Here Comes Volleyball Season: We Are Ready in the Ortho World!

Volleyball season is fast-approaching. Today, let’s discuss the four most common areas of injury, treatment and prevention.

Volleyball was my sport as a youth. I played all year-round, and if I wasn’t in practice or a tournament, I was working out. But is the constant wear and tear on our bodies without rest hurting us even at a young age? In parts, yes. We commonly see athletes whose injuries could have been prevented with a short period of rest or prevention methods. Let’s talk about that:

1.     Ankle

Most common: ankle sprain. It comes as no surprise that ankle injuries are one of the most common injuries seen in volleyball. Initial treatment includes RICE (rest, ice, compression, and elevation). However, it is always wise to see an orthopedic provider who can help guide you in treatment, prevention, and return to play. What many people do not know is younger children and teenagers’ growth plates are still open and are also at risk of injury with a twist of the ankle. When growth plates are still open, they are the most vulnerable and at risk for a Salter-Harris fracture which involves the growth plate. After growth plates close, the ligaments become the most vulnerable. I like to tell my patients that ligaments are like the candy Laffy Taffy. Once they are stretched out, they don’t necessarily return to their original state. Thus, prevention and strengthening are imperative.

Prevention: ankle range of motion, strengthening, and balance exercises; keeping footwear up to date; purchasing well-fitting and high-quality footwear; and ankle braces during practice and games.

2.     Knee

Most common: patellar tendonitis (chronic) and ACL tears (acute)

Patellar tendonitis, also known as jumper’s knee, is very common due to the amount of jumping volleyball requires. Many times, the athlete will localize the pain right under the kneecap at the proximal aspect of the patellar tendon. Our office utilizes diagnostic ultrasound to look at the characteristics of patellar tendon, identify if there is tearing, compare it to the unaffected size, and determine if there is any new blood vessel formation (neovascularization). Prevention and treatment include stretching and strengthening exercises, a period of rest from jumping, and a patellar tendon strap. Short-term anti-inflammatories can helpful. In difficult cases, we can turn to platelet-rich plasma injections (PRP). Those with an open growth plate at the tibial tuberosity are at risk of developing Osgood-Schlatter’s.

Anterior Cruciate Ligament (ACL) tears: Volleyball is relatively high risk for ACL tears due to potentially landing awkwardly after a jump or during pivoting maneuvers frequently required. The ACL is under the most load when the knee is under sudden valgus (knock-kneed) stress. The best preventative options are to strengthen the outer hip, upper thigh, and gluteal muscles along with jump-training techniques to help protect the knee. If diagnosed with an ACL tear, treatment can be conservative or surgical. Those who wish to continue participating in high-risk sports generally opt for surgical intervention.

3.     Shoulder

Most Common: Impingement, Labral Tears, Instability, and Rotator Cuff Tendinitis

Those who are hitters in volleyball are at risk for all of these shoulder conditions. Once again, relative rest, recovery, and strengthening are imperative in preventing these conditions. Improvement in form and hitting techniques are often helpful. Injections (occasional steroid, but more commonly PRP) can play a role in more difficult cases.

4.     Low Back

Most Common: Lower Back Strain/Sprain (acute) or Spondylolysis

Volleyball requires repetitive bending, twisting, and hyperextension movements which put the low back in vulnerable positions. The biggest takeaway is if you or your child is experiencing low back pain that is not relieved after a couple weeks, please see an orthopedic provider. This could indicate a spondylolysis (a stress fracture) or stress reaction in the bones of the lumbar spine. Low back strains/sprain can be muscular or ligamentous and tend to improve within 2 weeks. If that’s not the case, then we often look for spondylolysis or even disc problems.

As mentioned, strengthening and adequate rest while allowing our bodies to recover are the best ways to prevent these common injuries. However, if these injuries occur and you or your child’s symptoms are unresolved beyond a week or two, please give us a call!

Taylor Moore, NP

Hamstring Strains- The All Too Common Injury

Picture this….an explosive movement that involves hip flexion and knee extension. What could go wrong? Well, this is the mechanism of a hamstring strain or tear. The classic actions are jumping, kicking, or running. Occasionally, a pop will be felt. We see hamstring strains and tears in our practice often, and frequently, the patient is mistreating their hamstring pathology by the time they get to us. Because of this, we hope this blog will provide education on appropriate first-line treatment before and when you seek medical attention.

First, can anyone name the three hamstring muscles? The answer is: Biceps femoris, semitendinosus, and semimembranosus. What’s the common injury in Major League Baseball: you’re thinking a shoulder or elbow problem, right? Not so fast…a hamstring strain is the most common injury in baseball, and likely the NFL and Major League Soccer as well.

Hamstring strain/tear prevention: proper warm-up, dynamic stretching, adequate rest and recovery, and strengthening. Specifically, the quadriceps muscles tend to get a lot more attention than our hamstrings because they are “look good” muscles. However, neglecting the hamstrings and creating a muscle imbalance definitely increases one’s risks of a hamstring injury. Also in regards to prevention, when a hamstring starts to feel tight or crampy, then that’s a warning sign. It’s then wise to minimize those explosive activities that often lead to a major strain.

In terms of radiographic diagnosis, x-rays are primarily only helpful to evaluate a patient for an avulsion fracture when the pain and strain is near the ischial tuberosity. These fractures are most common in skeletally immature patients such as younger teenagers with open growth plates. Musculoskeletal ultrasound, one of our areas of expertise, is a great and inexpensive way to visualize and grade hamstring strains in our office. Finally, an MRI is the most complete test to visualize a hamstring injury, but is not necessary in most patients and certainly the most expensive and time-consuming test.

Complete tears: If a complete tear is found, particularly proximally (at the origin at the “sit bone”), then surgical reconstruction is the typical treatment. I once knew someone who had liquid courage, (a.k.a., too much alcohol) on board and attempted to do the splits. He made it down into the splits but the explosiveness of the movement caused his hamstring to avulse off of the ischial tuberosity. He had to undergo surgery to reattach it. Needless to say, don’t try to do the splits, folks! Fortunately, complete tears are rare.

Strain/partial tear: This is most commonly the hamstring pathology we see. Hamstring injuries take a long time to heal. With proper treatment, this can be accelerated. The BIGGEST piece of advice I can give initially after the strain is DO NOT STRETCH the hamstring. It will commonly feel tight and feel like you need to stretch, but this will only strain the tendon and muscle belly further. Rest and activity modification are important steps in recovery. This even means to not lead up the stairs with the affected leg or bending at the waist, but instead with at your knees. Any activity that can tug on the hamstring, you should avoid. Other treatment options include thigh sleeve, steroid injection, physical therapy, and platelet-rich plasma (PRP) injections under the guidance of musculoskeletal ultrasound. PRP becomes a great option for proximal hamstring tendon problems that persist beyond a few months. We most commonly see this problem in long distance runners.

Recurrence: hamstring injuries are highly prone to recurrence. This is often due to a return to activity or sport too quickly and/or inadequate rehabilitation. This is why having an expert guide you in your recovery often decreases your risk of re-injury.

In a nutshell, if you have an acute or chronic hamstring injury, it’s best to seek medical attention as opposed to managing this yourself. Proper diagnosis, grading of the strain, discussion of treatment and prevention strategies along with a return-to-play/exercise plan is what we offer our patients.

As always, let us know if we can be of assistance to you!

Taylor Moore, NP and F. Clarke Holmes, M.D.

What is a Sports Medicine Provider, and Can I See One?

You may be asking yourself what is a Sports Medicine provider? To be honest with you, I only found out the difference between sports medicine and general orthopedics in my last semester of Nurse Practitioner school. Because of this, I want to provide more insight into the differences so that you can be educated and empowered in choosing an orthopedic specialist that best fits your needs.

Sports Medicine is a specialty underneath the orthopedics umbrella. Just like you can see specialists who see only hips, shoulders and knees, foot and ankle, or the spine, you can see a sports medicine specialist. Dr. Clarke Holmes and I are Orthopedic Sports Medicine Providers. What might differentiate a sports medicine provider from a general or specialty orthopedist? Here are few key points:

1.      One stop shop: Sports Medicine Providers see orthopedic conditions from the top of your head (concussions) to the tip of your toes, and everything in between

2.      Conservative treatment options versus jumping right into surgery: Dr. Holmes and I will always be transparent with our patients if surgery is the best option, but why not try utilizing all the nonsurgical options first if surgery is not necessary?

3.      We are experts in minimally-invasive procedures that can either prevent surgery or be an alternative to surgery: For example, Platelet Rich Plasma (PRP) injections are very successfully used for partial tendon tears and osteoarthritis of numerous joints. See our PRP blogs or check out our social media posts to learn more about PRP.

4.      Improved accuracy of our injections by utilizing musculoskeletal (MSK) ultrasound guidance. Ultrasound is becoming a mainstay in the sports medicine world, and we’ve used MSK ultrasound for over a decade. We also use this daily to diagnose tendon tears, bursitis, joint swelling and ganglion cysts.

5.      Holistic treatment: We care about the patient as a whole person and do not see them as just a body part, a diagnosis or a potential surgery.  We develop a plan of action with the  patient that considers what activities they like to do, their occupation, weight, nutrition, mental health and any other contributors to formulate an individualized treatment plan.

6.      YOU DO NOT HAVE TO BE AN ATHLETE TO SEE A SPORTS MEDICINE PROVIDER. Yes, we experts in treating athletes ranging from the youth to the professional ranks, but we also treat those who do not consider themselves an athlete. In addition, we see patients of all ages and all activity levels. One of my favorite things to treat is arthritis, even in those who do not exercise and just want their pain to decrease and daily function/activities to improve.

Hopefully this has provided clarification on the differences between a sports medicine orthopedic specialist and a other types of orthopedists. As always, let us know if we can be a resource to you!

Taylor Moore, NP

BEING PROACTIVE, NOT REACTIVE, WHEN IT COMES TO PLATELET RICH PLASMA (PRP) INJECTIONS

I am a 28 year-old nurse practitioner and former competitive athlete, and I am strongly considering getting platelet-rich plasma (PRP) injections for my knees. Why? For one, as a provider, I have witnessed many improved patient outcomes. Two, this procedure is safe, has relatively no side effects, and is minimally-invasive. Lastly, we are seeing that by being proactive with PRP versus reactive when symptoms are present shows even further benefit.

After many years of intense volleyball training, games, and working out without any downtime throughout the year, I developed bilateral knee pain. Although I have no x-ray evidence of osteoarthritis at this time, based on my symptoms, there is no doubt I have cartilage damage. Because of this, I feel that PRP injections, in addition to other conservative treatments I’ve used, will boost the longevity of my knees. 

PRP helps soft tissue, joint, and cartilage pathology. It is a great way to use your own body’s healing system to improve musculoskeletal problems, and there is minimal risk because it uses your own blood. 

What’s our process?

1. Obtain blood from a vein.

2. Spin it in a centrifugation system in our office. This separates the components of the blood and concentrates the platelets.

3. We take the plasma that has platelets that are rich in growth factors to create the PRP injectable solution.

4. The PRP is then injected under ultrasound guidance in the targeted area.

When injecting the PRP solution to the targeted area, it creates an espresso shot-like effect for your body’s growth factors and repair cells to travel to this area. The main goal is to help repair the damaged area, decrease pain, and improve function. Keep in mind that this is a slow and methodical approach that can take up to 6 months to see maximum benefits. Sometimes more than one PRP injection is needed. How long does PRP last? It varies based on the severity of the patient’s condition, a patient’s activity level, and incorporation of other conservative treatments. Cost can vary per practice. We typical charge $800-$950 (*subject to change) depending on how many locations we are injecting and which centrifugation system we use. Keep in mind that PRP injections are NOT stem cell injections. 

My goal with this blog is to change the thought process that PRP injections should only be used reactively to treat orthopedic conditions and their accompanying symptoms to one instead that utilizes PRP in a proactive approach to slowly repair and stabilize conditions. 

So, why haven’t I had PRP injections in my knees already? Honestly, the only thing holding me back is my nervousness when it comes to needles. 

Interested to see if PRP injections would be helpful for you? We would love to have a consult with you to discuss these in detail! 

Taylor Moore, FNP

Impact Sports Medicine and Orthopedics

What is a Nurse Practitioner?

I have had the pleasure to meet and take care of many of our awesome patients since I joined Impact Sports Medicine in August 2020. However, questions still occasionally arise about what my role is at Impact.

What is a Nurse Practitioner?

You may hear the following interchangeable terms: Nurse Practitioner, NP, Mid-level, Advanced Practice Registered Nurse (APRN). Nurse Practitioners are trained to assess patient needs, order and interpret imaging and laboratory tests, diagnose conditions, formulate and prescribe treatment plans, and provide patient education. There are many different Nurse Practitioner Specialty degrees. You commonly see NPs in inpatient and outpatient settings, primary care, and specialist offices, occupational health, the health department, and more!

Are a Nurse Practitioner and a Nurse the same thing?

No, these are not the same roles and have different scopes of practice. A nurse assists providers and has an associates or bachelors degree, whereas an NP requires at least a masters degree and special training through an NP educational program.

Nurse Practitioners function as a provider just like a Medical Doctor (M.D.). In Tennessee, all Nurse Practitioners are required to be under the supervision of a Medical Doctor.

What is the difference between a Nurse Practitioner (NP) and a Physician Assistant (PA)?

These two roles function very similarly with tiny nuances. Both are considered mid-level roles. A Nurse Practitioner is required to be a Registered Nurse (RN) before advancing their training to become an NP.

What is my role at Impact Sports Medicine and Orthopedics?

I see patients independently of, and at times along side, Dr Holmes. This means I can assess and examine patients, interpret imaging and labs, prescribe medications, diagnose conditions, provide treatment plans, perform ultrasound guided injections, and provide education to patients. Overall, think of me as a provider extension of Dr. Holmes.

What else do I want you to know about me as an NP?

Although you will see me independently, Dr. Holmes and I work as a team. This means I discuss patient cases and my decisions with him, and always have him review x-ray and MRI images as well. I want patients to know he is involved in their care, even if you don’t see him directly. Yet, have confidence that I will deliver safe, compassionate, and competent care to get our patients better! I work with my patients as a team to devise decisions that are tailored to each individual, their conditions, and their needs.

Hopefully this provides more clarity on what a Nurse Practitioner is and my role at Impact Sports Medicine and Orthopedics. Looking forward to providing care to y’all in the future!

Taylor Moore, FNP-C

Instagram: @taylormoore_nashvillenp

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