Current Issue - Orthopedic Partners

Norwich Orthopedic Group, P.C.
Health & Wellness
Inside This Issue
“Back in Africa”
If the Shoe Fits…
Advances in Shoulder Arthroscopy
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— 2 —
Norwich Orthopedic Group, P.C.
welcome
contents
4. “Back in Africa”
6. Plantar Fasciitis
8. TruMatch Personalized Total
Knee Replacement
10.Don’t Let Golf Injuries Knock
You Off Course
12.Meet Our Doctors
16.If the Shoe Fits
18.Understanding Tennis
Elbow (Lateral Epicondylitis)
20.Athletic Trainers are Not
“Trainers”
22.Advances in Shoulder
Arthroscopy
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Welcome
orwich Orthopedic Group, PC is excited to bring you our third Health & Wellness
N
magazine. It is our-going commitment to provide the highest quality, comprehensive
orthopedic care to you and your family and we appreciate your confidence in our ability to do so.
Norwich Orthopedic Group is the largest full-service orthopedic group in southeastern
Connecticut. Our specialists cover all areas of bone and joint medicine. Many of our
physicians have fellowships with specific, advanced training in speciality areas. We
provide Specialists in Spine, Sports Medicine, Joint Replacement, Foot/Ankle, Hand and
Physiatry (pain management).
We provide a full range of orthopedic care including: workers’ compensation, sports
medicine, physical therapy, pain management, Fluoroscopic injections, EMGS and PRP
injections. Norwich Orthopedic Group physicians are involved in a number of studies
and utilize new technology to improve patient care and outcomes.
We realize that medicine is not just science and technology, but also caring for people,
one at a time, with respect and dignity. We are honored that you have chosen us to
provide your orthopedic care, whether past, present or future.
Give us a call - We’re Here When You Need Us!
Daniel T. Glenney, MD
President
Tammie Simao, CMPE
Chief Executive Officer
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—3—
“Back in Africa”
by Kenneth J. Paonessa, M.D.
Photos by Liz Paonessa, 2010
I
magine having a herniated disc and being unable to find
someone trained or with the proper equipment to operate
and relieve the constant pain. Or imagine having a child with
a terrible curvature of her spine that no one within several
thousand miles knows how to treat. Imagine being in an
accident, suffering a broken neck or back, and not having
access to the equipment to fix it. These are the realities of
living in many under developed countries in the third worlds
of Africa, South or Central America, and Asia. In these regions
of the world, many communities lack doctors with the proper
training and/or hospitals with the proper equipment to treat
these conditions.
Dr. Kenneth Paonessa, M.D. a fellowship trained orthopedic
spinal surgeon with the Norwich Orthopedic Group, has
traveled to Africa since 2005 to teach local surgeons the
skills necessary to treat some of these spinal problems. As a
volunteer with the Foundation of Complex Orthopedics and
Spine (FOCOS), he performs surgeries and conducts clinics
in Ghana (West Africa) and Ethiopia (East Africa.) FOCOS
was founded in 1998 by an orthopedic spinal surgeon, Dr.
Oheneba Boachie-Adjei, who is from Ghana. The all-volunteer
organization’s mission is to make optimal surgical and nonsurgical care of disabling musculoskeletal problems including
complex spine and pediatric orthopedic disorders available
in developing nations.
Spinal problems are very common in many developing
countries. In countries like the United States, conditions such
as scoliosis (which is a side to side curvature of the spine) can
be managed in many cases with braces instead of surgery
because they are usually recognized early in a patient’s life.
These braces are typically not available in Africa or are not
— 4 —
— 4 —
practical because of the severe heat. Spinal fractures in the
United States can be treated with braces or with surgery
before a severe deformity develops but in many developing
countries they are left untreated for several months. Many
developing countries also have higher rates of infectious
diseases such as tuberculosis or septic arthritis which can
spread to the spine and cause severe crippling arthritis.
Norwich Orthopedic Group, P.C.
Norwich Orthopedic Group, P.C.
When Dr. Paonessa learned of the need for experienced
spinal surgeons to treat these patients and teach the local
physicians in these countries to someday manage these
problems on their own he believed this would be a good
way to share his training. He did not realize how much it would
help him in his own practice. Many of the surgeries performed
in Africa are done with donated or outdated equipment
sent there when the equipment was thought to be too
antiquated to be used in the developed world. This makes
the surgeries more challenging in the first place. Because
many of the deformities like scoliosis are treated much earlier
in the United States, in developing countries they require
much more planning using advanced techniques. Many times
these severe spinal deformities require the use of controlled
and planned breaks of the spine (called osteotomies) to allow
the crooked spine to be made straighter. Cases Dr. Paonessa
performs in the United States look easier in comparison
because of state-of-the-art equipment and modern facilities.
In his almost dozen trips to Ghana, Dr. Paonessa travels to
Africa once or twice each year for one to two weeks. During
each trip he performs or assists in ten to twenty surgeries
with the local orthopedic and neurosurgeons. Other
volunteer surgeons come from university centers here in the
United States and other countries in Europe and Asia such as
Spain, Greece, France, Japan and Argentina. In addition, Dr.
Paonessa continues to sponsor operating room surgical
technologists, from the William W. Backus Hospital in
Norwich, who show interest in becoming part of the
operating team. These surgical technologists find the trips
rewarding and challenging.
Over the years Dr. Paonessa has found his involvement in
FOCOS and his volunteer work in Africa one of the high points
of his career. It has provided many new and rewarding
friendships with the physicians he has worked with and those
physicians he has taught. His volunteer work has led him to
accept the committee chairmanship of the Global Outreach
Committee of the Scoliosis Research Society in 2011. He will
coordinate the training of surgeons in the developing world
by volunteer surgeons from the international community
including FOCOS and other volunteer organizations. He
intends to continue this important work for many years for
his patients in Africa and Connecticut.
Kenneth J. Paonessa, M.D. graduated from the New
Jersey Medical School in Newark, New Jersey, and
received his M.D. degree in 1984. He completed his
internship and residency in Orthopedic Surgery at
St. Joseph’s Hospital in Paterson, New Jersey, as part of
the Seton Hall School of Graduate Medical Education.
Dr. Paonessa completed a year of fellowship training
in Spine Surgery and Scoliosis at the New York
University Medical Center in 1990. Part of this
training included assisting in the management of the
Scoliosis Clinic and the Spinal Cord Injury Center
at Bellevue Hospital. Dr. Paonessa has lectured and presented several papers on
spinal problems at national meetings including the Scoliosis Research Society,
the North American Spine Society, and the New England Spine Study Group.
His training includes the care of neck and back problems such as herniated discs,
arthritis of the spine, spinal fractures and scoliosis. In addition, he is interested
in osteoporosis and the care of tumors of the spine. Dr. Paonessa is on staff at
The William W. Backus Hospital in Norwich and the Lawrence & Memorial
Hospital in New London. For an appointment call: Norwich Orthopedic Group
860-889-7345
www.norwichorthopedic.com
—5—
Plantar Fasciitis
by James Woznicki, DPT
E
ver wonder what that foot pain is, and you have no idea
how it got there? It starts out in varying degrees in the
morning then may ease slightly as the day goes on and when
you finally think it has resolved it becomes progressively
worse. You may feel this in one foot or both. You may be
suffering from a common ailment called plantar fasciitis.
According to the American Academy of Orthopedic Surgeons,
more then two million seek treatment for plantar fasciitis
which is the most common cause of heel pain. Actual statistics
on its frequency in the United States population is difficult
to obtain due to many people do not seek medical treatment
for this issue.
Plantar fasciitis is an irritation to the plantar aponeurosis and
other associated structures. This is a thick tendonis band that
starts at the base of the calcaneus, the bone that makes up
your heel and then extends across the arch of the foot and
attaches distally to the end of the toes. This in the end acts
as a support structure and it becomes painful in response to
stresses. Plantar Fasciitis pain is not strictly constituted to the
base of one heel. It can exist in a variety of different areas of
the foot. However it primarily exists at the base of the heel.
Plantar fasciitis can either onset without a major incident or
attribute to a significant change in activity such as starting a
walking or jogging program or simply did far more walking
one day then they are accustomed to. A majority of people
with this issue attribute this pain either due to a very high arch
or a very low arch or a flat foot and these foot types do have
a larger potential for Plantar Fasciitis. This is only one piece to
the overall puzzle. Many other factors can predispose one to
suffering from this issue. Whether or not you have a high or
low arch largely depends on the other bony structures within
your foot. The relationship between the vertical position of
your calcaneus to the position of your forefoot.
There are many other factors that can predispose one to this
condition. Weight has an influence on this. As the plantar
— 6 —
fascia is a support structure, the more that is being carried
around the support structure has to respond accordingly.
Proper footwear is also very important. A shoe can either reduce or increase the amount of stress on a foot. A supportive
shoe or sneaker is usually best. Shoes that don’t fit correctly
either being too big or too small, will increase the amount of
stress placed on a foot.
There are many treatment possibilities that are effective at
treating Plantar Fasciitis. Unfortunately, there is no quick
cure for Plantar Fasciitis. The best thing to do is first, consult
your primary care or specialty physician. They can help best
guide you through the process. There are a vast number of
treatments that are available to begin to assist with your pain.
The doctor may start with a cam boot which will rest the
plantar fascia to allow it to heal and a night splinting program.
This consists of placing your foot in a boot that takes the
slack out of your plantar fascia and stretch your Gastrocnemius
or your calf muscle. Range of motion in ones calf is very
important because the more range that you have will allow
your foot to stay on the ground flat longer and delay the
amount of time until your foot goes up on the toes during the
push off phase of walking. Remember, the tract of the plantar
fascia which starts out at the base of the heel and extends to
the end of the toes, so if you come up on your toes to push
off earlier, that increases the amount of stress on the plantar
fascia. Beginning a good stretching program of the calf will
also help with this.
Quick fixes that can alleviate stress off of the plantar fascia,
is the placement of a heel cup or heel lift. What this does is
elevate your heel to reduce the amount of time that you
push off your toes in your gait pattern. However prolonged
use of this can result in a further decrease in range of motion
in your calf which can make the problem worse over time.
Next finding good supportive footwear is necessary. In order
to find an appropriate fitting shoe seeing a professional at a
shoe store is a good place to start. A shoe should mainly bend
Norwich Orthopedic Group, P.C.
Suisman Shapiro Injury Ad.indd 1
7/5/11 1:58:06 PM
in the toe box and not break down in the arch of the shoe. When
the shoe is twisted it should be firm, if you can wring it out like a
towel it is not going to be supportive.
A consultation with a skilled Physical Therapist which your
doctor can refer you to, if they feel it is appropriate. They can
help guide you through the in’s and outs of finding good foot
wear, improving the range of your foot and ankle as well as
pain relief modalities. Orthotics are also a good option as well
because they help appropriately align your foot to help reduce
stress. However, being given an inappropriate orthotic can
ultimately cause more pain. The skill of the prescriber comes into
play greatly. A skilled orthopedist or physical therapist can help
determine an appropriate orthotic.
Should some of these steps fail to help the pain your doctor
can guide you through more invasive options. However if the
source of the problem is not addressed which could be range
of motion, weight or footwear, the problem may continue to
resurface for years to come.
James Woznicki, DPT received his Bachelors Degree in
Physical Therapy in 2002 and his Doctorate in Physical
Therapy in 2005 both from Daemen College, Buffalo,
NY. James has experience in outpatient orthopedics
throughout Connecticut and in acute hospital care and sub
acute rehabilitation facilities. James is employed with the
Norwich Orthopedic Group, P.C.
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—7—
TruMatch Personalized Total Knee Replacement
by Ammar Anbari, M.D.
D
r. Ammar Anbari was the first surgeon in
the region to offer patients TruMatch, a
customized knee replacement solution designed
specifically for the patient’s anatomy. Since its
introduction, Dr. Anbari has implanted about 150
customized knee replacements. In the past two
years, Dr. Anbari and a number of other surgeons
in the country have worked very closely with the
TruMatch design team to refine the system’s
accuracy and precision.
Research has shown
that even a slight
misalignment of a knee
implant can lead to
uneven wear, instability
and early failure.
TruMatch uses CAT scan technology to create
a three-dimensional computer rendition of the
patient’s knee which is then used to create a customized surgical cutting guide based on the
patient’s unique anatomy. TruMatch is developed
by DePuy Orthopedics and designed to create
consistency in the placement and positioning of
a knee replacement. It is the result of extensive
research and development efforts aimed to
help the surgeon obtain a precise implant fit
which in turn leads to a more rapid recovery and
pain control.
Positioning and alignment are crucial to the
overall performance of a knee implant. Research
has shown that even a slight misalignment of
a knee implant can lead to uneven wear, instability
and early failure.
Benefits of TruMatch Personalized Solutions
 Create customized surgical guides: Every
knee is unique. Each cutting guide is
custom made for one patient and is
only used once. The guides are made
to recreate the patients’ normal nonarthritic anatomy and to restore their
mechanical axis.
— 8 —
Norwich Orthopedic Group, P.C.
 Decrease operative time: By doing all of the measurements and angular calculations on a computer prior
to surgery, the actual surgical time has decreased an
average of 30 minutes per case.
 Decrease intra-operative bleeding: Using TruMatch
cutting guides, there is no longer a need to drill
holes in the femur or tibia to find and follow the
mechanical axis of the knee; all the cuts are done on
the surface of the bone. This leads to less bleeding
during and after surgery.
 Decrease postoperative knee pain: Dr. Anbari’s
patients who had previous traditional total knees
on one side and a TruMatch knee on the opposite
unanimously reported far less post operative pain
and easier time bending and walking on their
TruMatch knees.
 Decrease the need for inpatient rehab: Using TruMatch
technology, Dr. Anbari has seen a 25% decrease in
patients’ need to transfer to inpatient rehab.
Figure 3
blocks are positioned on
the end of the thigh and
leg bones (Figure 4), and
the bones are cut and the
prostheses are implanted.
(Figure 5)
5.
Patients are encouraged to get out of
bed and ambulate the
day after surgery putting
full body weight on their
surgical knee.
How does TruMatch work?
1.
Patients scheduled
for a total knee replacement are ordered a CAT
scan of their affected
knee. (Figure 1)
2.
The scan is imported into a state-of-the-art
software which creates a
three-dimensional computer model of the knee.
This structure will show
where the knee is arthritic
and will account for every
deformity in it. (Figure 2)
3.
The software creFigure 1
ates a proposal detailing
where the cuts should be
made to restore the patient’s normal alignment.
The proposal is sent to
the surgeon electronically who double checks
the cuts and measurements and makes any
necessary modifications.
(Figure 3)
4. Custom
cutting
Figure 2
blocks are then manufactured and sent in a
sterile box to the surgeon to use when performing the
knee replacement. On the day of surgery, the custom
Figure 4
Figure 5
Dr. Anbari received his orthopedic training at
Temple University Hospital in Philadelphia, PA. He
completed a subspecialty fellowship in Sports Medicine
and Arthroscopy at Rush University in Chicago, IL
where he acted as an assistant team physician for
the Chicago White Sox and the Chicago Bulls. Dr.
Anbari has special training in the latest techniques
of shoulder, hip and knee arthroscopy, ligament and
tendon reconstruction and repair, and shoulder and
knee replacement. He is the team physician for the
WNBA CT Sun, Norwich Free Academy, Bacon
Academy, Lyman Memorial, St. Bernard School, and the Williams School. For
more information, visit: www.CTSportsDoc.com For an appointment call:
Norwich Orthopedic Group 860-889-7345
www.norwichorthopedic.com
—9—
Don’t Let Golf Injuries
Knock You Off Course
W
hile many of today’s golfers pass
on wearing plaid pants in favor of
sporting more updated apparel, the increasing number of injuries that result
each year from golfing will never become
fashionable. According to the U.S. Consumer Product Safety Commission, there
were more than 109,000 golf-related
injuries treated in doctors’ offices, clinics
and emergency rooms in 2003, incurring
a total cost of more than 2 billion dollars.
Like learning how to avoid driving your
ball into a sand trap, by following proper
techniques from the American Academy
of Orthopaedic Surgeons (AAOS), most
of these injuries can be prevented.
Golf can be a good outdoor fitness
activity, especially when players walk the
course (as opposed to riding it). However,
the sport does pose potential risk of
serious injury for golfers of all ages. In
fact, nearly one-quarter of golf-related
injuries reported in 2003 occurred in
children under the age of 19. Overuse
syndrome, as well as tendinitis, bursitis,
strains and sprains can put a halt to a
golfer’s game. The most common injured
areas include the elbow, spine, knee, hip
and wrist.
“Whether you are a veteran returning
to the green after a seasonal hiatus or
a beginning golfer, it is important to
start out slowly, gradually increasing
the number of holes you play,” explained
Matthew S. Shapiro, MD, orthopaedic
surgeon and vice president at Orthopedic Healthcare Northwest in Eugene,
Ore., and Secretary of the AAOS Board
of Councilors. “Instead of going for 36
holes your first day back on the green,
hit just a single bucket of balls the first
time out. The next day, see how your
bones and joints feel to gauge whether
or not you can increase your swing
velocity and number of repetitions.
Additionally, Dr. Shapiro recommends
— 10 —
that golfers of all ages regularly
participate in a muscle conditioning
program to not only reduce the risk of
experiencing golfer’s elbow – one of the
most common golf injuries – but also to
promote flexibility and longevity in their
game throughout the season.

The American Academy of Orthopaedic
Surgeons offers these simple tips to help
prevent golfing injuries:

 Take golfing lessons and begin
participating in the sport gradually.
 Choose the correct golf shoes: ones
with short cleats are the best.
 Warm up and stretch before golfing.
Improving your flexibility helps your
muscles accommodate to all sorts
of demands.
 Incorporate strength training exercises into your warm up routine. Visit
http://orthoinfo.aaos.org for golfrelated strength training exercises.
 Do not hunch over the ball too much,
as it may predispose you to neck
strain and rotator cuff tendinitis.
 Avoid golfer’s elbow – caused
by a strain of the muscles in the
inside of the forearm – by not overemphasizing your wrists when
swinging. It is important to build
your forearm muscles by completing
the exercises below:
 Squeeze a tennis ball for five minutes
at a time.
 Perform wrist curls using a lightweight dumbbell. Lower the weight
to the end of your fingers, then
curl the weight back into your
palm, followed by curling up your
wrist to lift the weight an inch or
two higher. Perform 10 repetitions
with one arm, then repeat with the
other arm.
 Do reverse wrist curls with a lightweight dumbbell. Place your hands
in front of you, palm side down.
Norwich Orthopedic Group, P.C.




Using your wrist, lift the weight up
and down. Hold the arm that you are
exercising above your elbow with
your other hand in order to limit the
motion to your forearm. Perform
10 repetitions with one arm, then
repeat with the other arm.
Help minimize low back injuries –
often caused by a poor swing – by
performing these simple exercises to
help strengthen lower back muscles:
Rowing: Firmly tie the ends of
rubber tubing. Place it around an
object that is shoulder height (like
a door hinge). Standing with your
arms straight out in front of you,
grasp the tubing and slowly pull it
toward your chest. Release slowly.
Perform three sets of 10 repetitions,
at least three times a week.
Pull-downs: With the rubber tubing
still around the door hinge, kneel
and hold the tubing over your head.
Pull down slowly toward your chest,
bending your elbows as you lower
your arms. Raise the tubing slowly
over your head. Perform three sets
of 10 repetitions, at least three times
a week.
Keep your pelvis as level as possible
throughout the swing.
Be alert for dehydration and heat
exhaustion.
Heed caution when driving a golf
cart, reducing speed for pedestrians,
inclines and weather conditions.
Keep hands, legs, feet and arms
inside the confines of the golf cart
when it is moving.
Internet users can find additional safety
tips and injury prevention information
on golf and other sports in the
Prevent Injuries America!® Program
section of the Academy’s web site,
www.aaos.org or www.orthoinfo.org
Norwich
Orthopedic
Group, P.C.
For more than 50 years, the Norwich Orthopedic Group, PC has
dedicated itself to providing patients with the highest quality
care. Quality care means not only providing modern techniques
in Orthopedic and Physical Medicine, but also that the personal
comfort and concerns of patients receive as high a priority as
their medical needs.
Our orthopedic group has been selected to participate in
a variety of Clinical trials, keeping us on the leading edge
of technology.
Specialties
 Comprehensive Evaluation
 Work Related Injuries
 Sports medicine
 Fracture Treatment
 Total knee, hip and shoulder joint replacement
 Reconstructive surgery
 Arthroscopy of knee and shoulder
 Hand and wrist surgery and lacerations
 Tendon Repair
 Spinal and disc surgery
 Scoliosis treatment
 Spinal injections with fluoroscopic guidance
 Plasma rich platelet injections (PRP)
 Nerve studies (EMG)
 Physical medicine (Physiatry)
 Foot and Ankle Surgery
 Non-surgical treatment of back, neck and
musculoskeletal injuries
Other Services
 Independent medical exams (IME)
 Second Opinions
 On site x-ray
 On site physical therapy and rehabilitation services
 Golf Camps
 Personal athletic training available
 High School Athletic Training Services/Camps
Our Doctors
Education:
Tufts University School
of Medicine
Education:
Tufts University School of
Medicine
Specialties:
Orthopedic Surgery
Specialties:
Orthopedic Surgery
Daniel T. Glenney, M.D.
Patricia A. Stuart, M.D.
Education:
George Washington
University
Specialties:
Physical Medicine &
Rehabilitation
Gabriel Abella, M.D.
Education:
Allama Iqbal Medical
College
Education:
Brown University School
of Medicine
Specialties:
Physical Medicine &
Rehabilitation
Speciality:
Orthopedic Surgery
Foot and Ankle Fellowship
Mohammad Pasha, M.D.
Our Physical &
Occupational Therapists
Nicole L. Arcand, M.D.
Norwich Orthopedic
Group, P.C.
All Physicians are Board Certified
Education:
New Jersey Medical School
Specialties:
Orthopedic Surgery
Scoliosis & Spinal
Surgery Fellowship
Diana Cloud PA-C
Kenneth J. Paonessa, M.D.
Physician Assistant
Education:
New York Medical College
Specialties:
Orthopedic Surgery
Spinal Surgery Fellowship
Gary Haynes PA-C
Michael J. Halperin, M.D.
Physician Assistant
Education:
University of Connecticut
School of Medicine
Speciality:
Orthopedic Surgery
Hand & Upper Extremity
Fellowship
Lisa Shea, PA-C
Tarik Kardestuncer, M.D.
Physician Assistant
Education:
Temple University School
of Medicine
Ammar Anbari, M.D.
Specialties:
Orthopedic Surgery
Arthroscopy, Sports
Medicine & Shoulder
Replacement Fellowship
David Farrington, PA-C
Physician Assistant
Norwich
Orthopedic
Group, P.C.
North Franklin
82 New Park Avenue • North Franklin, CT 06254
860-889-7345
www.norwichorthopedic.com
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www.norwichorthopedic.com
— 15 —
If the Shoe Fits…
by Nicole L. Arcand, M.D.
P
oor footwear contributes to the development of many
foot and ankle pains and deformities. With so many styles
and brands available it is sometimes difficult and overwhelming to find a pair that fits well. Also what fits well doesn’t
always appeal to everyone’s styles or tastes. Common foot
problems that are associated with poor footwear include
bunions, hammertoes, corns, and calluses.
Bunions are painful bumps on the joint at the base of your
big toe caused by the big toe angling towards your second
toe. When they are mild they may appear only as a reddened,
prominent area on the side of the joint. In severe cases, the
big toe may cross under or over the second toe. This deformity
can make it extremely difficult to wear shoes comfortably and
may make walking difficult.
Hammertoes are deformities of the second, third, and fourth
toes. With this deformity, the toe bends at the middle joint
and often rubs on the top of the shoe. This rubbing can cause
the skin on the top of the joint to blister or thicken. This
thickened skin is commonly referred to as a corn. Sometimes
the joint also becomes wider or angulated towards another
toe, which can cause thickened, painful skin between the toes
called soft corns. If these joints stay bent for long periods of
time, the deformities may become rigid and the toe will no
longer be able to straighten.
Bunions and hammertoes often occur together. As toes become more deformed, the foot distributes weight different-
— 16 —
ly. The foot bears approximately one and a half times body
weight with every step so it is important that the foot distributes weight through a large surface area. These foot deformities often lead to one area of the foot bearing more weight
than it should. The skin in these areas often thickens and can
cause painful calluses on the bottom and sides of the foot.
Nine in ten bunions occur in women. Some bunions and
hammertoes are passed in families through genes but many
are the result of ill-fitting shoes. For decades, contemporary
women’s footwear has been a prime offender for causing
bunions and hammertoes. Some men’s dress shoes can also
lead to these deformities. Shoes that are short, tight and
sharply pointed cause the toes to be curled and squished
together. Also, high heels, especially higher than 2 ¼ inches,
cause the foot to slide forward in the shoe and may contribute
to these toe deformities.
Some bunions and hammertoes can be avoided by using
proper footwear. Never force your foot into a tight fitting
shoe. You should be able to stretch your toes while you
are standing in your shoes. Avoid prolonged use of heels.
Shoes should be a half-inch longer than the longest toe and
have a soft, accommodative upper over the toes (the area
of the shoe called the toe box). If one of your feet is bigger
than the other, always size your shoes for the bigger foot
(some stores will even sell a pair of shoes with different sizes).
Shop for your shoes at the end of the day when your feet are
the most swollen.
Norwich Orthopedic Group, P.C.
Treatment of bunions and hammertoes starts with changes in footwear. High, wide toe box shoes often cause less
rubbing and therefore less pain. You may consider having your
shoes professionally stretched. Drug stores and pharmacies
often sell bunion pads or corn pads to help take some of the
pressure off these bony prominences. Surgery is reserved for
people who have persistent pain, progressive deformity, or
inability to wear reasonable shoes. These surgeries can often
be done on an out patient basis and under local anesthesia.
The type of surgery and the length of recovery is dependant on
many factors and should be discussed with your surgeon.
Taking good care of your feet will take you far in life…literally.
Making good choices in your daily foot wear is extremely
important for the health of your feet. Choosing activity
appropriate shoes for your daily routine will allow you to
wear the heeled platform shoes with your new dress out to
dinner for a few hours but overdoing with these same shoes
may spell trouble for your toes later in life.
A balance between style and function needs to be a priority
in choosing shoes. Shoes should be chosen because they
Allscripts proudly
partners with
Norwich Ortho
fit your foot. Never force your foot into an uncomfortable
shoe. After all, if the shoe fits…
Nicole L. Arcand, M.D. is a native of Rhode Island,
received her Medical Degree from Brown University
School of Medicine in 2002. She completed her
orthopedic residency in 2007, a trauma fellowship 2008
and a foot and ankle fellowship at Brown University
School of Medicine in 2009. Dr. Arcand joined the
Norwich Orthopedic Group, PC in August 2009. Dr.
Arcand’s orthopedic specialty interests are deformity
correction and sports injuries of the foot and ankle.
For an appointment call: Norwich Orthopedic
Group 860-889-7345
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www.norwichorthopedic.com
— 17 —
Understanding Tennis Elbow
(Lateral Epicondylitis)
O
verview:
Tennis Elbow, also known as Lateral Epicondylitis, is
inflammation, soreness, and/or pain on the outside (lateral)
aspect of the elbow where the forearm muscles attach to the
bone. The forearm muscles and tendons become damaged
from overuse, repeating the same motions over and over
again. This group of muscles is responsible for extending
the wrist and fingers. Although this condition is common
among tennis and other racquet sports, any person involved
in repetitive motion of the wrist can develop tennis elbow.
Therefore, painters, plumbers, construction workers, cooks,
and butchers are all more likely to develop this condition.
Tennis elbow accounts for 70% of all sports related injuries in
persons 40 to 50 years of age.
Symptoms:
In most people symptoms develop gradually. Pain typically
starts out as mild and slowly worsens over weeks or months.
Most people do not remember a specific injury that started
their symptoms. Common signs and symptoms are:
 Elbow pain or burning that starts on the outer
part of the elbow
 Pain radiating from the outside of the elbow to
the forearm when grasping or twisting
 Weak grip strength
by Christian E. Miglio OTR/L
 If tennis elbow is related to a specific sport, a check
of your equipment is important to make sure it is
performing at its optimal level and reducing strain on
the body.
 Occupational therapy has an excellent success rate
of reducing or eliminating symptoms. Treatment
would include stretches and strengthening for the
muscles of the forearm. The therapist may also use
ultrasound, iontophoresis to administer corticosteroids transdermally, manual therapy, and offer preventative education.
 Counterforce braces can help to relieve symptoms by
allowing the injured tissue to rest.
 Steroid injection, such as cortisone, can help reduce
the inflammatory process and swelling around the
area where the tendon attaches. Too many injections
of a steroid can damage soft tissue structures
(ligaments, tendons, cartilage, etc.) around and in
the elbow.
Signs and Tests:
A doctor will consider many factors in making
a diagnosis. These include how your symptoms
developed, occupational risk factors, and recreational
sports/activities. A common method to test for tennis
elbow is to provide resistance while the fingers and
wrist are straightened. This will be very painful if you
do in fact have tennis elbow. Also the doctor may
simply apply pressure to the tendon where it attaches
at the elbow. Again it will be tender or painful where
they press.
 X-rays maybe taken to rule out elbow arthritis
 MRI maybe taken to show how significant the
damage to the soft tissue is
 EMG maybe done to rule out nerve entrapment
Treatment:
Conservative
Approximately 80% to 95% of patients have success
with nonsurgical treatment.
 Rest is a vital aspect of recovery to allow the arm
to properly heal.
 Ice and Non-steroidal Anti-inflammatory
(NSAIDs) medicines will help to reduce pain
and swelling.
— 18 —
Norwich Orthopedic Group, P.C.
Norwich
Orthopedic
Group, P.C.
Surgical:
If pain and disuse continue for 6-12
months of conservative treatment, your
doctor may recommend surgery. Most
surgical procedures for tennis elbow
involve removing damaged muscle/
tendon and reattaching healthy muscle/
tendon back to the bone. A round of occupational therapy will be recommended
after your surgery to correctly stretch
and strengthen the repaired tissues. Your
orthopedic surgeon can speak with you
about risks, and whether surgery will help
you. Tennis elbow surgery is considered
successful in 80% to 90% of patients.
Christian Miglio, OTR/L,
graduated from Husson
College in 2004 with a
Bachelor of Science Degree
in Psychology. He received
his Masters Degree in Occupational Therapy with
a Practice Certificate in
Hand Therapy from Springfield College in 2008. To
earn a Practice Certificate
in Hand Therapy, Christian was required to attend an
extra semester and to complete an additional clinical
rotation dedicated to hand and upper extremity dysfunction. He has a special interest in treating tendon
and nerve injuries of the upper extremity. Christian is
employed with the Norwich Orthopedic Group, P.C.
New England Orthotic and Prosthetic Systems
400 Bayonet St. Suite 101
New London, CT 06320
115 Lafayette Street
Norwich, CT 06360
Phone: 860-447-0086
Fax: 860-447-0051
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www.norwichorthopedic.com
— 19 —
Athletic Trainers are Not “Trainers”
by Janeen Beetle, ATC-L, M. Ed and Anna Bergeron, ATC-L
I
f you have ever been watching a sporting event and
someone gets injured, you see the certified athletic trainer
run out to their aid. But you may not know what a certified
athletic trainer does. Many people think a certified athletic
trainer, “trainer”, is a personal trainer, someone who “gets
people in shape”; but that is not the case.
What is the difference between an Athletic Trainer and
Personal Trainer?
Athletic trainers, allied health care professionals who collaborate with physicians to optimize activity and participation of
patients and clients, practice athletic training. Athletic training encompasses the prevention, diagnosis, and intervention
of emergency, acute, and chronic medical conditions involving
impairment, functional limitations, and disabilities.1
Personal trainers are health/fitness professionals who, using
an individualized approach, assess, motivate, educate and train
clients regarding their health and fitness needs. They design
safe and effective exercise programs, provide the guidance
to help clients achieve their personal health/fitness goals and
respond appropriately in emergency situations. Recognizing
their own area of expertise, personal trainers refer clients to
other health care professionals when appropriate.2
Education requirements and Licenses:
The minimum qualifications to become a certified athletic
trainer include graduation with a bachelors or masters degree
from an accredited athletic training education program
and passing a comprehensive certification examination
administered by the Board of Certification. The educational
competencies and proficiencies of an athletic trainer are
organized into six different domains and further organized
into 12 content areas which are displayed in the table below.
Once certified, ATCs are required to complete ongoing
continuing education in order to remain certified.3
Athletic Trainers in Connecticut are licensed by the Department of Public Health. Athletic Trainers are recognized as allied
health professionals by the American Medical Association, and
are assigned National Provider Identifier (NPI) numbers, as are
all other health care professionals.4
Personal Trainers education and training requirements depends on the specific type of fitness work: personal training,
group fitness, and a specialization such as Pilates or yoga
each need different preparation. Personal trainers often start
out by taking classes to become certified. Then they may
begin by working alongside an experienced trainer before being allowed to train clients alone. Group fitness instructors,
often get started by participating in exercise classes until they
are ready to audition as instructors and, if the audition is
successful, begin teaching classes. They also may improve
their skills by taking training courses or attending fitness conventions. Most employers require instructors to work toward
becoming certified.5
Athletic trainers are not limited to just working sporting
events according to the National Athletic Trainers Association
Facts document; Athletic trainers work in physician offices
as physician extenders. They also work in rural and urban
hospitals, hospital emergency rooms, urgent and ambulatory
care centers, military hospitals, physical therapy clinics,
secondary schools, colleges/universities, youth leagues,
commercial settings and professional sports teams. They are in
6 Domains
Prevention
Clinical Evaluation and Diagnosis
Immediate Care
Treatment, Rehabilitation, and Reconditioning
Organization and Administration
Professional Responsibility
12 Content Areas
Risk Management and Injury Prevention
Pathology of Injury and Illnesses
Orthopedic Clinical Examination and Diagnosis
Medical Conditions and Disabilities
Psychosocial Intervention and Referral
Heath Care Administration
— 20 —
Acute Care of Injuries and Illnesses
Therapeutic Modalities
Conditioning and rehabilitative Exercise
Pharmacology
Nutritional Aspects of Injuries and Illnesses
Professional Development and Responsibilities
Norwich Orthopedic Group, P.C.
great demand for their versatile health and wellness services
and injury and illness prevention skills. The skills of ATCs have
been sought and valued by sports medicine specialists and
other physicians for more than 60 years. As the U.S. continues
its focus on reducing the effects of obesity and other chronic
diseases, it is important that people have access to health care
professionals who can support lifelong, safe physical activity.
ATCs are an important part of the health care workforce,
especially as the demand for workers is projected to greatly
increase over the next decade.6
At Norwich Orthopedic Group, P.C. we currently employ two
staff athletic trainers and a few per diem athletic trainers.
Our athletic training staff provides athletic training services
to our locally contracted high schools; additionally they
perform personal athletic training within our physical therapy
department, conduct educational coaching seminars as well
as staff our Elite Summer Strength and Conditioning camps.
For more information on the athletic training profession
please visit the National Athletic Trainers Association or the
Connecticut Athletic Trainers Association websites.
References:
1- Connecticut Athletic Trainers Association
<www.ctathletictrainers.org/page.php?id=34>
2- Triplett, Travis; Williams, Chat; McHenry, Patrick; Doscher, Michael.
“Strength & Conditioning Professional Standards and Guidelines” 8
July 2009 Web. May 2011
<www.nsca-cc.org/nsca-cpt/about.html>
3- Connecticut Athletic Trainers Association
<www.ctathletictrainers.org/page.php?id=34>
5- Connecticut Athletic Trainers Association
<www.ctathletictrainers.org/page.php?id=34>
6-“Occupational Outlook Handbook, 2010-11 Edition” Web. May 2011
<www.bls.gov/oco/ocos296.htm>
7- The FACTS about Athletic Trainers March 2009, Web. May 2011
<www.nata.org/sites/default/files/AT_Facts.pdf>
Janeen A. Beetle, ATC-L, M. Ed graduated from
Southern Connecticut State University in 1999
with a Bachelor of Exercise Science degree with a
concentration in Athletic Training. She attended the
University of Nebraska-Lincoln where she earned a
Master of Education degree in Athletic Administration
and was a graduate assistant for 3 years. In her first
year as a graduate assistant, Janeen worked in the
Injury Prevention and Care Center at the Recreation
Center on Campus and in her last two years she worked
with Women’s Gymnastic, and Men’s and Women’s
Track teams in the Athletic Department. During her final year at the University she
completed courses towards her doctorate in Athletic Administration. Janeen received
her Athletic Training Certification in 1999. Janeen joined the Norwich Orthopedic
Group, PC in 2008.
Anna E. Bergeron, ATC-L received a Bachelor of
Science Degree from the University of Connecticut
in 2009, concentrating in Athletic Training. While at
UCONN she worked with the men’s ice hockey, football
and soccer programs as a student athletic trainer
and gained clinical experience with NCAA (National
Collegiate Athletic Association) Division III and High
School Athletics. Anna received the National Emergency
Medical Association Special Merit Award in 1997 for
her actions as a first responder in her community. Anna
joined the Norwich Orthopedic Group, PC in 2009. She
currently represents the Norwich Orthopedic Group, PC as an athletic trainer and
provides coverage to several local high schools.
www.norwichorthopedic.com
— 21 —
Advances in Shoulder
Arthroscopy
by Ammar Anbari, M.D.
W
hat is shoulder arthroscopy?
Until recently, shoulder surgical procedures were done
by making large incisions over the operative
area. This resulted in large scars and significant
discomfort after surgery. With the advancement
of optical and orthopedic technology, orthopedic surgeons are now able to perform most
procedures in the shoulder by making very small
incisions and using a small camera (arthroscope)
to view the inside of the shoulder and fix it.
Every year, new instruments and techniques are
introduced which make arthroscopic surgery
easier and more successful.
acromion bone that may be causing the problem.
(Figure 1 - before and after acromioplasty)
How is it done?
Prior to surgery, most patients are given a numbing block in
their shoulder to anesthetize the nerves connected to the
shoulder. This enables the patients to require less anesthesia
and makes it possible for them to go home the same day and
have a more comfortable recovery.
 Rotator cuff tears: One of the four tendons which
form a cuff around the shoulder joint can get torn.
Treatment involves inserting suture anchors and
reattaching the tendon back to the bone. (Figure 2 –
before and after rotator cuff repair)
Figure 1
After anesthesia is administered, the patient is
either placed in a sitting position (beach chair)
or lying-on-the-side position (lateral decubitus).
This is decided based on the area of the shoulder
which requires attention.
Two to four small (under ¼”) incisions are made
around the shoulder. The camera is then introduced in the main shoulder joint. Sterile salt
water is used to inflate the joint and allow safe
placement of instruments in the shoulder. Small
instruments are placed to diagnose any abnormalities or tears.
Photographs and videos are taken of the different parts of the
shoulder to document its condition. Shavers and sutures are
utilized to fix any torn or damaged tissue.
Figure 2
 Arthritis of the acromioclavicular joint (the small
joint between the collarbone and the acromion):
Treatment involves excision of the end of the
collarbone to create more space inside the joint.
(Figure 3 – before and after distal clavicle resection)
At the conclusion of the procedure, sutures are
used to close the small portal sites and small
band-aids (steri-strips) are placed over the incisions with sterile dressings. When the patient
wakes up, they will find a cooling cuff over their
shoulder which is used to reduce pain and swelling. In addition, the patient is placed in a sling
which helps protect any performed repair and
gives the shoulder comfort and support.
Conditions treated with Shoulder
Arthroscopy
 Impingement: a condition in which the rotator cuff
tendon becomes inflamed or abraded. Treatment
involves shaving off a portion of the overlying
— 22 —
Figure 3
 Calcium deposits on the rotator cuff, which can cause
severe pain and stiffness. Treatment involves removal
of the calcium deposits and possible repair of the
Norwich Orthopedic Group, P.C.
rotator cuff tendon.
(Figure 4)
 Shoulder instability and dislocations:
The labrum (the rim
of soft tissue around
the shoulder socket)
can get torn which
leads to instability and
sometimes shoulder
dislocations. Treatment
Figure 4
involves repair of the
torn labrum and tightening of the capsule around the
shoulder joint. (Figure 5 – before and after labral repair)
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 Articular cartilage injuries: When the surface of
the ball or socket has an injury and cartilage is lost
exposing underlying bone, arthroscopy can be used to
restore cartilage in the injured area.
 Frozen shoulder, a condition in which the patient
develops inflammation and subsequent contracture
in the shoulder, resulting in a very limited range of
motion. Treatment involves making small cuts in the
tissue, releasing the contractures that are present.
 Arthritis of the shoulder: debridement of cartilage and
loose bodies can provide symptom relief and decreased
catching pain.
Dr. Anbari received his orthopedic training at
Temple University Hospital in Philadelphia, PA. He
completed a subspecialty fellowship in Sports Medicine
and Arthroscopy at Rush University in Chicago, IL
where he acted as an assistant team physician for
the Chicago White Sox and the Chicago Bulls. Dr.
Anbari has special training in the latest techniques
of shoulder, hip and knee arthroscopy, ligament and
tendon reconstruction and repair, and shoulder and
knee replacement. He is the team physician for the
WNBA CT Sun, Norwich Free Academy, Bacon
Academy, Lyman Memorial, St. Bernard School, and the Williams School. For
more information, visit: www.CTSportsDoc.com For an appointment call:
Norwich Orthopedic Group 860-889-7345
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— 23 —
Norwich
Orthopedic
Group, P.C.
We’re here when
you need us!
Committed to high quality
comprehensive orthopedic
care for adults and children.
82 New Park Avenue
North Franklin, CT 06254
(860) 889-7345
Physical Therapy
(860) 823-6221
Visit us online at www.norwichorthopedic.com