In this episode we talk with Dr. Ashutosh Ajri. Dr. Ashutosh is a specialized orthopaedic surgeon of shoulder, knee and sports injuries. He is among the best Shoulder, Knee and Joint replacement surgeons in Pune who specializes in Arthroscopy surgeries, replacement surgeries and Sports Ligament Injuries.

Key topics covered:

  • Common preventive steps for sports injuries
  • P.R.I.C.E protocol for sports injuries
  • Common knee injuries such as ACL (anterior cruciate ligament) Tear and Meniscus Tear in Knee
  • Treatment for ACL (anterior cruciate ligament) Tear and Meniscus Tear in Knee
  • Common shoulder injury which is dislocation of the shoulder
  • Treatment for shoulder dislocation
  • Rehabilitation program for sports injuries

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Sport Injuries of Knee and Shoulder

A talk with Dr. Ashutosh Ajri.

Speaker: Mr. Vivek

Hello, welcome to Dr. Talks. This is your host Vivek. Here we chat with the best doctors about diseases and conditions they treat. Our guest today is Dr. Ashutosh Ajri. Dr. Ashutosh is a specialized orthopedic surgeon in shoulder, knee and sports injuries. He is among the best shoulder, knee and joint replacement surgeons in Pune. He specializes in arthroscopy surgeries, replacement surgeries, and sports ligament injuries. Welcome Dr. Ashutosh.

Speaker: Dr. Ashutosh

Hello Vivek, thank you for inviting me to Dr. Talks.

Speaker: Mr. Vivek

To start with, I would request you to share your background in medicine.

Speaker: Dr. Ashutosh

Hello, I am Dr. Ashutosh Ajri. I’m a shoulder, knee and sports injury specialist. I’m specialized in arthroscopy, joint replacement surgeries . After completing my MBBS in 2005 from BJ Medical College Pune, I joined a diploma in orthopaedics in Sancheti Institute of orthopedics Pune, where I was awarded University gold medal. Then I further did my DNB orthopaedics in 2010 from the Deenanath Mangeshkar hospital Pune. During my diploma and D-orthopedics training, I developed an interest in sports medicine, especially in shoulder and knee injuries. To refine my skills, I got enrolled in various international fellowships. To start I joined Arcus Sportklinik in Germany in 2013. And then as a foreign medical scientist at the soldier department, Samsung Medical Centers, Seoul , South Korea in 2016. In between I joined the Department of shoulder and sports injuries at Deenanath mangeshkar hospital, Pune as a full time lecture for two and a half years. Last year, I was invited as a visiting fellow at Perth Australia to share and learn some complex shoulder surgeries. I am a founder of the Aadhya orthopaedic and physiotherapy care center for sports injuries in pune. I’m also unit head of shoulder department Sancheti hospital, Pune. I’m a visiting surgeon at Columbia Asia hospital and Deenanath mangeshkar hospital. I had conducted various workshops to treat arthroscopic and joint replacement surgeons. My special area of interest are arthroscopy surgeries around shoulder and knee injuries. These are arthroscopic surgeries of shoulder dislocations and cuff tears, shoulder replacement surgeries like reverse shoulder replacements, sports injuries around shoulder, knees, geriatic shoulder problems and also like to train sportsman’s to our injuries and perform better.

Speaker: Mr. Vivek

Thank you, doctor. Today I wanted to discuss sports injuries with you. Can you please share sports injuries that you treat?

Speaker: Dr. Ashutosh

The most common joints involved in sports injuries are knee, shoulder, ankle joints. Most of the patients come with ligament and muscle injuries around these joints, especially in sports like football, running. Sportsmen who are involved in overhead sport activities like cricket, volleyball, boxing, badminton come with symptoms related to shoulder, elbow and core weakness.

Speaker: Mr. Vivek

What are common preventive steps that sports players or anybody playing sports can take?

Speaker: Dr. Ashutosh

Good question, sometimes preventing common sports injuries beyond our control, but many times sports injuries can be preventable. Every workout should start with gentle warm up and stretching exercises to prevent common sports injuries. Getting warm up, increases the blood supply to the muscles and gets more flexibility and decreases the chances of injury. You should always respect your body when your body is in pain and fatigue, you should stop immediately. You should always use good sports related protection gears just to prevent the injuries. You should gradually increase the intensity and duration of the training. You should undertake a fitness program to develop strength, balance, coordination and flexibility and most common thing is you should allow adequate time to recover between the workouts and training sessions. You should practice in a safe sporting environment and you should also concentrate on good nutrition.

Speaker: Mr. Vivek

I have heard about PRICE protocol in case of sports injuries. can you please elaborate on it?

Speaker: Dr. Ashutosh

The PRICE protocol is effective for most sports related injuries. It is the most common protocol followed as a first aid and some time as treatment as well. The Price  means protection, rest, ice application, compression, and elevation. After the injury you should always protect the affected part with a splint, pad or crutches. Then, the joints should be given rest to restrict activity that aggravates your injury. Apply a lot of ice packs immediately, which will reduce pain and swelling. It resists the requirement of painkillers. Apply ice packs several times a day for at least 15 minutes. Apply compression like braces, caps, compression bandages as a support to prevent additional swelling and blood loss. You should elevate the limb above your heart level to reduce swelling. You can also supplement with non steroidal anti inflammatory drugs, which will help in reducing pain and swelling and recovery.

Speaker: Mr. Vivek

Let’s now discuss a few specific injuries. Can you share more about two common knee injuries which I have heard about one is ACL tear, knee injury and other is meniscus tear knee injury.

Speaker: Dr. Ashutosh

The knee is a very complex joint in the human body. Your knee is formed by four bones, thighbone, two leg bones and kneecap. These bones are connected to each other by ligaments. These ligaments will act like a strong rope to hold the bone together and keep your knee stable. There are four primary ligaments in the knee joint. These are two cruciate and two collateral ligaments and two cruciates we call it as a meniscus. The collateral ligaments are found on either side of your knee. They control your side to side stability to your knee joint. Cruciate ligaments as the name suggests, they form a cruciate at the center of the joint. They cross each other in the form of x. Front ligaments is called anterior cruciate ligament and back ligament is called posterior cruciate ligament. They both do front and back stability. meniscus are two very sharp pieces of cartilage, which act as shock absorbers between your thigh bone and shin bone. They are tough, rubbery to help cushion the joint and keep it stable. ACL and associate meniscus injury is one of the common knee injuries. And ACL meniscal injuries often happen during the sports and fitness activities that involve sudden stop changing direction jumping and landing. But in India, another main cause of ACL injury is road traffic accidents. At the time of injury, patient will feel a loud popping sound and a sensation in the knee joint association with the severe pain, swelling and collection of fluid in the joint so that athletes will not be able to continue Playing and walking later when pain and swelling reduces, he will have a feeling of instability or gingiva sensation while walking, stair climbing and running. Associate misc injury may be presented with locking of knee, there will be a combination of symptoms which can be presented in my OPD.

Speaker: Mr. Vivek

How do you treat these knee injuries if you can cover both medicine and surgical interventions required for complex cases.

Speaker: Dr. Ashutosh

When an athlete visits my consulting room I need to discuss in detail about the history of injury and symptoms. After that, I will examine the knee and check all the structures of the injured knee and compare it with a normal knee. Most ligament injuries can be diagnosed with thorough physical examination of the knee. I will further investigate in the form of X rays. X rays will not show any soft tissue injuries but it will help to locate associated damage to bones. The gold standard is MRI that is magnetic resonance imaging. It will give a better imaging of soft tissues like anterior cruciate ligament. It will help in grading the ACL tear that will help in deciding the further line of treatment. MRI will also help in identifying associated other soft tissue injuries, which can be managed accordingly. ACL can be graded in three grades, grade one is ligament where it is mildly damaged and stretched. All the fibers of this ligament are intact. So the treatment is PRICE for a few days then gradual mobilization and therapy so that the patient returns to the pre injury level. In grade two the ligament is further damaged and stretched. It is often referred to as a partial tear of ligament. If overall stability of the knee is intact, you may be recommended non surgical treatment as grade one tear. In grade three tear pain is also called complete tear of ligament where it will be torn into pieces. This type of pain is more commonly called a complete tear of ligament. Due to this the knee joint is unstable and complete tear ligament do not heal on its own. To restore the stability the ligament must be reconstructed using tissue graphs. This graph acts as a scaffold for knee ligament to heal. The regrowth of the ligament takes time, it may take six months or more before the athlete can return to sports after surgery. For meniscus treatment will depend on type of tear, you have its size and location. Incomplete tears can be managed with conservative treatment in the form of price initially, and then aggressive therapy later, but the complete tear needs surgical intervention. The peripheral tear where the blood supply is good, we can attempt to repair but the central tier where the blood supply is very poor. We may have to exercise the toner affected part of the meniscus. These all surgeries can be done with minimally invasive arthroscopic surgery with very small incisions. The benefits of lesser invasive techniques include minimal pain, minimal scar, minimal blood loss, reduced hospital stay, early mobilization, quick recovery time after the surgery and treatment.

Speaker: Mr. Vivek

For severe cases of ACL and meniscus tear, do players recover fully to their previous performance or certain challenges stay with them in terms of their capability and flexibility to move.

Speaker: Dr. Ashutosh

Most of the athletes return to the pre injury performances, but the physiotherapy plays an important role in recovery. It may take them six months or even more before the athlete can return to sports after surgery. We need to be very particular about the surgery, the time for healing and post surgery rehabilitation. These are the three important factors which contribute to the athlete to return to the pre injury level. It has to be very meticulous about all these aspects.

Speaker: Mr. Vivek

Let’s now discuss a common shoulder injury which is dislocation of the shoulder. Can you elaborate and explain it to us about this injury?

Speaker: Dr. Ashutosh

Yes, the shoulder is the most mobile joint in the body, which has compromised the stability for mobility. It is more susceptible to dislocation. As this joint is a ball and socket joint, ball is formed by the upper end of the arm bone and cup is formed by the socket, which is a part of shoulder blades. Ball is three times bigger than the socket. So there is a large discrepancy in shape, size and strength. But to increase the depth of the socket, there is a spatial ligament configuration around the socket we call it as a lebro capsule complex. This will increase the depth and stability of the joint. Shoulder joint can dislocate forward, backward, and downward. Maybe complete or incomplete. The most common is forward dislocation. When shoulder dislocates, the ligaments in the front of the shoulder are often injured and we call it as a bank card here, a shoulder dislocation may be caused due to sports injuries. The most common are contact sports such as cricket, football, hockey sports like gymnastics and volleyball. Other main causes are motor vehicle accidents and falling from height ladders or just tripping. In a small minority of patients that shoulder can become unstable without a history of injury. In such patients, the shoulder may feel loose or dislocate in multiple directions. We call it multidirectional instability. This patient had naturally lost ligament throughout the body.

Speaker: Mr. Vivek

How do you treat a shoulder dislocation?.

Speaker: Dr. Ashutosh

Whenever there is an acute dislocation of the shoulder you should get medical help right away. But while you are waiting for medical attention, don’t move your joint and the shoulder should be splinted or the sling should be applied in the correct position. You should apply a lot of ice packs so that the pain and swelling will subside. But after suitable assessment and x rays shoulder can be relaxed with gentle reduction methods. You may need to use muscle relaxants or seditions are rarely under anesthesia before manipulation of your shoulder joint. After reduction, you will be asked to use a sling for two to three weeks to keep her shoulder moving. Men in the 20s, a group that tends to be physically active, are at higher risk for shoulder dislocation. So prevention is better than cure. And to help prevent sort of dislocation. You should take care not to fall not to get injured. You should always wear protective gear while playing contact sports and you should exercise regularly to maintain strength, flexibility in your joints and muscles. Once you are dislocated in your shoulder joint, you may be more susceptible to further shoulder dislocations to our recurrences, you must follow a specific strength and stability exercises with the help of sports consultants who may need surgery if you have a recurrent shoulder dislocation, despite proper strengthening and rehabilitation. It’s an arthroscopic keyhole surgery to repair and recreate the torn ligament of the shoulder. It’s a minimally invasive surgery and the patient recovers very fast, some patients they need open surgical procedures. If you have damaged the bony socket due to recurrent dislocations.

Speaker: Mr. Vivek

Now let’s focus somewhat more towards the rehabilitation after a patient suffers from these kinds of sports injuries, which could be either a knee injury or a shoulder injury. How do you counsel your patients and guide and help them during this phase of the rehabilitation? Because I believe that’s also a very critical phase after the treatment, right?

Speaker: Dr. Ashutosh

Yes, rehabilitation is very important to the healing stage of ligaments. Rehabilitation protocols for athletes are customized as per the injury and sports. During this phase you will be put in a functional brace, then the isometric exercises are started as per the site of injury the target area during rehabilitation will be put to full range of movement to maintain the tone and strength of the joints. Then later, the strength program started to protect the healing ligament. The final phase of rehabilitation is aimed at the functional return which are tailored as per specific sports.

Speaker: Mr. Vivek

How is the rehabilitation program planned for the injuries we discussed? Namely, ACL tear in knee meniscus tear in knee and shoulder dislocation.

Speaker: Dr. Ashutosh

Yes, physical therapy is very important for recovery. The first focus will be on the range of movements of the joints and surrounding muscles. This is followed by a strength program designed to protect the reconstructed or repaired ligament. This tendon gradually increases the stress across the ligament. And the final phase of rehabilitation is aimed at the functional return, which are tailored for specific sports. It may take him six to 12 months for at least to return to the sports.

Speaker: Mr. Vivek

Doctor Can you cover how you do the tailoring of the recovery or the rehab program depending upon the kind of injury.

Speaker: Dr. Ashutosh

In athletes who had a knee injury and have been operated on knee to basically work on the multiple aspects the first and most important thing is the core. The second is the thigh and hamstring muscles. And third is the calf muscles. Not only strengthening the rebalancing of the muscles is very important. We basically focused more on core strengthening exercises first and gradually stretching and strengthening exercises. During the immediate post of rehabilitation we focus more on closed chain terrabone based exercises where there is a gradual stretching rebalancing of the muscles. And the further we put them on a gym based protocol where there is a immediate strengthening of the muscles and later we put him on the sports specific therapy where there is a rebalancing of the muscles and gradual put them stresses on the ligaments where it can regenerate and remodel according to those forces in the body. In a shoulder injury when it’s especially in the shoulder dislocations where there’s a loss of balance between the muscles and there is a loss of stability in the shoulder for that within work. Again, core, parry scapular muscles, the muscles around the shoulder and the portion of the shoulder. If you leave any of this link then there is a chance that the injury may reoccur and chances of dislocation are very high. So we’re working on spirit scapular muscles core and strengthening around the shoulder joint. This can be done with a supervised thera band based protocol where there are occlusion exercises where there is a rebalancing of the muscles and gradual tensioning of the muscles.

Speaker: Mr. Vivek

Doctor we have covered the common knee injuries and shoulder dislocation. We also talked about a price protocol and how it is very important to initially provide first aid to the sports player who gets injured. Can you recall any specific patient case and share about it with our listeners?

Speaker: Dr. Ashutosh

Yes, I can recall a badminton player. She had an injury to her right knee during the game. She had a sudden give away pop up sensation and swelling her right knee. She was not able to continue the game when I examined her knee. It was filled with fluid. There was swelling and her movement was very painful. I gave her a brace ,medicines and two basic knee exercises. I asked her to continue ice packs and rest. In a few days. Her MRI was done on the right knee which shows a complete ACL tear and complex inner meniscus tear. I explained to her that she needed surgery in the form of ACL reconstruction and in meniscus repair. She was a professional badminton player and she was put on pre rehab. Prior to the surgery, the pre rehab will increase this surgical outcome shorten hospital stay, she will regain strength fast and give her time for mental preparation for surgery. After a few weeks her arthroscopic ACL reconstruction was done using graft and also was able to repair her inner meniscus. After six weeks of rest basic exercises she was put on ACL rehabilitation protocol exercises and started hitting the gym. I sport specific training after three months of surgery. After four months of training, she was back on code. It’s been two years. Now she’s playing. I can also recall a second player. He’s a Ranjith, a cricketer, who had a fall during a practice session and had dislocated his right shoulder. He’s a right hand spinner, his shoulder was reduced locally, and latterly , he continues to have apprehension and subluxation. While throwing and bowling. I examined him and found his shoulder and was very unstable. His shoulder was further investigated with x rays, MRIs. We showed a bank tier with small bony defects in socket and ball. I explained to him that he needed arthroscopic keyhole surgery to repair the torn ligament. He was also put on pre rehab before the surgery. After surgery he was started on sling to basic shoulder exercises. And after six weeks of feeling he was starting With Thera band rehabilitation protocol, he started hitting the gym after four months of surgery and sport specific training after a few days. He started practicing in nets after eight months of surgery. And now he’s back with his team representing his state team. I’m very happy with his outcome.

Speaker: Mr. Vivek

Great, and that’s nice to hear. Once you treat such a sports player, do you continue to track their performance?

Speaker: Dr. Ashutosh

I follow them after six weeks, three months, six months and one year, and I follow every year. I ask him to come and visit me every year and we assess them every year. If I feel they’re lacking somewhere and need to be corrected. I make sure that they do a good rehab and go back to play.

Speaker: Mr. Vivek

Oh, That’s nice of you Dr. Ashutosh. Your inputs today helped us understand sports injuries and their management better. Thank you for talking to us.

Speaker: Dr. Ashutosh

Thank you, Vivek. It was a pleasure to be part of Dr. Talks. Bye.

Speaker: Mr. Vivek

Dear listeners, please share and spread awareness about sports injuries, their prevention, first aid and treatment by sharing this podcast of ours with Dr. Ashutosh. Cheers till we meet next time.

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