Thank you for watching this program tonight with the best physicians of the region.

My name is Dr. Luis Munoz.

In nine, the president of El Paso County Medical Society.

It is our hope that you will find this program informative and interesting.

We at El Paso County Medical Society invest in community education with our programs.

I hope you'll find this program very informative, with great medical advice and great medical information.

Thank you again for watching this program tonight.

And have a great night.

Hi.

During this program, we are going to pay homage to the weekend Sports Warriors and hopefully we're going to help keep all of us out of the hospital.

We also have a lot of true athletes in our town who share common injuries with each other.

And this panel that we have, this evening is the El Paso Chihuahuas, official team physicians from the past orthopedic surgery group.

And they're going to be talking about common sports injuries.

And we're here to hear some pointers on how to prevent them.

And we're also here to find out what to do if we do get into trouble and harm ourselves.

This evening's program is underwritten by tenant, the hospitals of Providence.

And we also want to thank the El Paso County Medical Society for bringing the show to you each and every month.

I'm Kathrin Berg and this is the El Paso physician.

Thanks again for joining us today.

We're going to be talking about common sports injuries and we have special guests with us this evening.

We have the team Physicians for the El Paso Chihuahuas.

And it's so nice to have all three of you here.

So we're going to talk a little bit about some of the games, but we're really going to talk a lot about what is so common both in baseball.

But really, we're here for the general public as well.

Those of us that go out in golf, if we haven't golfed in a long time and boom, there goes our shoulder or we step off a curb or they're soccer and you fall down.

So we're going to have a really good show that I think is great for the general populace.

I'm looking at Dr. Urrea because you are the vetera on the board here tonight.

So thank you for joining us.

And it's the first time that you've been in this studio, which is kind of nice.

We've been we've been doing this for about a year now.

So Dr. Urrea is a orthopedic sports medicine surgery.

And so that's the title for all three of you guys, which is going to be kind of hard to differentiate you right there.

We have Dr. William Arroyo, who is also orthopedics, sports, medicine, surgery, and then Dr. David Mansfield, who I think you've been on the show before, but obviously you have not.

You said, no, you haven't been out.

So I feel like I've known you forever, your family.

And again, orthopedics, sports, medicine, surgery.

So on that note, Dr. Urrea, let's start with you, since you know the routine we introduced you.

So what your title is, but what if it's a little bit different from the other two on the panel?

What is it that you do all day, every day?

And what exactly does that title mean?

Well, you know, as an orthopedic surgeon, you take care of injuries from your top of your head, of your spine down to your toes.

And some of us, like in this panel here, we have done a fellowship training an extra year where we specialize in minimally invasive surgery arthroscopy, particularly honing in the injuries of the shoulder hip knees, as well as the elbow and the ankle.

And then it involves, you know, whether it's ligaments, your tendons, your muscles, your bones.

And, you know, that extra year that we did was we all worked with professional teams in our respective fellowships for that year.

Then we specialize in doing, you know, the care of of of athletes.

But that also that's a fun part of certainly what I do I think we all agree with that but the bread and butter of our existence.

So what we do is take care people just like us, right?

You know, and, you know, we've we understand that we can warriors.

I certainly tried to do that for for quite a while, but now I have to be more careful.

But these younger bread brothers here able to do much more than that.

They're not that much younger.

I mean.

Well, he might be, you know, but that's that's nicely said, because I think that we all think that we're 25 in our heads until we get out.

For example, I became an empty nester and I had these roller blades left over in my son's closet.

And I thought, All this is going to be fun.

That happened fast.

I used to be great.

And then your body just changes.

You don't realize ten years later is like it's not the same.

Dr. Arroyo, how would you describe what you do all day, every day?

And if it's the same, you can say same and then go on.

And no, actually, I was going to mention something different.

Like, I think what we do as a sports medicine doctor is simply different compared to our like subspecialties in orthopedics, because we you know, like I was saying, like we're taking care mostly of the community, but we have a second job, which is the sports medicine physician role.

I in this case they were that she was or when we cover high schools or I UTEP athletes that we are assuming our second role as the caregiver for for that community.

Right right.

So we have our practice we are we started clinic at 7 a.m. where I am.

We end about 5 p.m. and then we had to go to a game.

Carver A game for two or 3 hours.

I really dedicating that time to those athletes, to their needs, to their families, to already trainers, to everyone.

So it's kind of interesting, like compared to other specialties that we have.

We assume that second role, right?

Because we love our what we do.

Right.

And that's going to be one of my main questions in a few moments too, is like, take me down or, you know, run through of what a game is.

But we'll get to that in a second.

Dr. Mansfield, how about you?

Well, I think I think, you know, basically we all do the same things.

But I would think what I'd like to stress about the way the three of us may look at the injuries a little differently than your non sports medicine orthopedic surgeon is we really focus on the injury and trying to get the patient back as quickly as possible in a time frame that allows them at maximal recovery, but also maximum benefit and athletic benefit.

Yeah, because, you know, a lot of the times, sometimes a lot of people who don't do sports medicine are a little bit more conservative about injuries that maybe should or should not be treated as severely, you know.

So keeping a kid out of sports for six weeks for an ankle sprain as opposed to, you know, talking to the trainer and say, hey, when do you manage with the trainer?

When the trainer says you can go back, you can go back and play as opposed to having to go to go see the doctor every, you know, six weeks.

I think that's something we learned as part of our fellowship by working with the athletic trainers, because I know that when I was an athlete in especially in college and high school, to me the trainer was just the coach that put tape on.

But I found out that in my fellowship that these were, you know, master level, educated people that had gone through extra training and were very well-educated and really understood physiology, the mechanics of injury.

And so they're a huge resource that we have in our communities.

So talk about and expand on that.

I know you mentioned it as well.

What exactly is the fellowship?

So you get your training, Do you have your orthopedic training?

And then knowing that you're going to be working with sports teams?

I know last time we talked we talked about the miners.

I think you were doing football games for UTEP.

We are what you are.

So when you have that training, just to kind of explain to the audience, what does that require?

Like what extra training are you getting and are you doing that like on the job training?

I'm assuming some of that's the case too.

But explain that to our audience, because I think they see you guys on the field, too.

And they're like, Oh, it's some doc or like you said, some trainer that put tapes on you.

So but so we all did five years of orthopedic surgery.

And then after that, we were lucky enough or we actually got lucky.

We worked hard enough to be accepted to really, really good extra training programs for another year.

So we didn't actually have training.

Just so happened that Louis was up in Vail, Colorado, and I was in New York City and he was in South Carolina.

So sorry.

South Southern California, California, Southern California, Southern California.

Hey, there's a song about that USC stuck in my brain.

But it was like natural and it was coming out.

So.

But yeah but it's so it's it's an extra year of training that does allow us to learn certain techniques.

You know, Louis will talk about as well and we'll talk about because Will's on a lot of extra training that it wasn't even around when Louis and I were doing our fellowships so and you know, in the hip but you can talk but you know the fellowship what it is, it's a usually a 12 year program, 12 month, 12 months just feels like called for.

So that's why my fellowship was one of the greatest years of of my life and so much fun.

But we took it's where you specialize and focus purely on sports injuries.

You get to where we work that we know the three of us have a unique training that, you know, during the three of us, nobody in this town.

And you know, if you go to L.A., that's where you going to find this type of broad training that we've had in sports between the three different regions where we were in New York, Southern California and Colorado.

And, you know, we took everything from NFL players to the US ski team, the Broncos, the Jets.

Wow.

UCLA.

I mean, we you know, it was like the disabled ski team.

It was you get to learn so much and you also get to do research and you're working with the people are professors who are state of the art.

Right.

And their foundations.

We're doing we're able to, you know, do all kinds of procedures in the lab before we're doing them and live.

And it's just a wonderful it's a it's a very unique investment in our time for our education to really focus on what we love to do.

And and then we got to come home and and provide now the same type of care that we want.

Thanks for coming home.

It's our we love.

No, I mean, this is this is but we've been doing this program for 27, almost 28 years.

And I love talking about physicians that are now being trained here, which is great.

But those that left and have come back home.

So thank you for that.

You're talking about because you use the young one on the panel.

Right?

So now you mentioned the word hip.

So I guess there's some kind of a different way of treating hips now, is that correct?

So let's go into that really quick and then we're going to go into some of the specific injury questions.

Absolutely.

So they my training, I was lucky enough to go into a program where they specialize in hip preservation.

So preservation is many, many basic surgery, arthroscopy.

For most part, though, we are, you know, doing different type of repair, cardio restoration, labor and repairs the compressions around the hip, ten repairs everything into a very minimally invasive way.

So you're using the word preservation, meaning that you're not quite at the point of injury or you are at a point of injury and you're trying to save things Pretty much.

I'm going this is someone that is probably on or no middle age patient with hip pain and they have somewhere on chair of the hip, but they're probably not at the point where they need a hip replacement.

I get you so I can help them with a more minimally invasive operation where I can help their restored the joint.

That could be my friend.

You then give them function and improve the pain.

Okay.

And probably more.

Right.

He's not saying this for those younger athletes that have hip injuries.

That point I started in when David started, we didn't quite understand the treatment.

What they can what he can do now is prevent major changes and problems in the joint and the hip joint if they're treated correctly.

Okay.

Now, it was back in the days there was like a high incidence of like young people having arthritis.

Right.

And then when they look back, that's our finding.

They are certain things going on in the hip that can be actually prevented or fixed before, you know, getting to the point that the patient requires a hip replacement.

So that's like what I do now.

Right when I was in fellowship, every patient was between, you know, 19, 25 years old.

Right.

But that's the fellowship.

That's the type of patient that you gathered in fellowship.

But now and in, you know, PASSO my community, they change a little bit.

Now I get the forties and fifties.

Do you treat anybody who's female in 57.

Oh I'm just wondering because this time I, I have scoliosis so I have a hip that doesn't behave and it hasn't been behaving for about a decade.

Yeah, but you'll be so you'll be surprised.

I have, you know, patients that age that they come and they were told you need a hip replacement.

Right.

And for some reason they just don't want to have a hip replacement.

They're very active.

They play golf, they swim, they run.

And just with a very simple operation, I can restore the function and potentially delay the need for like for for a hip replacement.

Sure.

I'm glad you guys are here today.

What I'd like to do and I think this is the fun part of the show that we don't get to do so often in medical shows.

I would love to know what a day at the game is.

And we can we can choose whether it's baseball.

We can choose whether it's basketball or football.

And I'd like to have just a snippet from each of you and maybe take a different sport.

And so, David, I want to start with you.

So I'll do football.

Okay, Perfect.

Perfect.

I'll do baseball otherwise, because we're in the middle of baseball season right now.

Okay.

So baseball is actually an interesting sport because especially with the Chihuahuas, because they are they're one they're one day away, a lot of these guys from going to the big leagues.

So these are real.

These are real, you know, the highest, you know, some of the highest caliber athletes in the world are actually here in El Paso.

And I think people forget that when they see, oh, it's just minor league baseball.

These guys are you know, these guys are big leaguers.

Almost everyone are potential big leaguers.

So our our usual day is we contact the trainer where one of us is in contact with the trainers every day, and they'll have to say, hey, we have a we have an injury.

Could you come by a little bit before the game and come see these guys?

We need some help, you know, managing some of the medications.

We actually and actually, you know, because of the way baseball is, a lot of the coaches get injured as well because they're throwing batting practice and they're hitting they're doing things.

They're out on the field getting run over by their players sometimes and some of the players.

So we we we treat, you know, the entire staff.

So during the game, we'll still be in the dugout around the game watching, making sure everything goes goes well for the most part, which it almost always does.

You basically deal with a lot of musculoskeletal or overuse injuries, which we will examine and start to start a treatment regimen with the athletic trainers and that's baseball basically.

So you're coaching the trainers, basically what you know, you are not they're the coach or yeah, the other way around the trainers are, you know, they are expert at this and what they're really looking for is confirmation a lot of times and sometimes, you know, will say, oh, you know what?

Yes, that he does have this, but maybe we need to think this as well.

One of the other things that we have the ability to do that the trainers don't is order special imaging tests that they you know, this this one probably needs an MRI.

Now, we're at the point now where we in the medical decision tree, we are able to take that next step, prescribed medications do the other things that the trainers can't do.

But the athletic trainers, especially at this level, again, these are people that are going to be big league trainers and these are unsung heroes that we never hear about the trainers, They're they are you know, you get some back to work.

But the last three years, she's now in the major leagues as a trainer.

And she was and she was the trainer for Team Mexico in the baseball World Series.

So.

Wow.

You know, I would say the thing about trainers and this is a my my shameless trainer plug and I think there's one thing that's important in Texas.

If you have football, you're mandated to have a trainer in high school.

And I think it's important to realize that a lot of times in a lot of communities, many, many children, this is the only health professional that they will see on a on a regular basis.

And I think I think just just remembering that in the trainers is such a powerful thing when I think about that all the time.

So I, I agree like sometimes we have young kids so they, they get like an ACL tear, right?

And then they probably have no insurance.

So, you know, we do the surgery, but they don't have money to pay for a physical therapist.

Oh, wow.

So this trainer will become their actual physical therapist.

And you know, we guy the trainer, you know, this is what we need to do.

This is how are we going to rehab this patient?

And then, you know, you just a good report with the trainer.

You know, you call them, you know, every other day, AC has got to be doing so we we we have a very tight connection with the trainers, you know, and that's an excellent point, because a lot of times when there is no medical treatment, you know, and hopefully some of those grow up to be trainers, I shamelessly will tell you I was I came from Germany.

I was very, very tall.

And they thought, oh, she's a basketball player, had never seen a basketball in my life.

So immediately after I made the wrong basket on the wrong side, I became a trainer.

And that's that's my view of trainers.

It's like, okay, so that's why I'm loving what's happening right here and talking about the real thing.

And let's take it to football, because I remember some of the things that you were talking about last time we were on the show is minor football.

You know, if somebody gets injured on the field, then what do what is available.

And I know different schools, different venues and facilities have different things, but from there you're on the spot and what do you do?

Maybe there's a case study out there that you can think of when somebody got hurt.

Do you take them then to the hospital?

Do you take them away and try to treat them in the facility?

How does that usually go down?

Well, you know, football is unique and that, you know, there's always a potential for a major injury.

Every sport has that.

Football certainly is one that's the biggest that are.

And then the next one would be rugby or rugby.

Rugby.

I mean they're collisions they're, they're Yeah, they are collisions, They're really nice context.

I mean soccer is a contact sport basketball but collision.

Yeah.

So football's that unique that somebody can really have a major injury and in every game there's always one or two injuries that that that bother you sometimes or none.

That's we're very happy about that and you know the name team physician I mean we work together to help the athletic trainers and the coaches all figure out what's going on, who can who's capable of returning to play or not.

So we'll evaluate every athlete that gets hurt on the field.

Sometimes somebody is on the on the field with a dislocated shoulder, Right?

Maybe they have, you know, their neck hurts or something.

And we'll evaluate them right there with the trainer, make that decision.

I can cut my hand maybe four or five times over.

I had to cart somebody off and go to the hospital straight.

And that's over the last 20 years or so.

Okay, That's not that common.

Yeah, but, you know, I mean, there's been the one that scared me the most was somebody who had ended up having a spinal cord concussion, which means that they didn't damage your cord, but they were hit.

We saw that.

And both players fell and they weren't moving.

Both of them.

Both of them.

And and of course, each team like, were in Division one football were very blessed to have each team has their own physician and football and their own trainers.

But we help each other.

And in this case, we were both out there and ours ended up he couldn't move his his legs or his his arms.

And we thought I mean, I thought he had a broken neck and he had severed his spinal cord.

Long story short, it sounds in the first quarter, at the beginning of the fourth quarter, here he comes walking in with a neck brace.

Luckily, matter of fact, we were in Houston at that time at David's alma mater on Rice University And the neurosurgeon who happens to be one of the team doctors was there.

And he was he was able to take that athlete straight to the E.R.

They got all the studies done.

And remarkably, he didn't have any structural damage.

And that's where the ash and he walked in.

He saw a little tingling in his hands, but it was miraculous.

And so that was a beautiful story.

And he recovered just fine.

He was just well, afterwards, you know, he did recover.

He did have something called little spinal stenosis where the where the cord goes down is a little tight.

Some people have that in his case, he already had one injury, most likely because of that, he was very high risk.

And so I remember talking with him and this was the spine surgeon, and he came back to me because he really wanted to play and I had to talk to his parents like we all do.

A lot of times it's about talking.

That's a good point.

You do, you talk and and then we discuss the risk benefits.

And, you know, the bottom line was, is it worth playing right and being paralyzed versus your life?

And he was really smart.

He ended up being an assistant, a graduate student, and he's coaching.

I don't know what you know, mercy, but he's smart.

So he used that as a positive and lose pretty modest.

He he has a how to do it a hip dislocation on the field, which is not true.

I forget and and it's funny because the players he's still in the community here and he's a great guy but you would never know that he had a hip dislocation.

He so so just because you describe that injury, like when you're saying I mean I hear of shoulder this location, what is the hip dislocation and can you it's not like something you can pop back in the joint assuming well or no a hip is very different.

Yeah he got he he fell just right where his knee and his separate 90 degrees each other and a big lineman fell in the back of his and the small back.

We only, we only figured that out when we saw film, but it was the perfect way that the hip came out posteriorly.

It's not the first thing you think about.

We went out there.

He held this hip would look like dislocated and he said, Don't, don't, don't move it.

So he carted him off.

And luckily, you know, we had the emergency room.

We went right to Providence.

I just, you know, took him straight to the OR we were able to reduce it.

He had just a small fracture and we were able to rehab him and he came back and played the next season.

So pardon my ignorance.

I'm trying to picture what you're doing in the O.R., so it's a lot of fun.

Yeah, I know.

It's it's one of those things like especially when you're second, first or second year resident, right in the E.R., you know, that's kind of your job.

And it's it's a lot of fun.

It's you have to get up on top of the table, right?

And then you get to hold their their leg.

And then depending on which way it's dislocated, you pull why somebody is holding down the pelvis and you do a little maneuver.

And unless there's a piece of which where the nature would tell, if there's a piece of bone, something blocking it, you'll pop it back in.

And then the hip is something that it's like an elbow, you know, it's in, it goes in and they have instant relief.

And you have to do all that without falling into a rhythm like that.

My hands under the table like, Oh, no, no, you're on your little wall.

You have to be right.

Because it's it's, it's, it's physical.

Oh, yes, I'm going to have to be sedated because, you know, you really have to pull very.

Tell me.

He was sedated.

No, he was sedated.

You had to pull very hard to get the hip back in place.

Yeah, a lot of grunting back there.

So it requires some extra help in the room, too.

Yeah, absolutely.

It's definitely like he's professional wrestling in the middle of the operating exercise.

You know this.

But now we've had I mean, you know, we've had kidney lacerations, liver lacerations, knee dislocation, multiple shoulder, some elbows.

So let's talk about some of the most common and maybe for the general public, which is me, I don't play on any sports team.

What are the most common sports injuries?

And Dr. Arroyo, I'm going to start with you guys.

We haven't talked with you for a while.

What are some of the common sports injury that you see just coming into your office?

It's like in me, in my head, I'm thinking ankles, knees, you know, So the way I see I classify in two different categories.

You have the young athletes, you have the older athletes right now you might experience, I don't know with them, but in my case, for younger athletes, the most common injury is ACL injuries and shoulder instability.

Right.

And shoulder instability.

Yeah.

Okay.

Shoulder dislocations, right on the older population are still active playing sport that we can wear for warriors.

What I see the most is is probably meniscus injuries like meniscus tears.

Right.

And rotator cuff injuries.

Okay.

And on that say they come in.

Do you do work on them immediately?

Do you say, oh, that can wait until Tuesday and I'm assuming they're coming in to the emergency room, they're hopping around or.

Yeah, I think so.

I mean, it depends of the I would say the mechanism of the injury and the type of force that are required to cause the injury.

Like he mentioned, knee dislocation.

Right.

So when you have someone that dislocated the knee, we look at a model like that means let's play with this model.

That means that pretty much like when they have a knee dislocation, you have the collateral ligaments, they are torn.

You can also have like the ACL and a PCL ligament or a torn.

So technically the knee just comes out of place.

But when that happens, so we have to think about all the nerves, right?

All the vessels that are behind also on the side of the can, they can be injured.

It can be.

So is it locked at a place like you say that it's locked out of place until somebody goes in there physically?

This is an it is location.

So technically they come they come to the air like this.

Oh, you know, the leg is crooked.

They have a lot of pain.

You can imagine all the vessels are being compressed.

Right.

So you actually have to be very careful and just really watch this, kids when you, like, put the knee back in place.

So this is an emergent situation right?

This cannot wait.

Right.

For Monday.

Right.

Right.

There has to be done immediately and most likely in the in the operating room.

So in the operating room.

So when you're doing this, is it just physical maneuver with your hands or you're actually going in there and in sizing something to when you say operating room, how are you getting in there and physically moving it?

So in the hip you said you're on top, you're moving everything in the place.

Same thing with the operating room on a knee.

Absolutely.

Yes.

I always have to go in there.

Yeah, I have to go in there.

Okay.

You want to be in the operating room just in case something else happened, Right?

Like he mentioned the hip dislocation reduction.

When I was a resident, I had a case where I have had a hip dislocation, and when I tried to reduce it, I broke my neck.

Right.

So from being a reduction now becomes an operation.

The good thing is you are already in the operating room.

So is easy.

You have the setup to move forward and take care of the situation.

Right?

Right, Right away.

Okay.

The same with this.

Right.

So let's say I do a reduction and then the blood flow is compromised of the leg.

Then we had to do something else.

Right?

Already in the operating room.

So we can we'll be able to manage and you can tell immediately at the blood flow is compromised.

Okay.

Yeah.

Okay.

And then when you're looking at nerves, too, I always think to my nerves or something to that we don't think about until you're in that situation.

And nerves are tiny, little are very tiny, you know.

So how, how do you I guess you just see it manually.

Correct.

And I do want to bring up just you talked about or the scar back in general, The Da Vinci.

I know that there is there's operations being done in all kinds of different ways.

20 years ago, it was a lot more hedonistic, if I can say that.

But if you're going to do this type of operation, how would it be different now than it was ten years ago?

Well, since you're the young guy in the pan, I think, well, maybe back in the days, you know, in order to perform like a reconstruction of this ligaments, it require what we say an open approach.

Right.

Or they will perform open incision big approaches to to get this ligament reconstructed.

Now, with the new technology and advances in the sports medicine, we can do all this reconstruction.

We just minimal incisions, less pain, less exposure.

That's probably most better outcome.

Mm hmm.

So, Dr. David, you said.

Mm hmm.

So explain maybe the procedure of going through, well, a surgery, one that as to say we're quick is like, I know there's there's all the exciting stuff we see, but I think a lot of what we see, especially we see now children, kids, a lot more are the overuse injuries because they're playing volleyball all year round and they're becoming super specialized athletes.

So they don't they don't ever stop their sport and go to another sport cross-training.

So they there's a lot of overuse that's we're asking about what I see mostly, probably that's the most thing I see in the weekend Warriors crowd.

You see the overuse, you see the muscle, the muscle injuries, things like that.

As far as the arthroscopic, back to your question, though, the arthroscopic, the way you would address this is, you know, there's a lot a lot of different ways.

That's a really complicated injury.

But if just arthroscopic things in general, generally what a what it entails is making two small incisions, one for a viewing portal, one for a working portal to go in there and look at what's going on in the knee.

And then from that you can address a lot of a lot of issues from those two incisions.

Sometimes you have to make other small ones to make different what we call portals, different entry points to the knee to move things around.

And how do you see what's happening in there?

There's a little camera that's basically I guess it's it's like a camera.

It's a camera.

It's a small camera with a with a tube that's about four millimeters in diameter.

So you can go in the knee and with and look inside the knee with fiber optics.

And that's definitely one of the things that technology has allowed us to do, as opposed to making the big open.

So it's basically like when people have the laparoscopic surgery, they have the I'm sure you've had them on with The Da Vinci and things like that.

The camera, same same type of technology, just the cameras more handheld.

And we have a bunch of tools that we can use, some shavers, some some arthroscopic like biters receptors, things that allow us to do things.

And then based on the damage we see sometimes, that's a ligament, that's damage.

We have to reconstruct the ligament.

So we may have to harvest the ligaments sometimes from this tendon here or this tendon here.

So this is the stuff that I love talking about.

Sorry.

Yes.

You guys see, this is intended here in this tendon here we harvest and can make.

So we have to reconstruct or make a new ligament that's that will then we then when the fun part comes in, we use the power tools, then the drills come out.

That's the drill down to and to anchor the and to anchor the tendons inside the bone.

We make a bone tunnel, put the new reconstructed ligament into the tunnels, hold them with either a combination of screws or there's some other fixation devices.

We can use most of the screws.

Now, again, talking about technology, muscle screws now are what we call bio eggs.

They so they become bone over time as opposed to back in the olden days when we first started was just metal screws.

That's all we had.

Exactly right.

So, you know, when you say harvesting, so are you taking part of this tendon and then and then regrowing it for the lack of a better way of describing it, or are you just replacing it?

So what we do is we'll take like the middle part of this tenere This is called the quadriceps tendons, where you have the quadriceps muscle attaches to the patella.

And so we'll take the middle part of this tendon and then we can show up the so the remaining part, it'll grow back and then heal.

And then using that little strip tendon, what we can do is we can make something that kind of approximates this ligament right here.

Okay?

And through drill holes, drill a hole through here and a hole through here and and get replace that ligament, okay, with the with the harvested tendon graft.

Okay.

So let's talk a little bit about physical therapy.

And I'm just just because it's your turn, but anybody can take that.

So when you're looking at this type of an injury and I'd really like to get to shoulders in a moment to when you look looking at a knee injury because you cannot be mobile without using your knee, what is the physical therapy that goes around that throw out an approximate amount of time?

I know everybody's different.

I get it.

Every injuries different.

But just in general, let's throw something out about physical therapy.

Well, we use the most extreme injury.

We're talking about a dislocation.

But for knees, if you have a dislocated knee, it has to be marginally reduced.

Okay.

As far as fixing their things, it is a little different.

You have to depending what's wrong and you have a lucky.

But let's just talk more simple things like an ACL, which is still because that's really patient's probably the most the biggest injury.

Most of us that occur here in that community, not a dislocated knee, but the most important part is when to operate.

And you never operate right away.

You have to let the knee calm down.

Needed inflammation to decrease, regain their motion, regain their quadriceps function.

If you don't do that, we know that people then develop a high risk of developing a very stiff knee, which we call our third fibrosis, which is a very difficult, a complication that takes a long time to recover from, is that the scar tissue, that's scar tissue death and everything.

So the most part, most important part is timing it correctly.

And and, you know, everybody wants to get back sooner than later, but sometimes it takes a couple of weeks and people get their motion.

Most people take a little longer.

Some people take 6 to 8 weeks and get really stiff.

And then a few of those people get really stiff.

They have so much scar that things do heal.

Those are unusual.

So the timing is very important and that's where we use the physical therapist to work with us.

And they can rehab and bring that knee back.

Now, if you have a dislocated let's say you're the meniscus, which is this little blue, and that in that case it's white.

But these blue little wedges between our bones, those are kind of the they're shock absorption.

They help with articulation and some stability.

But if those are flipped, those, you have to be faster in putting that up.

But if it's torn again, you want the knee to calm down.

Same thing with the ACL.

So it's important that we time it correctly to avoid a bigger complication.

Okay.

And you and all injuries have all people heal a little differently.

Have different inflammatory events.

So there's not just a common but I'd say an ACL 2 to 4 weeks, sometimes six.

Okay.

If it's a shoulder, you know, if it's a dislocated shoulder, that can be I mean, you're not going to jump right away.

No.

I mean, if it's if you have somebody who's young, a traumatic dislocation, who plays a collision sport or is a thrower, you're going to take the nowadays we know that the first time dislocated should be operated on.

Do minimize their complications later on and the risk if they keep hitting other people.

So there's not any important thing but important and there's not a time frame that's perfect, except if you have a dislocated shoulder, if you have something dislocated, has to be put in right away.

Right.

And then I think the most important part is after surgery, we have to respect biology.

It take the body remodels, it heals remodels and it takes different things.

And we have good studies now with ACL or with cartilage that what we use, what used to have what it's called accelerated rehab back in the nineties that we were pushing it too much and people were were getting reinjured too quickly and now we were better about that.

So letting the body do some of it, we got the body.

Yeah.

Because like David explained, you've taken a graft right.

You know, a quadriceps tendon.

Make it, it put it in toward an ACL.

Does.

And what's beautiful about that?

The body sees that ligament and says let's make a tendon out of it and it uses to college and everything else.

But it literally goes in and starts replacing all the different fibers and cells and covers that with Synovial.

And when you go back and you do some ACL, you know, let's say you had an injury later on and you look at it, I mean, it's hard to tell that the biology varies and everybody can do this, but you need to respect the biology of things interesting.

And so faster is not better.

And that's right.

And kids, unfortunately, they're kids.

Right.

And everybody wants to get back sooner.

But that's where they can really make a big difference in like an ACL.

You know, the average NFL player takes about ten, ten and a half months to get back to playing while that belongs.

I think you hire a guy, Adrian Peterson, you may remember him or not one of the greatest for a small by the time of fact he came played sun ball one year but he taught he came back at eight and a half months and everybody thought he's Superman and then he reinjured it.

Yeah.

So you have to respect that.

But and the same thing with the rotator cuff.

And I let them.

I don't want to.

Let's too let's talk about rotator cuff because there is that that the one that it's the only one in our body that really does the rotation that it does right.

More than any other.

Yeah.

So I want to throw this one.

So the Rotary Club is pretty much composed of four different tendons right here in the front we have the subs, capillaries, tendon and that tendon.

What it does is just rotates your shoulder internally.

Okay?

Right.

Then you have on top just next to it, you have the superstar pinatas and interest pinatas and the super spreaders.

For the most part, you just do a lateral motion of the shoulder and the interest bananas and Terry's minor.

They also do some elevation, but also like, you know, external rotation of the shoulder.

So like I said before, I see this injury is very common.

Probably this surgery we'll do probably the most in the middle of population, like just rotator cuff tears, either playing sports, people that fall, you know, all their patients that they've been having.

Like maybe they started with a small tear and it was really not symptomatic.

And over time, they just developing more pain in this function.

Right.

Right.

A lot of pain.

So when they come, you know, they have big rotator cuff tear.

So, yeah, this is probably want the stories that we do that we do the most.

So when you say this and this is me just wanting to know what it is that you're doing in surgery.

So it's a tear and you're not suturing it.

Or are you suturing it, Are you?

Oh, yeah.

So I think we we can have a lot of debate on this because I think I think the only way we do the same type of surgery, Mansfield might do something different, but love is all the same, pretty much.

So let's show it to this test.

So let's say we have let's say we have someone with a tear like this that involved this superspreaders an interest.

Benitez So that patient is going to come with, you know, pain with a lot of motion pain at night, weakness and a lot of pain on the shoulder.

So what we do, especially, you know, we're talking about arthroscopic surgery.

This is one of the surgeries that back in the days it used to be a big open operation.

Yeah.

Then they went to like many open and now we are just topic.

So in my cases I literally perform like three little like I want to say poke holes like one in the front, one little and one in the bag.

And actually the camera is probably a little bit thinner than this pen.

Oh, mine.

So you can imagine, like we're looking inside and even that this is like for millimeters, what we see inside is like ten times the size of what it really is.

Right.

So we have the ability of like using this small instruments and actually put like suture anchors.

And now with the technology, like he mentioned, now we can use angled are made of calcium.

They like to use they because it's like you're stapling calcium in there is that I'm just trying to use a point of fixation of like a little like a little screw, like a drywall anchors.

Okay.

It's like a drywall.

Okay.

Right.

So we put those I right there in the margin of the like the footprint of the rotator cuff.

And we have different instrument that we use to pass sutures through it.

And, you know, in our case, we just, you know, we just suture it down.

Gotcha.

Okay.

And wow, like arthroscopy.

It's amazing.

Like the shoulder of the knee.

You can see more what that little instrument than when you open up the shoulder knee, I mean, and longer have we had that technology.

Oh, it was decade.

I said, oh, well, now that technology when I started when I did my fellowship in 97, 96, 97, we we were doing that for knees and shoulders are just starting to do where I trained.

I was one of the places and where we started.

We would do arthroscopy like maybe drill the the at that time there were little metal anchors right?

And to me what the greatest thing now is, the sutures.

Back then you had to be so careful because they were weak.

Now the sutures, you don't even worry about it.

And that's that's something that I learned just you broke one.

They had to take out the little screw.

It was it was it was very difficult.

But now but back then and then we did the little mini op and we look inside and then, you know, and then, you know, within 2000, we were doing I mean, when David came to El Paso, 2000, to have 22,002, you know, we were the only two doing arthroscopic right to work, just okay, bank cards, other kinds of stuff.

And, you know, most people, most orthopedic surgeons know how to do on arthroscopy to diagnose, not as many are able to do everything under the arthroscopy and.

Then Dr. Arroyo doing, you know, the the hip that I mean, we didn't even do those kind of surgeries open.

And now it's doing some incredible reconstruction and recreating the normal anatomy.

So here's my question.

We have about 15 minutes.

I want you guys to think about some stuff that we haven't talked about yet that you do want to talk about.

But one of the things I love doing on this program is talking about what's new and what's next.

And I and I know that there are a bunch of studies that we talked about years ago that were happening in Europe that are now happening here.

But in general, in this world of sports, medicine, orthopedic surgery, etc., what's on the horizon that you wish you could do right now And maybe five or ten years from now, we're going to have the ability to A, B, C, or D, and I'm just throwing out out to anybody who wants to take it.

I think I think I think one of the things that I think is on the horizon, I think we're going to really start there's a lot of in a lot of in information coming out, but also a lot of interest in is that is the cartilage restoration.

So so right now right now it's it's advanced a lot even since since I started you know, when I came back in 2002, we would have to there was a procedure called the Genzyme re implantation or you take some you harvest in cells, you go to the lab.

Back then you had to grow in for like 12 weeks and then they they bring it back.

You would you would open up, you could open up and and replace it.

So this is when I say regenerate.

So these are like this is the shiny.

I tell people there's two kinds of cartilage in the in the knee there's the articular cartilage was kind of the shiny end of the chicken bone and the fiber cartilage with those discs that Louis was talking about earlier.

So a lot of times these the shiny of the chicken bone, this articular crotch gets these defects right here.

And so that's basically what arthritis is when people say, Oh, you went in to my knee, could you could you scrape out the arthritis?

And I said, well, I can't because it's it's like tire tread.

You can't just scrape off more tire tread that expect that interesting tire tread.

God I mean regenerate.

So what we would do is we would harvest some of this normal cartilage here and then grow, grow in the lab and then open it up and then reef and then fill this in with articular cartilage.

Are the new cells that were grown in the lab with the hopes that they would regrow the cartilage.

And and these are the cells of the person who's having surgery, you're saying?

Yeah.

Okay.

So it was it's a it was an effective procedure, but it was really time consuming, laborious, because you would have to take a patch of what we called various periosteum periosteum patch from later further down on the bone so that the lining of the bone, you'd have to cut this patch out, have to be perfectly, then you'd have to.

So it was really like six.

So like fine sutures like this.

There's the suture they use to do like heart surgery with, you know.

Yeah, it was it, it would take forever.

And so now they've got, they've got different, they've got different ways to deliver it where they it comes impregnated into a, into a like a wafer that that has a cells in it.

So you just kind of put it in there and you can just use some, some biologic adhesives for lack of a better word that keep the keep that keep it in place.

And so I think that's I think as we're going to move, I think as we're moving towards even better technology, we're going to be able to start using technology to fix the fiber cartilage, the meniscus little instead of having big gaps in there.

Now we can just put it in there, maybe put a suture in.

And so it and I think that's in five, ten years.

I think that's my hope is that we're going to get there because I know there's a lot of lot of hope with like stem cells and but stem cells are great because they have the ability to reproduce.

The problem with stem cells is they don't have the physical structure.

So like a lot of these problems are, it's not just a biologic problem as a physical, right?

So you have to correct both of them.

And right now we're just by putting stem cells on a bad knee, we're only correcting we're putting the cells in.

But we're not we're not we're not letting the scaffolding that's necessary to to let them do their whole job.

Yeah.

I think one of the the advances that we are seeing now and, you know, I think, you know, I being one of the few that are doing this intel is about the ACL surgery.

Right.

Like we've been talking about reconstructing the ACL, taking like a quad tendon, patellar tendon to use that to replace what the ACL used to be.

Now we have a new technology that we're calling the bridge and hands ACL restoration.

So with that, what we're doing now, instead of having to harvest and reconstruct the ACL, what we're doing is repairing the ACL, right?

The patient's own ACL that is stored.

We do a repair back in the days that was a very common surgery is doing an ACL repair.

But the environment inside the knee was not allowing that ACL to heal.

So because we have all this enzymes inside the knee fighting for, you know, destroying the repair of the AC van, you hear that you have all these enzymes inside the knee fighting for.

I mean, that's something we don't hear about, talk about at all.

So now with this new technology, I want you to show that to the cameras.

They kind of see.

Yeah.

So within the environment.

Yeah.

So right now inside the knee, we have a lot of enzyme, so the knee is a compartment is surrounded what we call synovial, just like a knee inside a balloon.

Right.

So you have water.

The water is just inside the knee.

So you can imagine inside this balloon you have all this enzymes that were you know, they cause inflammation, they cause they tear on where of the cartilage.

So now I think with this new technology, we're able to repair the ACL and we have a little device.

The skull is like a little sponge made of collagen.

And what we do, we put blood inside that sponge, the patient's own blood, and then we put a writing for the ACL.

And what that does, it actually protects the ACL from the outside environment and at the same time it provides a blood supply to the repair area and that's a permanent.

Yeah.

So the implant will dissolve.

So by the time you can solve the vehicles already heal.

So now, now we don't about biology again, something like that.

And we are really respecting the biology because we are repairing the ACL, we're putting an implant that has whole blood in there from the, from the patient, right to heal his own ACL.

And then there's no need to harvest this as being less swelling.

So the operation thinking is we're talking about this.

All the guys in the lab that are helping out with this process.

Right.

And we talk about the surgeries and everything that's happening here.

But in the lab and all the research that's going on, which is kind of in that same venue, we talked about stem cells probably a decade ago.

We were talking about what's going to be coming up.

And I think that we were talking about backs at that time and disks in the spine.

Where are we with that in this day?

I know we're not really talking about spines, but I feel like that's one of the first places that we're looking for cushion, you know, biology, lab cushion, happiness to help repair people where, you know, whether it's spine or knee or whatever, the the biol, the research and biology is trying to identify the the the cells that allow for repair.

So stem cells are you they're the cells inside mostly our pelvis, bone or femur.

They're very few of them, but they are capable in the right environment with the right scaffold, something to repair, bone, cartilage, whatever.

Mm hmm.

Mm hmm.

And a couple of years ago, Dr. Dog, a fellow for STEM in Hawkins, but now he's an.

And at Stanford, they've discovered the mother's stem cell.

So they got the stem cell.

Then the next lineage that does create cartilage.

That's the first time they've identified.

Now what they're trying to do is figure out how do we identify that in our own body?

Because we can go in there.

You know, when you talk about stem cells today, it's hit or miss and it's it's mostly mess to get.

You know, you get a lot of other positive proteins, enzymes, cells, but the mother, the stem cell.

And we don't know what they're doing, but they're trying to research.

And I do believe David hit on the spot where there's five or ten years.

But I do think in our lifetime, certainly and Dr. Arroyo you're older, so you may not know.

Hopefully it's going to be used, maybe, But we're going to be able identify hard to identify that stem cell that's yours and harvest that.

Then we have to learn how to stimulate it in the lab.

Mm hmm.

And then what's real important is you don't want a stem cell just to grow, grow, grow.

Because that's called cancer.

Oh, gosh, exactly.

So that's a challenge you can look at as we're going to be able to identify cells, be able to inject it in the knee.

Let's say you have cartilage damage, you go in arthroscopic, we take care of what's broken cartilage is like.

That's the hardest thing for us to take care of.

Mm hmm.

And if you can't get it fixed, you're at high risk for arthritis.

So you go and put in and you clean out, you inject the stem cell, and then we're going to understand the biology of it and how to activate it and how to slow it down.

And there's a lot of research and we're nowhere close to that.

Yeah, but it's, it's, it's every year there's more and more data.

We all go to the to the Sports Medicine Association society conferences and there's always a subsection talking about the the author biologics of things.

So it's always fascinating to me all the new stuff that comes on this table every time we do some kind of an auto show.

On that note, we have like 5 minutes, and since you're young and you're new, is there anything we haven't talked about that you want to throw out there before we wrap up?

I think we cover almost everything.

We talk about what we do as team physician.

We cover new advances in orthopedic surgery.

We talk about what we do and, you know, okay, everything have a nice day.

I'm going to put a shameless plug in for Will.

And I think Will's kind of downplaying what he actually brings to our community.

I mean, the way something is as as common as a hamstring tear, which is which basically my soccer career, basically, because I didn't take care of it correctly.

He has the ability to treat hamstring tears of varying degrees with much more effective techniques than we had before.

So.

And do you do that surgically?

Do you?

Yeah.

So yeah, so pretty much just kind of leg is kind of like a very kind of funny operation because technically, you know, the hamstring is literally in your butt, right?

So I had the patient facing down on the table and basically I just do like two little poker holes in that area of the glute.

And I could go in just with the camera, find the tendon and just do like a repair.

So when you say do a repair, I'm thinking sewing.

Yeah, this is very, very similar repair.

When talk about the rotator cuff, a surgery, what is what is good about this surgery?

Like, you know, this sciatic nerve not anything is he makes it sound so easy, but there's a glass.

And that's.

That's why people are afraid of doing this.

So we'll use your sciatic nerve, and all of a sudden, that's a whole nother.

So.

So literally, the sciatic nerve is like two centimeters from the tendon.

So we're talking about a very short distance.

So.

Okay, what used to happen when in the past you used to do them open and with open, you know, they say I'm bleeding.

Sometimes it's very hard to see the sciatic nerve.

And even if you identify the nerve, you do the repair.

The amount of scar tissue that can develop is massive in that area.

And then it can scar down to the sciatic nerve.

And then they get other symptoms from it.

Right now, with this technique that won't go away.

Well, you can be you can go back and, you know, release it, but you're always compromising the sciatic nerve.

So in this surgery, I can through the camera, I can identify the nerve.

I know what it is.

I can work around everything else without actually being close to the sciatic.

And you know how I don't feel those in town.

I don't think there's anyone doing those endoscopic early in the city.

And I even have people from, you know, Alamogordo, Albuquerque, just coming here because they you know, they they want to get that surgery.

Some is what it is.

So it's amazing.

Pretty amazing what we can do now.

Yeah, for sure.

It's amazing trying to try to when you have a good athlete with, you know, who's got very well built and they have a it's when the it's when the hamstring is torn off the bone that we're talking about.

Yeah.

And you know, I remember just trying to just get exposure.

It's a very difficult surgery and would will can do is it's amazing arthroscopic it looks like a rotator cuff but let me tell you the anatomy everything else it's I think it's I think it's just I'm happy like a the place in my career, like when I came back to El Paso and I was gone for, you know, college at residency and and medical school and fellowship, I brought I was the I was the guy that brought in the new stuff that nobody else was doing.

When Louie came back, he was the guy that brought in the new stuff that nobody else was doing.

And so now I feel like, you know, happy that I've passed.

We have a guy who's bringing in the new stuff, you know, keeping it going, you know, keeping it going.

And so just bringing in a sense of whatever, man, that guy, it's it's been an absolute joy.

I love doing this program and Dr. Ray knows this.

It's it's just been because it's so practical.

There's so many things that we talk about here that everybody has issues with.

So thank you so much.

We've had Dr. Louie, Urrea, we've had Dr. William.

Everybody calls you Will.

So Will Arroyo and Dr. David Mansfield.

And again, this is the El Paso Orthopedic Surgery Group that we're here, who is again, the official team, Physicians for the Chihuahuas.

And we want to say thank you very much to the hospitals of Providence and Tennant for bringing this program to you.

And if you didn't get a chance to watch all the show or if you want to watch it again, along with any other show that we produced over the last several years, you can do that in several.

The first one is PBS El Paso.

ORG Just look up the words, the El Paso physician.

You can actually see that on that website.

Also, the El Paso County Medical Society at EPCMS.

And that one's a dot com or like many people do.

And all of our kids who are addicted to YouTube, you can go to YouTube and type in the El Paso position and usually you can just slash whatever the the show is.

This one's called common sports injuries.

But anything that we do, you can go back and watch any of those programs.

So thank you so much for watching and paying attention and listening and thank you.

I am hopefully that I will try not to get hurt.

So again, you've been watching the White House physician.

I'm Kathrin Berg.

Goodnight.

Good evening.

I am Dr. Allison days a past president of the El Paso County Medical Society.

If you have questions on tonight's topic, please reach out to e p m e d s.o.

c at aol dot com and we will try to get your questions answered in a timely manner by an expert in the field.

A big thanks goes out from this society to all of our specialists who have been able to give their time as speakers on this program and to the El Paso community members who have welcomed us into their lives for all of these years.

Thank you again for tuning into the El Paso physician tonight.