 Hello, and welcome to this edition of Quality of Life. I'm your host, Dave Augustine. Today, our episode deals with orthopedics, and helping us discuss that topic is Dr. David Michaelizak from Lakeshore Orthopedics. Welcome to show Dr. Michaelizak. Thanks for having me. Just to get off started, your specialty is carpal tunnel with the hand in the wrist, correct? Correct. OK, wonderful. How long have you been in the field of orthopedics? Well, I've been practicing for just over five years now. I came straight out of training and went to Manitowoc, Lakeshore Orthopedics. And we also have an office here in Sheboygan. So I've been practicing just over five years. OK. With that, I'm sure you had some education that you had to go through first. As far as that goes, could you expand on the types of education that you've gone through? Yeah, I grew up here in Plymouth, so Sheboygan County native. I went to undergrad at the University of Notre Dame. And I did my medical school at Loyola in Chicago. I stayed there for orthopedic residency, which is five more years. And then I did an extra year of hand surgery fellowship in Cincinnati. Nice. So when you went into orthopedics, or spent more generally a surgeon, is there additional education that you have to go through versus you go through being doctor school, obviously? Then you've got all these other things to add on. Yeah, med school is four years. And then you pick what you want to go into. And if you pick a surgical field, whether it's general surgery or orthopedics or a variety of other ones, those are usually longer residencies. So orthopedics is five years, whereas family practice and some of the other ones are as little as three years. So there's a varying length of residency. That's the major difference. And then during residency, I choose to do hand and wrist fellowship. So that's an extra year of training. So within orthopedics, you can choose spine, foot and ankle, tumor, trauma, sports medicine, hand and wrist. There's a lot of variety that you can choose to subspecialize. So I went into the hand and wrist. OK, and that brings me to my next question. With orthopedics, what part of the body does it all affect and what is usually affected when it comes to that? So orthopedics is the bones. And it's pretty much all the bones except the head. So there's different specialties, whether it's the hand up to the elbow for hand and wrist, there's shoulder elbow surgeons, there's sports doctors who do knees and shoulders, joint replacement surgeons do hip and knee replacements, foot and ankle surgeons. So it pretty much covers all the bones except the head. That's up to the neurosurgeons. Sure. Now as a surgeon, do you have to recertify every so often? Yeah, you have to pass your initial boards. There's a set of written boards. And then there's oral boards for orthopedics. And then every 10 years, you have to recertify. OK. Getting into your specialty, carpal tunnel, the hand and the wrist, what is carpal tunnel? So carpal tunnel is a pinched nerve at the wrist. The median nerve is tight, basically. And it develops for a lot of various reasons, some of which we don't, most of the time, we don't know why it develops. And it leads to numbness and tingling in the fingers and pain. And people have symptoms at night and driving, using instruments, stuff like that. So it's a very common, very common problem. Now, is carpal tunnel the same thing as carpal tunnel syndrome? Yes. OK, I just wanted to clarify that for our viewers when you hear it. Yeah. Because I know, is it a fairly new thing? Or has this been around for quite a while? It's been around forever. Yeah, it's been around forever. A lot of people think it's related to activity, whether it's job related or using a computer. Some studies have shown some jobs can be related with carpal tunnel. But a lot of times, we don't know a specific cause. It happens to people that don't do those jobs, too. But yeah, it's been around for a long time. It's not new, but it's very common. So a lot of people know a little bit about it. OK. Where, on the wrist and arm, would I mostly feel pain for carpal tunnel? So usually, it's the nerve is tight here. So you'll feel pain that shoots up the arm on this side and up into the fingers. And usually, these three fingers, sometimes part of the ring finger, the small finger, a different nerve goes to the small finger. So it's usually not involved. OK. What are the different ways that you can treat carpal tunnel syndrome? Well, we often start with nonoperative treatment. Splints that you wear at night to keep your wrist straight. If you're sleeping and your wrist is moving back and forth, that can put pressure on the nerves. So the splints try and help that. Occasionally, we'll do therapy or cortisone injection to try and calm down the symptoms. And then if nothing works and the symptoms are persistent, then we'd talk about surgery. Surgery, OK. Will carpal tunnel go away by itself? It can. If people have a mild form, it's also very common with pregnancy. That goes away typically after they deliver the baby. Most of the time, however, it is calm at first, and then it gets more severe over time and more consistent. So a lot of the time, it doesn't go away. But sometimes it does. How many surgeries would you say you do on average in a year's time? In a year, between five and 600. Wow. Is it a real invasive type surgery or is it a pretty quick outpatient type? It's very quick. Yeah, the incision is small. It's only a couple centimeters in length. People get a little sedation. In my hands, they get a little sedation and I numb up the area. It only takes a few minutes for me to do a carpal tunnel. They wake up. They have a soft dressing and they're out the door pretty quickly. OK. What if someone would just, for whatever reason, let their carpal tunnel go? They don't want to get it treated. They're afraid. What can happen? Well, the problems can become permanent. If it's severe carpal tunnel and it's been there for years, you can get atrophy of the muscles, some of the muscles in the hand, and that will not get better even after a surgery. And the numbness and tingling can be permanent, too. OK. Is there anything that one can do to prevent getting carpal tunnel? Not really. No. Not really. Because most of the time, we don't know what causes it. So it's hard to prevent it. Usually when you notice the symptoms, it's good to get into be seen right away and start treatment with splints to try and get it to calm down on its own before we start talking about more invasive treatment. But as far as prevention, not necessarily. So on all the topics I've had on the show, for once it's not due to weight or my diet or anything like that. Not necessarily. It can be related to diabetes, which is can be related to diet and to take care of yourself. So there are some associations with that. But usually it's what we call idiopathic doesn't really have a specific cause. OK. What about age? Is that a factor? Yes. I mean, we don't see it in teenagers or 20-year-olds. But once you start getting to 30, 40-year-olds, we see it from them all the way through the rest of life. So it's a little more common in the 40, 50-year-old population. But we do see it throughout the range of adulthood. So with orthopedics, there's a specialty of obviously you said the bones and all of that. So you actually, when you go in, if you have to, is it a matter of just freeing up enough space so the nerve isn't pinched? Or do you actually have to move the nerve or do anything like that? It's giving the nerve more space. So there's a really tight ligament over the top of the nerve, so that's what we divide. And once you divide it, then the space opens up and the nerve can breathe and heal itself. So for this particular problem, we don't have to touch the nerve or move the nerve or anything like that, just giving it space. How long does a procedure like that usually take? It takes me five minutes. Five minutes, and it's all done. Probably more for the prep work and recovery than there is for the actual procedure. Right, wow. Flipping the arm over a little bit, I know another thing is tendonitis. And I know one thing I've got is a problem. Right in here, just below the elbow, as far as that goes, where it's probably just as painful as carpal tunnel. And there, too, what causes that? That's more overuse, repetitive use. It's typically lateral epicondylitis or tennis elbow. They're the same thing. And I see a lot in my workers' population, people doing repetitive work on the lines in the factories, a lot of twisting and manipulating parts. And that just causes inflammation and pain where the tendon that extends your wrists attaches to the elbow. So that's where the cause of the problem is. OK. There again, too, what are some of the ways that that can be treated? That's usually treated nonoperatively. There's a surgery for it, but it's pretty rare. So it's usually treated with therapy, cortisone injections, anti-inflammatories, trying to avoid the activities that aggravate it. And usually it gets better with time, but it can take months for it to calm down. Now I know there's been a few times where I've been treated with physical therapy where I have to do my exercises with the weights and all of that. So I guess with exercises and physical therapy, why doesn't it aggravate it? Or how does it help versus aggravating it more? Well, the exercises should be stretching out that muscle to try and get it to calm down. You don't want to do activity that aggravates it. So once it calms down, then you have to build up the strength. So some of the strength thing comes into play. But a lot of therapy is ultrasound treatments and different stuff like that to calm down the inflammation first before building up the strength. Sure. So like I said with that, again, there are some things that I can do either in general practices or everyday routines or exercises to help prevent it. Yeah, there are stretching exercises that you can do to stretch out those muscles on your own. But it's really more avoiding the activities that aggravate it, that repetitive twisting, turning. It's usually worse when your arm is straight. When your elbow is bent, it's a little better. So that usually helps more. It's just avoiding those activities that aggravate it. OK. Throughout the years have either condition changed or has it been pretty much the same throughout the years? Or has our activities changed, moving more into the computer realm and little games and phones and all of that? Have you seen an increase or has the change? There's not much studies on that yet, as far as texting and phones and carpal tunnel. It's still a relatively new phenomenon, but it hasn't really been borne out to cause more carpal tunnel. More people are active older because people are healthier now, so we see just more older people doing more activities so that can cause both the carpal tunnel and the tennis elbow. But otherwise, they're both pretty consistent over the years as to how often they occur. How have the treatments changed over the years through technology or just new procedures? Well, we have a lot less minimally invasive stuff. The incisions for carpal tunnel release now are much smaller. Some people do them through a scope, which is a smaller incision. So there's less recovery after surgery, just less healing, less dissection. The incisions used to be really large on the hand. Now they're very small. So that's probably the biggest change. And then for tennis elbow, it's more of the therapy modalities and ultrasound treatments and they make minimally invasive stuff that you can do for that through the ultrasound machine to treat it too. So technology has helped for both. Cortisol and shots, do they help for carpal tunnel as well or is that pretty much just tennis elbow that word that's good for? They can help with carpal tunnel, but it's usually temporary. It's usually not a permanent or long-term solution. Some people do get months of relief from it. I typically use it in carpal tunnel. If somebody has an EMG test, which is a nerve test, that comes back and it's not quite, it's borderline, a cortisone shot can be diagnostic. If the patient gets better with cortisone, it's a good sign that they'll get better with surgery. But it can help, but it's usually temporary. Okay. Could you explain how a cortisone shot really works and where it actually gets administrated to? So cortisone's an anti-inflammatory. So it works on a molecular level to try and decrease those inflammatory cells in the area. And so most of the time we're injecting it right into the area that hurts the most. So for tennis elbow, you push on the elbow and if it hurts, that's where you inject it to try and get it to calm down. So it's like taking an anti-inflammatory pill, but it goes right to the source. It doesn't go up through your bloodstream. So does it, is it injected directly into the muscle or the nerve or is it actually into the bone or by the bone? It's into the tendon, which is right by the bone. So the tendon attaches to the muscle. The tendon is where the muscle attaches to the bone and that's the problem for tennis elbow. So that's right where you put the injection. So it's right by the bone. You can't inject into the bone, but sometimes it feels like it. Sometimes they're a little uncomfortable, but that's where you put it. As I know, I've had a couple of shots of cortisone in the elbows, but also in the shoulder when I had, finally I had shoulder surgery or rotator cuff, but went to the doctor. He says, I'll give you a shot of cortisone. And he came up with a needle that looked about this long. And then when he says, going through the back, and I just said to him and I looked down, I says, if that thing comes out, my front of my side of my shoulder, we're gonna have a problem here, I think. So it was kind of intimidating a little bit. Just like with a dentist, you know, they come with a needle that long and it disappears and you don't know where it's going. Yeah, needles sometimes really scare patients. Usually mine are very small because I don't have to go that deep in the hand. But yeah, they can be a little intimidating. What are some of the risk factors? Risk factors, diabetes, like you mentioned, if people have thyroid problems that can lead to carpal tunnel. Those are the two biggest risk factors. For tennis elbow, it's more of the activity. It's activity related and what you're doing with your arm that causes it. Okay. Let's say if I have a surgery or I go ahead, yes, I'm gonna have a surgery or whatever treatments, whatever, are there any risk factors associated with each of those? For needing surgery? Right. Not necessarily, it's just if it doesn't get better with the other stuff. You know, if we try the splinting therapy, cortisone, all that stuff and it doesn't get better than surgery is an option for both problems. It's much more common to do carpal tunnel release than to do surgery for the tennis elbow. Sure. It's a more common problem and then the tennis elbow usually responds better to conservative treatment. Okay, nice. If I wanted to, let's say, I've got this problem. When should I go see an orthopedic versus maybe just go see a regular doctor? You know, if I feel, you know, it just doesn't feel right or it's starting to hurt more and more? Yeah, it's personal choice. A lot of people have good relationships with their family physician and I get a lot of referrals from the family physician when it gets to the point where splints aren't helping or they've gotten an EMG and it shows that it's pretty bad. That's usually when I get the referral. But you could start by just calling, you know, the office and making an appointment straight away. Sometimes your insurance companies require a referral. Referral. So you have to look at that too. Yeah. Can only orthopedic surgeons or somebody who's certified in orthopedics give cortisone shots or can any general physician? Any general physician can. A lot of times in the hand I feel like a lot of the family practice doctors aren't as comfortable maybe as they used to be just with all the anatomy and the arteries, nerves, stuff like that. So I don't see a lot of people already having had a cortisone shot for carpal tunnel or in the hand. But a lot of them have for the elbow but anybody can, any physician can. Okay. I'm gonna kind of throw you a curve ball here a little bit. Chiropractors. Mm-hmm. Is there any treatments that possibly, you know, they're manipulating the bones and the structures and everything. Any treatments that possibly a chiropractor could do which may help relieve some of the pains? I think there are. I don't know too much about chiropractics myself just because it's a different field. It's a different field, right? But yes, I always, you know, if patients want it I encourage it. Basically whatever helps them feel better. Certainly with tennis elbow it's very similar to therapy in different things they can do with the exercises around the elbow to help that tendon calm down. With carpal tunnel there are some things with, you know, tendon gliding and stuff again, very similar to therapy. But I don't know too much about specific chiropractic. There's not much they can do to give the nerve more room. Really, that's a surgical issue at that point because it's just a physical barrier. But, you know, I tell patients certainly you can try it if it helps, that's great. Okay. With tennis elbow and even with carpal tunnel, I'll ask, you know, there's some ointments you can get like let's say, icy hot. Bend gay, those deep heat type treatments, do they do any good? They can help with some of the symptoms. The bend gay type of stuff is really a kind of a pain masking thing. It doesn't treat the inflammation. They do make some topical anti-inflammatories that are gels that you can put on there that will actually treat it a little better. And sometimes we use that. Some patients have problems taking anti-inflammatory pills because their stomach gets upset and so sometimes we'll try topicals for that. Okay. So the good old thing of just take some ibuprofen and call me in the morning really doesn't apply all the time. Doesn't always work. You know, you can start with that, you can try it certainly and if it works, fine. But a lot of people get to the point where that just isn't helping and that's usually when they show up in my office. Yeah, that's when they should call instead of, well, I'll just take three ibuprofen, four ibuprofen. More isn't always better. No, no, you're just gonna have problems with your stomach. Then you wind up with an ulcer and then you go to a different hospital or whatever. So can you tell us about some of the tests that you do? Like you mentioned some of the new modalities that have come up. Can you give us some explanations on those? Well, the big test for a carpal tunnel is called an EMG or nerve conduction velocity test. Usually a neurologist or a physiatrist does it and that's where they test the nerves going down the arm and if a nerve is pinched, you can measure that. And so it gives you numbers to help quantify how bad the carpal tunnel may be. So that's the big test for carpal tunnel. The diagnosis is usually made on a history and physical exam, but the EMG can help augment that. For tennis elbow, I do get X-rays on everybody to make sure there's no arthritis in the joint or a bony problem underneath that's causing it. MRIs are usually not necessary to make the diagnosis. So usually that's more physical exam. What ultrasounds do you use, any of that? Yeah, my partners do. We have Sports Medicine, a family practice doctor who uses ultrasound to look at the tendon and she also does a minimally invasive procedure. And a lot of times I'll do that for tennis elbow before doing surgery as I'll refer patients to her just because it's a little easier recovery than an open surgery. You just bring up a good point or a question that I wanna bring up is you mentioned sports medicine versus everyday work versus computer work or whatever. I'll see kind of being more specialized these days. Where, how do I know where I would go to? If I come to you and let's say if it's a sports related something I did or whatever, would you treat it or would you get your partner involved or how does that all work? There's some overlap. Usually, I cover everything from the fingertip to the elbow. The elbow is kind of one of those overlap areas. A lot of sports medicine doctors will see the tennis elbow and some of the more repetitive use type of injuries about the elbow. Once you get down into the hand and wrist you don't see a lot of sports medicine doctors taking care of that stuff. It just gets a little too intricate and it's pretty specialized at that level. Plus just about anything can happen. I mean, I could fall over backwards in this sports thing and you know, or whatever. Right, yeah, the injury, you know whether it's a fracture or something like that the injury doesn't necessarily care whether you did it during sports or at work or on the ice or whatever. So usually the hand and wrist stuff usually comes to me. Sports medicine doctors don't see that type of stuff. Okay, what's the average recovery time? You know, if I say I go in I got carpal tunnel real bad and we do the surgery. When can I start feeling the relief and where I'm actually back to normal? So the first thing that gets better is symptoms at night. It's very common for people to have problems at night and they gotta wake up and they shake their hand out. Most patients say that gets better the day of surgery and then the numbness tingling varies as to when it gets better. Sometimes it's a couple days, sometimes it's weeks depending on the severity before a surgery. So I see patients back two weeks after surgery. A lot of them are doing much better. Some of them are completely better and some of them just need more time. So it's anywhere from two weeks to, you know sometimes six weeks and the real bad ones can take a while. Okay, have you ever had an instance where you had to go back in and make more room or is there ever a chance that it can, you know the bones or whatever you do it'll grow shut and actually pinch it again? It's very rare to have to go back. Usually carpal tunnel release is a permanent fix. Sometimes I see people that have had carpal tunnel 20, 30 years ago and they did well with it and then it comes back for whatever reason. Usually when you release that ligament over the nerve you'll get scar tissue that forms but it's usually at a bigger volume so the nerve has space. Occasionally people can get it back but it's pretty rare. Any chance of like, you know something like arthritis or does that play into a factor at all? Well arthritis, the wrist joint is just underneath where the nerve goes through. So if you have swelling of the soft tissues from arthritis that can put pressure on the nerve and cause it. Usually they're two separate problems but they can be related. Okay. Turning a little bit to, you know the types of surgeries and whatever like years ago like you said they lay you wide open just about. And now they have procedures like arthroscopic and is there endoscopic? Yep. Could you go into those two a little bit as far as what they all entail? Yeah, so arthroscopic means you're going into a joint with a scope through small incisions and I do wrist scopes for a variety of different problems ligament tear or stuff like that. Endoscopic, like there's endoscopic carpal tunnel that means you're doing it through a scope but it's not necessarily in a joint. So again, smaller incision and the goal is to try and get people to recover faster just because it's less surgery. Now, you know they say a scope, what is actually a scope and what is it doing? So it's a camera and so it's got a little metal sheath with a small camera on the end and you can put it in small spaces to look at things and it's minimally invasive so it helps you don't have to make big incisions and then you make other small incisions to put instruments in so if I'm doing a wrist scope you put the camera in one hole and you put instruments in other holes to try and manipulate things and debris things and clean things up. So it's much easier than making a big incision having a lot of scar tissue, stuff like that. Okay, because I always wondered, I always thought the instruments and everything were right on the scope when they say, well, we'll go in and scope it and it's like, I don't know, I can't understand how they do that all so it's actually different instruments. Different instruments and you gotta have more than one hole to kind of get both the scope and the instruments in there. Yeah. Okay. Do you see, this is kind of the future way out but some technologies like 3D printing or the way other technologies come out, do you ever see that coming into a factor of helping with, nowadays, I'm surprised I can't even just print a new wrist or a new, as far as that goes, any experimentation with that or anything that you weren't aware of? I think most of the stuff gonna be coming out is with gene therapy and genetics, making different injections with genetics that you can inject to help with, whether it's arthritis or carpal tunnel, I think that's probably where the future lies. They haven't quite figured out that yet but that's probably what's coming is more of a genetic based treatment for stuff. Okay. If I wanted to find out more about orthopedics, just reading up on it, general information, where are some good sources I could go to? Well, our website, HFM Health slash Lakeshore Orthopedics has different stuff on both hand and wrist surgery on my page and my partner's page have good patient information. Websites like WebMD are pretty reputable. They have good information. You have to be careful with the internet and what's out there, it's filled with horror stories. Oh, come on, if it's on the internet, it's gotta be true. Yeah, you have to be a little careful. A lot of patients come in with a preconceived idea of just because of what they've read on the internet. But if you go to good websites, you'll find a lot of good information. I just brought up another point that I wanted to ask you. Do you see, with all these resources available to people and they can go to wherever on the internet, do you see people tend to self diagnose themselves? Oh yeah. And then self treat? Yeah, exactly. A lot of people have come in trying this and that and they've read it on the internet or they've known somebody that's tried it and sometimes it works. And most of the time it doesn't because they're in my office. So obviously that ends up working. And then there is factors because they try to do something for themselves. Potentially, yeah. You haven't had anybody do surgery on themselves yet, have you? No. Okay, that's a good thing. Don't do surgery on yourself. Yeah, I wouldn't recommend it. Excellent. Before we wrap, is there any final thoughts you have on what we talked about today or any advice or just final thoughts? No, I think especially with the carpal tunnel and the tennis elbow, they're both very common problems. If you're having a problem, I'd be happy to see you in my office. They're very treatable. They do get better. You don't have to suffer. A lot of patients after they've been treated wish they had done it sooner. So you don't have to wait too long. Just get in, get treated and you'll get better. Okay. Do you have an office number or if somebody wanted to contact your office for additional information? Yeah, our Sheboygan office number is 452-6124 and in Manitowoc, it's 920-320-5241. And your website again is? It's HFMHealth slash Lakeshore Orthopedics. Appreciate it. Is that that org, I'm assuming? It's .org, yeah. .org, yeah. Okay. Dr. Michael Isaac, I'd like to thank you for having you on the show. I mean, this was very informational to me as far as that goes. So. I appreciate it. Thanks for having me. Okay. If our viewers at home would like to know any more information on this subject or have any ideas from our show, you can contact us on our website at www.wscssheboygan.com for quality of life on behalf of Dr. Michael Isaac. I'm Dave Augustine, your host. Thank you for watching.