Scott Webb (Host): This is the St. Joseph's Health Medcast from St. Joseph's Health. I'm Scott Webb. And today, I'm joined by orthopedic surgeon, Dr. Brad Raphael. He's here to discuss the various winter injuries that he sees and treats at St. Joseph's Health.

 Doctor, it's nice to have you here today. We're going to talk about winter injury prevention. And I know in Syracuse and the surrounding area, heavy winter season, lots of injuries. So, let's start there. Like, especially in the Syracuse area, why do we think of this as the sort of injury season?

Dr. Brad Raphael: The way that I see it is every season is injury season, whether it's indoor, outdoor, winter, spring, summer, or fall. You just get different injuries depending on the different time of year. The added risk at wintertime is that, in addition, to sports that are maybe all year-round.

You also have the new sports that we can't do in the summertime, such as skiing, ice skating, snowboarding, but also we have a whole new element with ice. And so, it's not only your typical sporting events, but we now have the treacherous, indoor and outdoor, you know, effects of being wintertime, such as slipping on the ice, getting stuck in snow, and items like that that are really localized to the winter months.

And so, obviously, you know, the thing that we always worry about is footwear, and you are slipping on the ice and you are slipping on the snow. And the fact that it's so important that, first and foremost, whether beyond playing outside in, whether it's skiing or skating, you just have to make sure that you have good footwear, good shoewear, and you have to be very vigilant about walking on slippery surfaces.

Right off the bat, just getting out of your car, it can be a minefield walking through your parking lot getting into work. And so, I always encourage people to, A, wear good footwear, nice, good-soled shoes, whether they're boots or sneakers with a good grip. But also, don't run in the snow. Don't run in the ice unless you're actively, you know, playing a sport. Look at the ground, make sure you're not missing any of the black ice and take small steps. Really, try not to carry too much at the same time. You don't want to be out of balance. And also, so many times you're opening up your door, you're trying to get a heavy bag out of the back, and the bag comes flying out. And now, you've lost your balance and you're slipping and falling.

So, just be cognizant of your surroundings. Make sure you have a good base. Make sure you have good footwear. And be aware of any slippery surfaces so you're not distracted on your phone, you're not distracted with your kids, you're not distracted from anything else, and really be aware of the ground surfaces.

Host: So then, you're mentioning there obviously that we need to, you know, wear good and proper footwear and watch out for black ice and all of that. Let's talk specifically about those sports that are unique to winter, like skiing. Tell us about some of the shoulder injuries you see and treat from skiing.

Dr. Brad Raphael: Skiing, we've had a great ski season and it's still going to continue. And what I always tell people is, obviously, don't fall. However, it's impossible to ski without falling. But it's really interesting to see the difference between some of the injuries we get with skiing and the injuries you get with snowboarding. Skiing, many times you have the advantage of having poles. So, poles can both help and hurt you. If you're planting your poles skiing, and you wipe out, a lot of times your hand stays with your pole while your body goes somewhere else. And so, that can cause more of a traction injury or a twisting injury to your shoulder.

Additionally, you can fall directly on your shoulder, and now you're looking at not only soft tissue injuries, such as rotator cuff injuries or labral injuries, where you're going to have potentially a shoulder dislocation or a shoulder subluxation, but now you're looking at collarbone fractures or AC joint injuries from falling directly on your shoulder, which is different from your hand and your pole getting twisted and causing more of a twisting or torsion injury—the trauma versus the twisting injury, whether you're using a pole or you're just falling such as snowboarding or, you know, a ski injury where you're landing directly on that shoulder.

Host: Yeah. And, Doctor, I'm not much of a skier, I have to say, but I am a shoveler, if that's a way to say that. So, let's talk about—I know things that I've suffered, but in general, what are folks doing to themselves, especially their shoulders whilst shoveling?

Dr. Brad Raphael: Unfortunately, everybody becomes a shoveler at some point.

Host: We sure do.

Dr. Brad Raphael: Whether you want to or not. And so, it's really important for shoveling to really be aware of your surroundings. Again, there's a lot of unbalance with shoveling And so you want to make sure that you have good shoe wear, you want to make sure you have a good wide base. You're not falling and suffering from any kind of traumatic injury when you're falling on your shoulder. But now you've got a good strong balance. You've got good shoe wear and you start shoveling.

A couple things you want to be weary of is, first of all, warm up a little bit first. In that, do a little bit of stretching. A lot of times, what do people do? They wake up, they're late for work, they want to jump right out and start shoveling. And so, if you're coming right out and it's obviously cold out, usually below 32 degrees if you're shoveling, and your body's going to tighten right up. And just that one thing can make it more risky for shoulder or musculoskeletal injuries. And so, it's cold out, you're breathing a little bit harder because it's a little harder to breathe when it's cold out. So, I won't even get into some of the chest injuries or the cardiac injuries from shoveling, which we do see this time of year.

But specifically, the musculoskeletal injuries, now you've got a nice wide base. You want to do a little bit of stretching, so you're not going to either pull a muscle or that heavy, heavy snow, you're going to not only hurt your shoulder, but hurt your back. You want to get down with your knees and kind of bend and use your legs to really get most of that torque, because otherwise all of that snow is going to really torque your shoulder and cause soft tissue injuries where you're looking at more rotator cuff injuries or, again, some shoulder instability injuries where you can not only injure the muscles that move the shoulder, but the actual cartilage in the shoulder because that snow just pulls your shoulder out of place and you can actually dislocate your shoulder and do soft tissue damage to the cartilage or the labrum in the shoulder joint itself.

Host: Right. Yeah. And, Doctor, I know many of us enjoyed the Olympics recently. And I love ice skating. It's so beautiful and majestic and amazing. And then, sometimes you watch the practice videos of these great stars, these medalists, and you realize that they fall a lot as they're practicing for the Olympics. And I'm sure those of us who do ice skate regularly, we fall a lot. Let's talk about some of those ice skating injuries to common folks like us who aren't in the Olympics, and specifically like some of the shoulder injuries you see.

Dr. Brad Raphael: Yes. You're ice skating, so all of a sudden you've gone from a nice, normal, stable surface that we walk on all the time, and now you're going on an icy surface. So, there's balance issues. Now, all of a sudden what you're seeing, whether it's ice skating or even just getting out of your car, when you're ice skating, the thing we see a lot of is fall directly on your wrist or your shoulder.

So instead of twisting injury on the shoulder, you're now looking at direct trauma, whether it's directly on your wrist, your elbow, or your shoulder. And we're seeing more traumatic bony injuries, so to speak. Because you're laying out on a hard surface, this isn't a nice powdery snow, like when you're skiing. This is more of a very hard, icy surface. You're seeing more wrist fractures, we're seeing more elbow fractures, we're talking more fracture, things like that. And then, obviously, if you land on your shoulder, you're talking about AC joint injuries, AC joint sprains, and proximal humerus or shoulder fractures around the actual ball and the socket where you can get some really bad injuries.

The other things we worry about with ice skating, as I take care of quite a few hockey teams, it's also very important to understand those skates are sharp. And so, not only do you worry about falling, but I worry about what happens when you fall, because now those skates become uncontrollable. And every year, I see a lot of injuries to Achilles tendon or I see lacerations on your arms and your hands. It's really important to remember that ice skate is very sharp, and you have to be very cognizant of where that's going when you fall. A, you don't want to cut yourself. B, you don't want to cut the people around you when you're undergoing those falls.

Host: Yeah, I saw one of those that you're describing in the speed skating. You know, when a number of skaters all fell at the same time, one of the skaters got slashed in the face by someone else's skate. Totally accidental, but as you say, something to be cognizant of, for sure.

How about knee injuries and skiing, doctor? You know, I'm trying to picture what it was like when I skied when I was younger and all the injuries I suffered, but specifically about knee injuries from skiing.

Dr. Brad Raphael: Yes. Well, this past Olympics, we all became experts watching Lindsey Vonn, who suffered two devastating injuries. One, suffering an ACL tear from an injury and a wipe out in the training session. It's pretty miraculous that she was able to get back to competing just a week or two later. But then, to have her knee give out again while she was training. And then, when she's competing, when you're going that fast, all it takes is a little bit of an instability in that knee. And then, you've lost total control when you're going 50, 60, 70, 80 miles per hour, and then all bets are off. Your knees are going in all different direction. Your skis are going in all different directions. And that's when we worry about not only knee injuries, but head injuries.

And so, knee injuries specifically, it doesn't have to be a major wipe out like Lindsey Vonn. You can just be a recreational skier. You get your knees crossed, it doesn't take much of a wipe out, and you're looking at a major ligamentous injury or even a fracture when you twist that knee. It's not so much the trauma from falling, but it's usually a torque injury or a twisting injury that's going to cause bony injuries such as an injury to the shin bone or the tibia, or an ACL tear, MCL tear, meniscus tear, all these things that we worry about when you have these twisting injuries, because it doesn't take much with skiing.

I love skiing. I think it's a great winter activity, but it's really important to be a very aware of your body. And if you should have an injury, I always tell people, you'll know when you hurt your knee. It's not up to you to figure out what the diagnosis is, but it is your responsibility to not go out and do more damage. So if there is a concern over knee injury, I always tell my patients, stop skiing. You know, take a break. It's always, "Well, I hurt my knee. And then, I had to go for two more runs, and it was a second run that it really got bad." So, try to prevent some of those injuries if you're sore, if you already have something that feels awkward or you're noticing some swelling. Give yourself a break because it can get worse. Have yourself get checked out by someone in the mountain or a physical therapist or your primary care doctor, or, you know, come see an orthopedist.

So, that's really, really important when you're in that ski move, listen to your body. But not everybody is going to get to that Lindsey Vonn open fracture where you have to have multiple surgeries. You can have some devastating injury that can be preventable if you listen to your body.

Host: Yeah, Doctor, I've never even considered snowboarding. I love watching it, you know, in the Olympics. But I've never really even thought, "I should probably do that." Maybe it's because of my age. But either way, what kind of injury, specifically knee injuries, do you see from snowboarding?

Dr. Brad Raphael: What's really interesting in snowboarding is the biomechanics difference of being on skis where you have both your legs are totally independent, the skis can cross, you can twist your knee, versus being stuck in a snowboard where your knees are locked in place. And because the snowboard is locked in place, that in itself does give you a little bit more protection on knee injuries because most of the knee injuries, it becomes very difficult to twist your knee, one knee and not the other knee when your feet are locked in place snowboarding.

The true injury is when you have a really bad wipe out and you're locked out of the bindings or you break out of the bindings of one of your knees in a snowboarding. But what's interesting is in snowboarding, because your knees are locked, most of the injuries we see are falling and direct trauma on your shoulder or your knee. So, you're seeing more shoulder injuries, wrist injuries in snowboarding because you're kind of falling forward versus skiing where you see more twisting injuries in your knee just because there's so many variables with skiing and whether you cross your skis or one ski gets stuck where the other keeps going, and so if your binds may be too tight.

Again, another point that I always tell my patients, make sure you get your bindings checked. I always recommend a little bit looser bindings, because you can pop out, then that does give you a little bit less risk for a knee injury. But it may not give you that same kind of speed and control over the ski. So, there is a balance. I'm by no means an expert, but it is something you want to talk about with your ski technician. But again, much different injuries in skiing versus snowboarding to answer your question, just because of the mechanism of injury.

Host: Yeah. Doctor, I wanted to slip in here just a little bit because we're focusing on, you know, the winter months, the winter season, and why it's the injury season. But it occurred to me that a lot of sports that would normally be played outdoors when it's not winter, probably move indoors. And you probably see a bunch of different types of injuries in the winter because folks are indoors playing sports on turf that they would normally play on grass. And just wondering, give us a sense of like what you see in the winter that's unique to these sports who've, you know, kind of moved indoors.

Dr. Brad Raphael: That is really important point there. So, what's interesting is that, you know, there's a really strong debate going on versus when you're talking about grass versus artificial turf. And the difference is there's friction between your shoe and the turf or your shoe and grass. And what that does is that can increase the torque or the twisting potential at the knee. And so, there is real biomechanical data—true, really good biomechanical data—that does show differences in injuries between turf and grass.

But just like anything else, it's not just uniform turf versus grass. Just like any place else, you can play on beautiful NFL stadium grass, you can also play on, you know, dried out, patchy grass with a hard dirt surface, and not all grass is created equal. Just like that, not all turf is created equal. So, what the issue is that a lot of these times, especially in central New York, you're looking at places that are only used for a few months out of the year, and the turf may be a little bit older, the turf may be a little bit more worn out. And so, that's why we see it in Central New York or some areas that they're not playing outdoor turf that gets renovated or replaced every couple years. We're seeing more injuries indoors because the turf may not be as new, it may not be as up-to-date. So, it's not all turf is bad, it's just worn out turf can also increase your risk of knee injuries. And so, that's why we see more indoor injuries in the winter in some of these areas because they're playing on turf, you may not have the right shoe wear, you're also seeing more kind of recreational athletes that may not be as conditioned. And so, that's all really important. And so, again, I tell my patients, make sure—just like anything else—you need to really warm up before you start playing. You need to stretch, you need to stretch out your Achilles, you need to stretch out your hamstrings. That's all going to help prevent injury.

Most of these injuries that we see in the wintertime on indoor turf, for instance, they're non-contact sports. There's a lot of injuries to ACLs. There may not be as many knee injuries in the winter indoors because a lot fewer people play than, you know, all the kids that play in the summertime. So, the volume may be less, but the percentage of injuries of people that play becomes much higher because you're stuck on these turfs that may not be as well kept. So, it's important again to really warm up, to stretch.

And also, there's a lot of injury prevention programs out there to work on your core, to work on your hips and your quads when you're not playing, because that is so important. There's been some great data looking at, for instance, ACL prevention studies where there are programs that I encourage the teams that I cover, whether it's collegiate, high school, even professional, they all have some component of a prevention program that you're doing in the off season to strengthen the muscles around your knee and your hip and your core to help stabilize that and prevent that devastating knee injury, such as an ACL tear or meniscus tear that we do see even in the wintertime months.

Host: Yeah. You mentioned earlier, Doctor, about listening to our bodies. I'm assuming that would fall into this category when I ask you, you know, when should we seek medical attention, and I'm guessing listening to our bodies is a component of that.

Dr. Brad Raphael: Yes, exactly. It's so important. Nobody knows your body as well as you do. And so, we see patients. And at that point, they've obviously are either have an injury or there's some swelling or there's pain, which is the number one reason why they reach out to us. But it's important to really identify, if you're starting to notice pain in your ankle, be aware of it because then you have pain in your ankle, you may be walking awkwardly. And what does that do? That puts more stress on your knee.

So, it's not just the knee pain that's going to cause a knee injury. Listen to your back, listen to your hips. You know, all these things, it's very important to be aware of these different, I don't want to say injuries, but even, you know, chronic pain issues, or if something doesn't feel right, that doesn't mean you need to have surgery or injections, but it may mean that take a break. A lot of the overuse injuries can cause other major injuries that goes from an overuse injury that's treatable to a major devastating injury that may need surgery.

So, listen to your body. Get to see a physical therapist if needed. Maybe talk to your primary care. A lot of times, it's satisfied with just a little bit of a break, some ice, a little bit of an anti-inflammatory if your primary care allows you to take that. And then, it gets better. And by taking a week or two off from, you know, that indoor soccer league or the pickleball that you've been playing, oftentimes just taking that little break can really prevent a more devastating injury that takes you out for a year.

Host: Right. Let's talk broadly, Doctor, about treatment options at St. Joseph's Health. You know, we're not going to be able to cover all the injuries and everything, but you mentioned some of the options there, be it physical therapy, injections. Just give us a sense of if we decided to reach out to help ourselves, you know what some of our options would be.

Dr. Brad Raphael: And we are truly fortunate at St. Joe's and Trinity Health in the region, because we have such a great access to interdisciplinary and multidisciplinary care. So, it's not just orthopedist. We've got a huge network of primary care. A lot of this starts off with the primary care. See your primary care doctor and a lot of things can be treated with a little bit of rest and medication. You know, we've got some access to urgent care facilities. And then, eventually, it becomes a evaluation with an orthopedist. We've got this great network of orthopedists at St. Joe's.

I always tell people, everybody always wants to go to the worst case scenario—surgery. Well, most of the cases that we see are not surgery patients, they're not surgery indications. A lot of these things can be treated with advanced imaging, you know, to a make a diagnosis, which we all have. We have all this on site, x-ray, MRI, CT scan, all these things to help diagnose the problem, which is quite frankly the most important thing, because we can't treat it if we don't know what we're dealing with. Then, once we get the diagnosis, medication, nutrition, we've got nutrition specialists, we've got dietician specialists, then we've got physical therapy. We can get you to see a physical therapist. That, again, is one of those things where, you know, I tell patients, you go once or twice, get some exercises, do it on your own. That will help prevent the injury from progressing.

Then, at the end of the day, should it require surgery, we do have, you know, state-of-the-art equipment at our surgery center and our hospital when it comes to that. But that's very, very rare. You know, of all the patients we see, very, very few that actually require some sort of surgical intervention. But we do have a lot of things, tools in our armamentarium from physical therapy to nutrition, to medication. And we're very fortunate to have it all under one umbrella with the Trinity and St. Joseph's network.

Host: Right. Yeah. Good stuff today, Doctor, I just want to finish up and get some tips, some suggestions from you about how to prevent winter injuries. I guess we could say, "Well, just don't do some of these things and you won't get hurt." But you might get hurt, as you say, just walking into the store or, you know... So, in general, like, your best advice to keep us all safe during these injury-prone winter months.

Dr. Brad Raphael: So, the first thing I always tell people is treat every day with the respect that it deserves. So when you wake up in the morning, don't just wait till last minute, get out of bed, shower, get your clothes on, run out the door. Winter months, you're more likely to get hurt with day-to-day activities because of the surfaces, because of the cold, which constricts all your muscles.

So, I tell people, get up a few minutes early, do a little stretching. Get a nice physical therapy program. Do some stretching, warm your body up before you're going to go shovel. Warm your body up before you're going to go walk on the ice just to get out of your car because you're already at a disadvantage as soon as that dose temperatures drop, your body tightens up. Everybody knows that feeling when you get up, and all of a sudden everything tenses up. Well, that puts you at risk right away. So, always warm up a little bit. Do a little bit of stretching before you get out of your house. It's very easy and we've got a lot of stretching programs. We've got a lot of strengthening programs. You can go to one of our websites and that's the first thing.

Second thing is be aware of your surroundings. You know, if it's cold out, you know it's going to be icy, look down, not look up. When I say look down, don't look down at your phone. Just put your phone away when you're outside on that slippery surface and your body's all tense, just make sure that you're not going to be distracted and be aware of that slippery surface. Walk slowly. Get some good shoe wear. It's okay to put some ugly-looking boots on that may not be fashionable to get to your office and put on your fancy shoes.

And then, just listen to your body. If you're skiing or if you're skating or if something doesn't feel right, take a break. Call your primary care doctor. Call your orthopedist, call your physical therapist. Get it checked out. There's never a harm in getting it checked out. Always better to get it checked out before it becomes a major problem because oftentimes it is treatable.

Host: Yeah, that's a perfect way to end. Obviously, if we could prevent injuries, great. If we are unable to prevent the injuries, help is available. As you said, lots of tools in the toolbox. So, I appreciate your time and your expertise today. Thanks so much.

Dr. Brad Raphael: Thank you so much.

Host: And to reach St. Joseph's Health Orthopedic and Spine Care, call 315-329-2555. And for more information, please visit sjhsyr.org. That's sjhsyr.org. And if you found this podcast helpful, please share it on your social media. I'm Scott Webb. Thanks again for listening to the St. Joseph's Health Medcast from St. Joseph's Health.