Sleep, Melatonin, Musculoskeletal Health and COVID-19…..What’s the Link?

New Studies Reveal Impact of Sleep and Melatonin on Physical Health and Disease Prevention in Adults and Adolescents

We all know how sleep deprivation can negatively affect health – impacting everything from our cognitive ability and immune response to heart function and disease prevention.

Now additional research underscores the important role that sleep plays in musculoskeletal health and the surprising link between melatonin, a key component in inducing sleep, and COVID-19.

The studies, which recognized that the pandemic has fueled anxiety related insomnia weakening the immune system vital in combating a host of diseases, including COVID-19, revealed that not only has melatonin (a hormone released primarily by the pineal gland at night) shown to improve restorative sleep but also immune response – potentially providing added protection against COVID-19.

According to a Cleveland Clinic study, researchers found that “melatonin reduced the likelihood of study participants getting COVID-19 by 28%.”  Among black participants, a population disproportionately affected by the disease, “infection likelihood was reduced by 52%.”1

The study further indicated that aside from potentially preventative benefits, melatonin may also help aid in the treatment of COVID-19 “due to its antioxidant and anti-inflammatory effects.”

Another study found that taking melatonin to improve sleep in the two weeks prior to a COVID-19 vaccination could help ensure that the vaccine is taken amid optimal sleep conditions, when the immune system is at its best.  And using melatonin for at least two to four weeks following receipt of the vaccine may enhance the body’s immune response to the vaccine and possibly increase length of time a person has immunity.2

If this information isn’t compelling enough, as COVID begins to increasingly affect younger population groups, data from the Centers for Disease Control and Prevention (CDC) show that insufficient sleep – common among high school students – is associated with an “increased risk for unintentional injury from drowsy driving crashes, sports injuries and occupational injuries.”3

The data showed that students reporting less than seven hours of sleep per night were more likely to report several injury-related risk behaviors than those sleeping nine hours or more.

The lack of sleep in both adult and adolescent population groups can be attributed to a number of factors, including anxiety, nutritional deficiencies impacting melatonin production, and over exposure to “blue light” affecting the body’s natural circadian rhythm (24-hour cycles that regulate sleep patterns and essential function based on sunrise and sunset).

Synthesized from tryptophan, an essential dietary amino acid, melatonin production can be impacted by nutritional factors such as the intake of vegetables, caffeine and some vitamins and minerals – though with less intensity than light, which is “the most dominant synchronizer of melatonin production.”4

According to the Sleep Foundation, blue light is a portion of the visible light spectrum that can affect alertness, hormone production and sleep cycles. It is emitted by LED and fluorescent lights, as well as many electronic devices.  Blue light is the largest disrupter of natural circadian rhythm and melatonin production.5

It is important to monitor behavior and discuss changes in sleep and activity patterns with your physician to determine if inadequate melatonin levels and disrupted sleep cycles are compromising restorative sleep and protective immune system function. Melatonin supplements, dietary changes and behavior modifications may be recommended.

 References

  1. Zhou Y, Hou Y, Shen J, Mehra R, et al. A network medicine approach to investigation and population-based validation of disease manifestations and drug repurposing for COVID-19. PLOS Biology. 2020. Doi.org/10.1371/ journal.pbio.3000970.
  2. Cardinali DP, Brown GM, and Pandi-Perumal SR. An urgent proposal for the immediate use of melatonin as an adjuvant to anti SARS-COV-2 vaccination. Melatonin Res. melatonin-research.net .
  3. Wheaton AG, Olsen EO, Miller GF, and Croft JB. Sleep duration and injury-related risk behaviors among high school students – United States, 2007-2013. Centers for Disease Control and Prevention (CDC). 2016;65(13):337-341. https://www.cdc.gov/mmwr/volumes/65/wr/mm6513a1.htm
  4. Peuhkuri K, Sihvola N, and Korpela R. Dietary factors and fluctuating levels of melatonin. Food Nutr Res. 2012;56:10.3402/fnr.v56i0.17252.
  5. Newsom R. How blue light affects sleep. 2021 June 24. Sleep Foundation. https://www.sleepfoundation.org/bedroom-environment/blue-light

 

This information is provided for educational purposes only and does not replace a discussion with your healthcare provider.

Dr. Korsh Jafarnia is one of Houston’s leading board certified, fellowship trained hand and upper extremity specialists.  A member of Houston Methodist Orthopedics & Sports Medicine, Dr. Jafarnia also serves as an assistant professor in the Department of Orthopedic Surgery at Weill Cornell-affiliated Houston Methodist Hospital. Call 888.621.HAND (4263) for an appointment, or go to www.korshjafarniamd.com to learn more.

Unexpected Pangs of Pregnancy

Why Carpal Tunnel Syndrome Risk Increases During Pregnancy

Pregnancy brings many unexpected surprises. It is difficult for physicians to communicate all  potentially related conditions that may occur and how they may impact each woman. One of those conditions is carpal tunnel syndrome (CTS).

CTS is the result of compression occurring within the narrow carpal tunnel located at the wrist – through which one of the major nerves in the arm, the median nerve, passes. This nerve becomes irritated in the compressed tunnel and can cause numbness, pain, tingling and weakness in the thumb and certain fingers.

Compression on the median nerve as it passes through the narrow carpal tunnel.

While CTS occurs in just five percent of the general population, it affects 31 to 62 percent of pregnant women, according to a study reported in BJOG, an international journal of Obstetrics and Gynecology.1

There is little consensus on why CTS is so prevalent during pregnancy, but hormone-related swelling is the suspected culprit. The same fluid retention swelling affecting ankles and fingers during pregnancy can also cause swelling and corresponding compression within the narrow carpal tunnel, resulting in CTS.2,3

Some of the common symptoms of CTS in pregnancy may include:

  • Numbness and tingling (pins-and-needles sensation) in the thumb, index finger, middle finger and radial half of the ring finger.
  • Throbbing sensation in the wrists and hands, which may become worse at night.
  • Swelling in the fingers.
  • Difficulty gripping objects and performing such tasks as buttoning a shirt or opening the clasp on a necklace.

CTS can affect one or both hands.   A study appearing in the journal of Advanced Biomedical Research reported that almost 50 percent of pregnant participants with CTS experienced the condition in both hands.4

Carpal Tunnel Syndrome Diagnosis and Treatment

CTS is easily diagnosed and includes a history of the symptoms and a physical examination.  It may also include sensation testing on the hand, as well as sensory testing of the forearm and arm.  Other tests may include the Phalen’s maneuver, the Tinel’s test and a compression test.  Electrodiagnostic studies (EMG) may also be used to confirm diagnosis.

Physical examination for Carpal Tunnel Syndrome.

Conservative treatment is used in the initial diagnosis of CTS, particularly in pregnant women.  This may entail wrist splinting at night followed by steroid injection in the carpal tunnel if unresolved.

Most women experience symptom relief following delivery and/or breastfeeding.  Though, some women may experience symptoms for months after – and in some cases up to three years.  In those experiencing chronic CTS-related pain that hinders day-to-day activities and remains unresolved by conservative treatment, a minimally invasive procedure known as Endoscopic Carpal Tunnel Release may be considered.  A discussion with a hand specialist can help determine the best course of action.

References

  1. Meems M, Truijens SEM, Spek V, Visser LH, Pop VJM. Prevalence, course and determinants of carpal tunnel syndrome symptoms during pregnancy: a prospective study. BJOG. 2015 17 March. https://doi.org/10.1111/1471-0528.13360
  2. Zyluk A. Carpal tunnel syndrome in pregnancy: a review. Pol Orthop Traumatol. 2013 Oct 7;78:223-227.
  3. Ablove RH, Ablove TS. Prevalence of carpal tunnel syndrome in pregnant women. WMJ. 2009 Jul;108(4):194-196.
  4. Khosrawi S, Maghrouri R. The prevalence and severity of carpal tunnel syndrome during pregnancy. Adv Biomed Res. 2012. Aug 28;1:43.

Dr. Korsh Jafarnia is one of Houston’s leading board certified, fellowship trained hand and upper extremity specialists.  A member of Houston Methodist Orthopedics & Sports Medicine, Dr. Jafarnia is affiliated with Houston Methodist Hospital at Memorial City/Spring Valley.  He also serves as an assistant professor, Weill Cornell Medical College. Call 888.621.4263 for an appointment.

This information is made available for educational purposes only.  It does not serve as a diagnosis in the absence of a consult with a qualified healthcare provider.

 

 

A Roadmap to Staying Pain Free on Long Rides

Avoiding Possible Pitfalls as Upcoming Bike MS 150 Takes Cyclists of Varied Skill Levels on Two-Day Trek Across Texas

 The 2021 Bike MS 150, previously the BP MS 150, is scheduled for May 1 in Houston and expected to host thousands of cyclist of varied skill levels.  This requires lots of preparation … and patience.Repetitive stress conditions cyclists experience.

While we have written over the years about some of the common hand, wrist and elbow injuries and conditions avid cyclists experience, there are additional considerations following a year that paused many of the training activities previously available. Less training sets the stage for mishaps and repetitive stress conditions.

Recognizing the areas of vulnerability following the 2020 pandemic “pause” can help riders modify behavior and reduce risks.

Repetitive Stress
Nearly one-third of the overuse strains associated with avid cyclists competing year-round in weekend rides and races affect the hand and upper extremity. These types of injuries can also affect those who have not adequately trained yet embark upon a 150-mile ride between Houston and, this year, the Texas A&M College Station campus.

The constant vibration, griped hand position for hours at a time or tense ride into the wind, up a hill and alongside Interstate traffic and inexperienced riders can result in such repetitive stress conditions as carpal tunnel syndrome or handlebar palsy, also known as ulnar neuropathy.  Cold weather also makes tissue more distensible and may slightly increase risk for carpal tunnel syndrome as well.

Carpal Tunnel Syndrome
One of the most common tendinopathic conditions associated with overuse activity and repetitive stress in the hand and wrist is Carpal Tunnel Syndrome (CTS).  CTS is one of the most common overuse hand and wrist conditions affecting cyclists.Median nerve and carpal ligament in the hand.

The result of irritation and swelling, CTS causes compression within the narrow carpal tunnel located at the wrist – through which the median nerve, one of the major nerves in the arm, passes. When the median nerve becomes irritated in this compressed and subsequently inflamed tunnel, numbness, pain, tingling and weakness may result in the thumb, index and middle fingers.  This may cause discomfort, affecting a cyclist’s ability to even shift gears with the affected hand.

Resting periodically and stretching the hands, as well as changing grip and handlebar positioning to reduce hyperextension and hyper flexion may help during the ride. But ongoing pain may require treatment, which is generally nonsurgical and may entail night bracing and/or injection therapy.  Chronic carpal tunnel syndrome following nonsurgical treatment may require a minimally invasive procedure known as Endoscopic Carpal Tunnel Release.

 Handlebar Palsy (Ulnar Neuropathy)
Handlebar palsy, known medically as ulnar neuritis or neuropathy, is another common overuse or repetitive stress condition affecting cyclists.  This results when direct pressure is placed on the ulnar nerve at the hand and wrist – from the grip of a cyclist’s hands on handlebars, causing stretching or hyperextension of the nerve.

The ulnar nerve controls sensation in the ring and little fingers as well as the muscular function of the hand.  Compression of this nerve can cause numbness and tingling in the ring and little fingers, as well as hand weakness. Nonsurgical treatment such as rest, stretching exercises, and anti-inflammatory medications generally resolves this condition.Handlebar palsy affects the ulnar nerve.

These overuse, repetitive stress conditions affecting bicyclists also often affect motorcyclists as well, as the continuous vibration of the motorcycle causes the same type of conditions that long rides and regular bicycling can cause.

 Other Riding Tips for Reducing Risks
Professional cyclists and medical experts have contributed to an array of preventative tools and recommendations for reducing risks for such conditions.

These include:

  • Cycling gloves – both basic or specialized gel cycling gloves to reduce pressure on the ulnar nerve.
  • Additional handlebar padding.
  • Custom adjustments in handlebar height and overall bike fit specific to each rider.
  • Applying less pressure or weight to the handlebars and avoiding hyperextension and hyper flexion.
  • Frequent adjustments to grip and position on the handlebars during a ride.
  • Hand exercises between rides, such as squeezing an Isoball.

Dr. Korsh Jafarnia is one of Houston’s leading board certified, fellowship trained hand and upper extremity specialists.  A member of Houston Methodist Orthopedics & Sports Medicine, Dr. Jafarnia is affiliated with Houston Methodist Hospital at Memorial City/Spring Valley.  He also serves as an assistant professor, Weill Cornell Medical College. Call 888.621.4263 for an appointment, or go to www.korshjafarniamd.com to learn more. 

This information is made available for educational purposes only.  It does not serve as a diagnosis in the absence of a consult with a qualified healthcare provided.

Vitamin D and a COVID Link?

Several years ago we featured a blog discussing the rise in Vitamin D deficiency and the corresponding rise in certain injuries and diseases, including an increase in the number of fracture cases in younger Vitamin D deficient patients.

Over the years scientific research has identified a visible link between Vitamin D deficiency and increased risk of fracture, diabetes, cardiovascular disease and cancer [1, 2].  Testing Vitamin D levels of our fracture patients is now common practice in our clinic.

While the widespread deficiency identified in adolescents, young and middle-aged adults and elderly alike has itself been called a “pandemic,” new studies are now also showing the important role that adequate Vitamin D levels may play in not only maintaining good health but also accelerating recovery when diagnosed with COVID-19 [3].

Though research is ongoing, according to one recently published report, adults with vitamin D deficiency are at greater risk for severe COVID-19 infection and death. The data presented at the American Society for Bone and Mineral Research virtual meeting showed that the hospitalized COVID-19 group had lower 25-(OH)D levels (mean, 18.2 ng/mL) than the group with mild symptoms (30.3 ng/mL), or the control group (25.4 ng/mL; p < .0001 for both) (Figure 1) [3].

The report indicated that intervention trials are needed to explore whether vitamin D supplementation could prevent respiratory failure in people with COVID-19 or other serious respiratory infections.

The data is among the new information learned almost daily on the novel coronavirus.  And while researchers admit that additional research is necessary to further explore this link and the COVID prevention and recovery implications, most agree that encouraging adequate Vitamin D intake and addressing deficiencies present no downside in the interim.

Figure 1. Mean Vitamin D Levels found in adults with or without COVID-19.

 

 

Causes of Vitamin D Deficiency

While studies continue to explore possible causes of the widespread Vitamin D deficiency, a number have already been identified.  Some are the result of societal changes such as increased use of sun blocks/sun screens for fear of skin cancer (limiting unprotected sun exposure) and changes in our diet (processed, nutrient-deficient foods versus nutrient and Vitamin D-rich foods). Both of which have gradually reduced the amount of Vitamin D intake we receive.

 Other possible causes of Vitamin D Deficiency include:

 1.) Obesity

Some studies suggest that a higher BMI leads to lower 25(OH) D. Greater amounts of subcutaneous fat sequesters more of the vitamin and alter its release into circulation.

2.) Naturally dark-skinned individuals

Greater amounts of the pigment melanin in the epidermal layer (resulting in darker skin) reduces the skin’s ability to produce Vitamin D from sunlight.

3.) Certain Medications

Corticosteroid medications such as prednisone (often prescribed to reduce inflammation) can reduce calcium absorption and hinder Vitamin D metabolism. Other weight-loss, cholesterol-lowering and epileptic seizure medications have also been implicated in reduced calcium absorption and Vitamin D levels.

4.)  Age

As we age, our skin cannot synthesize Vitamin D as efficiently. The elderly are also likely to spend more time indoors, leading to inadequate intakes of the vitamin [4,5].

References

  1. Holick MF. Vitamin D: importance in the preventioin of cancers, type 1 diabetes, heart disease, and osteoporosis.  Am J Clin Nutr. 2004;79(3):362-371.
  2. Holick MF. The vitamin D Deficiency pandemic and consequences for nonskeletal health: mechanisms of action. Mol Aspects Med. 2008;29(6):361-8.
  3. Monostra M. Low vitamin D levels independently associated with severe COVID-19 cases, death. EndocrinToday. Helio. 2020 Sept 11.
  4. Armas LA, Hollis BW, Heaney RP. Vitamin D2 is much less effective than vitamin D3 in humans. J Clin Endocrinol Metab. 2004;89(11):5387-5391.
  5. Institutes of Health, Office of Dietary Supplements – https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/ .
  6. Vimaleswaran KS, Berry DJ, Lu C et al. Causal relationship between obesity and Vitamin D status:  bi-directional Mendelian randomization analysis of multiple cohorts. 2013 – http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001383.

Dr. Korsh Jafarnia is one of Houston’s leading board certified, fellowship trained hand and upper extremity specialists.  A member of Houston Methodist Orthopedics & Sports Medicine, Dr. Jafarnia is affiliated with Houston Methodist Hospital at Memorial City/Spring Valley.  He also serves as an assistant professor, Weill Cornell Medical College. Call 888.621.4263 for an appointment, or go to www.korshjafarniamd.com to learn more. 

This information is made available for educational purposes only.  It does not serve as a diagnosis in the absence of a consult with a qualified healthcare provided.

 

 

The Texas Bowl, Championing Community

Stemming from a rich history that dates to 1959, the Texas Bowl we know today champions community and charitable initiatives – designating the Depelchin Children’s Center as its charitable beneficiary.

A post-season NCAA-sanctioned Division I FBS college football bowl game, the Texas Bowl takes top tier performance off the field to strengthen the Texas communities they call home.

Aside from the direct support provided the Depelchin Center through its ticket sales, the Texas Bowl community initiatives include; the Kendra Scott Gives Back event, Gridiron Legends – honoring epic players in Texas football, Gridiron Legends Golf Tournament, Mr. Football – Player of the Year Award, Day at the Museum, Team Football, Rodeo Bowl, Bowl Buddy and THSCA Tickets – Texas Bowl tickets offered to outstanding coaches through the Texas High School Coaches Association & Coaches Education Foundation.

Together the Texas Bowl has contributed over $1.6 million in financial support to the center and millions of dollars in promotional support, while boosting spirits and empowering children from the Depelchin Center throughout the year – something needed today more than ever before.

The Depelchin Center, which has been a beneficiary of the Texas Bowl since 2006, has served as one of Houston’s leading centers for foster care and adoption services since 1892.  The center is a nonprofit provider of mental health, prevention and early intervention and child welfare services.

Texas Legends

The Gridiron Legends program honors individuals who have made a significant contribution to the game of football in the state of Texas (high school, collegiate or professional). 

The 2020 Gridiron Legends class will be honored on-field during the 2020 Texas Bowl, which is scheduled for December and currently taking names for the Priority Waiting List.

The History of the Texas Bowl

The Texas Bowl played its first game in 2006, replacing the Houston Bowl (2000-2005).  Prior to that, the bowl was called the Bluebonnet Bowl (1959 – 1987).  It has had different title sponsors over the years including AdvoCare (2014-2016), Meineke Car Care (2011 – 2012) and currently Academy Sports + Outdoors (2017 to present).  The bowl game today is officially called the Academy Sports + Outdoors Texas Bowl.

Dr. Jafarnia has recently joined the board of directors of the Texas Bowl – committed to ensuring the success of the organization and vital role it plays in improving community and the lives of Houston kids.

Dr. Korsh Jafarnia plays with golf legend Calvin Murphy in the Gridiron Legends Golf Tournament

Dr. Jafarnia (second from right) with golf legend Calvin Murphy (center) and colleagues at the 2019 Gridiron Legends Golf Tournament.

Learn more about the Texas Bowl, the Depelchin Children’s Center and the center’s current School Supply Drive.

 

 

 

 

 

Triceps Tendon Trauma – Rare but Serious

In our last blog we discussed biceps tendon ruptures, which occur when the biceps tendon (located in front of the upper arm) is torn from the bone at the point of tendon attachment – either at the shoulder or the elbow.

In contrast, rupture of the triceps tendon (representing the opposing muscle group to the biceps and located at the back of the elbow) is an injury that occurs most commonly from the forced bending of the elbow during a forceful pushing activity, causing the triceps tendon attachment to separate from the bone.

The triceps muscle tendon is responsible for elbow straightening/extension and strength. A triceps tendon that has ruptured prevents the muscle’s normal function and results in weakness and restricted elbow extension.

Triceps Tendon Rupture Diagnosis

Triceps tendon ruptures are rare, accounting for just 0.8% of tendon ruptures, and therefore often misdiagnosed in the emergency department (1,2).

Symptoms may include:

  • Swelling and tenderness to touch at the back of the elbow (where tendon attaches)
  • Weakness/loss of strength when elbow is extended against resistance
  • Inability to follow through with certain movements

This type of injury generally occurs in a sports-related trauma or harsh impact and are more frequently diagnosed in men aged 30 -50.  They are more likely to occur when the biceps and triceps muscle groups are not equally strengthened and pushed to an extreme.

Additional Risk Factors:

  • Excessive weight/power lifting, body building
  • Systemic illness (hyperparathyroidism, renal osteodystrophy)
  • Anabolic steroid use
  • Local steroid injection
  • Fluoroquinolone use
  • Chronic olecranon bursitis
  • Previous triceps surgery
  • Marfan syndrome (2,3)

If this injury is missed or neglected, the individual/athlete may experience weakness with elbow extension and an inability to support a block in football, lift weights, or perform push-ups.

Triceps Tendon Rupture Treatment

While the severity of the injury will determine treatment, surgery is usually indicated in cases of complete rupture and entails tendon repair using bone suture anchors or bone tunnels. Surgery is then followed by a rigorous rehabilitation program that moves from isometric extension exercises to weight-resisted and eventually throwing exercises.

Delayed repair becomes technically demanding and yields treatment results that are inferior to acute repair (2). Early diagnosis and repair will lead to the best possible outcome.

Preventing Injury

While a triceps tendon rupture caused by trauma may be difficult to avoid, those involved in power lifting and body building should be cognizant of such repercussions from the load sport and affiliated supplements.  Equal training of opposing muscle groups, regular stretching and adequate muscle rest have also been found to reduce risk of many different types of musculoskeletal injuries (4).

References

  1. Ahn L., Ahmad CS. Triceps Rupture. American Shoulder and Elbow Surgeons, Orthobullets.com, 2019. Retrieved from https://www.orthobullets.com/shoulder-and-elbow/3071/triceps-rupture
  2. Kocialkowski C, Carter R, Peach C. Triceps Tendon Rupture: Repair and Rehabilitation. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5734527/.
  3. Nikolaido ME., Banke IJ., Laios T., et al.Synthetic Augmented Suture Anchor Reconstruction for a Complete Traumatic Distal Triceps Tendon Rupture in a Male Professional Bodybuilder with Postoperative Biomechanical Assessment. Case Rep Orthop. 2014; 2014:962930. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3965944/.
  4. Tucker A. Why it Matters if One Side of Your Body is Stronger than the Other – and How to Fix It. Self, 2017. Retrieved from https://www.self.com/story/muscle-imbalances.

 

 

Biceps Tendon Tears – When Not to Push Through the Pain

From a young age we’ve heard; “no pain, no gain.”  Some even see it as a personal challenge.  And while a youthful body can be forgiving when pushed beyond its limits, an adult one is not.

Pain is our body’s warning to either stop or proceed with caution.  Ignoring this or “pushing through” could come at a cost, particularly as we get older.

As working professionals workouts are less frequent and muscle mass, correspondingly, less sufficient to sustain the same weights and reps.

Additionally, as we age, our musculoskeletal system changes.  Joints, tendons and ligaments are feeling the cumulative effects of decades of activity.  To ensure decades more, we need to be smart in our workout routines and the challenges we’re willing to take on.

One injury we often see in men ages 40 – 60 are biceps tendon tears and ruptures.  This often happens when the biceps tendon experiences chronic wear as a result of lifting excessive weights or participating in aggressive contact sports.  It can also occur in those performing repetitive overhead lifting or work in occupations requiring regular heavy lifting.

The Biceps Muscle and the Difference between a Tear and a Rupture

The biceps muscle is located in the front of the upper arm and helps to bend and rotate the arm. It has two tendons; 1.) the long head and the short head of the biceps, which attach the muscle to the shoulder, and 2.) the distal biceps tendon, which attaches at the elbow/forearm.

The terms biceps tear and biceps rupture are often used interchangeably and occur when the biceps muscle is torn from the bone at the point of tendon attachment, either at the shoulder or the elbow.  A tear could represent either a partial or a complete tear.

Biceps tendon tears most often occur at the long head of the biceps at the upper arm bone.  It rarely occurs at the elbow, unless trauma from a sudden accident occurs.

While biceps tears do not repair themselves and can limit full function of the arm unless surgically repaired, those occurring at the elbow cause greater arm weakness than those occurring more commonly at the shoulder/upper arm.

Indications of a Biceps Tendon Tear or Rupture

  • A “pop” or snap at the shoulder or elbow.
  • Sharp pain in the upper arm.
  • Bruising and swelling in the affected area.
  • Weakness and tenderness in the shoulder or when bending the elbow, rotating the forearm, or lifting the arm overhead.
  • A deformity/bulge in the lower part of the biceps referred to as “Popeye arm.”

Treatment of a Distal Biceps Tendon Tear

Following a physical examination and functional testing, the severity of the injury will be determined.  While physical therapy may suffice for elderly patients with low upper body demands, surgery is generally indicated for younger patients.  This may entail either a nonanatomic repair to the brachialis or, most commonly, an anatomic repair to the radial tuberosity [1].

The surgical approach has evolved from an anterior approach to a two-incision approach and most recently to a single-incision approach with a bone anchor or ENDOBUTTON™.

Advantages of this approach include anatomical reinsertion, flexion restoration and supination strengthening [2].

Preventing Biceps Tendon Rupture

  • Maintain equal strength throughout the arm – biceps/triceps, elbow and forearm – and in the shoulders.
  • Avoid repetitive overhead lifting of excessive weight.
  • Use the entire upper body when lowering heaving objects to the ground.
  • Avoid steroid use and smoking, as they weaken muscles and tendons and inhibit muscle recovery and growth.

References

  1. Ward JP, Shreve MC, Youm T, Strauss EJ. Ruptures of the distal biceps tendon. Bull Hosp Jt Dis (2013). 2014;72(1):110–119. Article Summary in PubMed.
  2. Tarrallo L, Lombardi M, Zambianchi F, Giogini A, Cantani F. Distal biceps tendon rupture: advantages and drawbacks of the anatomical reinsertion with a modified double incision approach.BMC Musculoskelet Disord. 2018;19:364. Full articles online.

 

Have an Injury-Free Fourth!

Considered the official kickoff to summer, the Fourth of July is a fun-filled celebration commemorated with outdoor barbeques and festivities.  Unfortunately, too many find themselves in the emergency room over this holiday weekend as a result of firework-related accidents.

While unofficially those at highest risk for firework injuries are adolescent boys, the adult male population are a close second in the highest risk group – according to reports of ER physicians and orthopedic hand specialists….

And it is estimated that over 40 percent of firework injuries occur to the hand, wrist and elbow.

Injuries most commonly occur when an ignited firework seemingly fails to go off, though explodes when handled.  Other injuries occur as a result of the extreme heat many fireworks omit.  Even the unassuming “sparkler” can heat to over 2000 degrees, capable of causing 2nd and 3rd degree burns.

The fireworks most implicated in causing injury include small firecrackers, bottle rockets and sparklers, because they are assumed to be less dangerous.  Individuals mistakenly use less caution when handling these types of fireworks.

Some of the most common hand and upper extremity traumatic injuries resulting from firework-related accidents include:

  • Burns
  • Contusions and lacerations
  • Damage to bones, muscle, ligaments and nerves 

Medical Attention for a Traumatic Firework Injury

It is important to seek immediate attention for a traumatic firework injury, to avoid permanent damage to the hand and wrist.

The hand alone contains approximately 50 nerves, with 34 muscles moving the fingers and thumb, and over 120 known ligaments, 30 major joints, 30 bones and a myriad of connective tendons involved in carrying out our everyday activities.

Long-term hand function is dependent on not only immediate care but proper follow up.  If such injuries are not adequately addressed, permanent nerve and tendon damage can impair hand feeling and movement. And the early onset of osteoarthritis from post-traumatic bone and joint damage can further hinder hand function.

Reducing Risks of Traumatic Firework-Related Injury

While many of the tips for reducing risk of hand injury from fireworks seem common sense, they can be overlooked during the excitement.  They include:

  • Ignite all fireworks with extended lighters.
  • Remain a safe distance from ignited fireworks.
  • Allow sufficient time for fireworks to go off / explode before approaching (and handle previously ignited fireworks with an extended apparatus such as BBQ tongs).
  • Supervise young children holding sparklers, advise teens of the heat hazard of these and other small, seemingly harmless fireworks.
  • Protective glasses and gloves can also reduce risks.

 Have a happy and safe Fourth of the July!

Getting a Handle on Repetitive Stress in Cycling

Hand & Wrist Conditions Cyclists Can Avoid

As cyclists across Texas ready for the upcoming BP MS 150, a two-day bike ride from Houston to Austin, we thought we’d talk about some of the most common overuse, or repetitive stress, hand and wrist conditions affecting cyclists and ways to avoid them to ensure a pain-free ride.hand and wrist repetitive stress in cycling

How Repetitive Stress Occurs
Nearly one-third of the overuse strains associated with avid cyclists competing year-round in weekend rides and races affect the hand and upper extremity. These types of injuries can also affect those who have not adequately trained yet embark upon a 150-mile ride between Houston and our state’s capital.

Despite the best equipment and preventative measures, the constant vibration, griped hand position for hours at a time or tense ride into the wind, up a hill and alongside Interstate traffic can result in such repetitive stress conditions as carpal tunnel syndrome or handlebar palsy, also known as ulnar neuropathy.  Cold weather also makes tissue more distensible and may slightly increase risk for carpal tunnel syndrome as well.

 Carpal Tunnel Syndrome

One of the most common tendinopathic conditions associated with overuse activity and repetitive stress in the hand and wrist is Carpal Tunnel Syndrome (CTS).  The result of irritation and swelling, CTS causes compression within the narrow carpal tunnel located at the wrist – through which one of the major nerves in the arm, the median nerve, passes. CTS is one of the most common overuse hand and wrist conditions affecting cyclists. When the median nerve becomes irritated in this inflamed and compressed tunnel, numbness, pain, tingling and weakness may result in the thumb, index and middle fingers – causing discomfort and affecting a cyclist’s ability to even shift gears with the affected hand.  Resting periodically and stretching the hands, changing grip to reduce hyperextension and hyper flexion may help during the ride, but ongoing pain may require treatment – which is generally nonsurgical and may entail night bracing and/or injection therapy.  CTS pain remaining unresolved following nonsurgical treatment may require a minimally invasive Endoscopic Carpal Tunnel Release.

Handlebar Palsy (Ulnar Neuropathy)
Handlebar palsy, known medically as ulnar neuritis or neuropathy, is another common overuse or repetitive stress condition affecting cyclists.  This results when direct pressure is placed on the ulnar nerve at the hand and wrist – from the grip of a cyclist’s hands on handlebars, causing stretching or hyperextension of the nerve.  The ulnar nerve controls sensation in the ring and little fingers as well as the muscular function of the hand.  Compression of this nerve can cause numbness and tingling in the ring and little fingers and/or hand weakness. Nonsurgical treatment such as rest, stretching exercises, and anti-inflammatory medications generally resolves this condition.

handlebar palsy

Hyperflexed Wrist

These overuse, repetitive stress conditions affecting bicyclists also often affect motorcyclists as well – as the continuous vibration of the motorcycle causes the same type of conditions that long rides and regular bicycling can cause.

Ulnar neuritis in cycling

Hyperextended Wrist

Cycling Tips for Reducing Your Risks
Professional cyclists and medical experts have contributed to an array of preventative cycling gear and recommendations for reducing risks for such conditions.

These include:

  • Cycling gloves – both basic or specialized gel cycling gloves to reduce pressure on the ulnar nerve.
  • Additional handlebar padding.
  • Custom adjustments in handlebar height and overall bike fit specific to each rider.
  • Applying less pressure or weight to the handlebars and avoiding hyperextension and hyper flexion.
  • Frequent adjustments to grip and position on the handlebars during a ride.
  • Hand exercises between rides, such as squeezing an Iso-Ball.

Figures source:  http://www.hughston.com/hha/a_15_3_2.htm

 

Motorized Mobility Mishaps Increasing on College Campuses

The abundance and popularity of motorized vehicles, like Bird Rides and LimeBikes, on college campuses are changing transportation norms faster than the development of new safety guidelines and regulations. [1] As a result, the number of accidents and injuries related to motorized mobility scooters (MMS) are on the rise.

Students can pick up scooters wherever they’re left and head to class or meet up with friends – with bookbag and cellphone in hand, though without a helmet or operating instructions.  The scooters have no designated travel lane, and buzz alongside pedestrians, cyclists and motorists at a speed of 15 miles per hour. Additionally, the short wheel base and small wheel size of the scooter makes it more unstable than a bicycle and vulnerable to debris or uneven pavement.

And if that combination doesn’t raise the hazard flag up the pole fast enough, these young MMS operators are often distracted by their cell phone as well – continuing to text and check messages while in route…

According to a recently published study, ‘low-energy as well as high-energy crashes involving the motorized mobility scooters may result in serious injuries and sometimes death.’ The study suggests that “awareness by multidisciplinary treatment teams may help to avoid underestimation of injury severity. MMS drivers need to improve their driving skills in order to reduce the number of MMS crashes.” [2]

Orthopedic specialists are seeing an increase in hand and wrist fractures, which include distal radius fractures and boxer’s fracture as well as severe lacerations, concussions and neck injuries – resulting in some undergoing repair surgery over this past winter break before returning for spring semester. [3]

Following a study conducted by the Journal of the American Planning Association on pedestrian and cycling traffic, three specific “danger zones” involving more serious crashes and injuries were identified – campus activity hubs, campus access hubs and through traffic hubs. [4]

Recommendations to reduce risk of accident and injury for this population may also prove effective in reducing risks to the growing MMS operating population.

Students are encouraged to avoid distraction while using an MMS and recognize that its speed and instability can increase risk of injury if safety precautions are not taken.

References

  1. A Flock of electric scooters suddenly descended on Austin. Now the city is scrambling to regulate them.  Reported in the Texas Tribune (May 1, 2018).  Located online:https://www.texastribune.org/2018/05/01/flock-electric-scooters-suddenly-descended-austin-now-city-scrambling-/.
  2. Leijdesdorff HA, van Dijck JT, Krijnen P, Schipper I. Accidents involving a motorized mobility scooter: a growing problem. Ned Tijdschr Geneeskd. 2014;158:A7858.
  3. That electric scooter might be fun. It also might be deadly.  Reported on CNN online (October 1, 2018).  Located online: https://www.cnn.com/2018/09/29/health/scooter-injuries/index.html.
  4. Loukaitou-Sideris A, Medury A, Fink C, Grembek O, Shafizadeh K, Wong N. Crashes on and near college campuses:  A comparative analysis of pedestrian and bicyclist safety. Journal of the American Planning Association. 2014;80(3):198-217.  https://doi.org/10.1080/01944363.2014.978354.