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Scott Webb: There are many surgical and nonsurgical options in the respective orthopedic toolboxes for my guest today. And I'm joined by Dr. Schuyler DeJong, he's a board-certified sports medicine orthopedic surgeon. And I'm also joined by Dr. Kyle Rockwell, he's a board-eligible non-operative sports medicine physician and both are with Health First.

This is Putting Your Health First, the podcast from Health First. I'm Scott Webb. Doctors, thanks so much for joining me today. We're going to talk about surgical and non-surgical options in sports medicine. And I was joking with Dr. Rockwell. You know, my son has a titanium screw in his elbow. My daughter broke her wrist. So I have a little bit of background on this as a parent. So I'm sure folks listening are going to really appreciate your expertise. And as we get rolling here, Dr. DeJong, what is the patient journey? When I ask you that, what does that mean exactly? And when would a patient see an orthopedic surgeon?

Dr. Schuyler DeJong: So the patient journey can vary significantly depending on their access to care. Sometimes it'll go from an athletic trainer at a school field directly to an orthopedic surgeon, if they have that line of communication. Other times they have a close relationship with their primary care physician and they might go see the primary care physician who would do an initial evaluation. And if the patient's injury warranted, then the referral to the orthopedic surgeon would be made at that time. So it can be variable from person to person.

Scott Webb: Yeah. When we think about, you know, when is it time to speak with a surgeon, you know, how does someone go from, again, having had a couple of young athletes in my life, my children, when they are injured, so when my son's elbow blew up on the baseball field from, you know, there to when we talked to the doctor who said, "We need to put a titanium screw in there for you, pal." When is it time? When do you know that you really do need to see an orthopedic surgeon?

Dr. Schuyler DeJong: So that example, you know, an injury with an acute swelling and they're having a hard time doing what they were doing, whether that's throwing a baseball or walking because their knees are all acutely swollen, that's probably more time to go see an orthopedic surgeon. There are certainly a number of injuries where it's more of an insidious onset. It's been sore for a while and it hasn't really gotten any better. And then, there's a bit of a gray zone. Sometimes those can be evaluated initially without an orthopedic surgeon. Sometimes they may go through me to take a look at it first too.

Scott Webb: Yeah. And Dr. Rockwell, I want to switch to you here. Let's talk about the non-operative side of this. And for most of us, you know, surgery, obviously, especially with my kids, a little bit scary. We think about scars and recovery time and all of that. And the fact that there are non-operative options for sports medicine is pretty awesome. So when would a patient see someone like yourself for that non-operative route?

Dr. Kyle Rockwell: Well, I would say that 80 to 90% of musculoskeletal complaints don't require surgery. So anyone that has an ache and a pain from head to toe can go to either Dr. DeJong or myself and get funneled into the system and be treated appropriately. I know my colleague, Dr. DeJong, likes to operate. I do not like to operate, and so I can filter those cases out and send those to him so that there's less workup that he needs to do and he can spend more time in the operating room.

I like to tell everyone that I'm a very big ultrasound needle jockey. I've been very well trained with the use of an ultrasound, and so that's a specialized skill set that I have. Now, I can drive a needle and inject a solution of choice, usually a steroid or a numbing solution, into a joint or a muscle or a tendon sheath, not only to help calm down any pain in an area, but sometimes it can be useful to answer a question because if there's some case where you just can't identify where this pain is coming from, is it coming from this muscle, this ligament, this tendon, this joint? I don't know. Well, I can guide a needle specifically to that spot and numb it. And if the pain went away, that's the area that's causing the pain. So, do I do something non-operatively or does that area need surgery? And that helps us answer some questions before you just go to an operating room so you can be more confident in what you're doing.

Another thing that I can add in is there are areas in the body that have some tendinopathy or tendinosis, and we can kind of talk about that a little bit more later on when we talk can be very useful in treating that as well, which surgery can be somewhat hit or miss with diseased tendon tissue.

Scott Webb: Yeah. And just staying with you, Dr. Rockwell. Do you find that patients appreciate sort of the approach of, you know, "Let's try the most minimally invasive options first," right? "So we think we have a good idea, good handle on what's going on with you. Let's try this first. And if it doesn't work through some trial and error, then we can kind of work our way up to Dr. DeJong's office, and start talking surgery." Do you find that patients really appreciate that?

Dr. Kyle Rockwell: Oh, absolutely. I've already had numerous patients tell me that they appreciate looking at all the different options for them and laying everything out. So, I like to think that I send off patients to Dr. DeJong and my surgical colleagues when it's appropriate. Sometimes patients just need surgery in order to get better, and I like to counsel them on that. And sometimes patients don't require surgery and I like to give them conservative and a little bit more aggressive options, and they like to know what the entire plan is ahead of them and what their options are so they can make better informed decisions for their own body.

Scott Webb: Yeah, that makes sense. Most of us would like to avoid surgery if we can, right? But as you say, sometimes that's what's indicated, that's the best solution. And so we have experts like Dr. DeJong. And switching back to you, DeJong, are there any characteristics to determine the best approach for a patient? So when you think of when you do like a patient workup, patient history, those types of things, whether it's age, career, medical history, genetics, when we think about those characteristics, does that help with diagnosis?

Dr. Schuyler DeJong: Yes, it helps with diagnosis and it also helps with your decision-making. Now, I appreciate ultimately, yes, I am a surgeon, but I completely agree with Dr. Rockwell that the vast majority of complaints aren't necessarily surgical. And while I am a surgeon, I am also trying to do the best thing for our patients. Dr. Rockwell's skillset is definitely the optimal and the non-operative management, and I have some of these other tools.

In terms of when you choose surgery, you've discussed your own son when his elbow blows up and he has a bone fragment that, you know, I'm assuming that's like his medial epicondyle that popped off. You know, those sorts of things, there just isn't a non-surgical option sometimes. So are hand is sort of forced in terms of picking the best option for that.

When it comes to non-operative treatment of a chronic condition, you try what you can. And sometimes the lack of improvement with some of the less aggressive options sort of starts guiding you towards a more aggressive option if the things you're trying just aren't working. So I would ultimately answer your question with, I think the conditioner is the abnormality frequently will give us a series of options. Sometimes there are some conservative things and frequently those conservative options do work very well for the management of a musculoskeletal condition. Sometimes they just don't. Or if the things that we've tried non-operatively aren't working, then maybe it is time to take something a little bit to the next level.

Scott Webb: Yeah, you're so right. In my son's case, his surgeon just said, "Well, so you've got this little bone fragment here floating around in your elbow, and that's not good. You can't have that, right? So we need to take this and we need to put it back where it goes, and we're going to use a screw." And Dr. Rockwell, I want to learn more about this. I want to learn more about PRP injections, which of course wasn't an option for him, but it may be an option for many patients. So how were they used in orthopedics?

Dr. Kyle Rockwell: So PRP stands for platelet-rich plasma. If you take your blood and spin it into a centrifuge, it'll be separated out into various components. There'll be red blood cells, white blood cells, and then there's plasma, which is a liquid component of your blood. And in the plasma, you can find a bunch of platelets. Platelets are what make clots when you get a cut. And with those platelets, they have growth factors and a whole bunch of other cell-signaling molecules. And so what we can do is take that PRP layer and inject it into an area of your body.

And there's really two main areas that we can inject this into. One is a joint, usually an arthritic joint or a joint that has a labral tear, a labrum usually being piece of cartilage that goes around like your hip or your shoulder. So if the joint is angry, sometimes PRP can be used in there to inject. Not to regrow cartilage to heal the labrum, but it changes the cell-signaling environment so it's not as disorganized and inflammatory response. It kind of calms the area down, hopefully.

And then, another area that it's used heavily is with tendInopathy. TendInopathy is kind of a fancy word that says diseased tendon tissue. Now, if you think of a tendon, and you look at it under a microscope, it has collagen fibers that resist stress in one direction very well. That's normal. But with lack of use, you're sedentary, maybe you have an injury, those parallel collagen fibers can tear and reheal and tear and reheal, and all of a sudden they become like a plate of cooked spaghetti. They just don't resist stress in one direction very well.

So how do you induce an appropriate healing inflammatory response and get that to heal? And so that's when I can take PRP and I can use my ultrasound machine and my needle, and I can direct it directly into that diseased tissue and inject the PRP and hopefully stimulate a healing response. And then, you do therapy to induce those appropriate stresses and see if you can get those parallel collagen fibers back.

Scott Webb: It's very cool. One of the things I love about hosting these is just the advances in science and medicine, how it happens almost on a daily basis. So, very cool. How active can patients be using PRP injections? Is there like a limit or some best practices that you follow?

Dr. Kyle Rockwell: So what I usually tell patients is I'm kind of inducing what is equivalent to a bruise in an already angry part of your body. So it's probably going to be upset for a couple days. But as soon as a patient feels ready to do stuff, I want them up and using that area as soon as possible. There's typically not any risk of like a tendon rupturing or worsening arthritis in the joint, because I want them to be able to get back to their life and do what they want to do. So I usually say get back to activity with toleration and get back into physical therapy as soon as you can tolerate. Because like I said, you want to induce stresses into that tendon or into that joint to get that appropriate healing response. So I usually tell my patients, "Hey, you go live your life."

My best practice is I go by something called the rules of pain. There are three rules of pain that I have. The first one is it can't be more than a three out of 10, meaning you can do an activity and there can be a little bit of pain, but I don't want it to be the only thing you think about during an activity. Another thing is that I don't want you to have extreme pain later that night or the next day after an activity. And I don't want you to change the mechanics or the form of the way you're doing something. And if you can do that, you can avoid those issues and live your life.

Scott Webb: I love it. Yeah. You know, I said these things are so educational. And sort of the rules of pain, I was jotting those down for me and my daughter as well, who's still playing sports. It's been really educational today. As patients, and of course doctors are patients too, we all want to know that we have options, surgical, nonsurgical, cool stuff like PRP. It's really awesome. I want to give you a chance here, Dr. DeJong, to wrap up and give us some final thoughts and takeaways when folks are confronted with either surgical or nonsurgical, how the both of you and everyone else there can help.

Dr. Schuyler DeJong: Clearly, you tear the ACL and that's something that might need surgery in a young, active individual. But let's say shoulder pain starts off with a tendinopathy of the tendon and it's inflamed. You know, there we have a lot of room for non-surgical treatment, such as the things that Dr. Rockwell's discussing. And then, at some point, that tendon gets a tear in it and it's actually a hole. And then, now it becomes a little bit more of a surgical problem. So frequently, these things are kind of a continuum, but a lot of times nonsurgical options can help. If they don't, we certainly have surgical options and we can cover both that way.

Scott Webb: Yeah. And it certainly seems that you both, listen to the patients sort of really listen to injury, follow what the injury is telling you, especially based on patient history, how they injured themself and so on. And with options like PRP injections and more, it sounds like folks are in good hands. So thank you both. You both stay well.

Dr. Schuyler DeJong: Thank you very much.

Dr. Kyle Rockwell: Thank you.

Scott Webb: And thank you for listening to Putting Your Health First. To learn more about Sports Medicine Services at Health First, visit hf.org/sportsmedicine. And if you enjoyed this episode, please be sure to tell a friend share on social media and check out our entire podcast library. We look forward to you joining us again.