Heel pain is an extremely common orthopaedic complaint. The heel or hindfoot is made up of several large bones, muscles, tendons, fascia, nerves, and ligaments. Any or all of these structures can be injured or irritated.

The vast majority of compaints regarding pain in the bottom of the heel are due to plantar fasciitis or heel spur syndrome. Actually heel spur syndrome is a misnomer as the heel spur is thought to be secondary. The primary cause is an overuse or inflammation of the thick fibrous tissue that supports the medial arch of the foot. The primary site of inflammation is the origin of this fascia from the bottom of the heel.

Other causes can include a compressed nerve, or possibly a stress fracture, or benign cyst.

Your doctor will take a history of your complaints, perform a physical examination, and possibly request X-rays. Treatment includes shoe modification, activity restriction, flexible pads, a rehabilitation program emphasizing stretching and possibly antiinflammatory medicines. Occasionally cortizone shots may be suggested and rarely is surgery required. Please see your personal physician regarding treatment of this malady..

Shoulder Pain

The shoulder joint is one of the most complex joints in the body. It is composed of bones, muscles, ligaments, nerves, and tendons. Many of the problems we see in the shoulder are the result of overuse syndromes. Frequently the rotator cuff muscles become inflamed. Part of the cause is muscle imbalance but arthritic spurs in the bony arch and injury can be factors as well.

Another problem we see is called adhesive capsulitis. Both tendinitis and capsulitis initially present the same way though the predominant problem in adhesive capsulitis is a scarring of the inferior joint capsule. Though the cause is unknown this problem is seen more often in women and involves three stages which consist of the pain stage, the stiffness stage, and the recovery stage. Physical therapy is largely successful at restoring function in the shoulder with this problem. A few patients need closed manipulation of the joint under general anesthesia. Refractory cases occassionally need arthroscopic lysis of adhesions.

Another problem seen in the shoulder is instability. This is a complex problem and can be seen with tendinitis as well. Directions of instability can be anterior (common), posterior, inferior or multidirectional. Generalized ligamentous instability can complicate treatment. Physical therapy in many cases can be helpful. Some cases require stabilization either by an open procedure or an arthroscopic procedure.

Trauma to the shoulder can produce fractures, torn rotator cuff, torn glenoid labrum or rupture of muscle insertions.



Low back pain is very common. Over 6 million people a year see a doctor because of back pain. One out of 6 people will experience back pain that lasts at least 2 weeks sometime during their life. In most people muscles, ligaments , are the primary sources of low back pain. These structures are prone to injury and wear over time particularly the disc ligaments. Discs begin to wear at an early age. They serve two major functions. Firstly, they serve as shock absorbers between the bony vertebrae. Secondly, they help stabilize the spine. Pain endings have been found in the outer regions of the disc known as the annulus. There are other causes of back pain so always see your general medical doctor first.

You can do the following things. Use the correct lifting and moving techniques. Get help if an object is too heavy or an awkward size. Exercise regularly to keep the muscles that support your back strong and flexible. Always get your physician's approval prior to beginning an exercise program. Don't slouch; poor posture puts a strain on your lower back. Maintain your proper body weight. Make sure your home and work environment are as ergonomic as possible. Realize that significant stress and or fatigue impact back problems. Antiinflammatory medicines may be helpful as prescribed by a physician. Bed rest is most helpful as it reduces disc pressure whereas sitting markedly increases disc pressure. See your regular doctor or orthopaedist.

Some of the above information provided by the AAOS.


The elbow is a complex joint consisting of muscles, tendons, nerves, ligaments and bones. A strong, flexible, painfree elbow requires that all parts function together as a unit

Frequently elbow pain results from an imbalance or overuse of the muscles and tendons around the elbow. This pain can be severe and disabling and significantly impair the function of the arm.

Most commonly, patients present with pain on the outer aspect of the the elbow. This is referred to as lateral tennis elbow or lateral epicondylitis. Though a nerve can be compressed in this area, it is the tendons that originate on the outer aspect of the joint that are often irritated.

Surprisingly this overuse syndrome is seen in all types of people from postmen to lawyers to file clerks to heavy equipment operators and athletes. Your doctor will ask you about the nature and onset of symptoms, perform a physical examination, request specific X-rays ( to rule out a problem with the bones) and design a treatment plan to restore strength and flexibility to the elbow. This can often include a specific rehab program of exercises, a measure of activity restriction, antiinflamatory medicine (if there are no contraindications), possibly a counterforce brace and an occasional cortisone shot when the patient plateaus in their recovery. With this treatment 90% of patients will recover. Please see your personal physician first for treatment of this malady.

Richard S. McCain Orthopaedic Surgeon



1. MICROFRACTURE TECHNIQUE:  A technique whereby small chondral lesions of the articular cartilage are treated with a microfracture technique using a "pick" to penetrate into subchondral bone with the hope of releasing pluri-potential cells to allow the regeneration of a type of fibro-cartilage over the joint surface.



2. CARTICEL  A   B    C    D    E


3.OATS    A    B 


Growth Plate Injuries


1.    Typically, the germinal part of the growth plate stays attached to the epiphyseal side of the fracture fragment.

2.    Salter Harris classification 1-VI, there is an increased chance of growth arrest with increasing number of the Salter Harris classification.

3.    Repeated reduction attempts may increase the chance for growth plate injury

4.    Internal fixation should not cross the physis but smooth pins removed as early as possible may be required.

5.    Accurate anatomic reduction though the goal--- perfect alignment is unnecessary for a good result in non-intraarticular fractures because of the remodeling potential.

6.    Fractures close to the physis have a greater potential for remodeling, expecially if residual angulation in plane of motion.

7.    Growth disturbance in 10-30% of patients

8.    Greatest damage to the growth plate occurs at the time of injury.

9.    Significant redisplacement can occur in 7-13% within 1-3 weeks of injury

10.                        10% per year of correction of residual angulation is from distal epiphyseal growth.

11.                       Age greater than 12 years should be controlled to less than 15 degrees.

12.                       In distal radial physis fractures, 50% apposition of distal fragment is acceptable.


1.  Avoid pitching with arm fatigue

2.  Avoid pitching with are pain

3.   Avoid pitching too much, further research is needed on this topic, but reasonable limits are as follows.

      a.  Avoid pitching more than 80 pitches a game.

      b.  Avoid pitching competitively more than 8 months per year.

      c.   Avoid pithing more than 2500 pitches in competition per year.

4.   Monitor pitchers

      a     Who regularly  use anti-inflammatory drugs or ice to prevent an injury

      b      Who are regular starters

      c      Who throw with a velocity greater than 85 mph

      d      Taller and heavier pitchers

      e       Pitchers who warm up excessively

      f       Those who participate in showcases.

Additional information

      1.     Pitchers who had surgery averaged 8 months of competitive pitching per year, compared with 5.5 in the control group

      2.     Injured pitchers pitched on average 6 innings per apperance, compared with 4 innings in the control group.

      3.     Injured pitchers pitched approximately 88 pitches per game, compared with 66 pitches in the control group.

      4.     Pitchers who pitched at velocities greater than 85 mph were 2.6 times more likely to require surgery.