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Orthopedics – A trend toward less surgery

Trends in Sports Medicine

  • As a field, sports medicine has moved from care for elite athletes to care for the general public.
  • Demand has risen as procedures have become less invasive.
  • Insurance coverage always is an important factor.
  • Practices have boosted profitability with a greater utilization of aides and assistants and combining services.
  • Historically, elite athletes paid big to go with an expert doctor. Now, doctors and hospitals push for the chance to secure status as a team’s official health care provider, relishing the exposure that comes with it or with being the doctor who prolongs a star athlete’s career.
  • There’s a shortage of physical therapists.

Source: IBISWorld

Trend: Less Surgery

Dr. Michael Seifert Dr. Michael Seifert

University of Central Florida sports medicine doctor Michael Seifert is among a growing cadre of physicians who now specialize in non-operative treatments of many sports and orthopedic conditions. “I try to keep people away from the surgeon’s table if I can,” he says. Florida orthopedists say that in recent years they’ve been operating less often on conditions such as rotator-cuff injuries and meniscus tears for some age groups and patients. Physical therapy has been shown in some cases to be just as effective. There’s also been a move toward “incision-less” treatments to prolong function and postpone knee and hip replacements.

Alternatives to Surgery


One long-emerging treatment is platelet rich plasma injection, in which a patient’s own platelets are injected into the knee or problem area. “It seems to work better in the lab than in people,” says Seifert, but it does show evidence of working. PRP started in dentistry and then in spinal care but took off when high-profile athletes used it. Quality studies supporting it have been slow to come, and insurance typically doesn’t cover it. At some places, it’s also used to treat hip ailments and tennis elbow.


Dr. David Westerdahl Dr. David Westerdahl

At Cleveland Clinic Florida in Weston, Dr. David Westerdahl and colleagues have started using cooled radio frequency ablation to treat people who are not yet candidates for knee replacement surgery. It’s a technique that started with the spine and, as of April 2017, has been approved by the FDA for knees for non-narcotic pain relief — an important approach amid an opioid epidemic. “Right now it can provide pain relief for up to two years,” says Westerdahl. The technique knocks out the nerves that provide pain feedback in the knee while leaving motor nerves intact. It takes the body a long time to reroute the nerve pain signal, letting people be more active and continue working. It gets people active again, which helps with, among other things, weight management. “There have been lots of studies that for arthritis, being more active is better than less,” Westerdahl says.

Exercise More; Eat Less

In all things medical, it’s important for consumers to realize that what’s promising may not pan out. Doctors themselves have seen it in some surgical approaches that came about in recent years but now are out of favor. Meniscus tear surgery for older people now is viewed with more caution thanks to evidence showing that it accelerates arthritis and the need for a knee replacement.

Asked whether there’s a changing mindset in orthopedics, Dr. David Westerdahl prefaces his thoughts with “ask 10 different doctors …” Then he says, “I think overall what we’re seeing, there are many surgical treatments that over time have gone away in orthopedics. Many of the things we did 10 years ago weren’t always the best thing for patients.”

Dr. Charles Nofsinger Dr. Charles Nofsinger

Of course, people should do what they can to minimize the chance of needing anything done. Seifert says first maintain a healthy weight to keep from stressing joints. Exercise to keep the muscles controlling joints strong. Vary exercise to stave off injury and to keep all muscles conditioned.

Supplements? Views conflict, and there’s no miracle drug. Certainly, the obvious strategy is to first make lifestyle changes. But USF’s Dr. Charles Nofsinger says turmeric and coenzyemeQ10 merit a look. He also notes there’s an epidemic of vitamin D deficiency in Florida. Even though it can be miserably hot out and we need to protect our skin, we still need sun.

Sound Waves

Another approach, which requires a tiny incision, is “percutaneous ultrasonic tenotomy” that uses a vibrating needle to break down damaged tissue and suck it away. The body replaces the harmed tissue with healthy tissue. It’s being used at Cleveland Clinic for tennis elbow, hip tendon, rotator cuff and Achilles tendon repairs. Some patients who’ve had chronic tennis elbow pain have been back to full activity, including sports, in six weeks, Dr. David Westerdahl says.

Stem Cells

The University of South Florida College of Medicine’s Dr. Charles Nofsinger, an orthopedist, has used stem cells to treat tendons and arthritis-related damage in early or mid-state cases. He says the scientific literature is trending toward supporting their aggressive use. “We’ve been doing it for several years now and having good results,” Nofsinger says. “It appears that it helps cells regrow. Especially if you have some existing cartilage, you can help those tissues. It only really works if there is something left.”


Dr. Richard de Asla Dr. Richard de Asla

Naples-based Arthrex, a surgical device company, rolls out innovations regularly. Just one: InternalBrace, a ligament augmentation device to fix bad ankle sprains that require surgery to repair the ligament. InternalBrace augments standard ligament repair by acting as a kind of seat belt to prevent the ankle from moving beyond a certain point. There are 35,000 to 40,000 reported ankle sprains a year and, of course, many more that go unreported.

Dr. Richard de Asla, a Naples Community Hospital orthopedic surgeon with fellowship training in foot and ankle issues, says the synthetic ribbon — permanently attached to bones in the ankle — has produced good results, getting people out of the immobilization boot sooner, walking sooner and into physical therapy sooner.

“It’s sort of changed how we manage this very common problem,” de Asla says. He uses it primarily to protect repaired ankle ligaments, but it has a number of applications. He notes, though, that the evidence is anecdotal and would benefit from having prospective, randomized studies done.

Fans of Thursday and Sunday night football on NBC Sports may recognize one of Arthrex’s innovations. NBC uses Arthrex’s OrthoIllustrated.com 3-D animations to explain player injuries. The website provides animations that patients can use to understand their own injuries and arthritis and treatments. It’s accessible by computer, tablet and smart phone. (See videos on YouTube, here.) This is its second season on NBC Sports. The animations, supplemented with patient-friendly explanations, are the same ones used by Arthrex in-house to educate surgeons on using Arthrex products and techniques.

Gym, Health and Fitness Club Industry

  • $1.4 billion - Value of the industry in Florida
  • $30.5 billion - Value nationally
  • $206.6 million - Industry profit in Florida
  • 2% - Projected growth in annual revenue through 2022
  • Market Leaders - Fitness International, the parent company of LA Fitness, has at least 20% of the Florida market, followed by Equinox, 24 Hour Fitness, Gold’s Gym, Life Time Fitness and Florida-based Zone Fitness.

Sports Medicine Industry

  • The American Medical Society for Sports Medicine has 254 members in Florida out of 4,000 nationally.
  • $19.5 billion - Revenue nationally in 2016
  • 2. 1% - Projected revenue growth through 2021
  • 8. 2% - Florida’s share of sports medicine practitioners, the largest share in the Southeast U. S.
  • 9. 1% - California’s share, the nation’s largest

Source: IBISWorld

Recovery Time is Vital

Youth baseball is played year-round in Florida, resulting in an increase in overuse injuries among players.

Dr. Lee Kaplan, director of the University of Miami Sports Medicine Institute, notes that Major League Baseball players generally finish their season in October and have months to rest before reporting in February for physicals. Not so for teen baseball players in south Florida.

The downside of Florida weather is that youth athletes go year-round through school seasons, travel team seasons, holiday tournaments and so on. It’s true in baseball, tennis and other sports. The result: “There’s defi nitely an increase in overuse injuries. Many kids are specializing earlier. In south Florida, they’re playing baseball four seasons a year,” Kaplan says. Parents and kids need to realize the importance of active rest and cross training and, if injured, to get with a physical therapist and get a program before restarting. Says Kaplan, “There needs to be a little rational thought.”

Meanwhile, Dr. George Pujalte at Mayo Clinic in Jacksonville conducted a study on Olympiccaliber athletes and found the data failed to support the notion that starting young led to elite performance. Many started late. The difference: “They were meant for that sport.” If your kid is destined for athletic greatness, playing a variety of sports and taking breaks won’t hurt. Pujalte has seen arthritis linked to early specialization and overuse of joints in teens. “It’s very worrisome that we see a 16 or 17 year old with arthritis. It’s just better to let your kids be kids and find their sport through the years.”


With all the attention on concussions in the NFL, should parents allow their boys to play football? Essentially, yes. There’s a theoretical basis, doctors say, for linking concussions to degenerative brain disease CTE, but science hasn’t proved it. The risk of concussions, and repetitive ones, grows as a youth moves to higher levels of the sport, but there are risks in being sedentary as well.

Dr. George Pujalte Dr. George Pujalte

“It’s certainly still better for people to be active. I’m not discouraging a kid from activity based on a fear of concussion,” says Dr. George Pujalte, of Mayo Jacksonville.

Dr. David Westerdahl of the Cleveland Clinic in Weston says he lets his middle schooland high school-age children play sports — soccer — that have a risk of concussion because of the benefi ts of exercise and camaraderie and other positives that come with team sports. “As a parent, it’s important to provide for your child an opportunity to be active. Play those sports smartly and safely. Make sure the child has good equipment.” He does anticipate football adopting more rules to reduce harmful contact.

Weekend Warriors

Heather Vincent, director of the UF Sports Performance Center and UF Human Performance Laboratory, and husband Dr. Kevin Vincent, medical director of the Department of Orthopaedics and director of the UF Running Management Clinic, share their advice for aging amateur athletes who want to stay active:

Heather Vincent: “What we try to recommend is just stay off of your chair as much as you can. Where possible, avoid sitting for long periods and only doing pockets of exercise. The people who do some movement every day, even if it’s a brisk walk, do a lot better healthwise than those who do an intense workout sporadically. Do something several times a week that’s going to get your heart rate up and get you a little sweaty and in addition to that we want some kind of strengthening exercise.”

Kevin Vincent: “The best exercise is the one you’ll do and do consistently. The body I have today is not the body I had 10 years ago. The body is going to tell you the things it likes and the things it doesn’t like. Say I’m a runner and I’m 57 years old and today my knee aches but today is my five-mile run. Could be I go to the gym and lift weights instead, or elliptical or cycle? Rest is not a four-letter word. It’s actually OK not to exercise every day. If you have arthritic issues around the joint, it doesn’t mean give up. It means work around it. It just means be smart. Maybe you have to do it as a walk-jog. Older people can still do those things. They just have to be willing to make adaptions around it. The most important thing is to not just give up and become sedentary.”

Heather: “If you think about strategies of successful athletes around the world in their 80s and 90s, aside from their genetic gifts, they tend to consume diets with very healthy fats, like olive oil, in low quantities, cold-water fishes like salmon and halibut, lots of fruits and vegetables, really managing themselves with natural foods. Always try to eat every day some orange vegetable, a green vegetable and some sort of dark berry and fiber.”

Kevin: “I believe that grandma needs a treadmill, not a rocking chair. You’re never too old to exercise. There’s a big difference between existence and living.”

Heather: “If people are looking for that magic pill — exercise. If exercise is not a priority now, it should be as you get older. Find an exercise partner or find a group class you might enjoy and have that social piece of the exercise. Those people who stick with it over decades are those not afraid to try something new and stick with it. We have a core group here on mindfulness. That is just appreciating the moment when you’re in it. If you have the opportunity to be outside, try not to rush through the exercise. Enjoy it while you’re out there.”

Weather Factor

You may know what the heat index is, but do you know today’s wetbulb globe temperature? It’s a cousin of the heat index but takes into account not only temperature and humidity but also wind speed, the sun’s intensity and cloud cover and does so in direct sunlight rather than the shade as with the heat index.

The military, OSHA and sports teams use it to decide when enough is enough outdoors. Dr. George Pujalte, assistant professor in family medicine and sports medicine at Mayo Clinic in Jacksonville, and his colleagues are examining whether marathons and half-marathons — there are more than 100 annually in Florida — get called off as recommended by the American College of Sports Medicine when the WBGT runs higher than the recommended WBGT cutoff of 82 degrees.

Pujalte says the researchers hoped to find races called off or altered — perhaps earlier start times or fans blowing mist the length of the route — when it was too warm. Instead, just a bit into the study, they have already found two that should have been canceled but weren’t. Race organizers have a lot of money at stake in running races as scheduled. “We need to talk to people and show them our data and say, look this is dangerous. High schools are supposed to monitor WBGT for student athletic activities but a large number aren’t equipped.”


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