First Aid trainedFirst-Aid trained personnel needed at school sports venues.

Across the US each year, a number of high school students die after sustaining head injuries while playing. This has led to parents being concerned about their kids playing contact sports in general, not only football. As far as head injuries go, high school leagues have decreed that all public school coaches in the state receive sports medicine training every 2 years in how to identify and address concussions.

With the focus on head injuries which have potentially serious implications, sideline treatment must ensure that players who have symptoms of possible head injury must immediately be removed from play and sent for medical evaluation.

It is interesting to note that Steve Tisch, chairman of New York Giants, has made a donation of $1.2 million to help have trainers or emergency medical technicians present at all New York public school football training or competitive games..

What other kind of sports injuries are there?

A sports injury is by no means confined to football players. A sports injury can often occur at a gym venue, the athletic track, tennis court, hockey matches and any other non-contact field events, to name but a few. Sprains and strains are especially common to the ankles, knees and wrists, and sometimes the shoulder.

Competent coaches, trained in basic injury management, should ideally be compulsory at all sports venues to assess any injury such as:

kind of sports injuriesA knee injury, because of its complex construction, is usually the most common injury suffered by sportsmen and sportswomen. If the injury does not respond to conservative treatment, a visit to an orthopedist should be mandatory. A decision will be made whether or not surgery is required to assist in the recovery. Surgery would probably take the form of an arthroscopy, which is minimally invasive, and performed by a specialist orthopedic surgeon.
Muscle and ligament sprains which might be a tear or rupture.
Ankle and wrist injuries to investigate the chance of a broken bone.
Shoulder pain which could be the result of dislocation, or the result of a more serious

joint injury requiring the attention of an orthopedist.

Proper sideline training can quickly evaluate degree of injury.
“Sports injury” refers to the kinds of injuries that most commonly occur during sports or exercise at various sporting venues, whether contact sports or other less vigorous activities. Any part of the body can be injured during sports, but it is usually the musculoskeletal system which is affected. This includes muscles, bones, ligaments and cartilage.

Sports injuryTraumatic brain and spinal cord injuries are relatively rare, but still absolutely possible, needing immediate evaluation.

A nation-wide call to action!

Parents across the nation, whose children are involved in all sorts of sporting activities, especially contact sports, are calling for basic injury management training for coaches and trainers at schools and colleges.

Emergency medical technicians should also be available at contact sports such as football matches. This, however, is expensive, and unaffordable by many public schools.

The generous donation by the chairman of the New York Giants to fund this requirement to the New York City public schools is most greatly appreciated.

Similar funds are needed in other areas to keep children safe from injuries which may require urgent medical evaluation.

If you have any questions about a sports related injury, contact our experts to determine the best course of action for you.


sports injuriesThere are so many activities we do during the day that can ultimately cause knee and joint problems. Sports and accidental injuries are common ways for knee injuries to occur, but another factor that those in sports medicine are finding, is that the kind of shoes we wear can also put us at risk for pain.

Shoes are items we wear everyday starting at a young age.  We put them on babies to keep their feet warm, plus it’s just adorable to see a 9 month old wearing Nikes. We buy the Barbie and Superman shoes for our preschoolers and elementary-aged children, and eventually we move on to buying shoes that are good for us.

We can find all kinds of shoes we wear for fashion, athletics, work, different weather, and for lazing around the house, some comfortable, some not, but what makes a good shoe, and who determines what goes into one?

Good shoes that are designed to keep knee problems at bay will have arch and heel support. Shoes that are flat with no arches, or shoes with high heels put pressure on your feet, knees, and back. This can cause the wearer to compensate for the lack of support with their knees, back, and hips, which can ultimately through the body out of alignment. This will cause knee pain which will continue as long as the wrong shoes are being worn.

woman wearingGood, supportive shoes are not made by accident. There are many teams of scientists and doctors that specialize in biomechanics give input to shoe manufacturers to make better shoes with better support.  Biomechanics is the study of the structures and functions of living things. Sports biomechanics is based specifically on studying different types of sports, and how the activities affect the functions of the body.

Stacy Steffen, a biomechanist, is one such person who works hard to study the body in order to design a shoe that will keep orthopedists at bay. In an interview with New York Times reporter Patricia R. Olsen, Steffen discusses what goes into making great shoes. Steffen works at Brooks Running Company in Seattle and has studies body mechanics, physiology, and how people walk and run. In her company, they run tests on runners using a specialized treadmill that has the ability to calculate the amount of pressure runners put on the ground and their feet. They also have a running track to observe and record data on runners.

knee 4 painThe team uses reflective markers on different points of the subject’s body and film them running. They then evaluate the motions of the body, and use the data they find to make better shoe designs.  They also seek and use input from the runners themselves on what feels and fits better, and what they are looking for in a shoe. Steffen suggests that if your shoes and activity levels feel good and you are not causing injury to yourself, you’re on the right track.
If you are having pain, contact our sports medicine specialists for an evaluation today at Orthopedic Surgery San Diego.


Knee Pain in OsteoarthritisKnee pain is a significant symptom that is associated with developing knee arthritis. In most cases, knee pain is often reduced to an uncomplicated pain felt by a patient. Consequently, it is always too late for effective interventions to be instituted. The structural damage or injury to the knee is already evident and now require more advanced interventions like surgery (e.g. knee replacement or arthroplasty), invasive diagnostic procedures sometimes using injection (e.g. arthroscopy), and physical therapy.


In an attempt to clinically define the onset of early osteoarthritis (OA), a group of researchers led by Elizabeth M. A. Hensor, conducted a research study entitled, “Toward a Clinical Definition of Early Osteoarthritis: Onset of Patient-Reported Knee Pain Begins on Stairs. Data From the Osteoarthritis Initiative”. According to them, the early the detection of OA is done, the higher will be the chances of recovery because of prompt and effective intervention. The study’s primary aim is to detect which activity is first associated with knee pain. The hypothesis of the study stated that ‘it occurs during activities requiring weight bearing and knee bending’.

OA The researchers gathered information from OA Initiative, which is longitudinal prospective observational cohort multicenter for people who have OA. The data is available for public access at Data used were the completed Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores of these participants annually for up to 7 years. They were asked to rate the pain they felt in the following activities: during walking, using stairs, in bed, sitting or lying, and standing. A Likert scale was used which include the following pain scales: none, mild, moderate, severe, and extreme. These scores were ranked using Rasch Analysis. For every gap of 20 in the scores, 25 participants were randomly selected.


A total of 4,673 people were included in the study. 1,390 of this were diagnosed with OA through radiography, 3,284 at high-risk OA groups, and a control group composed of 122 individuals. However, controls were not included on the performance of analyses.


It was found out that knee pain in early OA begins from using the stairs. This is consistent with the research’s hypothesis which states that pain begins or involves activities that require the joints to bear weight. It was followed by pain when walking, standing, lying/sitting, and lastly, pain when in bed. It was a consistent order all throughout the visits.


Some limitations of the study include the observed multidimensionality of the participants. pain when in bed. However, researchers stated that there is little that can be done to accurately assess dimensionality as the nature of the scale would not accurately permit it. Second, the use of WOMAC is largely based on self-reported pain and subjectivity of pain will result to variable results.


In conclusion, the research study was able to improve the clinical definition of onset of pain in knee OA. It was found out that it starts to appear during weigh-bearing activities, particularly when using the stairs. Researchers recommend conducting trials to determine ways to identify people who have early OA to, thereby facilitating prompt action and preventing worsening of damages.

If you have been told you are need in a total knee replacement or suffer from knee pain, contact our specialists at Orthopedic Surgery San Diego today to receive the best care.


brains .Our delicate brains are surrounded in spinal fluid inside the skull which acts as protection. When the body or head is hit hard enough, the brain can connect with the skull, which can cause an injury. This injury is called a concussion, and they are many symptoms that can accompany it, some which are obvious, and others that are not.

On TV and movies, when a person gets hit on the head, they are more often than not shown to lose consciousness. While a head trauma can result in being “knocked out cold”, it is not a prerequisite to be diagnosed with a concussion.

There is a large range of symptoms associated with a concussion, and some can last a few hours, while others a few weeks. Common signs are headaches, nausea, vomiting, blurred vision, light and noise sensitivity, feeling sluggish, and some memory loss. Concussions can also cause issues with thinking clearly, balance, loss of energy, feeling sad, nervous, or irritated, and either sleeping more than usual, or having problems sleeping. Eye MovementsYounger children, who do not understand what is happening are more prone to crying, tantrums, sleeping or eating difficulties, headaches, and generally not acting like their usual selves.

When a cartoon character gets hit on the head they usually see stars and birds flying around them, along with their eyes rolling every which way. This is actually not too far off from what happens to someone when they have a head trauma (sans birds and stars). Concussions can actually cause eye movement issues for up to 90 percent of patients. The basic method doctors had of assessing eye movement was asking a patient to track an object.

Researchers from the NYU Langone Medical Center in New York City have discovered what they feel is a better way of tracking eye movements to assess patients with head trauma. Dr. Uzma Samadani, assistant professor of neurosurgery, neuroscience, and physiology at the Medical Center, and some colleagues have developed a new method of assessment that was first used in the U.S. military on those suspected of having a concussion.

The researchers compared eye movements of 75 patients with head trauma to a control group of 64 healthy people during a viewing of a music video. Dr. Uzma SamadaniPatients who had hit their heads and either had a normal CT scan, or one that showed brain damage, could not coordinate their eye movements as those with in the control group and had not hit their head. The severity of eye movement issues was directly related to the severity of the concussion.

While this will help doctors and nurses working in Emergency Services, this new find will be an extremely valuable assessment tool for sports or military settings. Patients may try to minimize their symptoms, or not realize the extent of their head trauma, but this simple test allows the medical team to diagnose based on results of the patient’s pupil movements.

Because of the awareness being spread about concussions, the number of concussion recorded in the NFL has gone down, along with youth and amateur sports.


If you have questions contact our specialists at Orthopedic Surgery San Diego.


Damage to the jointDamage to the joint of the knee can be debilitating to an individual. Simple activities such as walking and changing positions would require more than usual amount of effort. Managing this condition would require supportive devices and medications to provide comfort and safety as well as relieve pain. However, if both are not effective, surgery would be suggested by the physician.

Total Knee Replacement, or Knee Arthroplasty, basically means replacing the surface of the affected knee. In addition to this, it is one of the surgeries with the most successful outcome. It is indicated for individuals with progressive knee pain and osteoarthritis, among other causes. The bone is prepared by removing damaged cartilages at the site of affectation. Next, the removed part is replaced with an implant, usually a metal. Then, as an optional step, the patella is resurfaced to accommodate the implant. Lastly, a plastic component called spacer is inserted between the metal components to facilitate smooth movement.

Knee replacement 2Knee replacement has been successfully changing lives since 1968. However, a group of researchers want to provide evidence-based support to the claimed improvement in the intermediate and long-term quality of life in individuals who have undergone total knee replacement. Led by Leonard Shan, these researchers conducted the study entitled, “Intermediate and Long-Term Quality of Life After Total Knee Replacement: A Systematic Review and Meta-Analysis”. The study is published in The Journal of Bone and Joint Surgery on January 21, 2015.

The researchers compiled all systematic reviews and meta-analysis of all studies published from January 2000 to present. A total of 19 studies were included in the systematic review and meta-analysis done by the researchers. An evaluation of quality of life on various health-related aspects was done. These aspects include quality of life after the operation, function, and patient satisfaction. These three were compared to the preoperative status of an individual. Inclusion and exclusion criteria were made and were strictly followed. With the evaluation of three criteria, tabulation and quality appraisal were performed. Qualitative data were synthesized using narrative review and random-effects meta-analysis.

Total Knee Replacement 5Results show that in both qualitative and quantitative analyses that were done, quality of life in post-operative state is superior compared to the pre-operative state. There is also a significant improvement in the pain experienced by the patients from pre-operative to post-operative state according to scores in Western Ontario and Mc Master Universities Osteoarthritis (WOMAC) Index and Knee Society Score (KSS). Lastly, results show that majority of patients are satisfied with the outcome of the surgery and the quality of life they have after total knee replacement, particularly in terms of the level of functionality in performing activities of daily living.

In conclusion, total knee replacement or knee arthroplasty has significant effect on the improvement of quality of life of patients who undergo the surgery, both on immediate and long-term basis. Most noticeable improvement includes improvement in pain and function which largely contribute to increased patient satisfaction. Researchers recommend future studies.

For an evaluation by our specialists, please contact Orthopedic Surgery San Diego for an appointment today.


shoulder joints

The shoulder is not a single joint, but is rather made up of three separate bones, the humerus (upper arm), scapula (shoulder blade), and clavicle (collar bone).   A combination of muscles, tendons, and tissues  together known as the rotator cuff, keep the arm bone fixed in the shoulder socket.

An injury or damage to any part of these linked bones or muscles can cause severe shoulder pain and lack of mobility. The pain may be of a temporary nature, or it may get worse and require a professional diagnosis and treatment. A visit to your general practitioner, depending on the nature of the problem, will probably result in a recommendation to consult an orthopedic surgeon for a second opinion, appropriate tests, or expert treatment.

What are some causes of shoulder pain?

Bursas are small fluid-filled sacs located in joints throughout the body, including the shoulder. The bursa acts as a cushion between bones and soft tissue. Overuse of the shoulder can cause swelling and pain of the bursa and render it somewhat ineffectual, leading to shoulder pain.
Tendon tear. A tendon tear is mostly caused by a sporting injury or a fall. It can also be as a result of advancing age, wear and tear or long-term overuse. If the tendon is detached from the bone, the consequence is severe shoulder pain.


The shoulder is usually affected by osteoarthritis, mainly due to participation in vigorous sporting activities, or an injury from a fall. The result is a painful restriction of movement and a loss of shoulder mobility.
When the shoulder joint is dislocated, either fully or partially, there is a great deal of shoulder instability. A partial dislocation occurs when the upper arm comes partly out of the socket, while a full dislocation is when the ball comes completely out of the socket. Either way, there is huge shoulder pain.
Broken bones. Any broken bone in the shoulder area such as the collar bone, upper arm or shoulder blade, always results in severe pain and swelling.

What kind of treatment could be necessary?

Once the doctor has established the cause of the pain, you will most probably be offered various treatment protocols which would help to relieve the problem.

A rotator cuff injury will sometimes respond to physical therapy treatment and exercises to improve the strength of the muscles surrounding the shoulder joint. However a serious rotator cuff injury involving a complete tear of a muscle or tendon may require surgical repair.

shoulder joints pain treatment

A severely broken bone will require surgical intervention to reset the bone. A comprehensive orthopedic assessment will enable the doctor to fully explain the type of surgery which could be required.

In many instances, arthroscopic surgery which is highly successful and minimally invasive, is often recommended.

Be sure to visit a competent orthopedic surgeon who will be able to give you the best advice to effectively deal with your shoulder pain and problems.

Our specialists provide the best orthopedic and medical care available.  We incorporate a multipronged approach to optimize your medical care.  If you have been told you need surgery or suffer from shoulder pain, contact our specialists at Orthopedic Surgery San Diego today.

Dr. Robert Afra, M.D.


AllergiesThe next time the kids drag their feet to do the dishes, you can remind them you are doing them a huge favor. Not only does this build character, teach life skills, and let the parents take a break, it may also keep the kids from going to the doctor. Now we’re not talking about putting dishes in the dishwasher, but a good old fashioned hand scrubbing.

While the state of your children’s room may contradict this finding, studies suggest that our environments are too clean. This doesn’t mean free from clutter or piles of dirty clothes, but instead of bacteria. This idea, called the “hygiene hypothesis”, speculates that allergies in children today are more commonplace than ever before due to the lack of germs or bacteria in their surroundings.

New mothers often keep their babies and young children away from others so as not to get them sick. Studies show, however, that young children who are exposed to bacteria and germs will help their immune system build up a tolerance and decrease the amount of allergies they could develop.  A highly sanitized environment, while well-meaning, does the opposite.Allergies 2 This is not to say that families shouldn’t sanitize areas of the house with harmful bacteria, such as bathrooms or cutting boards, but over doing it kills bacteria that could be helpful to the body.

A study was conducted in Sweden of 1029 children ages 7 or 8 years old. A questionnaire was given to the children regarding issues such as asthma (Ventolin inhaler), rhino conjunctivitis, and skin problems. The results of the questionnaire showed that those who engaged in hand dishwashing show a lesser degree of allergy issues than those that used a dishwasher. For those with eczema, only 23% of the children who hand-washed dishes had a history, unlike the 38% of children who used a dishwashing machine. The study also noted an even larger reduce of risk families who bought their food from farms rather than the market, and ate fermented foods such as kefir, yogurt, and sauerkraut.

Over the years, research has indicated that different lifestyle factors have been known to reduce the risk of allergies. Families that own pets, or come in daily contact with animals developed a stronger immune system, as did families that consumed fish. Interestingly, it has also been found that children of families with low socioeconomic status, overcrowded living conditions, or immigrants had a history of fewer allergies. hand wash germsSince many people are touching the dishes, there are more germs, microbes, and bacteria that help build up the immune system of who hand wash the family’s dishes.

Other lifestyle factors can contribute to a lowered risk of allergy development. Families that engage in healthy eating and consume raw vegetables and fruits have been known to be healthier overall due to the good bacteria that is consumed. Children that are encouraged to play sports also have stronger immune systems and less allergies to the vast amount of bacteria encountered during games.

If you have questions about a healthy lifestyle contact our specialists at Orthopedic Surgery San Diego.


u.s.d.aA top nutritionist from the U.S. Department of Agriculture has reported that opinion is divided as to whether the so-called juice cleanse actually works, and whether it really is necessary.  Research has shown that the gastro-intestinal tract (GI) is set up to naturally detox, especially when a healthy diet is followed which includes plenty of fibre.

There is nothing wrong with drinking juice, but it is less healthful than eating fruit and veggies in their natural state which are packed with vitamins, minerals and fibre. A juice cleanse does not involve carton juices from the supermarket. Instead it requires expensive blends of fruit and veggies, which can be economically prepared at home if you have a blender. To get a beneficial effect, you will need to take about 500ml of the concoction every few hours.

There will be some benefits, but not everyone agrees that an all-liquid diet or juice cleanse is a way to real wellness.

Do people need to detox to be healthy?

The body is in a constant state of detox mainly through the functions of the liver, kidneys and the GI tract. These organs collectively help to remove toxins and harmful substances from the body. detox your bodyMaintain a healthy diet to keep them functioning effectively.

Will a cleanse improve my energy level and will I lose weight?

A juice cleanse will eliminate water from the body which will reflect as weight loss on the scale. But this is not FAT LOSS and the water will come back with time to reach a normal level which could show a false weight gain reading on the scale.
Sometimes cleansing can lead to side effects such as a lack of energy due to a sudden drop in blood sugar. Once you begin to eat normally again and follow a balanced, healthy diet your energy level will be restored and quite possibly improve.

Why do so many celebrities rave about the results of a body cleanse?

People in the public eye always enthuse about their participation (and success) in the latest fad diet. It brings attention and publicity to their persona than actual permanent results.
When the “ordinary people” hear about the hype, they all want to do the same, in spite of the fact that most dieticians do not recommend these cleanses or so-called detox diets, which only offer a quick fix.

Something to remember.

detox and cleanseA detox, or cleanse, is always low in dietary protein and calories, resulting in a possible lack of energy to exercise so that you can build muscle to replace fat and effectively lose weight.

Many nutritionists agree that although cleansing may produce promising short-term results, the long-term benefits are actually minimal.

Some people may experience a psychological boost from a detox which could motivate them to adopt healthier eating habits in the future.

If you have questions about maintaining a healthier lifestyle, contact our specialists at Orthopedic Surgery San Diego.


athletes collageThere has always been the risk of sustaining a concussion for athletes who participate in contact sports. However, due to the recent NFL concussion controversy head traumas from sports injuries are being looked at more closely than before.
A concussion is a head trauma that occurs when the brain is shaken around in the skull from a fall, or hard impact. Loss of consciousness is not a requirement for a concussion, which are actually graded into three categories, with Grade 1 showing symptoms for 15 minutes or less, Grade 2 with symptoms lasting longer than 15 minutes, and Grade 3 includes loss of consciousness.
The usual test on the field for an athlete who is suspected of sustaining a concussion is called the “Standardized Assessment of Concussion”. This includes a doctor asking the player a few questions, such as date, their name, memorizing a list, walk in a straight line, or do jumping jacks. Unfortunately, younger athletes from grade school to high school do not usually have the luxury of a doctor on staff, and concussions often go unrecognized.
Interested in finding a way to easily evaluate a concussion, Dr. Steven Galetta, New York University’s Langone Concussion Center’s neurology chairman, gathered a team of researchers to conduct a study.illustration of a concussion Knowing that 50% of the brain is tied to vision, they surmised that eye tests would be useful evaluation tools. Many athletes performing in hand-to-hand combat sports sustain concussions, and their trainers implement the King-Devick eye test. This is used to test cognition, eye movement, and tracking.
The King-Devick test involves the athletes reading numbers on three different cards. They lines are jumbled, but the way an athlete reads them is an indicator of whether or not a concussion is present. The research team decided to test this on younger athletes, and used 332 athletes that played hockey and lacrosse for the test. The age range was between 5 and 18 for 243 of the athletes, and the other 89 played college hockey and lacrosse.
The study had each athletes complete a baseline test for the King-Devick during preseason to have scores to compare later. During the season, 12 of the athletes sustained a sports injury and were put through the concussion tests. In order to have a control group, the researchers matched the ages of those hurt with 14 athletes that were uninjured. It was later confirmed that all 12 of the hurt athletes definitely sustained a concussion.
athletes complete a baselineUnfortunately, by using only the Standard Assessment of Concussion, only 2 of the injured 12 athletes appeared to have concussions, and misidentified 3 of the non-injured athletes as having one, due to their baseline scores being lower. The King-Devick test, though not perfect, identified 9 out of 12 athletes as having a concussion, and one 1 of the uninjured.
If a concussion is suspected, and the Standard Assessment of Concussion does not identify one, a second opinion from an orthopedic surgeon, or a medical professional using the King-Devick Test may be helpful for a diagnosis.
Contact our specialists at Orthopedic Surgery San Diego should you have any questions.


Hip Fractures
Hip fractures are occur more and more commonly. We are told from an early age how important it is to get our calcium and Vitamin D to keep our bones as healthy and strong as possible. As we age, our bones begin to become brittle and weaken causing falls which often result in hip injury, fractures, and eventually hip surgery. The likelihood of being affected by osteoporosis begins to increase. Osteoporosis is a disease in which the mass and density of our bones decrease. When this occurs, we are at a greater risk of fractures, which is why many elderly suffer from more fractures than they did when younger.
Along with osteoporosis, cardiovascular disease, (CVD) is also a possible issue with the elderly. CVD includes diseases that affect and involve the heart or blood vessels. This can be caused by a myriad of things, but usually by long term high blood pressure, smoking, obesity, high cholesterol, diabetes, alcohol, and poor diet. CVD is often due to a pattern of poor habits and behaviors learned as children.osteoporosis
Both CVD and osteoporosis are common ailments in the elderly, and until recently have been thought as disorders that are completely independent from one another, but they do have some commonalities. A well-known risk factor for hip fractures is a stroke, although other CVD’s have not been documented enough to be included as a risk. To find correlations between CVDs and hip fracture risks, a study was conducted in Sweden.
This study, performed by Ulf Sennerby, M.D. a doctor at the Uppsala University in Uppsala, Sweden, and colleagues, included almost 32,000 sets of twins from the Swedish Twin Registry. Twins were used to determine if the association between CVD and hip fractures were due to genetics, lifestyle, or sex. This type of study not only helps determine genetic and environmental factors on families, but also as an individual study at the same time.
The twins used in the study were born between 1914 and 1944, and were followed up after they turned 50. osteoporosis hipMany twins were identified in the National Patient Registry as having CVD and fractures from 1964 to 2005. Results show that after suffering a stroke or heart failure, rates increased for hip fractures. This was compared to diagnoses of other types of CVD’s versus hip fractures. Those with heart failure had 4 more times the risk of a hip fracture, while those suffering from a stroke had 5 times the risk.
In the study, an interesting discovery was found in sets of twins where one suffered from heart failure or stroke and the other did not. The twin with no CVD also had an increased rate of fractures to the hip. This is called “pseudoexposure”. If their twin had heart failure, the pseudoexposed twin would have a 3.7 increase in hip fractures, and if their twin had a stroke, the pseudoexposed twin would have a 2.3 times higher risk for hip fracture. This data shows that genetics are most likely involved when it comes to developing cardiovascular disease and hip fractures.

© 2023 Dr. Robert Afra – San Diego Orthopedic Surgery Shoulder – Knee – Elbow