the amount of possible playing time lost. Those of us that evaluate athletes know that they may try to conceal these infections by band aids, socks or other clothing, or even burning their skin to disguise one of these lesions. Communication between the parents, coaches, and athletic trainers can help identify these areas and help prevent a possible worse infection. Because of the extensive variety of infections, it is beyond the scope of this discussion to go into their details, but a few key points should be noted. Key symptoms such as pain, discharge, redness, abrupt changes, or swelling should always be monitored. Fever, as always, is an important symptom with any athlete and no person should practice or compete in sports with a fever.

When a particular area of skin appears suspicious it is important to make the coach and Athletic trainer aware. Mild skin ir-ritations/insect bites should be watched closely as they too may become infected. Mild abrasions and cuts should be properly treated to prevent them from becoming larger areas of concerns. Proper diagnosis and quick treatment are the best ways to ensure not only the safety of that athlete, but reduce the spread of these infections. With everyone’s help, we can continue to keep our athlete’s safe, healthy, and in the game!

S k i n I n f e c t i o n s i n W r e s t l i n g/// By: J. Stephen Kroll, MD

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William G. Littlefield, MDAdvanced Hand & Upper Extremity Surgery, PC

Cumming Off ice : 1505 Northside Blvd - Sui te 4500 - Cumming, GA 30041Johns Creek/Duluth Off ice : 4255 Johns Creek Pkwy - Sui te A - Suwanee, GA 30024

Office : 678 .608 .1951 -Cell : 678-849-9111 Fax: 678 .608 .1952www.ahuespc.com

Excellence because we CARE about you, your time, and your wellbeing

Dr. Littlefield brings almost 30 years of experience treating ath-letes to Gwinnett, North Fulton, and Forsyth Counties. He was an Academic All Conference and All-American basketball player at Ohio University where he lettered for four years and was captain as a senior. He provided care to the football and ice hockey teams as a medical student at The Ohio State University. While in private practice in Day-ton, Ohio, he cared for athletes from local high schools, colleges, and professional sports teams including the University of Dayton, Wright State, Wittenberg and Cedarville Universities as well as the Dayton Bombers ECHL ice hockey team. He cared for athletes at Duke Uni-versity while completing his fellowship in Hand, Upper Extremity and Micro-vascular surgery in 1992. Based on his experience as an athlete, coach, official and orthopaedic surgeon, he is able to bring a balanced approach to returning athletes to competition immediately or as soon as possible, without compromising the health of the athlete. Dr. Littlefield served in the Air Force for over 15 years, separating in 1995 as a Lt. Colonel. He serves his Lord Jesus Christ in all aspects of life including bringing clean, running water to villages in Honduras as a member of Impact Ministries. As a member of the Golf Club of Georgia, he enjoys golfing with his wife and caring for golfers compet-ing at all levels. Dr. Littlefield is a fellow of the American Academy of Orthopaedic Surgeons and a member of the American Society for Surgery of the Hand. He holds the Certificate of Added Qualifications in Hand Sur-gery from the American Board of Orthopaedic Surgeons.

Our PracticeAdvanced Hand and Upper Extremity Surgery is a practice dedicated to providing the best care of the hand, wrist, forearm and certain el-bow conditions to persons of all ages and athletes of all skill levels. All patients are seen the same day or within 24 hours Monday through Friday. We answer our telephones personally and each patient re-ceives the doctor’s cell phone number (no pagers, answering service). Parents, trainers, coaches and physicians receive the same access, if our patient provides permission.. Our office provides a unique sched-uling system that allows our doctors to stay “on-time” barring any emergencies. Dr. Littlefield completed post-residency training at the world renowned Duke University Medical Center and has trained un-der the best hand surgeons in the world. Please visit our website for additional details.

Teams & Athletes we serve: •PGA, Nationwide Tour, E.com Tour, Georgia Tech, Amateur & Recreational golfers•South, North, Central, & West Forsyth High schools•Lambert High School•Chattahoochee High School•Milton High School•Johns Creek High School•Alpharetta High School•Northview High School

RingwormMRSAHerpes Simplex

Diagnostic Radiologists in sports medicine imag-ing have been referred to as the doctor’s doctor. Using advanced imaging tools, we provide our orthopedic colleagues confirmation of their sus-

pected diagnosis along with critical information that guides their treatment plan. Over the past 20 years technological advance-ments in Magnetic Resonance Imaging (MRI) and arthroscopy have changed the way sports medicine injuries are both evalu-ated and treated. These changes have thrust the Radiologist into the forefront of patient care and, despite physically working in the dark, we often provide the guiding light that helps other doctors provide the best treatment to their patients. Just as Orthopedic Surgeons have subspecialized to provide better care to patients, so have the Radiologists. The 26 Radi-ologists of the Gwinnett Health System have received additional training in order to practice subspecialty Radiology in numerous fields including interventional radiology, breast imaging, neuro-radiology and, of course, Sports Medicine Imaging. Our group hasfive fellowship-trained radiologists concentrating in Sports Medicine Imaging. With this expertise, last year we provided im-aging services to the Atlanta Falcons, the Atlanta Thrashers,

after an injury on the soccer or football field. The knee hurts on both the inside and outside. A knee injury is obvious, but is it a torn ACL (anterior cruciate tendon), a torn medical col-lateral ligament, or is this transient lateral dislocation of the patella? Each diagnosis requires specific treatment and has a different prognosis. An MRI of the knee is requested and this powerful tool provides an accurate image of the inside and outside of the knee without radiation. Not only is a definitive diagnosis made, but also the extent of injury to the surrounding bones and soft tissues is assessed. The MR is the most powerful tool in our quiver but all im-aging modalities have certain strengths and weaknesses. Other imaging modalities include CT(computed tomogra-phy), Sonography, Nuclear Medicine, Fluoroscopy, and plain radiographs. Routine radiographs of a joint may be normal and the MR will reveal an occult fracture, bone bruise, carti-laginous or ligamentous injury. Bone bruises, which are mi-crofractures of the trabecular bone, occur three quarters of the time when a major ligament is disrupted yet cannot be seen on plain films. Cooperation between the sports medicine physician and ra-diologist occurs with every patient regardless of whether they are casual players or professional athletes. A High School foot-ball player after a hard tackle presents with shoulder pain and symptoms of instability. Did he sublux his shoulder and tear his labrum (meniscal counterpart in the shoulder) and, if so, how severe is the injury? Will rehabilitation work or is surgery indicated? In these circumstances, we often perform MR arthrography. By injecting salineand MR contrast into the joint in order to produce joint dis-tention, we are provided a more accurate and detailed MR picture, which allows us to convey even more important in-formation to the Orthopedic Surgeon. This ability to more fully evaluate and confirm diagnosis is paralleled in the spine. A young male or female athlete presents with increasing or persistent low back pain. Is it a herniated disc, muscle strain, pars defect or stress fracture? MRI can help but often we may use SPECT-CT to evaluate for a suspected stress fracture. SPECT, available at both the

LanierTherapyin Motion

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Providing Physical Therapy in North Georgia since 2004

Radiologist’s Role in Sports Medicine Imaging/// By: Val Phillips MD

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the University of Georgia Athletic Department, and the citi-zens of greater Gwinnett County along with their minor league sports teams. Top-notch diagnosis and treatment in Sports Medicine re-quires the highest level of technology. We are fortunate to have the support of a progressive hospital administration in providing “state of the art” imaging equipment that includes a brand new 3T MR unit in Lawrenceville and an open-short bore 1.5T unit in Duluth, in addition to two other excellent MR units. This equipment provides advanced imaging capability to all patients regardless of size or claustrophobia concerns, which is as good, if not better, than any other facility in the country. This advanced technology along with our Sports Medicine subspecialized radiologists, orthopedic surgeons and associates allows us to offer superior care. High-level imaging and subspecialized Radiologists provide the Sports Medicine Physician a more complete and accu-rate diagnosis that allows them to plan the best treatment course whether it is rehabilitation or surgery. This integral role of the radiologist is performed seven days a week. A teenage athlete presents with a painful and swollen knee

Lawrenceville and Duluth hospital campuses, provides a three-dimensional bone scan of the spine, which is then overlaid with a thin section CT scan of the region. This com-bination of functional and anatomic imaging can confirm the presence of a stress fracture and whether it is acute or chronic which may dramatically alter the patient’s treat-ment. Providing a diagnosis and roadmap are not the only ser-vices we provide. With consultation and referral from the sports medicine physicians, we also offer interventional therapies including injection treatments with steroids, anes-thetics, and have a large experience with PRP (platelet rich plasma) therapy. In PRP therapy, we concentrate specific parts of the patient’s own blood in order to harvest growth and healing factors. Injecting the PRP with a small needle under image guidance into damaged tendons or ligament helps speed healing and diminishes pain. Just as success in sports requires the coordinated effort of a team, so does success in Sports Medicine. The best pa-tient care is provided when primary care physician, sports medicine orthopedic surgeon, diagnostic radiologist, physi-cal therapist, trainer, and nurse work together as a team. It is our pleasure to be involved with the winning team of the Gwinnett Medical System.

GSMM Affiliate Basketball SchedulesDATE ARCHER BERKMAR BROOKWOOD C. GWINNETT COLLINS HILL DACULA DULUTH GRAYSON LANIER Jan 3 C.Gwinnett at Shiloh at Archer N. Gwinnett Parkview at Mill Creek at S. Gwinnett at N. OconeeJan 6 Berkmar at Archer at Grayson at Meadowcreek S. Gwinnett at Norcross at C. Gwinnett at MonroeJan 7 Mtn View Grayson Parkview Dacula at C. Gwinnett at Berkmar West HallJan 10 at Grayson at Dacula at S. Gwinnett at Shiloh Duluth Berkmar at Collins Hill Archer at Oconee Jan 13 Dacula at Shiloh at C. Gwinnett Brookwood Mountain View at Archer at Ptree RidgeJan 14 at Winder Barrow at McIntosh ButlerJan 17 Shiloh at Brookwood Berkmar Parkview Ptree Ridge Grayson Mtn View at Dacula JohnsonJan 20 at Norcross (B) at Starrs Mill (G) Grayson at Norcross at Shiloh at Meadowcrk at BrookwoodJan 21 at Parkview at S. Gwinnett Mountain View L. Hughes MonroeJan 24 S. Gwinnett C. Gwinnett Dacula at Berkmar Mill Creek at Brookwood N. Gwinnett at Parkview at West HallJan 27 Brookwood Parkview at Archer at S. Gwinnett at N. Gwinnett Mill Creek Oconee Jan 28 at AlpharettaJan 31 at C. Gwinnett Shiloh Archer Meadowcreek at Parkview Norcross at GainesvilleFeb 3 at Berkmar Archer Grayson at Duluth at S. Gwinnett Collins Hill at JohnsonFeb 4 MeadowcreekFeb 7 at Grayson at Parkview at Dacula Mountain View C. Gwinnett Ptree Ridge at Walnut GroveFeb 10 Grayson Dacula S. Gwinnett Shiloh at Ptree Ridge at Berkmar at Mtn View

DATE MEADOWCRK MILL CREEK MOUNTAIN VIEW NORCROSS N. GWINNETT PARKVIEW PTREE RIDGE SHILOH S. GWINNETT Jan 3 at Ptree Ridge Duluth Norcross at Collins Hill at Dacula Meadowcreek Brookwood GraysonJan 4 at Mtn ViewJan 6 Collins Hill Ptree Ridge at N. Gwinnett Duluth Mountain View Shiloh Mill Creek at Parkview at DaculaJan 7 at Archer SW Dekalb at Brookwood Roswell at S. Gwinnett ShilohJan 10 N.Gwinnett at Ptree Ridge at Meadowcreek at Mill Creek Mtn View C. Gwinnett BrookwoodJan 13 at N. Gwinnett at Norcross at Collins Hill Mill Creek Meadowcreek S. Gwinnett Duluth Berkmar at ParkviewJan 14 at Salem( B) Shiloh at Ptree Ridge at Salem (G) at McEachern Jan 17 Mill Creek at Meadowcrk. at Duluth N. Gwinnett at Norcross at C. Gwinnett at Collins Hill at Archer NorthviewJan 20 Duluth Mountain View Mill Creek Ptree Ridge at N. Gwinnett Dacula at Norcross (B)Jan 21 at C. Gwinnett Archer Centennial BerkmarJan 24 at Mtn View at Collins Hill Meadowcreek at Ptree Ridge at Duluth at Grayson Norcross ArcherJan 27 Ptree Ridge at Duluth at Norcross Mountain View Collins Hill at Berkmar at Meadowcrk. at Grayson C. GwinnettJan 28 NorcrossJan 31 at Collins Hill at Ptree Ridge N. Gwinnett at Duluth at Mountain View Dacula Mill Creek at GraysonFeb 3 at Norcross at N. Gwinnett Ptree Ridge Meadowcreek Mill Creek at Shiloh at Mtn View DaculaFeb 4 at Berkmar ParkviewFeb 7 N. Gwinnett Norcross Collins Hill at Mill Creek at Meadowcreek Brookwood at Duluth S. Gwinnett at ShilohFeb 10 at Mill Creek Meadowcreek Duluth at N. Gwinnett Norcross Collins Hill at BrookwoodFeb 11 at C. Gwinnett

THE SPORTS MEDICINE & ORTHOPAEDICINSTITUTE OF GWINNETT

•Academy Orthopedics3540 Duluth Park Lane Ste. 220Duluth, Georgia - 770-271-9857www.academyorthopedics.com

•Sports Medicine South 1900 Riverside Parkway Lawrenceville, GA 30043 -770.237.3475www.sportsmedsouth.com

•Georgia Sports Medicine & Orthopaedic Surgery6340 Sugarloaf Parkway Suite 375Duluth, GA. 30097 - 770.814.2223www.georgiasportsmedicine.com

•Resurgens Orthopaedics 758 Old Norcross Road, Suite 100 Lawrenceville, GA 30046 - 770.962.4300www.resurgens.com

•Southern Orthopaedic Specialists771 Old Norcross Road, Suite 390Lawrenceville GA 30046 - 678-957-0757www.sos-atlanta.com

•The Sports Medicine & Orthopaedic Institute of Gwinnett3855 Pleasant Hill Road, Suite 470 Duluth, GA 30096 - 770.813.8888www.gwinnettsportsmedicine.com

MVPs of Sports Medicine

LAWRENCEVILLE

DULUTH

NORCROSS

BUFORD

GWINNETT COUNTY

SNELLVILLE

85

23 120

85

985

141

20

24 GSMM