On Tuesday, November 27, William Vranos, MD, will discuss the new anterior hip replacement surgery technique that may be less painful and result in faster recovery times for some patients. Elizabeth McLarney, MD, will address treatment options for shoulder pain and arthritis issues on Wednesday, December 6. Jonathan Thatcher, MD, closes out the series on Wednesday, December 12, with a discussion about the pros and cons of partial knee replacement and total knee replacement surgeries for patients with knee pain or knee arthritis.

All presentations take place in the Brew Barry Conference Center at Brattleboro Memorial Hospital starting at 6:00 PM. BMH is located at 17 Belmont Avenue in Brattleboro, Vermont.

For more information, contact Southern Vermont Orthopaedics and Sports Medicine at 802-258-6400.

By Dr. Elizabeth McLarney

Elizabeth A. McLarney, MD

In the coming months you may hear about a new drug for treating cellulite, called Xiaflex. The pharmaceutical manufacturer that makes it just began clinical trials of its effects in January. I am not recommending Xiaflex for treatment of cellulite because I’m not a cosmetic surgeon. I am familiar with Xiaflex, however, because it was originally developed to treat a hand disorder called Dupytren’s contracture. Normally, I hesitate to use words like “revolutionary” when describing medical advancements; few things truly change the way we do something. The arthroscope was revolutionary; it completely changed the way people have surgery, and ultimately not just in orthopedics. But Xiaflex really belongs in that revolutionary category because it has helped us treat Dupuytren’s patients in a much less invasive way.

Dupuytren’s contracture is a disease that causes a person’s fingers to curl down toward their palms. It can also affect the feet but it’s far more prevalent in the hands. There’s a layer of tissue just below the skin called fascia, which gives your skin the flexibility to move and grab things without disrupting or damaging the tendons, nerves, arteries and muscles underneath. Dupuytren’s turns fascia from being soft and pliable into hardened scar tissue that adheres to the skin, tendons, nerves and arteries. It feels like thick cords or nodules under your skin. The fingers can curl all the way down to the palm if it goes untreated, causing a person to completely lose function in the affected digits. You can’t grip anything. You can’t even get your hand in your pocket. It can be a very debilitating disease. In fact, one of the recommendations if the small finger becomes flexed all the way down is amputation.

The surgical treatments for Dupuytren’s are pretty extreme. In the early 1960s, a Scottish physician named McCash introduced a technique that removed all skin from the palm. The operation restored partial functionality to the fingers. But can you imagine what rehab must be like when you’re waiting for the skin to grow back on your hands so you can use them again? The more traditional surgery has been to make a series of zigzag incisions running from palm to finger, and then remove the cords and nodules. This procedure is fraught with risks of stiffness and nerve or artery damage, however, and the recovery time can be as long as a year.

I started reading about Xiaflex and hearing about it in professional development meetings sometime in 2009. It was being used with good success in Australia, New Zealand and Europe, and I was advising some of my patients to hold on until it was approved by the Food and Drug Administration. When that finally happened in 2010, I went through the training to do the injections. A lot of injections in orthopedic surgeries are made into spaces. Xiaflex is injected directly into the tissue and it essentially eats away at the cord or nodule in that spot. After waiting anywhere from 24 to 48 hours, you numb the hand and manipulate it until you hear a pop. I still jump every time I hear that pop because it’s so loud. But after the pop you can generally straighten the finger all the way out, though it depends on how severe the contracture was to begin with. There is physical therapy afterward to strengthen the hand, and you might wear a splint at night. But it really surprised me how quickly it resolves compared to surgery. You can be using your hand normally within a month.

The other thing that surprised me was the amount of swelling and bruising the injections cause. It looks like somebody has taken a sledgehammer to your hand, and in some people the bruises track all the way up the arm. The swelling subsides as you recover. Risks include the chance of rupturing the flexor tendons in your fingers. There have not been many reports of this happening fortunately, and it is occurring mostly in the pinky finger. Longer term studies may eventually show that there is more risk than benefit to using Xiaflex in smaller finger joints due to the potential for a ruptured tendon. Other risks include incomplete release, need for further injections, skin tears, nerve or blood vessel injuries, or even fracture of the finger. It should be stressed that all Dupytren’s disease, no matter how it is treated, will recur.

We do see a fair amount of Dupytren’s here in southern Vermont. It’s a genetic disease that happens most frequently in males of northern European descent. The condition can also be brought on by excessive alcohol use or certain types of seizure medication; but by and large, it’s a condition passed down from generation to generation. The trouble is most people aren’t diagnosed. They think they’ve sustained an injury to their hand and don’t get it looked at soon enough, which means the disease progresses and makes treating it much harder. We talk about it with primary care physicians when we do presentations on orthopedic issues to make them aware of it.

It’s very easy for an individual to determine whether they need treatment for Dupuytren’s. Try putting your palm flat down on the table. If you can’t do that then you need to get medical attention. The key is not to wait and let it get worse.

Xiaflex is not a cure for Dupytren’s. It could always return in a person who is genetically disposed. But unlike the surgeries, Xiaflex can restore a person’s quality of life faster and with far less risk. Think about a carpenter grabbing a hammer, an office worker typing on a keyboard, or any of the hundreds of other things we do with our hands each day and it’s really exciting that we have this kind of cutting edge treatment available in our community.

Elizabeth McLarney, MD, is a board-certified orthopedic surgeon with Southern Vermont Orthopaedic & Sports Medicine, which also includes Dr. Jonathan Thatcher, Dr. William Vranos and Robert Feinberg, P.A. She can be reached at 802-254-6211.

By Robert Feinberg, Physician Assistant

In last week’s Health Matters column, my colleague Dr. William Vranos referenced some studies that indicated a significant rise in total joint replacement surgeries being carried out. Indeed, one study by the Agency for Healthcare Research and Quality projects a 670 percent increase in knee replacement surgeries alone by 2030.

Robert Feinberg, PA

But the good news is that a lot of people seeking orthopedic care aren’t in need of immediate surgery. In fact, some patients may not need surgery at all to treat their conditions. One of the main roles of physician assistants who practice in orthopaedic surgery, like myself, is to help make that determination.

Physicians have been utilizing physician assistants for about 40 years now. A PA’s training is a condensed medical school training. We do similar coursework but over a shorter time; most of our experience comes on the job. Instead of four years of medical school, we do one and a half years of didactic, followed by a year of clinicals and then it’s all on-the-job training. PAs can specialize in any specialty with orthopaedic surgery one of the most common.

PAs who specialize in orthopaedic surgery see a lot of non-surgical, musculoskeletal injuries and complaints which are orthopedic in nature but may not require surgery to fix: anyone who strains or sprains their knee, people who twist or trip, people who have meniscal injuries and those with cartilage or other soft tissue injuries. Often, these injuries are not severe enough to require surgery. Many knee problems, for example, can respond well to rest and physical therapy as well as injections of cortisone. In addition, synvisc (lubricating injections) are beneficial in many cases of degenerative arthritis. So, working with Drs. McLarney, Thatcher and Vranos, I may try some of those methods first and see what kind of results we get. If the results are less than optimal then I can work with the team of physicians to coordinate further evaluation and surgical interventions as needed.

I ask every patient this one question: How much does this injury affect you every day?

The ones who say it limits their everyday activities are the ones I refer on to surgery. In addition, some patients need to be put on a pre-surgery treatment plan to reduce inflammation and strengthen the affected area prior to an operation. A patient who follows a pre-surgery plan can recover more strength more quickly when doing rehab afterwards.

If it comes to surgery, a PA can assist the surgeon in all phases of the planned surgery. We assist in the pre-operative, inter-operative and post-op phases. Every state has different laws and different doctors have their own preferences. I’ve worked very closely with the surgeons on learning incisions and closures, fracture reduction, and assisting with total hip and knee replacements. With their guidance I can be a useful addition to the surgical team, which will enhance your surgical experience.

At most orthopedic practices in the United States there’s generally a 2-3 month waiting period to see somebody. Having a PA opens a practice to a lot of patients who couldn’t get in here before, especially for non-surgery complaints. Since I joined Southern Vermont Orthopaedics and Sports Medicine last fall, we’ve been able to schedule appointments within a couple of days and sometimes even the same day. There are people who are exclusively my patients. If there’s no surgery involved I treat them until they’re better. New patients will see me first and if they’re a candidate for surgery they will be assigned to whichever surgeon is here with me that particular day. However, if a patient already has an established relationship with a particular surgeon we try to keep it. So I learn the routines and preferences of Drs. McLarney, Thatcher and Vranos for approaching a patient. Each has their own area of expertise and their own preferences when determining when the time is right for surgery.

Part of my job is to facilitate pre-surgical planning. I will work closely with each patient and the surgical team as we map out a treatment plan. So when we are considering whether a patient is a candidate for surgery, I have to take into account not only the surgery but the recovery period, lifestyle, age and other medical issues. I will order x-rays, MRIs and lab work to make sure there are no other health-related risks, such as cardiac problems. We look at every individual patient’s case and determine the cost benefit of doing the surgery versus not doing the surgery and what it’s going to be like for her or him. I then work closely with the patient and surgeon to determine the best timing and course of treatment for each individual patient. This way BMH can provide optimal care for your orthopaedic needs.

Robert Feinberg, PA, is a physician’s assistant in the Southern Vermont Orthopaedic and Sports Medicine practice. He can be reached at 802-254-6211.

by Dr. William Vranos

Just after the new year, a group of orthopedic surgeons in Finland published the findings of a study showing that over the 25 year period between 1980 and 2006 there was a 130 percent increase worldwide in knee replacement surgeries for patients between the ages of 30 and 59, with the greatest increase occurring in patients between 50 and 59 years old. There was a time when we would have to tell people suffering from arthritis they would have to wait until they were 65 years old before surgery would be advisable. But the incremental advances in surgical technology that have occurred over these last few decades have combined to make knee, hip and shoulder replacements into three of the most successful elective surgeries ever introduced.

William Vranos, MD

For one thing, the materials used in joint replacement surgery have increased the lifespan of the prosthesis dramatically. It’s hard to believe that 50 or 60 years ago people were in nursing homes or housebound just because of arthritis. They just couldn’t move around anymore. In 2009, the Agency for Healthcare Research and Quality reported that over 600,000 people in the U.S. had joint replacement surgery for osteoarthritis of the knee alone. Now even a younger adult who puts a lot of strain on a joint replacement can expect the materials to last through most of their adult life. The risk of multiple revisions due to wear over the course of the patient’s life is much less now than twenty years ago.

Some advancements have been tangential. For example, knee replacements went through a period where surgeons were using an alternative approach that made a much smaller incision. Most orthopods have stopped doing the procedure because the complication rates ultimately didn’t justify it. But my incisions are about 60 percent smaller than what they were five years ago because of the instruments that were developed for the approach.

New instruments are also contributing to a more straightforward approach for performing hip replacements in certain patients. These new instruments have been modified in a way that lets the surgeon approach from the anterior, or front, of the hip. The procedure is performed under x-ray guidance, which allows a small incision between muscle plains, so it’s really very atraumatic for the patients. You have a small incision, which doesn’t cut through any muscle and post-operatively it seems like the recovery is that much faster.

The biggest improvement of all has probably been the use of regional anesthesia, especially for knee replacements and, to a lesser degree, shoulder surgery. The anesthesiologist can now use ultrasound equipment to put the anesthesia around the nerve with a very high success rate. Regional nerve blocks eliminate the nausea or breathing complications that may occur with general anesthesia and it results in less post-operative pain for the patient because the block can last for up to 24 hours.

Here at BMH we have an excellent approach where the anesthesiologists, the surgeons and the nursing staff discuss how we’re going to treat a patient’s post-operative pain before the procedure. We agree on a very specific set of medications and a schedule that enables us to preemptively treat a patient’s typical post-operative problems with incredible results. Now patients are up the morning of surgery and are generally able to eat a light breakfast. It not only benefits the patient’s comfort but their recovery as well. The sooner you can get the patient moving the less risk they have of getting a blood clot (deep vein thrombosis). Whereas before some patients would have to sit in bed for a day or two while the nurses tried to control their pain, now we can get them up in a chair or walking more quickly. IV’s and catheters are usually out within 24 hours of the procedure.

Studies show the percentage of patients who are satisfied with hip replacement is in the high nineties. Satisfaction after knee replacement is in the low nineties and for shoulder replacements it’s in the high eighties. But there are objective and subjective measurements to any outcome. Orthopods and physical therapists have a scoring system that takes into account the patient’s range of motion, what the x-rays look like, and limb function. Most of the time, the objective measurements correlate very well with what the patient is feeling. However, some patients will have really good measurements but still experience pain and discomfort. Others will have low scores but feel satisfied with the outcome. I remember doing a shoulder replacement for an elderly woman who had severe osteoarthritis. She didn’t go to therapy so her range of motion was limited. But she was a violinist and the surgery enabled her to move her bow arm back and forth and she could once again carry her violin case. Her shoulder scores were terrible but she was happy because she could play again.

All these improvements, big and small, add up to total joint replacement being more accessible than ever before, and the number of people having the procedures will continue to increase in younger patients. There’s really nothing that a big hospital does that we can’t do here. A patient and their primary care doctor should confer with an orthopedist to decide when the time is right for an operation, but arthritis at any age no longer has to be the painful, restrictive condition that it once was.

William Vranos, MD, is a board-certified orthopedic surgeon with Southern Vermont Orthopaedic & Sports Medicine, which also includes Dr. Elizabeth McLarney, Dr. Jonathan Thatcher and Robert Feinberg, P.A. He can be reached at 802-254-6211.

By Dr. Jon Thatcher

It’s almost a certainty that each and every one of us is going to experience back pain at some point or another in our lives. The most commonly quoted statistic says four out of every five people will suffer some sort of back problem. But despite its prevalence, the causes of back pain are complicated and even mysterious at times, making treatment difficult.

Another commonly accepted statistic is that 85 percent of the time the origins of back pain cannot be determined. Some people injure their back by doing nothing more than getting out of bed in the morning. Muscle strains from accidents or physical activity can have their roots in the lifestyle choices we make, or can be brought on by mental and emotional stress.

Jon Thatcher, MD

The back is a huge system of muscle, bone and nerves performing a vast array of tasks for the body. We as humans sit a lot but we’re meant to move. Our core muscles deep in the pelvis and spine get weak because we don’t use them. You sit at your desk all week and then during the weekend you injure your back trying to move a TV or a refrigerator down the stairs. Maybe you experience the pain right away or you might not feel the effects until a week later.

So much of the back pain is just muscle strains or tears or inflammation — what medical professionals call soft tissue mechanical back pain. There’s no real surgical treatment that can help muscles. The ligaments, tendons and muscles get sore or cranky from overuse and they need rest or medicine to get better. Back surgeries only account for about 15 percent of my practice, in fact. But there is an easy way to tell when a surgical procedure can fix your back, and it starts with paying attention to pain in your legs.

In general, the surgeries that work best for the spine are ones that alleviate the pain, weakness, tingling or numbness in any part of your leg from your rear end down to your feet. Sciatica is the all-encompassing name for this kind of nerve pain, and many patients feel it in their legs long before it starts to affect their back. It’s very easy to detect with an MRI test. Often the pain will map out from the lower parts of the backbone right down the nerve roots like one of those diagrams you see in medical books.

A herniated disc is the most classic cause of sciatica. The inside of a disc is like crabmeat or putty and, if the disc tears, that material begins to push out and hit the neighboring nerves causing this terrible pain in the legs. Sometimes it will go away on its own; sometimes it could lead to an even worse back condition. But all orthopedic surgeons are trained to perform the straightforward operation that can quickly cure the pain by removing the extruded fragment and relieving pressure on the nerve.

Another back problem that leg pain could be warning you about is spinal stenosis, or tightening of the spinal canal housing the spinal cord. This is a condition where little joints in your back, called facet joints, swell up around the spinal canal. Think of how the waist of an hourglass gets narrower in the middle before widening again and that paints a pretty close picture. These facet joints also sit right next to the leg nerves, so the narrowing will cause aching or weakness in the legs usually with walking. Unlike the immediate pain of sciatica, spinal stenosis occurs more slowly, so over a long period of time you may find that you can’t walk very far without feeling it.

Some people have a congenital or developmental abnormality that can cause spinal stenosis at an early age but the condition usually occurs when people reach their seventies or eighties. In either case, once an MRI determines the exact location of the narrowing, the procedure to remove the bone and ligaments around the nerve is straightforward and the resulting relief from pain comes quickly.

One of the only times that back pain can be relieved by surgery is with a compression fracture. These mainly occur in older people suffering from osteoporosis. An x-ray can see right away if one vertebrae has compressed down. About 10 years ago, a new procedure called kyphoplasty became available to surgically relieve pain from compression fractures. Through puncture wounds, small cannula are placed into the compressed vertebral fracture. Small balloons are inserted through the cannula and inflated to elevate the compressed vertebrae. Then the balloons are deflated and removed and replaced with liquid bone cement. This hardens in ten minutes, relieving most of the pain and improving curvature of the spine.

While some orthopedic surgeons do go on to specialize in complex back procedures for advanced conditions or severe spinal injuries, these simple procedures are part of every orthopedist’s training, and don’t require patients to travel to large centers that specialize in treating backs in order to get relief. If you’re experiencing leg pain or back pain that is lasting longer than several weeks, the first step is talk to your primary care physician. He or she can order an MRI to determine whether back surgery is a viable option and then refer you to a local orthopedist accepting patients in need of back surgery.

Jon Thatcher, MD, is a board-certified orthopedic surgeon with Southern Vermont Orthopaedic & Sports Medicine, which also includes Dr. Elizabeth McLarney, Dr. William Vranos and Robert Feinberg, P.A. He can be reached at 802-254-6211.

Elizabeth A. McLarney, MD

Did you know that May is National Osteoporosis Month? It’s important to pay attention to the possibility of osteoporosis because, as a woman ages, she faces a far higher risk than her male counterparts of osteoporosis – a disease characterized by thinning bones and a high risk of fractures in the wrist, hip and spine.

Bones form the scaffolding for the human body. But unlike scaffolding, which is static and over time will rust and decay, our bones are in a constant state of turnover and repair, a process called remodeling. The remodeling process requires raw materials–calcium, vitamin D and exercise–to keep bones in good repair.

Adults reach peak bone mass in their 30s, followed by a slow decline. Women fare worse than men because they have smaller frames on average than men–with less bone to start with. When they hit menopause in their late 40s or early 50s the rate of bone loss accelerates for a few years, leaving many women vulnerable to fractures.

To some degree women are helped by having higher estrogen levels prior to menopause. And until recently many women have taken hormone replacement therapy to maintain bone density. Following negative findings about the increased risks of heart attack and stroke associated with HRT, most physicians are presently reluctant to prescribe it for most patients.

Other prescription drugs are available, however, that can help prevent bone loss and actually increase bone density. Biphosphanates, a class that includes Fosamax (alendronate) and Actonel (risedronate) have been shown to help prevent bone loss.

Just about every woman can presume that she needs to follow the basic guidelines of getting recommended amounts of calcium and vitamin D  for her age plus plenty of weight bearing exercise to ensure adequate bone density.  But how does she know if she needs a bone-building drug as well?

A non-invasive test – bone densitometry (known as dual energy x-ray absorptiometry DEXA) is considered the gold standard for measuring bone density and the future risk of fractures. This test can be used to measure bone density at the wrist, hip and spine, all high risk areas for fractures.

The definition of osteoporosis is based on how much  bone mineral density varies from the average bone mineral density of a young adult. Expressed in T-scores, osteoporosis is diagnosed when the T-score is below -2.5. Scores of -1 to -2.5, indicate osteopenia, a less serious condition but an early warning that either lifestyle changes or medical interventions are necessary.

The advantage of having a bone density test is that it can provide an early warning of what is all too frequently a silent disease. For many women the first sign of osteoporosis is the broken wrist, hip or spine that comes with a fall. on the kitchen floor.

Fosamax or Actonel are frequently prescribed for women who have suffered broken bones because of osteoporosis or who have low DEXA scores.

A recent study found that too often patients quit worrying about getting adequate calcium and vitamin D when they start taking medication, assuming that the drug is taking care of the problem. Researchers found that bone building drugs were far more effective when women also consumed recommended levels of calcium and vitamin D.

Raloxifene, a selective estrogen receptor modulator (SERM), has some of the benefits of estrogen but without the risk of breast cancer associated with estrogen replacement. It also increases bone  mineral density and is prescribed for some women with osteoporosis. One negative side effect is that it can intensify hot flashes.

Calcitriol, sometimes prescribed for women who can’t tolerate biphosphonates,  has to be taken twice a day and requires monitoring of calcium levels.

While medications are effective,  women can do much to help themselves.

Lower your risk by getting regular weight-bearing exercise and avoiding smoking and excess alcohol consumption. You should also consume the equivalent of one and one-half pints of reduced fat or fat-free milk or milk products per day as well as calcium-rich foods such as dried beans, green leafy vegetables, dried fruit and calcium-fortified orange juice. In order to use calcium effectively, the body needs vitamin D, which is most readily available through sunlight.

If you’re planning for good health in the second half of life, make sure you include your bones in the blueprint. They’re the frame that keeps your body strong and mobile. So be as attentive to your bones as you are to your skin. Keep feeding them the raw materials they need to renew and rebuild for a strong and active future.

Dr. McLarney is an orthopaedic surgeon in practice at Brattleboro Memorial Hospital. An orthopaedic surgeon is a medical doctor with extensive training in the diagnosis and nonsurgical as well as surgical treatment of the musculoskeletal system including bones, joints, ligaments, tendons, muscles and nerves. 

Jon Thatcher, MD

Secondary to arthritis, knee pain is becoming the most current common condition seen by the general orthopedist. As people are living finger and staying more active, wearing out of the articular cartilage – bearing surface of the knee – has become very common.  Symptoms generally begin with a deep, subtle ache in the knee – usually on the medial side (the inside of the knee) – and this is usually after taxing it with, for instance, hard court tennis, gardening, or a daily run. At first the pain will resolve with a few days of rest, but gradually the symptoms do not go away.

If the wear of the articular cartilage is minimal, x-rays would be normal. However, as more surface cartilage abrades, x-rays will eventually reveal subtle changes consistent with early or moderate arthritis. Fortunately there are several treatment options available that do not involve surgery.

The old standard is aspirin – the original and still one of the best anti-inflammatory medications. Motrin and Naprosyn (Advil and Aleve) have been around for thirty years and are cheap, effective, and do not require a doctor’s prescription.

The above-mentioned medications block the inflammation to reduce the swelling of the lining of the arthritic knee and thus reduce pain, but they do not help the cartilage at all. And, if taken long-term or in excess, they can have untoward side effects, such as bleeding ulcers. The good news is there are also many natural anti-inflammatories such as ginger, tumeric,  and Zyflamend that can be helpful and are safer.

Another oral treatment is glucosamine and chondroitin sulfate, the main building blocks of articular cartilage. This pill is considered a supplement and is commonly found in pharmacies or health food stores. It was originally used by veterinarians to treat hip arthritis in dogs, and eventually found its way into traditional medicine. The Orthopedic Academy, after reviewing favorable outcomes and double blind scientific studies for human use, now supports its use for arthritis of any joint. Its effect of improving the function of the cells which make the cartilage are subtle and often unnoticeable. The only adverse effect is on your wallet. Tylenol is a commonly used, non narcotic pain reliever that works in the brain and is not an anti-inflammatory.

There are two types of injections currently available for knee arthritis. The most common is cortisone, the supreme anti-inflammatory medication. When you take a pill like Motrin it is distributed throughout your body, whereas the injection into the joint puts all of the medicine where it belongs. Its benefit is often dramatic, but always temporary. It is not a cure, although it may feel that way for a while. In fact, it is caustic to the articular cartilage and its excessive use, i.e. more than three or four injections over several years can actually damage the cartilage.

Synvisc is a relatively new injectable that lubricates and nourishes the damaged articular cartilage. This is normal, good quality synovial fluid which is an important component to a healthy joint. It really is an oil change or grease job. The fluid is harvested from the crowns of chickens (I figured Frank Perdue could not stand throwing out any part). It comes in three syringes injected over three weeks. The benefits last up to a year and can be repeated annually without any adverse effects.

Activity modification, such as avoiding knee flexion greater than 50 degrees while weight bearing, will reduce loads across the knee and thus reduce stress to the aging cartilage. Strengthening the thigh with sit down exercises, such as cycling also help reduce stress across the cartilage. There are various braces that can be used during vigorous activity to alter loads and protect the damaged area in the knee.

Should you develop an arthritic knee, I encourage you to try these options to find out what works for you and then play on, but play smart. Know your limits. If you push too hard and all else fails, you may end up with surgery.

William Vranos, MD

As an orthopedic surgeon, I’m often asked about the risks and benefits of strength and weight training for young people.  Unfortunately, there is a lot of misinformation passed along in gyms and weight rooms. I hope this article will give some guidelines to young people who wish to start a strength training program as well instruct the parents and coaches who will also be involved.  Whether a strength training program is intended solely as a fitness program or as an adjunct to other athletic endeavors, if done properly, it can be safe and effective.  Before discussing details of a strength program for young people, however, certain myths need to be dispelled and obtaining a basic understanding of youth physiology is necessary.  Children and adolescents are not small adults.  They have different bone and hormonal physiologies which need to be considered.

Because these young athletes have open epiphysis (growth plates) there is concern that strength training will “stunt their growth.”  This myth is based on some poorly done studies on children who were forced to carry heavy loads while at hard labor.  Nutritional and other health factors were not considered.  Recent studies have shown no effect on growth and many positive health benefits.  The American Academy of Pediatrics (AAP), the American College of Sports Medicine (ACSM), and the American Orthopaedic Society for Sports Medicine (AOSSM) all endorse strength and weight training as part of an overall fitness program for young people, as long as the program is properly supervised and performed in an appropriate manner.

The intent of the program needs to be focused on increasing strength and not bulk or “body sculpting.”  The classic training pyramid of multiple sets of increasing weight building to a “max” is to be discouraged as it has been implicated in overuse strains and, more seriously, low back injuries.  Studies have shown that a proper training program can consistently build strength, but children and adolescents have little ability to increase muscle bulk because they have yet to produce the levels of hormonal support necessary.  Strength increases are achieved through increased muscle fiber recruitment and efficiency as well as improved muscle coordination.  Programs with as little as two training sessions a week have been shown to be useful and four day per week programs have demonstrated an increase in strength of 9-12% over a two month period.

The sports of power lifting and Olympic style weight lifting are not considered appropriate in this age group.  Serious injuries have been reported and there is little additional benefit compared to a “whole body” approach to strength training.

Given this, reasonable guidelines have been proposed by the AAP.

• Strength training is only a part of a balanced fitness program which should include daily aerobic exercise.
• All major muscle groups should be trained with a day of rest between sessions.
• Exercises should be done through a full range of motion.
• Abdominal and Para spinal (trunk) muscles should be included.
• Three sets of 10-15 repetitions with proper technique should be achieved before weight is added.
• Proper spotting or assistance should be available for all lifts.

Finally, there is absolutely no role for steroid or hormonal supplementation.  Recent studies have shown that abuse of these products in adolescents is growing.  These products are dangerous to both the short- and long-term health of the young athlete, and have been linked to problems ranging from acne to suicide. Remember, increased physical fitness and strength, improved self esteem, and better sports performance is possible in this age group.  These benefits are easily identifiable for the young athlete.   Increased muscle bulk and body sculpting are not realistic goals and stressing these characteristics will lead to frustration or the temptation to abuse supplements or steroids.  These are children and any athletic program should be fun and stress a healthy lifestyle.

Dr. Vranos is a board-certified orthopedic surgeon at Brattleboro Memorial Hospital.