Ski season is almost done, but there were still some amazing days this year! Dr. Scholl and other members of the Endurance Orthopedics team got to get out for some good ski days both at resorts and enjoying the Wasatch backcountry. A bit fewer and far between than we are used to in Utah, but there were some great powder days, if you got the timing right. The good news is that there were fewer skiing injuries than average this year, but that may represent a low year for skier-days in total. Of course, Dr. Scholl is always working on programs to help reduce injury risk and was able to spend time spreading that education on a few of the local television stations this year. He discussed risk reduction techniques, including fall techniques and how to be ready for ski season.

-Dr. Scholl takes some turns at Snowbird.

If you have concerns about a ski injury, or are having trouble with pain related to sports like skiing, come in and discuss it with our team.

Dr. Scholl has previously run many trail ultras in the 50 mile distance, as well as Rim-to-Rim-to-Rim crossings of the Grand Canyon, and this is his first 100-mile effort! Dr. Scholl has called this race “…a bit of everything,” since the race included running in the day and night, the heat and the cold, with friends and solo, and brought laughter and energy contrasted with heavy fatigue. “I never felt like my finish was in jeopardy, but there were points I really had to dig deep and work through the sheer exhaustion,” said Dr. Scholl about his effort across the 100-mile course. The race includes 26,882 feet of uphill and 26,131 feet of downhill as it stretches along the Wasatch Mountains from Kaysville to Midway, Utah. Dr. Scholl says that he felt stronger than he expected at the finish and is already working on strategies for a faster time next year.

The 2011 Edition of Going Big! Safely. was another great success! We gathered at Snowbird Resort‘s Conference Center at the Cliff Lodge for an evening of learning from the pros about what has helped them become successful skiers. The lineup of skiers was World-Class, with Julian Carr, Jeremy Nobis, Jen Hudak, Jamie Pierre, Grete Eliassen and Cody Barnhill all taking the stage to share their experience. Each of the skiers spoke about the practices they use to help keep them prepared and safe on the big lines and big airs. The evening also featured Grant Helgeson, a forecaster from the Utah Avalanche Center, who spoke about the unique elements of risk in the backcountry, and how to manage those risks. Dr. Scholl, spoke on ski related injuries and discussed prevention strategies to minimize injury on the slopes.

The presentations were genuine and showed very clearly that beyond their amazing skiing talents, the members of the panel all have looked at their skiing careers as a process of learning. Each of the skiers was able to share lessons that they had learned about how to prepare for the risks of the mountain, some lessons were from injuries, some from close calls and some from being a keen observer of conditions both on the mountain and internally. There was a fascinating discussion on how to read your internal anxiety and adrenaline in an effort to determine if this was appropriate excitement and something to harness in your performance, or a red flag anxiety telling you that you should bail out on the run or trick you are thinking about hitting. Jen Hudak, shared a very personal story on motivation as she spoke about her Dad’s diagnosis of Leukemia and how he looks at the process of treatment as a challenge similar to conquering your own personal Mt. Everest. She shared something from her blog that she had written for her Dad about driving yourself to excellence on the path to Conquer Your Everest.

After the presentations and panel discussion, many of the audience were lucky to take home some great new gear from program sponsors: Discrete Headwear, Smith Optics, ProBar, Skullcandy and Obermeyer. Some of the winners got their SWAG from a winning raffle number and others performed a talent or took on Julian Carr in a handstand contest to grab their cool gear! Grete Eliassen proved herself a natural with the microphone as she went M.C. on the gear giveaway as easily as she had talked about keeping skiing as part of a balanced life earlier in the program.

After the program, we received great feedback from the audience and sponsors and we are already looking forward to next year’s event! Special thanks to those who helped get the word out for this event and build our growing audience, including: KALL 700 Sports Radio, Park City TV and ESPN Action Sports.

Dr. Scholl is an Inspired Mountain Ambassador for Cloudveil outdoor apparel company and contributes regularly to their blog site The Mountain Murmur. Here is his latest post about returning from injury.

(-This article was first published in Cycling Utah in the Fall of 2009)

A Bad Break?

- The Current State of Collarbone Injuries in Cycling

Mark D. Scholl, M.D. – Orthopedic Sports Medicine Surgeon

Avid viewers of professional cycling all know that when commentator Phil Ligget sees a crash on the road, he is about to immediately express grave concern for that rider’s collarbone. Despite the fact that occasionally the rider is holding his knee or wrist while the collarbone is getting all the worry, there is a good reason that a seasoned commentator will use this as a first-guess injury from a crash. Clavicle fractures are among the most common orthopedic cycling injuries, along with fractures of the radial head and wrist fractures.

The clavicle is a doubly curved bone that connects the sternum to a projection of the shoulder blade called the acromion. Its primary function is acting as a strut to position the shoulder joint broadly outside the rib cage, to maximize function and range-of-motion. It derives its name from the Latin word “clavicula” which means “little key” because as the hand is taken above the head, the clavicle is seen to rotate on its long axis like a key in a lock.

Throughout the majority of modern medicine, fractures of the clavicle have been treated with limited intervention. Comfort measures such as a sling, or a figure-of-eight brace are used to help support the bone as the healing process occurs over time. Surgery was reserved for uncommon situations where the bone had broken through the skin, or was nearly through and was “tenting” the skin demonstrating significant stretch and risk of pressure injury developing. Traditional teaching instructed us that the vast majority of fractures would heal without intervention, often leaving a residual ‘bump’ but having no detrimental functional effect on the shoulder.

Over the past decade, or so, orthopedic surgeons have begun to re-define what the effects of a clavicle fracture on a shoulder may be. It turns out our previous notion – that all patients who have a broken clavicle and successfully heal the bone go on to have full function of the shoulder without problems – may have been a bit shortsighted. Reports in the Journal of Bone and Joint Surgery (British & American versions) have begun to look at long-term outcomes after successful healing of displaced clavicle fractures. We have found that although these fractures often go on to heal, some patients with a healed fracture still have weakness or other functional limitations in the affected shoulder. Recent articles have shown that even at an average of 4 ½ years after healing a displaced fracture of the clavicle, tested subjects were found to only have around 80% strength in their shoulder compared to their uninjured side.

The key turns out to be in the component of displacement. This is a term that defines how much the fracture has shifted after it has broken. The clavicle has many various forces that act upon it, mostly related to the muscles that attach to the clavicle and the muscles that cross from the chest wall to the shoulder. If you recall, we said previously, that the clavicle was a strut to keep the shoulder away from the rib cage. However, if that strut is broken, there are large muscle groups – such as the pectoralis, which may act to compress or shorten the clavicle at the fracture, and draw the shoulder closer to the chest wall. If the clavicle fracture heals in this shortened place, there is a change in the relative position of the shoulder to the body and this is believed to be responsible for the residual weakness we can sometimes see after the fracture heals. This is one of the main reasons orthopedic surgeons now treat many more fractures of the clavicle with surgery than we did even five or ten years ago.

The other reason we have begun to see orthopedic surgeons recommend treating clavicle fractures with surgery more often, has to do with the speed with which we can rehabilitate an athlete and return them to sport after surgery. Orthopedics has seen important recent advancements in the technology of devices available to stabilize clavicle fractures in surgery. As we are able to hold the fracture more securely, we can be more aggressive with our rehabilitation and get athletes back to sport much sooner than if we treat with immobilization and waiting. Most of the pain from a fracture comes from motion between the bones where there should not be any. Anybody who has had a fracture and has felt the grinding sensation between bones will tell you it’s like listening to nails on a chalkboard while getting stabbed with an ice pick at the same time. Not fun at all. Stabilizing the fracture with a titanium plate and screws brings the bone ends together solidly, so there is no longer motion at the fracture site. This improves comfort much sooner, allowing early advancement in range-of-motion, sooner resumption of cardiovascular activities, and faster return to strengthening. All of these lead to faster return to sport.

When the most famous collarbone in cycling (belonging to the most famous cyclist, Lance Armstrong) was broken in the process of his return to the pro peleton, there was much speculation about how this would affect his chances at his favorite proving ground, the Tour de France. Anybody who follows Lance’s enthusiastic Twittering knows that he had a remarkably speedy recovery. He reported biking on the road just eight days after his surgery (though he did appeal to those following, not to tell his doctor!). This is a bit sooner than most surgeons would recommend for road riding (I often have cyclists on a trainer this early, but for safety, like to keep off the road and trails until healing is a bit further progressed). However, it just goes to show that not only can Lance get up Mont Ventoux faster than you, he can heal quicker as well!

Many of us watched as Lance stood upon the podium at the Tour de France this year, an achievement that might not have been possible had he not gotten past his clavicle fracture like a Category 4 climb. What might have been a major setback, was just a small bump in the road, and early surgical intervention that restored his fracture’s displacement and shortening may also end up maintaining better strength in his shoulder in the long term.

The best clavicle is the one that was never broken, so using caution while riding, particularly in traffic or other adverse conditions, is the best program. However, if you do have a crash and hear Phil Ligget’s voice in your head worrying about your collarbone, have it checked out by an orthopedic surgeon. We may be able to get you back in the saddle sooner than you think, and quite possibly with a better long-term outcome than a few years ago.

The last thing young skiers want to hear is someone talking to them about safety. They want to watch Teton Gravity Research films and read Powder Magazine and then go hit the slopes. With Utah’s amazing terrain, skiers can find themselves on the very slopes where they saw the professionals skiing in their favorite magazine or movie, sometimes in less than an hour! With such easy access to expert skiing within the Utah resorts as well as in the local sidecountry and backcountry, it’s easy to get over your head trying to emulate the skills and style of the pros. But how does a skier progress from whatever level they are at, to hit the big features and make the huge lines like an X-Games Gold Medalist? Why not hear it from the source!

“Going Big! Safely.” is an annual event developed by Dr. Mark Scholl, to provide education and advice to young and old freeskiers who are looking to advance their skills. The inaugural program featured a series of short talks by professional skiers who call Utah home, as well as a backcountry safety presentation by the Utah Avalanche Center. A full lecture hall heard professional skiers like Jen Hudak (who went on to score Gold at the Winter X-Games in Superpipe a couple weeks later), Julian Carr, Dash Longe, Cody Barnhill and U.S. Ski Team Aerialist, Jaime Myers talk about their experiences as they developed their talents to the professional level. All the athletes were amazing with their openness as they shared their personal stories about preparation and daily routines, the safety precautions they take when trying to push the envelope, and the mistakes they have made along the way. Additionally, the audience heard Drew Hardesty, a forecaster from the Utah Avalanche Center and snow safety expert, talk about the unique risks associated with skiing in the backcountry and where to find the right education to start the lifelong learning process that is associated with traveling in the backcountry.

In addition to the fantastic knowledge that everyone in attendance received, many of the audience scored some sweet schwag donated by program sponsors. Gear from Cloudveil, Discrete Headwear, Smith, Under Armour, Surface and others went to lucky raffle winners.

Read more on Dr. Scholl’s blog as a Cloudveil Inspired Mountain Ambassador for The Mountain Murmur.

Feedback was incredible for this first event, and plans are already in the works for next year’s program. Updates will be posted as dates become finalized.

All cases used in Teaching Cases are provided for educational purposes to help patients understand the variety of injuries that athletes and active patients sustain and what treatment options may be available.

Please realize that every injury has many elements which factor into our treatment plan and all of those elements may not be listed in the brief synopsis here. Additionally, there are a variety of appropriate treatments for most injuries. If you have had a similar injury that was treated differently, do not worry that the treatment you received was inappropriate in any way. The medical literature often documents multiple successful and appropriate methods of approaching the same injury.

No identifying information is present on images provided or in the descriptive text. We believe firmly in protecting the privacy of our patients.

This is a healthy, active 34 year-old male who was injured sparring in martial arts. Upon initial examination this was a severe injury to the knee that involved multiple ligaments. The patient was begun on a Physical Therapy “pre-hab” program and an MRI was obtained.

We use the term “pre-hab” to describe Physical Therapy done before an anticipated surgical reconstruction, since “rehab” is commonly used to describe the therapy after surgery. This period is used to work on improving range-of-motion for the involved joint and to gently work on strengthening. Many of the strengthening exercises done are the very same as the exercises that will be done after the surgery, sometimes at a lesser resistance or with lighter weight. One of the major benefits to “pre-hab” is that the patient can learn the exercises and start to develop the “motor memory” pathways so that after surgery, when the joint may be swollen and the muscles are inhibited, the beneficial exercises are familiar. This way, the exercises are familiar and the inhibited muscles are not trying to learn new exercise, they already know them!

The MRI showed injury to the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL) and the posterolateral corner (PLC) ligament complex. This athlete had sustained substantial injury to 3 out of the 4 main stabilizing groups of the knee, which is a very severe injury. As progress was made in therapy, surgical reconstruction was planned.

The surgical treatment involved reconstruction of the ACL and the PLC with grafts and a repair of the PCL which had sustained a near complete rupture but had some residual fibers intact.

Reconstruction means that the surgeon is using a graft or substitute tissue to re-create the injured part of the body, in this case, ligaments. That graft acts as a combination of a structural substitute for the original ligament as well as a scaffolding for the patient’s own body to incorporate the graft through a process called “ligamentization.” This process basically means that over the course of time, the patient’s body removes some cells from the graft and adds the patient’s own ligament cells. Over time, if we look at biopsies or samples of grafted ligaments, the microscopic breakdown of tissues such as collagen begin to look less like the tissue used for the graft and more like a normal ligament.

Repair means that the patient’s own tissue is re-attached and placed in a setting to optimize healing of that tissue. In this case, the PCL had some structure still attached and most ruptured, so the attachment footprint from the portion that was ruptured was “prepared” to stimulate a healing response prior to re-attaching the ligament to that footprint. This re-attachment was done by passing suture through the torn portion of the ligament and then docking that part of the ligament to the footprint or normal attachment site via a small tunnel for the suture and a metallic button outside the joint to maintain tension and keep the ligament docked to the footprint while the patient’s body heals it back in place.

After the reconstruction of the ACL and PLC as well as the repair of the PCL, the patient’s knee was examined and found to have near normal stability to testing of all ligaments and full range-of-motion.

At this point, only a couple months from surgery, the patient is working on a rehabilitation program with a Physical Therapist and making excellent progress. He is walking without crutches and no limp. His strength is returning well and he is back to work with some partial limitations. He has some residual stiffness in the knee as he brings it into full flexion and cannot yet get his heel all the way to his buttock. Residual stiffness at this stage after such a big surgery is common. Our hopes are high that he will be able to resume a fully active lifestyle without limitations, he is off to a great start!