Thanks to West Bay Orthopedics for their responses to your questions on orthopedics. The physicians of West Bay Orthopedics care for patients with fractures, sports injuries, arthritic conditions, and work related problems. Physicians offer subspecialty expertise including spine surgery, joint replacement, hand surgery, and arthroscopic procedures for shoulder and knee injuries. The main office of West Bay Orthopedic Associates, Inc. is located at 120 Centerville Road Warwick, RI 02886. They may be reached by phone at 401-738-3730 and on line at www.westbayortho.com
Question: I have been physically active for the past 11 weeks. The past couple of weeks, I have been having problems with my knee and shoulder joints. My knees keep on cracking when I'm on the eliptical device or the bike. Also, my shoulder kept on making the "popping" noises when I did the vertical chest press, which is part of my circuit training at the gym. I feel no pain in my shoulder but I do feel pain in the knee area. I am only in my late 20's.
Submitted by Nary from Providence, RI
Dr. Winslow Alford of West Bay Orthopedics responds:
In young healthy, active people, joints often click with normal motion and function. There are several non-bone structures surrounding the joints which move and fold against one another, and sometimes this causes clicking. Therefore, painless clicking of otherwise normally functioning joints is not usually concerning. However, if the clicking is associated with pain, weakness, stiffness, locking or instability of the joint, it should be evaluated further by an orthopedic specialist.
Question: My 15 year old daughter was diagnosed at age 11 with a grade 1 spondylolitsthesis. After treatment for a year, she began to feel better, with some discomfort. Recently, she fell and landed open her bank. She was treated at an emergency room but continued to experience lower back pain and spasms. A follow up with her orthopedic specialist resulted in a reconfirmation of the spondylolitheses. There has been no improvement after 5 weeks of treatment. Her physician said he will try an epidural steroid injection and send her for another opinion before a decision is made on surgery (fusion). I wonder if you have any other ideas.
Submitted by Amy from Cranston
Dr. Norman Kornwitz responds:
Spondylolisthesis is a defect of one or both pars interarticularis (the part of the vertebra located between the superior and inferior facet joints) of the posterior elements of vertebral bodies of the lower back area. It is seen in about 4% - 6% of the general population. Spondylolithesis represents a slippage of the vertebral body at the site of the defect. In children this usually occurs between L5 and the sacrum. The usual course of treatment involves exercises that include hamstring stretching, pelvic tilts, and abdominal strengthening. Bracing, including a low profile antilordotic brace, can also be tried. The Grade I defect you describe has a good chance of becoming asymptomatic with conservative treatment, but if after 6 months of failed non-surgical treatment, a bilateral posterolateral L5-S1 in-situ fusion may need to be considered.
Question: I have a 3-Bone shoulder fracture (02/16/08) from a heel over head fall, I possible have a rota-cuff tear. I've had two MRI's. My Surgeon is suggesting possible a shoulder manipulation under local. I have had 7 weeks of therapy, with excellent improvement, however limited extended forward & side mobility. What is your expert opinion?
Submitted by Giovanna from West Warwick
Dr. Matthew Smith responds:
Answer: I will assume that you have had appropriate management and healing of your fractures, in light of your participation in therapy and your surgeon's recommendations. I, too, believe that restoring full range of motion is important. You are likely at high risk of developing what is known as a "frozen shoulder," or "adhesive capsulitis." The good news about this condition is that it gets better with time. The bad news is that this time can be around 2 years. Methods of shortening this time frame are controversial. Some people believe that aggressive range of motion exercises help, others feel that it increases inflammation and perpetuates the condition. Some surgeons perform manipulation under general anesthesia, and others think that further insults the shoulder. I think that if it is done correctly, manual treatments can be helpful. The subscapularis muscle is often involved and can be addressed. If the capsule is indeed involved, injecting 20-30cc of local anesthetic into the glenohumeral joint and performing accessory mobilizations may help. The most important part of your story is that you have had "excellent improvement" with therapy. As long as you are seeing improvement, you can expect to see more. Your injury is still relatively new. Additional resource information can be found at
Frozen shoulder - MayoClinic.com
Question: A year ago I was diagnosed with spinal stenosis, moderate to severe at L4/5, which caused a sporadic pinched sciatic nerve which was excruciatingly painful when in the car, standing, or sitting on a hard seat. Tried everything...exercise programs, epidurals in my back, heat/cold, and finally acupuncture, which seems to have helped. Have not experienced the pinched nerve (spasm from butt to toe so painful I couldn't move) for 7 weeks now. COULD SOMETHING LIKE THAT JUST HEAL ITSELF OVER TIME?
Submitted by Nancy from Charlestown
Answer: Dr. Matthew Smith responds:
The symptoms that you experience typically are related to two factors. The first is anatomic, physical problems. In you, this is a small, narrow spine that creates a mechanical compromise of the nerves. This structural problem has developed over many years and should not be expected to change for the better. However, it is the second factor that likely tips the scales to where you seek medical attention. Inflammation develops which can create pressure, swelling and chemical irritation of the nerves. This will fluctuate and may account for some of the oscillation of your symptoms. Do not discount the potential effect of acupuncture in your improvement. Also remember that trying to understand how acupuncture works in terms of Western theories may discount some of it's foundation. Perhaps your original chi is being depleted as you age, allowing your fire to overwhelm your water. Additional resource information can be found at
NIH consensus statement on acupuncture: 4832 Acupuncture
Spinal stenosis - MayoClinic.com
Question: After hip replacement, heterotopic bone growth developed. Now, tightness in the quadricep makes walking normally difficult. Will stretching exercises help? Any other suggestions would be welcomed.
Submitted by Charles from North Smithfield
Dr. Robert Monighetti responds:
Answer: Heterotopic ossification or HO is a known complication from any trauma to a large joint. It is not uncommonly seen after hip replacement surgery. Various approaches to prevent it have been developed with variable success. These include taking antiinflamatory medication such as Indocin or Naprocin or others, irradiating the joint, or taking a class of drugs known as bisphosphonates ( e.g. Didronel) which affect new bone formation. Once HO has developed, these approaches may have limited value. HO causes new bone to be formed around the joint which can limit range of motion of the joint. The "tightness of the quadriceps" that you feel may actually be due to the HO limiting joint movement. Your orthopedic surgeon should be able to give you an indication as to how extensive your HO is. On the other hand, if a joint is painful, either from surgery or HO, the muscles around the joint tend to get less exercise and will naturally tighten. Gentle stretching exercises would be expected to help in a situation like that. The risk of stretching is that a too aggressive stretch may cause micro-trauma which can actually lead to more HO. A physical therapist should be able to help you gauge how much force would be appropriate when stretching.
Question: How much supplemental calcium does a post-menopausal woman need?
Submitted by Carol from Seekonk,MA
Dr. George Pasquarello responds:
What is the recommended amount of calcium and vitamin D for healthy bones?
The American Dietetic Association recommends 1000-1200 mg /day of calcium and 200-600 IU / day of vitamin D for healthy adults. The daily amount recommended increases with age.
And how much should come from eating dairy products instead of taking a vitamin/mineral supplement?
There is no specific recommendation for food vs supplement sources of calcium. It is difficult to get to the recommended amounts of calcium with food alone, as it is not easily absorbed. Dairy products are good sources of calcium and most milk products are fortified with vitamin D to help calcium absorption. Good nondairy sources of calcium are calcium fortified breakfast cereals, orange juice and soy beverages, tofu prepared with calcium, sardines and salmon with bones, broccoli, bok choy, collard greens, blackstrap molasses, and legumes (peas, beans, lentils). Weight-bearing activities like walking also benefit bone health, so get plenty of exercise. Your skin makes vitamin D when it is exposed to direct sunshine, so spending some time outdoors is important.
Is one form better than the other?
Calcium carbonate is difficult to absorb and should be taken with food. Some people think calcium citrate and calcium phosphate are easier to digest, but there is no research to support this. Many people have side effects such as stomach upset from supplements, so use one that you can tolerate. For more information, log onto:
NIAMS Bone Health Overview
NIAMS Nutrition and Bone Health
Question: I am a 55 year old male. I am very active in my work, I run and do a some weight lifting. About two weeks ago I began to experience a fairly severe pain from my left shoulder up behind my left ear. This most often, but not always, occurs after I have been sitting on a kitchen stool or in a similar position. I do not feel the pain when I run. Also, I do some neck exercises with weights and this does not hurt. Any advice would be appreciated.
Submitted by Bill from South Kingstown.
Dr. Matthew Smith responds:
Symptoms which come on with certain postures often represent pain starting in or around a joint. The area you are having trouble with is very common source of problems, because the neck is designed for mobility and the rib cage is much more rigid. Where they come together, there are a number of small joints. The intervertebral zygapophysial (facet, or "z") joints, the costo vertebral and costo-transverse joints all must move symmetrically through their physiologic ranges of motion in order to be pain free. Dysfunctional movement or restriction in these joints is thought to happen for a number of reasons. Corresponding muscle spasm is common and can produce radiating symptoms, often from the scapular region to the upper cervical spine along the muscle's course. The basis of treatment is to restore the symmetrical range of motion. Stretching, physical therapy, osteopathic manipulative treatment and chiropractic care can help. Anti-inflammatory medicines, muscle relaxants and topical medicines can help. Although rare, more worrisome problems can contribute. If you have any concerns, consider seeking appropriate medical care. For more information, log into:
Mayo Clinic-neck pain
East Greenwich Spine and Sport
Question: I have lower back pain with the pain traveling down my left leg in to my foot. I am taking 800mg of Motrin twice daily along with 10mg of cyclobenzaprine. I get some relief but what do I need to do to get permanent relief? I’m 65 and in good physical cond.190 lbs and 5’ll" sitting down seems to be my enemy-can I play golf or exercise while keeping on my medicine or should I consider a spine clinic?
Submitted by Joseph from Providence
Dr. George Pasquarello responds:
ANSWER: This needs further evaluation. You should start with your primary care physician. Pain radiating from the low back and into the leg may be due to injury or irritation of a nerve root as it leaves the spine. This is often described as sciatica or lumbar radiculopathy. Unfortunately, many things can cause the same symptoms and a thorough neurological exam is needed to make a diagnosis. Imaging of the spine including CT scan or MRI may be necessary.
Golf might exacerbate your symptoms or even make them worse. High impact exercise such as running should be avoided until an accurate diagnosis is established.
The following links will give you more information about lumbar radiculopathy and sciatica:
Mediline Plus-lumbar radiculopathy
Mayo Clinic-Herniated Disk
Question: I am 65 years old and have suffered with scoliosis all my live. The big muscle in the middle of my back wells all the time and cause much pain. Has anyone tried using Botox to relax this muscle?
Submitted by Ellen (no home town provided)
Dr. Robert Monighetti Responds:
Botox, which is a brand name for botulinum toxin, works to interfere with neuromuscular transmission at the cellular level. This means that it weakens the muscles into which it is injected. This can be helpful in cases of muscle spasm where the muscle is continuously contracting and causing pain. At this time, however, Botox is approved for cervical dystonia, which is a kind of neck muscle spasm, but it is not approved for back spasm. What this means in practical terms is that most insurance companies will not pay for this treatment for back spasms. As the drug itself is quite expensive and rather large doses of it are needed to affect a large muscle, most people simply can’t afford to pay out of pocket for this treatment if the insurer denies payment.
There are other ways to deal with back pain and spasm. These include oral medication, trigger point injections, physical therapy, manipulation, acupuncture, and others.
Question: What causes bone spurs?
Submitted by Kathleen from Warwick
Dr. Matthew Smith responds:
Bone spurs are also referred to osteophytes. Bones are alive. A bone which does not seemingly change shape is continuously reabsorbing old bone and creating new bone in response to the stresses placed upon it. As a joint surface ages and is subjected to consistent forces, additional bone is created to share the load. A good example is a football player's knee at the end of his career. A second type of bone spur can occur at the insertion of a tendon into a bone. Here, calcium is deposited at the tissue interface in response to repeated stresses. As we age, we tend to replace all of our elastic tissues with more rigid substitutes. Heel spurs are a good example of this second type of bone spur. Bone spurs are not problematic in and of themselves. For general information, see:
Spine Health-Bone Spurs and Back Pain
MayoClinic-Bones, Joints and Muscles
Question: I have had stiffness in my neck and upper back for several months and have gone to PT with some adjustments in posture and strength building which has been completed. I continue to do some of the exercises on an irregular basis. I had cervical x-rays showing narrowing between C6 & C7, also bone spurs in same area and degenerative changes. I continue to have limited rotation in my neck and some discomfort remains. My questions are (1) now what? and (2)will golf make it better or worse?
Submitted by Barbara from Wakefield
Dr. Robert Monighettii responds:
There is no easy answer to your question. We need to know if the source of your stiffness is muscle strain, a pinched nerve in your neck, arthritic or degenerated joints in the spine, or some other cause. The first question is, why did you develop this several months ago?
Yes your x-ray shows narrowing and bone spurs but they didn’t just develop several months ago; they have been coming on for years. Was there some trauma or change in activity when the symptoms began? Physical or emotional stress can lead to muscle strain and spasm, existing bone spurs in conjunction with unusual neck movements or postures can lead to a pinching of a nerve root, as can a herniated disc. Vigorous activity can lead to a flare up of arthritic symptoms. A detailed history and physical examination, possibly with the addition of advanced imaging, such as MRI, would be needed to find the answer to your first question. You should discuss with your primary care provider whether a specialty consultation Is needed.
Unfortunately, the answer to your second question is,"it depends". As a general rule, gentle exercise is usually beneficial for musculoskeletal problems, but golf may be too vigorous for some. I frequently advise my patients with muscle strain to ease back into golf. Go to the driving range and take gentle swings, perhaps half the intensity you are used to. Then see how you feel the next day. If the problem is a herniated disc causing pressure and inflammation of a nerve root , it may be wiser to stay away from golf until the problem starts to resolve.
For further information you may wish to view the following web sites.
Question: What is the recommended amount of calcium and vitamin D for healthy bones and how much should come from eating dairy products instead of taking a vitamin/mineral supplement? Is this difficult to absorb?
Submitted by Joan from Providence, RI
Dr. George Pasquarello responds:
The American Dietetic Association recommends 1000-1200 mg /day of calcium and 200-600 IU / day of vitamin D for healthy adults. The daily amount recommended increases with age. The following links may be helpful:
There is no specific recommendation for food vs supplement sources of calcium. It is difficult to get to the recommended amounts of calcium with food alone, as it is not easily absorbed. Dairy products are good sources of calcium and most milk products are fortified with vitamin D to help calcium absorption. Good nondairy sources of calcium are calcium fortified breakfast cereals, orange juice and soy beverages, tofu prepared with calcium, sardines and salmon with bones, broccoli, bok choy, collard greens, blackstrap molasses, and legumes (peas, beans, lentils). Weight-bearing activities like walking also benefit bone health, so get plenty of exercise.
Your skin makes vitamin D when it is exposed to direct sunshine, so spending some time outdoors is important. Calcium carbonate is difficult to absorb and should be taken with food. Some people think calcium citrate and calcium phosphate are easier to digest, but there is no research to support this. Many people have side effects such as stomach upset from supplements, so use one that you can tolerate.
Question: My mom is 81 and has chronic lower back pain. Should she see a specialist or her general physician?
Submitted by Joan from Warwick, RI
Dr. George Pasquarello responds:
It would be best to have her first evaluated by her primary care physician. Chronic back pain in this age group can have many causes and in addition to a good physical exam, she may need evaluation with lab work or imaging. The primary care physician can refer her on to a specialist if necessary.