Ask the Doctor- Orthopedics

Q: I am six months pregnant and have developed shooting pain down my leg, which I think is sciatica. What are the causes, and what course of treatment should I consider during my pregnancy?

Q: Can you offer some tips on safe skiing this winter?

Q: What is spinal stenosis, and what are the treatments available?

Q: Two months after having a Laminectomy/Discectomy, I re-injured my lower back. An MRI with and without contrast was negative, but I am again experiencing pain down my left leg. Can the disc slip back and forth against the sciatic nerve and possibly not show up on an MRI? Is that causing my pain?

Q: My mother is having knee replacement surgery. What things can I do to make life more comfortable for her when she returns home?

Q: I have been diagnosed with carpal tunnel syndrome. Is it true that it is the result of using the computer keyboard every day? How is treated?

Q: Both my son and daughter play high school basketball. What are the most common injuries?

Q: Is it best to use ice or heat after injuring a joint, such as a sprained ankle, if it is not fractured?

Q: I have been told that I have a Herniated Disc. Does that mean that I need surgery? 

Q: I have sharp pain on the bottom of my heel, especially when I first get out of bed in the morning.  I have heard that this is caused by a heel spur and that surgery to remove the spur is the only way to cure it.  Is this true?


Q: I am six months pregnant and have developed shooting pain down my leg, which I think is sciatica. What are the causes, and what course of treatment should I consider during my pregnancy?

It’s not unusual for pregnant women to have multiple maladies, which temporarily manifest themselves then disappear after pregnancy. Some pregnant women may suffer from sciatica, which is caused by irritation of the sciatic nerve. The Sciatic nerve is actually a cluster of nerves that exits the lumbar spine, enters the buttocks, and then travels down the leg into the foot. For this reason, a major symptom of sciatica is shooting pain from the buttock down the back of the leg into the foot. The pain can vary from being of moderate severity to being completely disabling.  

The pain is usually caused by compression of the sciatic nerve and is commonly the result of a degenerative or herniated disk. While most cases clear up in time, patients suffering from extreme pain or loss of bowel and bladder function, may require urgent surgical intervention to address the source of the issue.

If a herniated disk is indeed the cause of a patient’s sciatica, rest, pain management, and physical therapy interventions such as core strengthening exercises are the first steps towards recovery. Normally the pain and symptoms will go away after pregnancy, but in a small percentage of patients these symptoms could persist or recur at a later time.

If the patient’s pain and quality of life has not improved after the pregnancy, the patient should consult her physician or a spine surgeon for an accurate diagnosis and a review of surgical and non-surgical treatment options. They may elect a minimally invasive procedure called a microdis cectomy or microdecompression surgery to remove the protruding part of the disk. A slightly more invasive procedure, referred to as a lumbar laminectomy, entails a bigger incision and involves manipulating more tissue around the disc . An additional cutting edge surgery for patients with severely damaged disc s is the artificial disc replacement where the entire disc is replaced with a prosthesis.

Patients should consult their physician and/or a spine surgeon to determine the best treatment options. At Pocono Medical Center, our new spine surgery program is a comprehensive team of healthcare professionals who can help diagnose and treat back pain and injury through both surgical and nonsurgical methods.

Allister Williams, MD is the head of Pocono Medical Center’s Spine Program. He completed a comprehensive Spinal Fellowship at Yale University.

 

Q: Can you offer some tips on safe skiing this winter?

With ski season in full swing in the Poconos, it’s a good idea to review some key steps to stay safe out on the slopes. Every year, thousands of skiers end up in the emergency room with injuries that may have been avoidable.

First off, make sure you’re in good physical shape. It’s important to achieve a certain fitness level, particularly early in the season. Skiing can be exhausting, so don’t push yourself. It’s important to listen to your body. The majority of accidents happen later in the day after skiers are tired.

Next, get a full tune-up on your equipment, and have a qualified pro make sure your gear is ready for the season.  Pay particular attention to boots and bindings, since poor adjustment of bindings is a significant source of leg injuries. You should also let your techs know exactly where you’ll be skiing, since conditions vary from region to region. Also, make sure you dress properly in layers to avoid frostbite and hypothermia.

No matter what your skill level, invest in a helmet and have it professionally fitted. Helmets can lessen the severity of impact in the event of blunt trauma to your head. Wearing a helmet should not, however, give you a false sense of security or an excuse to take extra risks. Be sure the helmet doesn’t obscure your vision. Test it out and get used to the different sight lines before you hit the slopes.

It’s also a good idea to ski with a buddy. Use walkie-talkies to stay in touch on the trail if you get separated. Agree on break times throughout the day and stick to them. Remember to refuel with snacks and fluids often.

Know your limits and avoid trails beyond your skill level. Take lessons from qualified instructors or experts to learn proper techniques. Inexperienced skiers who try to tackle difficult trails put themselves and others in danger. No matter what your level of experience, don’t take unnecessary risks. By following these tips, you’ll enjoy your time on the mountain.

David Scaff, DO, FACS, is a Lehigh Valley Hospital Trauma Surgeon and the director of Pocono Medical Center’s Trauma Program.

 

Q: What is spinal stenosis, and what are the treatments available?

Spinal stenosis is caused by a decrease in the size of the spinal canal. As a result, there’s less room for the nerves to pass. The nerves then become compressed and irritated causing the pain that marks this condition. Spinal stenosis can be caused by a herniated disc disease within the spinal canal, or arthritis, which causes bone spurs and enlargement of the joints in the spine. All of these issues can cause bone spurs to form, decreasing the diameter of the spinal canal.

Spinal stenosis is usually a consequence of the normal aging process. It occurs in most patients after the age of 50 and can afflict the lower back (lumbar spine) or the neck (cervical spine). Common symptoms of lumbar spinal stenosis are pain in the buttocks or thighs as well as a felling of weakness in the legs and thighs decreasing a patient’s ability to walk significant distances. Patients often report that their legs feel good when they initially start walking and then their legs quickly start to feel very heavy and tired.  Patients with cervical spinal stenosis suffer from arm and hand pain, numbness, and may even find that they frequently  drop objects,  have trouble with their balance,  or have trouble with activities that require fine motor skills such as buttoning a shirt or putting on jewelry.

There are a variety of effective surgical treatments for both lumbar and cervical stenosis. The Classic treatment for patients with severe stenosis is a laminectomy. In this relatively invasive procedure, bone is removed from the back of the spine, allowing more room for the nerves in the spinal canal. However, there are less invasive options available, especially for patients with lumbar spinal stenosis. A new treatment, called an X-stop, is best for those who have mild to moderate spinal stenosis. This minimally invasive procedure takes about 30 or 40 minutes and involves implanting a small titanium device near the region of the stenosis.  Through manipulation of the bones in the spine, this device helps to increase the space in the spinal canal, thus easing compression of the nerves. Since the spinal canal is never entered in this surgery the risks are far less than with a laminectomy.  Many patients can be discharged the next day or sometimes even the same day. In fact, the results can be dramatic. Some patients who were previously homebound and unable to walk any significant distance can now can walk up to a mile.

Patients should consult their physician and/or a spine surgeon to determine the best treatment options. At Pocono Medical Center, our new spine surgery program is a comprehensive team of healthcare professionals who can help diagnose and treat back pain and injury through both surgical and nonsurgical methods.

Allister Williams, MD is the head of Pocono Medical Center’s Spine Program. He completed a comprehensive Spinal Fellowship at Yale University.

 

Q: Two months after having a Laminectomy/Discectomy, I re-injured my lower back. An MRI with and without contrast was negative, but I am again experiencing pain down my left leg. Can the disc slip back and forth against the sciatic nerve and possibly not show up on an MRI? Is that causing my pain?

To answer this question, I have to first clarify something. A disc cannot anatomically push against the sciatic nerve (the body’s largest nerve, which roughly runs from the lower buttocks to the lower leg). The term “sciatica,” which is often used to refer generally to pain in the sciatic nerve, is actually a misnomer. Lower back pain that radiates down the back of the leg is generally due to a “radiculopathy,” which actually pertains to a problem in the spinal nerve roots, not the sciatic nerve itself.

The sciatic nerve is formed after the nerve roots have left the spine, roughly at the level of the buttocks. Sciatic nerve injuries are rare. The medical community coin the phrase “sciatica,” since many radiculopathies radiate in the same distribution as the sciatic nerve, particularly the first sacral nerve root (S1), which is a major nerve contributor to the sciatic nerve.

In your case, you apparently had a successful surgery, and I assume that you experienced improvement or resolution of your initial pain symptoms. You had a re-injury, which is giving you pain down the left leg. Follow-up MRI studies are negative. In this case, your symptoms may be from permanent nerve damage; however, the initial resolution of symptoms after surgery goes against this idea. Another possibility, then, is that you might be having a leakage of disc material, which can be irritating the nerve roots. This situation might not show up on an MRI. A diskogram would be a better test.

The diskogram is a test where dye is injected into each disc, under a radiologist’s guidance. The test operator can then see if there is any leakage of material. Since the patient is awake, he or she can also determine which level injection reproduces the pain. Further surgical recommendations can be made, depending on the results.

As far as discs slipping back and forth, that simply does not happen. Disc material leakage, however, can happen. Remember, in “sciatica,” it is not the sciatic nerve that's being pinched. It's the spinal nerve root.

James B. Kim, DO is Board-certified in Physical Medicine and Rehabilitation and is a member of the Medical Staff at Pocono Medical Center. Dr. Kim practices at Dr. Kim’s Rehabilitation Office, located in East Stroudsburg and Wind Gap.

    

Q: My mother is having knee replacement surgery.  What things can I do to make life more comfortable for her when she returns home?

Answer by Frederick J. Barnes, MD, Pocono Medical Center:

Degenerative joint disease, also known as osteoarthritis, affects more than 20 million Americans. Patients with disabling arthritis of the knees that have failed conservative treatment may benefit from total knee replacement.  The operation entails the surgical excision of the arthritic joint surfaces and replacement with a prosthesis made of metal and polyethylene. 

Usually, the patient is allowed to bare weight almost immediately after surgery, then begins a course of rehabilitation, which lasts anywhere from several weeks to several months, depending on the patient.  During this time, the patient works on regaining the strength and range of motion of the knee.

When the patient returns home, it is important to make sure that the home is a safe environment, and one way that can be done is to perform an inspection. It is important to make sure there are no loose electrical cords or floor coverings that may cause the patient to trip.  Also, it is important to make sure that the furniture is spaced widely enough so that the patient can negotiate the hallways and living quarters safely.

Two areas of the house where the patient may spend a significant amount of time are the bathroom and the kitchen.  In the bathroom, the addition of a high toilet seat and shower chair could be very helpful.  The kitchen should be uncluttered and the flooring should be stable.  It is commonplace to enlist the assistance of a home care agency that will help in the inspection of the home and offer advice and expertise to facilitate the transition from hospital to home. 

Fortunately, in the great majority of patients, modern total knee replacement allows the patient to regain function as well as decrease the discomfort associated with severe degenerative joint disease.

Frederick J. Barnes, MD is Board-certified in Orthopedic Surgery. He is Chief of Orthopedic Surgery and a member of the Medical Staff at Pocono Medical Center. Dr. Barnes practices at the Mountain Valley Orthopedics in East Stroudsburg and at the Mountain Healthcare Center in Tobyhanna.

 

Q: I have been diagnosed with carpal tunnel syndrome. Is it true that it is the result of using the computer keyboard every day? How is treated?

A: Carpal tunnel syndrome - a very common condition - is not necessarily the result of repetitive movement, as many believe. For people who are predisposed to the condition, using a keyboard on a regular basis may aggravate it, but the actual cause is a compressed median nerve in the hand. The median nerve and nine tendons run inside a tunnel that is comprised of what are known as carpal bones. A ligament acts as a roof over the bones. When the tendons become inflamed, there is less space for the nerve to glide back and forth, and it becomes compressed. Carpal tunnel often occurs with chronic conditions like diabetes, gout and thyroid disease, after an accident, and in women in the third trimester of pregnancy. In many people it happens for no reason - what is called "idiopathic." The symptoms are usually tingling in the hand that often begins at night, and some people develop pain and weakness in the hand. Splints and anti-inflammatory drugs sometimes relieve the symptoms, and if that fails, a rather simple surgery is performed. The surgeon divides the ligament at the roof of the tunnel, making room for the nerve.

Dr. GEORGE PRIMIANO

 

Q: Both my son and daughter play high school basketball. What are the most common injuries?

A: The most common injury in basketball for males and females is, by far, a sprained ankle. That's because it's an injury that occurs when a player lands after jumping. It's common for players to land on someone else's foot, or be bumped while in the air and then twist an ankle as they land.

Sprained ankles can take anywhere from two to 12 weeks to heal; however, if an athlete is still having a great deal of pain after three to four weeks, he or she should have an MRI to be sure there are no hidden cartilage injuries.

A more serious injury is a torn ACL, or anterior cruciate ligament, which is in the middle of the knee. The ACL keeps the knee stable when a player suddenly changes direction. This move is common in basketball and is referred to as a cutting maneuver. Usually when the ACL tears, the player will hear or feel a pop, and his or her knee swells quickly, within 20 or 25 minutes.

ACL tears are four times more common in women than men, and while no one is exactly sure why, researchers believe it could be due to differences in the female and male anatomy of the knee. Cyclical hormonal changes that occur in women have also been blamed, as well as the fact that female players have been shown to have a slower reaction time when their knees are under the same sudden stress as that of men.

Young athletes are usually devastated when they sustain a torn ACL, since the injury puts an abrupt end to their season. But most doctors agree that the best treatment is an ACL reconstruction, which will put the athlete back in the game and prevent debilitating arthritis from developing later on.

Dr. MAURIZIO CIBISCHINO

 
Q: Is it best to use ice or heat after injuring a joint, such as a sprained ankle, if it is not fractured?

A: Immediately following an injury when swelling and pain begin, it is best to use ice. The rule is, ice for 20 minutes, wait one hour, then ice for 20 more minutes, etc. When the swelling and pain subside and/or the joint becomes stiff, use heat. That can be in the form of a hot bath or shower or a heating pad. If in doubt, always use ice.

Gregory Menio, Orthopedic surgeon 


Q: I have been told that I have a Herniated Disc. Does that mean that I need surgery?




A: A disc herniation (also known as a herniated nucleus pulposus or HNP) is when the shock-absorbing disc between your vertebrae (spinal bones) protrudes outwards, sometimes with extrusion of the gelatin-like center material. The problem develops when the disc compresses or lies on a nerve. This is called a radiculopathy, and it can give you shooting pains as well as weakness in a limb. It is the combination of the severity of the disc herniation, the severity of the symptoms, and the outcomes of the non-surgical treatments that will determine whether or not surgery should be performed.
 
Statistically, most herniated discs can be successfully treated non-surgically. Initial treatments include rest, medication and physical therapy (or at least performing at-home exercises).
You're usually given a trial of about one to three months on this regimen. Depending on how severe your symptoms remain, the next avenues of treatment may include different types of injections, such as epidural steroid injections. If another portion of your back is involved, such as the facet joints, then a facet joint injection may be offered.

If injections are chosen, it is recommended that specialists who have added board credentialing for pain management perform the injections. Several existing specialties have this extra credentialing, including anesthesiology, neurology, and physical medicine and rehabilitation. Interventional radiologists can also perform these injections, as the injections are generally performed under radiological guidance.

It is important to note, however, that the non-surgical treatments do not reduce the disc herniation; their goals are to reduce the symptoms so that you can live with the disc herniation. Over time, disc herniations will eventually shrink on their own through a degenerative process of drying out, known as desiccation.
 
Patients should also be advised that the aforementioned treatments could be utilized for disc herniations in the neck (cervical), mid back (thoracic) or low back (lumbar). If the non-surgical treatments fail to alleviate your symptoms, then a spinal surgical evaluation would be in order.

Generally, surgery is recommended when the disc is in a position that is compressing a nerve root and is causing symptoms of pain, burning, tingling or numbness in a corresponding arm or leg (this is called a radicular symptom).

More urgent calls for surgery include profound weakness in a corresponding limb, spinal cord compression, loss of control of urination or defecation or numbness in your anogenital area (saddle numbness). Fortunately, though, these last circumstances are rare.
 
In conclusion, most disc herniations do not require surgery and can improve with conservative management.

James B. Kim, DO is Board certified in physical medicine and rehabilitation and is a member of the Medical Staff of Pocono Medical Center. Dr. Kim practices at Dr. Kim’s Rehabilitation Office, located in East Stroudsburg and Wind Gap.

Q: I have sharp pain on the bottom of my heel, especially when I first get out of bed in the morning.  I have heard that this is caused by a heel spur and that surgery to remove the spur is the only way to cure it.  Is this true?


The short answer is no.  In fact the pain you are experiencing is usually not the result of a heel spur, although a heel spur may be present.  What you are describing is most commonly called Plantar Fasciitis (pronounced PLAN-tar fashee-EYE-tiss).   Plantar, meaning the bottom of the foot and fasciitis meaning an inflammation of the fascia (pronounced FA-shee-ah), or soft tissue. The fascia runs from the ball of your foot and connects to the front and bottom part of your heel.  This band of tissue can become tight and exert abnormal tension on the heel.  As this occurs the area becomes inflamed and causes pain when you step down.  This pain might often diminish the more you walk on it as the fascia stretches out again, but then may return after a period of rest.  Common reasons for this include improper foot mechanics, flat feet, increased activity level, improper shoe gear, weight gain, inactivity, or even injury.

A heel spur may form as the body’s reaction to this extra tension.  The spur forms in line with the pull of the fascia in an effort to relieve the heel of this stress by effectively shortening the band of tissue.  So as you can imagine the pain itself isn’t from the spur but rather the inflammation and tension of the tissue on the heel. 

Treatment for this primarily consists of stretching exercises, icing, anti-inflammatories, and heel padding.  Control of foot mechanics is also addressed with shoe inserts or orthotics.  If pain still persists after several weeks then physical therapy or cortisone injections may be necessary.  These conservative treatment options have been documented to work 80 to 90 percent of the time. 

Surgical treatment is reserved only for those who have exhausted all of these options and still have pain.  If necessary the surgery is a minimally invasive outpatient procedure that has you back to normal activities in just couple of days.


Patrick R. McDonald, D.P.M., AACFAS is an Associate of the American College of Foot and Ankle Surgeons. He specializes as a foot and ankle surgeon and practices at Mountain Valley Orthopedics, PC located in East Stroudsburg.

 

layout graphic