journal - joi jacksonville orthopaedic institute · journal winter/spring 2012 jacksonville...

JournalThe official publication of Jacksonville Orthopaedic Institute Volume X Issue I

www.JOIonline.net

Autoimmune Diseases

Delicious & NutritiousSmoothies Hit The Spot

Synovial Chondromatosis:An Atypical Cause of Hip Pain in an Elite Cyclist

Care of the Aging Knee:Baby Boomers May Need Lifestyle Changes

Eating Vegetables is Food Smart

The Perfect Swing

Finding the right doctor just got easier.

Learn more about Baptist Primary Care and find a doctor in your neighborhood

by visiting

BaptistPrimaryCare.net.

Baptist Primary Care has more than 40 convenient office locations throughout Northeast Florida and Southeast Georgia.

o Sports/school physicals o Well visits for adults and children

o Immunizations o Newborns through geriatrics

o Coordination of care for chronic conditions (diabetes, hypertension, etc.)

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JournalWinter/Spring 2012

JACKSONVILLE ORTHOPAEDIC INSTITUTE1325 San Marco Boulevard, Suite 701

Jacksonville, FL 32207904-858-7199

Patrick A. Hinton, Executive Director

The mission of the Jacksonville Orthopaedic Institute (JOI) is to provide high quality orthopaedic

health care for our patientswith musculoskeletal disorders.

Or point your smartphone’s browser towww.joionline.net/m

JOI providesexpertise in:

HAND

FOOT & ANKLE

JOINT REPLACEMENT

SPINESPORTS MEDICINE

We are dedicated to fostering a personalized and compassionate level of medical care for our patients.

The JOI Journal is designed & published by Custom Medical Design Group.

www.CustomMedicalMagazine.com

To advertise in an upcoming issue pleasecontact us at 800.246.1637.

Exclusive Sports Medicine Provider

Baptist Health and Jacksonville Orthopaedic Institute now offer Robot-Assisted Partial Knee Resurfacing to address the damaging effects of osteoarthritis. For patients with limited damage, this new minimally invasive option offers a better alternative to total knee replacement because it is less invasive, has a shorter hospital stay, a quicker recovery time, and results in more

natural knee function. The procedure is ideally suited for patients who have early to mid-stage osteoarthritis in just one or two compartments of the knee, including younger patients who were precisely not considered good candidates for total knee replacements. JOI physicians who have been certified to date are Drs. Steven Crenshaw, Stephen Lucie and Carlos Tandron.

Another exciting new piece of equipment JOI is pleased to showcase is the new AlterG “anti-gravity” treadmill located at JOI San Marco. This revolutionary approach to rehabilitation offers the ability to defy gravity and work toward increased function like never before. Some of the world’s best athletes and teams use this unit as part of their sports conditioning and rehabilitation programs. For post-operative and post-injury patients, the “unweighting” treadmill provides a safe way to treat the lower extremities, if you are approved by your physician for at least 25% partial weight-bearing and are allowed to flex and extend your hip, knee and ankle through a limited range of motion. This conditioning provides a significant reduction in pain, and nearly 100% of patients who have tried it have said they like it because pain-free progress can be easily tracked

and charted, and you are soon restored to your natural gait, range of motion and have an improved patient outcome. It’s also used to improve balance and confidence of those with prostheses.

With regard to sports medicine, JOI continues its leadership position as we are “on the field” serving the needs of the NFL Jaguars, 2011 Arena Bowl XXIV Champions The Jacksonville Sharks, and JU, just to name a few. We offer a variety of FREE Sports Medicine Seminars at 1st Place Sports locations – go to joionline.net for the community event schedule. Also, TEAM JOI Cycling, Running and Walking Teams frequently participate in many of the region’s top events, including the GATE River Run – look for our employees and physicians on their bikes and on the pavement!

This year, we are pleased to offer our annual continuing medical education programs for phy-sicians, starting with the CME I presentation at the Museum of Science and History (MOSH) in the Planetarium. These events allow our physicians to communicate “how to” perform various orthopaedic examinations, as well as give an update on orthopaedics to primary care physicians.

We congratulate those who walked with TEAM PICERNO during the Juvenile Diabetes Research Foundation’s “Walk to Cure Diabetes Now” on March 24th, and the Arthritis Foundation’s “Touchdown To A Cure” Arthritis Walk, on Saturday, March 31st, at Metro Park with JOI’s Kevin Michael Kaplan, MD, Honorary Walk Chair. If you are a golfer, please join JOI for the annual Florida State College Foundation’s “Golf Classic” on Monday, April 30th at the Deerwood Country Club presented by JOI and Co-Chaired by Michael S. Scharf, MD (floridastatecollegefoundation.org). Hope to see you “on the green!”

R. Stephen Lucie, MDChairman, Jacksonville Orthopaedic Institute

Medical

Medical

facebook.com/myjoi

Visit us on

Greetings from the Chairman of JOI...

R. Stephen Lucie, MDSports Medicine,

Joint ReplacementSAN MARCO

The MAKO RIO™ Robotic Arm Interactive Orthopedic System available at Baptist Medical Center Downtown

AlterG “anti-gravity” treadmill

JOI Rehabilitation CentersPoiNT MeADoWS 7740 Pt. Meadow Dr., Suite 1 & 2 Jacksonville, FL 32210 Phone: 904-564-9594 Fax: 904-564-9687

RiVeRSiDe/WeSTSiDe 4339 Roosevelt Blvd., Suite 600 Jacksonville, FL 32210 Phone: 904-389-8570 Fax: 904-389-8599

SAN MARCo 1325 San Marco Blvd., Suite 102 Jacksonville, FL 32207 Phone: 904-858-7045 Fax: 904-858-7047

SoUTH 14985 Old St. Augustine Road Suite 106 (Durbin Crossing) Jacksonville, FL 32258 Phone: 904-288-9491 Fax: 904-288-9698

UNiVeRSiTY 5737 Barnhill Drive, Suite 204

Jacksonville, FL 32207 Phone: 904-733-9948

Fax: 904-733-9984

BeACHeS 1577 Roberts Drive, Suite 320 Jacksonville Beach, FL 32250 Phone: 904-247-3324 Fax: 904-247-3926

MANDARiN 12276 San Jose Blvd., Suites 716 & 717 Jacksonville, FL 32233 Phone: 904-288-9604 Fax: 904-288-9643

NoRTH 12961 North Main Street Suite 201 & 202 Jacksonville, FL 32218 Phone: 904-757-2474 Fax: 904-757-5541

oRANGe PARK/CLAY CoUNTY 1845 Town Center Blvd., Suite 410 Fleming Island, FL 32003 Phone: 904-621-0396 Fax: 904-621-0397

For Getting Better, It Doesn’t Get Any Better!When on the road to recovery, every stop on your journey is important. That’s why JOI offers its own first-rate rehabilitation facilities. We find it is the best way to offer cohesive, streamlined care. As with every aspect of your care, JOI will provide expert therapists, the best equipment and technology, and an outstanding environment to bring about the best results. All you need is the desire to improve. We will encourage you along the way to keep you motivated and thinking positive about your treatment. If for a particular reason you choose a non-JOI rehabilitation facility, we can work with other rehabilitation facilities as well. n

4 joionline.net JOI Journal

JOI patients cango home with

their prescriptions.

• Conveniently located

• Full range of prescriptionand over-the-countermedications

• Most insurance plansaccepted

Baptist Pharmacy PavilionBaptist Medical Center Downtown Pavilion Medical Building, 836 Prudential Drive904.202.5288

Baptist Pharmacy BeachesBaptist Medical Center Beaches1370 13th Avenue South, Jacksonville Beach904.241.0116

Baptist Pharmacy NassauBaptist Medical Center Nassau1250 South 18th Street, Fernandina Beach904.261.3251

Baptist Pharmacy SouthBaptist Medical Center SouthMedical Office Building, 14546 Old St. Augustine Road904.271.6690

Baptist Pharmacy Children’sNemours Children’s Clinic, 807 Children’s Way904.697.3601

Baptist Pharmacy San MarcoReid Medical Building, 1325 San Marco Boulevard904.202.5292

Baptist Pharmacy Lane AvenueBaptist Primary Care, 810 Lane Avenue South904.693.2389

PharmacyAd_JOIJournal2010_Layout 1 6/11/10 4:27 PM Page 1

Join us for aFREE Sports Medicine Seminar

the FIRST THURSDAY of the monthat one of the 1st Place Sports convenient locations!

“Fun Run” from – 6:00 - 6:45 pmRefreshments – 6:45 - 7:00 pm

JOI Physician seminar on sports medicine “hot” topics – 7:00 - 7:30 pmQ&A/Door Prize Drawing – 7:30 - 7:45 pm

For reservations, go to joionline.net

1st Thursdays @ 1st Place Sports

Photo Credit: Hope Kinchen

“First Coast Connect” with Melissa Ross presents

WEEKEND WARRIOR Every Friday at 9:50 am

Weekly Guests Listed on www.joionline.net

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Autoimmune Diseases

he autoimmune diseases now currently recognized, number into

the hundreds these days, and the extent to which they are responsible for

multiple disorders is just beginning to be appreciated.

The classic autoimmune disease that presents with involvement of the musculoskeletal system is Rheumatoid Arthritis. This syndrome has several different manifestations, beginning with Juvenile Rheumatoid Arthritis in the youngest patients, and presenting as “Pauciarticular Rheumatoid Arthritis” in patients in their teens to thirties, and as the more widely recognized variety, which occurs commonly in the middle-aged to the elderly.

The one factor that all autoimmune diseases have in common, is that the body’s own defense mechanism -- its immune system -- starts to attack the body’s own tissues. Beginning with an inflammatory phase, which, if left unchecked, can lead to the overt destruction of joints and other tissues, leaving them mere scarred remnants of their previous forms. Awareness of autoimmune diseases is critically important because there are disease-modifying agents available today that can alter the course of these illnesses and provide the patient with enhanced quality of life, to levels that could never have been possible before these agents were discovered.

Two main groups of autoimmune diseases affect the musculoskeletal system. The ‘seropositive’ type, where the test for Rheumatoid Arthritis is positive, and the ‘seronegative’ types, commonly called ‘seronegative spondyloarthropathies’, where the test for Rheumatoid Arthritis is

by Philip R. Hardy, MD Sports Medicine, Joint ReplacementSAN MARCO

Philip R. Hardy, MD


negative, and the areas involved include the spine and the joints. There are some tests, such as the HLA-B27, which, although not diagnostic, are found to be present in a much higher percentage of patients with Ankylosing Spondylitis than in the normal population.

Many well-known diseases, such as the skin disease Psoriasis, have recently been appreciated as being autoimmune. It has been known for many years, however, that patients with Psoriasis can develop joint involvement, often characterized by stiffness and ankylosis, that is, fibrous or bony fusion. Other diseases, such as Inflammatory Bowel disease, are also associated with arthritis, as are diseases such as Systemic Lupus Erythematosus (Lupus), Sjogren’s disease, Scleroderma, and Reiter’s disease.

The cause of many of these disorders turns out to be a genetic predisposition, plus other environmental factors. Reiter’s disease, for example is also called ‘Reactive Arthritis’ and has been shown to be associated with a chronic infection by an organism called Chlamydia. In common with many of these maladies, chronic infections start the immune system along the path toward the production of the patient’s own antibodies, and the genetic predisposition allows these antibodies to attack the patient’s own tissues. Very few other forms of autoimmune arthritis have had the initiating agent determined, but the chances are that at some point in the future, these agents will be discovered.

Once the inflammatory process has started, there are several ways of dealing with it. The typical “non-steroidal anti-inflammatory” agents, of which aspirin was the first, have been used extensively, as have steroid anti-inflammatory agents such as prednisone. Antimetabolic agents, such as methotrexate are also used, especially in Rheumatoid Arthritis. The new more specific agents, so called “anti-tumor necrosis factor alpha agents,” such as Enbrel or Humira, are now being more widely used, and belong to the disease-modifying anti-rheumatic drugs (DMARDs). DMARDs can really enhance the quality of life of patients with these diseases. These agents are really antibodies themselves that target the antibodies produced by the patient, which are the ones causing the tissue destruction. The problem of using one set of antibodies to tackle a different set is that, on occasion, the body’s own immune system starts to produce even newer antibodies against the treatment antibodies, and thus the treating agents are unfortunately rendered ineffective. To add even more confusion, there have been cases of patients being treated for Ankylosing Spondylitis with these agents who have developed Psoriasis as a side effect of the treatment.

The bottom line is that if a patient has any autoimmune disease, he or she is more likely to get another, and the presence of vague, multi-organ system symptoms characterized by stiffness after periods of inactivity, along with a family history of any autoimmune disease, should immediately alert the physician to the possibility that the patient’s problem could easily be another variety of such a disease.


Homework first, then Olympic training.

The Bolles School ranks among the nation’s top in college preparatory. Students here discover the gifts and talents that lead them to richer accomplishments and higher academic capabilities. From pre-kindergarten through high school graduation, our students gain the advantage from a faculty and staff leadership who are committed to a truly comprehensive and holistic instruction. Your son or daughter may also benefit from our highly celebrated athletic programs, led by their passionate and dedicated coaches, trainers and instructors. Together, the Bolles Bulldogs’ teams are among the most awarded and accomplished in the country. Plus, scores of Bolles student athletes graduate and become standout players on ranked college squads, compete in the Olympic Games and even play on professional sports teams in the NFL, NBA and MLB. None, however, were allowed to compete or train without turning in their homework first. Four Unique CampusesPonte Vedra Beach | Whitehurst | Bartram | San JoseDay and Boarding School from Pre-K through Grade 12

Explore what Bolles has to offer by visiting www.Bolles.org or calling us at (904) 256-5030.

Delicious & NutritiousSmoothies Hit The Spot


ruity, frothy

smoothies are ideal

for breakfast or quick snacks, providing both great taste and nutrition.

Kids like them. Grownups love them,

and you don’t have to heat up your kitchen to make them.

Just toss some fruit in the blender, add yogurt, juice, and voilà—instant perfection.

Not all smoothies are created equal. Touted as healthy alternatives to fat-laden milkshakes or ice cream, some smoothies sold in commercial outlets are actually higher in calories than some popular junk food commodities.

According to a CNN report in 1997, beverages served up at a Smoothie King in Atlanta contained an average of 460 calories—equivalent to a McDonald’s Quarter Pounder hamburger! Some drinks sold at smoothie bars add in high-fat ingredients such as chocolate or peanut butter, raising calories to

700 or more.

“If you are looking to watch your weight, I’d pay attention to the nutritional analysis you can get at a restaurant or smoothie vendor and check to see what’s in it,” registered dietitian Nancy Anderson of Atlanta told CNN.

Fortunately, it’s easy to create a low-fat smoothie without sacrificing taste or nutrition. Start with a handful of fresh or

frozen fruit, such as strawberries, blueberries, or a sliced banana. Then add low-fat or non-fat yogurt in plain, vanilla, or any fruit flavor. If you wish, freeze a small container of yogurt overnight for an extra frosty concoction. Fruit sorbets or soy-based yogurts can be substituted for dairy-based yogurts, if desired.

Next, add fruit juice; orange, apple, or cranberry are popular choices. If you prefer, stir in a small can of crushed pineapple with juice. Alternatively, you can pour in some low-fat milk or soymilk. As a finishing touch, toss a few ice cubes in the blender, hit “puree,” and savor the results.

There’s no right or wrong way to mix a smoothie. Proportions depend on your preferences—creamy or icy in texture? Sweet or tart? Cool and refreshing, or cold enough to make a penguin shiver?

A good rule of thumb is to offset sweet fruits with tart ones. For a thicker texture, use frozen fruits, such as blackberries. Not creamy enough? Just add some more yogurt, frozen yogurt, milk, soymilk, or sorbet. Fruit not ripe enough? Sweeten your smoothie with a small amount of honey. Too thick? Add ice or juice.

Smoothies packed with fruit are naturally rich in Vitamin C and antioxidants, while dairy products provide calcium. Some people like to further fortify their smoothies with extra ingredients to boost nutritional content or add fiber. Optional additives include wheat

Strawberry Delight Smoothie

Combine in blender:

1 banana, sliced5 or 6 frozen strawberries1 cup orange juice1 small carton lowfat vanilla yogurt3 or 4 ice cubes, if desired

By Miriam Raftery


germ, protein powder, blackstrap molasses for extra iron, spirulina for a vitamin boost, or 1/4 teaspoon of uncooked oatmeal.

In a mood for a luau? A nip of rum can transform a simple smoothie into a potent tropical delight.

Feeling truly decadent? Combine chocolate syrup, bananas, and some cappuccino-flavored yogurt for a sumptuous palate-pleaser.

True, smoothies have captured the hearts and appetites of adults. But smoothies are also great for kids with picky appetites, since it’s easy to hide those oh-so-good-for-you fresh ingredients in a blended drink that’s every bit as cool and refreshing as those Slushies and Slurpies so many of us guzzled when we were kids.

While smoothies are best served fresh, you can make them ahead of time and store your mixture in the freezer for up to three days. To freeze, pour into a freezer-safe container, leave room for expansion, and cover. Thaw at room temperature for an hour or so before serving—or defrost in your microwave for instant gratification.

Just how popular have smoothies become?

Smoothie bars such as Jamba Juice and Smoothie King have popped up across the nation over the past few years, turning up seemingly everywhere from airports to shopping malls. A search of one popular culinary website turned up no less than 16 different cookbooks devoted entirely to smoothies. Visit www.ekitchendepot.com/smoothies.html to shop for smoothie cookbooks with such tantalizing titles Super Smoothies! Taste the Nectar of Life and Great American Smoothies: The Ultimate Blending Guide for Shakes, Slushes, Desserts & Thirst Quenchers. Americans everywhere are “chilling out” with cool, refreshing smoothies, it seems.

Want a smoothie to take to the beach or slurp down in the car? Stop by a grocery store and pick up the latest product to hit store shelves—Tropicana smoothies sold in bottles. Although not quite the same in flavor or texture as a fresh-from-the-blender smoothie, the Tropicana blends do contain real fruit juice, nonfat yogurt, and ample amounts of Vitamins C, E, calcium and fiber—all with just 240 calories.

For more information on smoothies check out Smoothie Central. You’ll find free smoothie recipes at www.recipezaar.com

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Northeast Florida’s Most Respected Name in Orthopaedics®

Office Locations

Rehabilitation Centers

Here’s what the community has to say about JOI:

Community Voiceswww.joionline.netjoionline.net/mfacebook.com/myjoi

Riverside 2 Shircliff Way, DePaul Bldg, Suite 300 - Jacksonville, FL 32204 P: 904.388.1400 • F: 388.9644

San Marco 1325 San Marco Blvd, Suite 200 - Jacksonville, FL 32207 P: 904.346.3465 • F: 396.0388

University 5737 Barnhill Dr., Suite 102 - Jacksonville, FL 32207 P: 904.739.3319 • F: 448.1416

Baptist Beaches 1577 Roberts Dr., Suite 225 - Jacksonville Beach, FL 32250 P: 904.241.1204 • F: 241.7331

Baptist South 14540 Old St. Augustine Rd., Suite 2201 - Jacksonville, FL 32258 P: 904.880.1260 • F: 880.1210

Orange Park/Clay County 1845 Town Center Blvd., Suite 405 - Fleming Island, FL 32003 P: 904.276.5776 • F: 276.5958

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Riverside/Westside 4339 Roosevelt Blvd., Suite 600 - Jacksonville, FL 32210 P: 904.389.8570 • F: 389.8599

San Marco 1325 San Marco Blvd., Suite 102 - Jacksonville, FL 32207 P: 904.858.7045 • F: 858.7047

South 14985 Old St. Augustine Rd., Suite 106 - Jacksonville, FL 32258 P: 904.288.9491 • F: 288.9698



Mandarin 12276 San Jose Blvd., Suite 716 & 717 - Jacksonville, FL 32223 P : 904.288.9604 • F: 288.9643

North 12961 North Main St., Suite 201 & 202 - Jacksonville, FL 32218 P: 904.757.2474 • F: 757.5541

Orange Park/Clay County 1845 Town Center Blvd. Suite 410 - Fleming Island, FL 32003 P: 904-621-0396 • F: 621.0397

Point Meadows 7740 Point Meadows Dr., Suite 1 & 2 - Jacksonville, FL 32256 P: 904.564.9594 • F: 564.9687

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JOI 4 Page Brown.indd 1 10/12/11 10:27 AM

We offer 31 specialty-trained physicians, many with fellowships, who are dedicated to delivering comprehensive care for the muscles, bones and joints. Our diverse practice includes five Centers of Expertise:

Foot & Ankle

Hand

Joint Replacement

Spine

Sports Medicine

Our mission is to provide the highest level of coordinated care so all aspects of recovery are seemlessly integrated from initial diagnosis through rehabilitation.

Serving this region, we have six convenient office locations and nine rehabilitation centers. JOI accepts more than 140 health plans, including Aetna, Blue Cross Blue Shield of Florida, CIGNA, Medicare, Humana, United and workers’ compensation. We make every effort to work with our referring Primary Care physicians to serve the needs of patients and their plan requirements.

Questions about our physicians, facilities or treatment options? Call for an appointment today.

Stephen J. Augustine, DOSports Medicine;

Joint ReplacementRiverside

Steven M. Crenshaw, MDSports Medicine;

Joint ReplacementSan Marco

Philip R. Hardy, MDSports Medicine;


Aaron Michael Bates, MDSports Medicine;

Joint ReplacementOrange Park / Clay County

David A. Doward, MDPhysical Medicine & Rehabilitation -

Spine Team; Sports MedicineSan Marco

Timothy R. Hastings, MDSports Medicine; Joint Replacement

Foot & Ankle; Spine; HandBaptist Beaches

Sunday U. Ero, MDSpine Surgery

Orthopaedic Traumatology Riverside

Patrick M.J. Hutton, MDSports Medicine

Orange Park / Clay County

Hiram A. Carrasquillo, MDFoot & Ankle; Sports Medicine

San Marco

Richard R. Grimsley, MDJoint Replacement

Orange Park / Clay County& Riverside

Brandon J. Kambach, MDSpine

Baptist South

Kevin Michael Kaplan, MDSports Medicine;


Steven J. Lancaster, MDSports Medicine;

Joint Replacement; Foot & Ankle; Hand

Baptist Beaches

H. Lynn Norman, MDSports Medicine;

Joint ReplacementRiverside

Michael S. Scharf, MDSpine; Joint Replacement

San Marco

Carlos R. Tandron, MDSports Medicine;


Gregory C. Keller, MDSpine; Joint Replacement

Sports MedicineBaptist South & San Marco

Stanton L. Longenecker, MDJoint Replacement;

Sports MedicineRiverside

Richard A. Picerno II, MDSports Medicine;

Joint ReplacementBaptist South

Gregory Solis, MDFoot & Ankle; Sports Medicine

Baptist South

M. John Von Thron, MDSports Medicine;


Baptist Beaches

Garry S. Kitay, MDHand; Joint Replacement;

Sports MedicineSan Marco

R. Stephen Lucie, MDSports Medicine;


William G. Pujadas, MDJoint Replacement; Spine;

Sports MedicineSan Marco

Maxwell W. Steel III, MDSports Medicine; Foot & Ankle;

Joint ReplacementUniversity

Dale A. Whitaker, MDSports Medicine;


Baptist Beaches

Robert J. Kleinhans, MDHand; Joint Replacement;

Sports MedicineUniversity

Jennifer L.M. Manuel, MDHand

Baptist South

Robert G. Savarese, DOPhysical Medicine &

Rehabilitation - Spine TeamBaptist South & San Marco

Bruce Steinberg, MDHand & Upper Extremity;

Joint Replacement;Sports Medicine

Baptist South & San Marco

Edward D. Young, MDSports Medicine;


Baptist Beaches

Proven Leaders with the Highest Training and Experience


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Northeast Florida’s Most Respected Name in Orthopaedics®

Office Locations

Rehabilitation Centers

Here’s what the community has to say about JOI:

Community Voiceswww.joionline.netjoionline.net/mfacebook.com/myjoi

Riverside 2 Shircliff Way, DePaul Bldg, Suite 300 - Jacksonville, FL 32204 P: 904.388.1400 • F: 388.9644

San Marco 1325 San Marco Blvd, Suite 200 - Jacksonville, FL 32207 P: 904.346.3465 • F: 396.0388



Baptist South 14540 Old St. Augustine Rd., Suite 2201 - Jacksonville, FL 32258 P: 904.880.1260 • F: 880.1210

Orange Park/Clay County 1845 Town Center Blvd., Suite 405 - Fleming Island, FL 32003 P: 904.276.5776 • F: 276.5958

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Riverside/Westside 4339 Roosevelt Blvd., Suite 600 - Jacksonville, FL 32210 P: 904.389.8570 • F: 389.8599

San Marco 1325 San Marco Blvd., Suite 102 - Jacksonville, FL 32207 P: 904.858.7045 • F: 858.7047

South 14985 Old St. Augustine Rd., Suite 106 - Jacksonville, FL 32258 P: 904.288.9491 • F: 288.9698



Mandarin 12276 San Jose Blvd., Suite 716 & 717 - Jacksonville, FL 32223 P : 904.288.9604 • F: 288.9643

North 12961 North Main St., Suite 201 & 202 - Jacksonville, FL 32218 P: 904.757.2474 • F: 757.5541

Orange Park/Clay County 1845 Town Center Blvd. Suite 410 - Fleming Island, FL 32003 P: 904-621-0396 • F: 621.0397

Point Meadows 7740 Point Meadows Dr., Suite 1 & 2 - Jacksonville, FL 32256 P: 904.564.9594 • F: 564.9687

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rimary synovial chondromatosis is a rare disorder that can present as chronic hip and

groin pain. It is characterized by formation of nodules (made of

bone and cartilage) which arise from the synovium (thin layer of tissue which lines the joint). We discovered an Olympic caliber cyclist, in her mid thirties, with primary synovial chondromatosis of the left hip. She presented with a 1-year history of progressive hip and groin pain that occasionally radiated to the front of her thigh. She complained of left hip tightness and described her pain as deep, dull and achy. Her symptoms initially began with running but then progressed to occur with walking, cycling and lying on the hip.

She was extensively examined and found to have decreased range of motion of the left hip. She complained of deep hip pain with external rotation. Provocative tests designed to localize pain to the hip joint were all positive. Next, a plain x-ray was ordered revealing slight narrowing of the left hip joint. This was followed by a magnetic resonance imaging arthrogram which showed a small anterior labral tear and many tiny abnormalities in the joint fluid. At this point, she was treated with a steroid injection to the left hip which was done via image-guidance with temporary relief of her pain. She was then enrolled in a formal physical therapy program but only received marginal improvement of her symptoms. She was

Synovial Chondromatosis:An Atypical Cause of Hip Pain in an Elite Cyclistby David A. Doward, MD Physical Medicine and Rehabilitation – Spine Team, Sports MedicineSAN MARCO

David A. Doward, MD


ultimately sent for surgery which involved removal of the loose nodules (fig 1, 2) and the synovial lining of the hip joint. The diagnosis of primary synovial chondromatosis was confirmed by microscopic analysis (fig 3).

Evaluating a patient with chronic hip and groin pain can present a diagnostic and treatment challenge. It is essential to localize the area of abnormality. Pain may originate from the hip joint and its surrounding structures, as is seen with a labral tear or stress fracture. It also may arise from the adductor muscles where chronic muscle strain or tendinopathy occur. Injury to the pubic bones or abdominal muscles can be the cause of a patient’s symptoms. Likewise, the lower thoracic and lumbar spine may refer pain to the groin. Other less common causes of pain in this region must also be considered.

Our patient had a fairly classic presentation of synovial chrondromatosis. Most patients complain of a several-year history of joint pain, swelling, and loss of joint motion (signs of advanced disease) before diagnosis is made. Malignant transformation has been reported in cases involving repeated recurrence after treatment but is rare. Without intervention this disease can progress, the joint can deteriorate and secondary osteoarthritis can occur. Early recognition and treatment are the keys to preventing this. We don’t know if our patient’s sport involvement played a role, but it is possible that the high-level demands of cycling contributed to this condition. She did receive the appropriate treatment and at follow-up was found to be pain free and able to return to her previous athletic activities.

References

1. Mora R, Sodini F, Rashella F, paparella F, Belluati A, Basile G. Primitive synovial chondromatosis of the hip. Ital J Orthop Traumatol. 1992; 18:231-239

2. Coles MJ, Tara HH. Synovial chondromatosis (a case study and brief review). Am J Orthop. 1997; 26:37-40

3. Reichel PF. Chondromatose der Kniegelenkkapsel. Arch Klien Chir. 1900;61:717-721

4. Davis RI, Hamilton A, Biggart JD. Primary synovial chondromatosis (a clinicopathologic review and assessment of malignant potential). Hum Pathol. 1998;29:683-688

5. McKinney CD, Mills SE, Fechner RE. Intraarticular synovial sarcoma. Am J Surg Pathol. 1992;16:1017-1020

6. Lovell G. The diagnosis of chronic pain in athletes (a review of 189 cases). Aust J Sci Med Sport. 1995;27:76-79

7. Monu JU, Oka M. Synovial osteochondromatosis. eMedicine. 2004;1-13

8. Pope TL, Keats TE, de Lange EE, Fechner RE, Harvey JW. Idiopathic synovial chondromatosis in two unusual sites (inferior radioulnar joint and ischial bursa). Skeletal Radiol. 1987;16:205-208.

9. Sviland L, Malcolm AJ. Synovial chondromatosis presenting as painless soft tissue mass - a re-port of 19 cases. Histopathology. 1995;27:275-279

10. Taconis WK, van der Heul RO, Taminiau AM. Synovial chondrosarcoma (report of a case and re-view of literature). Skeletal Radiol. 1997;26:682-685

11. Gille J, Kruger S, Aberle J, Boehm S, Ince A, Loehr JF. Synovial chondromatosis of the hip (a case report and clinicopathologic study). Acta Orthop Belg. 2004;70:182-188


Fig 1. (A-D) Arthroscopic view of cartilaginous nodules in hip joint. Fig 2. Specimen consists of cartilage and vary in size

Fig 3. (A) Histology slide for microscopic analysis (B) Magnified view - diagnostic of synovial chondromatosis

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any people in the “baby boomer” generation are staying active as they age. This is healthy. But playing team sports, jogging or doing other high impact activities that repeatedly

pound, twist and turn the knees can stress aging joints. Highly active, middle-aged patients may develop painful knees as a result of osteoarthritis (OA). This painful condition happens when the cartilage lining on the ends of bones gradually wears away. It can affect one or both knees.

• Symptoms:Youmayexperiencepainwhenstandingorgoing up and down stairs. The knee may buckle and give way, lock in place, or become stiff and swollen.

• Patients:MostpeoplewithOAofthekneeareoverage55and/orobeseand/orhaveafamilyhistoryofOA.Younger,

highly active people may also develop OA if their knee suffered a significant injury.

• Diagnosis:Seeyourdoctorfordiagnosisandtreatment. The doctor will consider your comprehensive medical history, perform a physical examination and possibly order tests and/or imaging studies before recommending a course of treatment.

Extending the Life of the Middle-Aged Knee

Increasingly, baby boomers with OA of the knee are asking for total knee replacement surgery. But first they should try making changes to their lifestyles. Mayo Clinic orthopaedic surgeon Arlen D. Hanssen, MD presented a briefing on “Our Aging Population” at the 2002 Annual Meeting of the American

Care of the Aging Knee: Baby Boomers May Need Lifestyle Changes


Academy of Orthopaedic Surgeons (AAOS). He said many highly active patients in their 40s and 50s feel inspired by advertising and news reports about the success of knee replacement surgeries. But often they refuse to change their lifestyles to extend the life of their natural knees.

“They come in and say, -fix me,’” Dr. Hanssen explained, and they hope for a complete end to their symptoms without making any changes in their activities. In reality, doctors use a complex medical process to determine whether total knee replacement is appropriate for a patient - considering age, activity demands and other factors. Longterm results of joint replacement are less certain in younger patients.

For middle-aged people, the earlier a doctor diagnoses OA of the knee, the more likely conservative treatment may help. If OA of the knee is in its early

stages, your doctor may recommend low impact activities and other non-operative treatments that can delay or eliminate the need for surgery. In some cases, activity modification may be the only treatment a middle-aged patient needs. “In other cases when surgery is eventually needed, the patient still has to modify activities first to preserve the replacement joint,” Hanssen advises.

Substitute Smooth, Low Impact Activities

Moderate physical activity lessens joint pain and improves flexibility and function. Baby boomer patients with OA of the knee should continue exercising, but change the forms of their activities:

• Stopdoinghighimpactactivitiesthat twist and turn the joints. This includes running, tennis, racquetball, basketball, baseball, etc.



• Startdoingsmooth,lowimpactactivities that are easier on the joints. Recommended activities include stretching, swimming, water aerobics, cycling, walking on a treadmill or outside, playing golf, etc.

Other Conservative Options

Other options that may extend the life of your natural knee include medications, steroid injections, physical therapy and mechanical aids.

• Medications:Thedoctormayprescribe non-steroidal anti-inflammatory medications to help reduce inflammation. Certain dietary supplements may also help. Glucosamine stimulates formation and repair of articular cartilage, and chondroitin sulfate prevents

cartilage from degrading. (Note: The U.S. Food and Drug Administration does not test dietary supplements. These compounds may cause negative interactions with other medications or excessive bleeding during surgery. Always consult your doctor before taking dietary supplements.)

• Injections:Thedoctormayinject

the knee joint with strong anti-inflammatory medications called corticosteroids. This can relieve pain and swelling for awhile.

• Physicaltherapy:Thedoctormay

give you a balanced fitness program including physical/occupational therapy to improve joint flexibility, increase range of motion, strengthen muscle, bone and cartilage tissues

and reduce pain. It may also help to ice the affected joint for short periods, several times a day.

• Mechanicalaids:Youmayneed

supportive or assistive devices such as an elastic bandage, splint, brace, cane, crutches or walker.


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Eating Vegetablesis Food Smart


or generations, parents encouraged their children to “Eat your vegetables.” As it turns

out, mom knew broccoli may have tasted awful, but was loaded with valuable nutrients.

Today, the inclusion of vegetables in your diet is one of the tried and true recommendations for a healthy lifestyle. No matter what diet fad is in fashion, no one can dispute the benefits of consuming vegetables.

Vegetables are rich in essential vitamins and minerals. Vegetables are low in calories, sodium, and fat and high in fiber, keeping hunger and weight down. There is compelling evidence that a diet rich in vegetables is linked to many health benefits, including lowered risk for certain cancers, stroke, heart disease, and high blood pressure. It is well known that cultures that follow diets high in vegetable content (like those found in Asia) have higher life expectancies and lower health risks than cultures with diets low in vegetable content.

Vegetables are rich sources of naturally protective substances called “phytochemicals” or “phytonutrients.” Phytonutrients are protective compounds found in plants that boost the body’s immune system and help the body prevent degenerative diseases within cellular structures.

Some familiar protective phytonutrients are: allicin in garlic; isoflavones in soybeans; lycopene in tomatoes; flavanoids in green and black teas; sulforaphane glucosinolate (SGS) in broccoli and broccoli sprouts; carotenoids in carrots; lignans in flax seed; and anthocyanin in blueberries.

Green, leafy vegetables seem particularly beneficial. Carotenoids are the pigments that color dark green and orange vegetables. Many are precursors to vitamin A and act as powerful antioxidants that can protect cells in the body from damage by free radicals, which is thought to lead to a number of health problems. Thus antioxidants may help protect against many diseases.

Dark, leafy green vegetables are also rich in folate. Researchers have linked low blood levels of folate with an increased risk of certain types of cancer and a high intake of folate with a lower risk.

Consumption of vegetables is found to be extremely beneficial to heart health, as cardiovascular strength relies on certain

nutrients only found in plants. The fiber and phytochemicals found in most vegetables prevent damage to blood vessels, decrease the risk of strokes, and can help the body eliminate harmful carcinogens and toxins.

Even a small increase in the consumption of vegetables, or at least the addition of vegetable supplements, can improve health and overall well being and increase energy. So for once, your mother was right.

by Charles Hudson

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The Perfect Swing

THE SET UP

Back straight. Knees slightly bent. Buttocks out. Feet set at shoulder width. Feet, knees, hips and shoulders parallel to target line. Ball located in center of stance. Chin up from chest to allow the left shoulder room during the backswing. Arms hang relaxed almost straight down to the club, which angles out toward the ball. Arms form a strong triangle to the body.

THETAKEAWAY

Arms slowly and smoothly pull the club back to the right in an arc while the knees begin to gently twist clockwise, following the path of the arms. Left arm stays straight, forcing left shoulder to follow smoothly. Upper body begins rotating to the right while legs continue twisting in place, building tension. Hips twist clockwise. Weight slowly transfers to right foot.

THE BACKSWING

Arms extend completely to create maximum torque. Wrists hinge up, cocking the club near the top of the backswing. Weight almost fully on right foot. At the top of the swing, tensed knees should be pointed slightly to the right of the ball. Right hip turned about 45 degrees clockwise. Shoulders turned about 90 degrees clockwise. Left shoulder underneath chin. Head remains over the ball. Club’s shaft parallel to the ground, facing target.

THE DOWNSWING

Hands drop slightly from full extension as body uncoils from the hips. Legs release from coiled position, forcing upper body to follow. As the club swings down, about two-thirds of the way to the ball, it gains a direct plane toward the target. Wrists remain cocked until just before impact.

IMPACT

Left hip well in front of the ball,

straightening left leg. Right foot starts to rise as

weight shifts completely to left foot. Right arm slightly bent, pushing straight left arm through the ball. Club head perfectly square to the ball. Wrists snap through the ball, both straight and firm at impact. Head in same position as at address.

THE FOLLOW THROUGH

Club follows a path directly toward the target. Arms both extend straight to the club, hips continue to turn, and shoulders follow until the club extends fully around. Right shoulder turns under chin. Left arm bends to accommodate the club’s follow-through. Hands finish behind turned left shoulder and high behind head. Most of the body weight is on left side of left foot. Torso faces the target. Head finally follows body well after the shot has been hit.

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