Sled hockey, referred to as “sledge hockey” outside of the United States, was started at a rehab center in Sweden in the early 1960′s. The sled is designed with two skate blades and enough space for the puck to pass underneath, allowing people with certain physical challenges to play ice hockey. Over time the sport has grown in popularity and became an official event in the Paralympic Games in 1994. Our U.S. National Team just recently took the silver medal at the 2013 International Paralympic Committee Ice Sledge Hockey World Championship in South Korea. The United States is also the reigning gold medal winner heading into the 2014 Paralympics in Sochi, Russia.

This was my second season with the program, and I’m always incredibly impressed with the level of skill, dedication and perseverance that these athletes bring to the ice. The players on the D-Team, as it is called, range in age from 15 to 30, with an average age of 21. They play on club teams in their home area and are selected to play at the national level at a try-out camp held by USA Hockey in July. This roster draws players from Texas, Wisconsin, Colorado, New Jersey, New York, Massachusetts, Illinois, Missouri, Ohio and Florida. Their conditions include traumatic and congenital single and double amputations, spina bifida, traumatic paraplegia and Legg-Calve-Perthes (a disease of the hip joint). Nine of the players use wheelchairs as their primary means of transportation in their day-to-day lives.

This team was together for four weekend training camps beginning in September and played in the USA Hockey Sled Cup in January against the U.S. National Team, the South Korean National Team and the Russian National Team. The D-Team was quite outmatched in skill, experience and maturity compared to the other National Team squads, but it was an amazing chance for these players to experience international play for the first time. Even more amazing to me is how comparatively easy it is for all of these athletes once they get on the ice – the greater effort and challenge is just what it takes to get to and from the locker room and on and off the bus and the plane, managing all their own gear from a wheelchair in many cases.

My responsibilities with the team included treating injuries and ailments, getting their equipment to the rink, and setting up for practice sessions and games. The days were long, and it wasn’t uncommon to get back to my room at one or two in the morning. Logistics with this group is a huge task as there are massive amounts of equipment to handle and transportation requires extensive planning. Injuries that I saw included what’s known as a Gamekeeper’s thumb (laxity of the first MCP ulnar collateral ligament) and biceps tendinitis. Gamekeeper’s thumb is typically treated with tape support to the joint, and most find relief from tendinitis with icing after sessions, applying a little light manual stretching, and using some over-the-counter nonsteroidal anti-inflammatory medications.

The facility where we played the Team Canada series was the same one where the Toronto Maple Leafs practice, and it’s a huge space. There are four “sheets,” hockey lingo for an ice rink. On our first game day, the U.S. National Developmental Sled Hockey Team beat Canada 4-1. From my perspective any game in which we had no significant injuries was a good game, but it was fantastic to celebrate this victory with them. The team actually went on to sweep the three games, winning game two on a shootout and taking the third game 3-1 on a late empty net goal.

Though I will not get a ticket to Sochi, and though the weekend camps and competitions bring me home more worn out than a full week in the clinic, it has been more rewarding than could be imagined. We are supporting our National Team’s effort to remain elite in the sport of sled hockey. At any given time one of our players could be called up due to injury or illness or personal life conflict in order to fill a role at the 2014 Paralympics. For me that would be worth the time of this volunteerism.

To learn more about Disabled Hockey Programs supported by USA Hockey, visit http://www.usahockey.com/players/disabled.aspx.

Rett Talbot is a physical therapist, sports clinical specialist, board certified athletic trainer, and certified strength and conditioning specialist at HSS Spine & Sport in Jupiter, Florida.

While there is no cure, medications and therapies address the symptoms of arthritis to improve quality of life. Rheumatologist Dr. Susan Goodman answered questions from our social media audience on treatment options for dealing with arthritis.

Q1: What arthritis treatments are safe for young women who may be pregnant, breastfeeding or trying to become pregnant? 

The safety of RA treatment in pregnancy has not been tested, but since 2/3 of women with RA improve while pregnant, some prefer to stop all medications. Nonetheless, many doctors feel comfortable continuing TNF inhibitors (which block the inflammatory response) in severe cases, or using low dose prednisone (another inflammation medication) when symptoms flare.

Q2: Can vitamins or supplements help my arthritis pain?

Although there is no proof that vitamins or supplements are helpful for arthritis, some feel that fish oil and turmeric ease their symptoms.

Q3: What kinds of exercises should I try to help manage my arthritis symptoms? 

Low-impact exercise such as walking or swimming, as well as core strengthening programs, can build up muscle to provide support for achy joints.

Q4: When should I consider surgery as an option to address my arthritis?

When joint pain seriously limits activities and you have x-ray evidence of advanced joint damage, then surgery may be appropriate to restore function and treat pain.

Q5: Are there any alternative therapies that can help my pain?

Acupuncture may help with arthritis-related pain through the stimulation of endorphin production. It is a tool to fight pain with minimal side effects, which can be undertaken along with medication treatment.

Discuss with your physician before beginning any of the above therapies or if you have any questions or concerns about arthritis and treatment options.

Dr. Susan Goodman is a rheumatologist and internist at Hospital for Special Surgery. She specializes in the treatment of rheumatic disease such as inflammatory arthritis. Dr. Goodman’s research interests have focused on the perioperative outcomes of rheumatic disease patients undergoing arthroplasty.

The information provided in this chat is for informational and educational purposes, and doesn’t constitute medical or health advice for any individual problem. Please consult with your health care providers for any health problem and/or prior to starting any new exercise regimen and/or medication or changing or discontinuing any medication you have been prescribed. This chat is not intended to create a physical therapist-patient relationship, or any other duty, between you and any member of HSS’ rehabilitation team.

Q: I am having quite horrible throbbing pains in both calves. My left leg is slightly worse, with pain moving up the whole way to my hip. Do you think it is tendonitis?

Tendonitis is more of a local pain. It doesn’t radiate up and down the leg, so the fact that it’s up to your hips means it may be more of an issue coming from your back. You should seek medical attention.

Q: I’ve been having pain in the bottom of the ball of my left foot. Should I have it checked out by a doctor? Does this type of injury response to RICE or should I just not run until the pain goes away?

Simply start by stretching. Run only until it starts to hurt. You shouldn’t run into pain. If the pain continues, see a physician.

Q: How should I go about treating a pain that’s starting in my lower back and is continuing down into my foot. I’m also feeling this pain on the inner thigh. Any tips?

This is radicular pain from your lower back. You definitely should see a physician or physical therapist who specializes in spine because this may be related to a nerve.

Q: I’ve had a stress fracture of my tibia in the past. How can I strengthen my legs so that I won’t be prone to another stress fracture? I’ve cut down the mileage and have been very good with recovery after races.

Strengthening the whole leg from the core to the floor – core, hip, quad – as well as performing flexibility exercises to maintain muscular balance can help. You may also want to cross train.

Q: My last two discs have degenerative disc disease, and I can’t run without lower back pain. I don’t want to have to give up running. Is there anything I can do so that I can continue running with less pain?

Working on core exercises may help you. Also, flexibility exercises can help relieve the stress in your low back. Finding the right balance of running for you is the key. You may not be able to run as often, but it could be part of a mix. You could look into an anti-gravity treadmill, too.

Q: I have a pain on the upper top left of my right knee, just where thigh joins knee. It started one year back and whenever I went for a run, I wore a knee brace. I don’t have pain anymore, but once in a while it’s just uncomfortable. Any idea what it could be?

Your pain could be related to your patella or your quadricep tendon. It could be as simple as doing adequate stretching for your quadriceps and hip flexors.

Q: I’ve been dealing with a bothersome “injury” on the outer back side of my left knee. I did the stationary bike one day with pedals too far down. Maybe I over stretched my ligament? I am able to run two miles, and if I apply pressure on it using a strap, I can run longer. Any suggestions?

It sounds like you may have hamstring tendonitis. You may want to try stretching your hamstrings as well as hamstring strengthening. The strap may help relieve pressure on the tendon.

Q: I’m having ankle pain when running. Stepping down, like from a bus, can hurt as well, but walking doesn’t. I can use cardio equipment like the elliptical and stationary bike with no problem at the gym, but cannot run at all. I started some ankle stretches. Do you have any other suggestions?

It sounds like there’s something limiting your motion in your ankle. See a physician or physical therapist to get an appropriate diagnosis and treatment. If it’s a soft-tissue problem, some gentle stretching may help. If it’s a joint issue, your physician can recommend another treatment option.

Theresa Chiaia, PT, DPT is the Section Manager of The James M. Benson Sports Rehabilitation Center and Tisch Sports Performance Center at Hospital for Special Surgery (HSS). She has been part of the HSS Women’s Sports Medicine Center since its inception and has consulted with and performed pre-season screening examinations of the New York Power and NY/NJ Metrostars soccer teams, the New York Liberty basketball team, and college soccer programs.

As an inpatient nurse, each day is unique and unpredictable. Since our role is patient-driven, the day’s agenda can change often as we’re reacting to patient care needs. I enjoy that no day is the same, which is especially true at HSS since we deal with a wide spectrum of disease states and surgical interventions in our orthopedic and rheumatological pediatric populations.

My philosophy in pediatric nursing is to treat the “family unit,” which includes the patient, parents or caregivers, siblings and other loved ones. As nurses, we need to cultivate trust and acceptance by the family unit in a very concentrated period of time. Assessing and addressing family dynamics fascinates me and is a part of my holistic nursing approach. Emotional support is an essential part of pediatric nursing. Especially among adolescent patients, feelings of self-esteem and independence can be affected by a disease or injury. My help in decreasing patients’ and parents’ anxieties through teaching and emotional support often results in visible outcomes, much happier patients and gratified nurses.

I also try to make the hospital experience positive and fun. One rarely thinks of having fun in a hospital, but it is often therapeutic for a patient to have positive associations with their hospitalization. I play board games or video games with the patients, and a little levity helps maintain a favorable connection.

Because of the nature of musculoskeletal disease, many of our patients return to the unit for follow-up procedures, sometimes over years. As a result we get to know the children very well, and many come back for a visit after they’re discharged to show us how well they are doing.

I also enjoy that nursing allows me to work on projects outside of patient care. I am a member of a committee of the Orthopaedic Nursing Certification Board to write questions for the national exam, and I have written two academic articles on topics of pediatric spine and international nursing. I travel annually for a medical mission to Ghana, West Africa, where I treat children with severe spine disorders. This experience has enriched my life immeasurably.

Richard J. Slote, R.N., is a nurse at the HSS Lerner Children’s Pavilion. Slote serves the Orthopaedic Nursing Certification Board and the National Council of State Boards of Nursing, and is a volunteer for the Foundation of Orthopedics and Complex Spine in Ghana, West Africa.

There is no single reason to explain the increased rate of significant knee injuries seen in children and adolescents, but it is likely a combination of factors:

• More children being involved in sports
• Children playing more hours per week and playing harder per hour of participation
• Higher percentage of female sports participants
• Doctors’ improved ability to detect injuries

Overall, boys are more likely to have major sports injuries than girls because they are more likely to participate in sports with the highest injury rates, such as football and wrestling. However, when comparing within a sport, such as injury rate of boys versus girls playing basketball, girls are more likely to have a significant sports injury.

Some injuries, such as ACL tears, occur more frequently in girls than in boys, per hour of sport played. The alignment of bones, the size and strength of the tendons and ligaments, as well as patterns of movement differ between boys and girls, putting girls at higher risk of injury.

Studies have shown that significant injuries are more likely to occur during more intense play, as injuries happen more frequently in games than in practices.

Certain sports are considered riskier for knee injuries than others. Although football and wrestling are highest risk for significant sports injury in general, ACL injuries have been most frequently associated with football, basketball, soccer and skiing.

Part of the reason that knee injury rates appear to be increasing may be related to better methods of examination and diagnosis (such as MRI), and more sophisticated systems to keep track of injuries, such as local, state and national injury registries.

Being aware of the increasing rate of knee injuries in children and adolescents, and understanding what makes them vulnerable is the first step to avoiding future injury.

Steps that may help prevent future injury:

1. Pre-seasonal physical exam: Ensure your child is healthy to participate.
2. Limit hours of play per week, take some rest: Technique may falter when a player is fatigued. Avoid playing when tired/exhausted as this may place the player at increased risk of injury.
3. Stretching: Incorporate a warm-up and cool-down.
4. Safe environment: Weather and turf conditions may play a role in injury. Avoiding play when the environment is not right.
5. Safe coaching and instruction: Ensure proper technique, and rotate players during practice and games.
6. Variety: Participation in different sports and activities gives children the opportunity to cross-train to prevent constant stress to specific muscle groups and ligaments.
7. Start prevention programs early: Knee injuries such as ACL tears can happen well before puberty. Programs typically include exercises for stretching, strengthening, balance, and specific drills to encourage landing with hips and knees bent, and avoiding landing in a valgus (knock kneed) position. Children often demonstrate decreased flexibility and core and hip strength during growth spurts resulting in altered body mechanics with sports-specific movements including sprinting, cutting, and jumping, which can lead to an increased risk of injury.

Treatment is dependent on the severity of the knee injury. More severe injuries, such as an ACL tear, may require surgical intervention to ensure a child’s mobility in the future. In addition, there are many knee injuries that may be treated conservatively. Physical therapy may be prescribed by a physician and typically includes:

RICE: Since most injuries are secondary to overuse, immediate rehabilitation usually follows the RICE Principle – Rest, Ice, Compression (if needed) and Elevation. Children are usually taken out of the sport for a period of time to allow the body to heal.

Exercise and Training: Physical therapy focuses on reducing inflammation; improving strength, flexibility and balance; and improving neuromuscular patterning for daily living and sports-specific movements. Exercises may include emphasis on abdominal and gluteal strengthening to improve leg alignment with activities including stepping down from a step, squatting and landing a jump. Children are progressed to higher level balance, proprioception and agility activities to ensure a safe and pain-free return to sport.

Home Exercise Program: This is incorporated throughout therapy and is of prime importance to allow the child to achieve their highest potential of recovery and assist in prevention of future injury.

Dr. Emily Dodwell is a pediatric orthopedic surgeon at Hospital for Special Surgery’s Lerner Children’s Pavilion.

Kristin Flynn is a doctor of physical therapy at the CA Technologies Rehabilitation Center within Hospital for Special Surgery’s Lerner Children’s Pavilion.

Q1: What are the symptoms of osteoporosis?

Osteoporosis is a quiet disease. An individual might have osteoporosis if he or she suffers fractures after low-impact injury, a decrease in height of more than two inches, or a newly present curvature of the spine.

Q2: How much calcium and vitamin D is recommended in order to prevent osteoporosis? 

Calcium intake should be around 1200 milligrams per day. Consider taking a calcium supplement if you’re not getting enough calcium in your diet. Calcium citrate (as opposed to calcium carbonate) is preferred as it is more easily digested and absorbed.

For those deficient in Vitamin D, a daily intake of 1,000-2,000 IU (international units) is necessary to reach a normal range minimum of 30 nanograms per milliliter, detected through a 25-hydroxy vitamin D test. When in normal range, 600 IU/day of Vitamin D is recommended. Consult with your treating physician before starting a new supplement regimen.

Q3: If I cannot get calcium from dairy foods and I do not want to take a supplement, how can I meet the requirements?

Non-dairy foods such as salmon, tofu, beans, kale and almonds are good sources of calcium. Some soy products such as soy milk are fortified with extra calcium.

Q4: Can exercise help keep my bones strong and prevent osteoporosis?

Exercise can help you retain bone mass and decrease your risk of fracture. Thirty minutes of a weight-bearing exercise, such as walking, five times a week and strengthening exercises using resistance three times a week are recommended.

Q5: How do menopause and hormones affect osteoporosis?

In menopause, estrogen production decreases, which leads to bone loss and fragility. Taking an estrogen supplement can help prevent bone loss.

Dr. Joseph Lane is an orthopedic surgeon and chief of the Metabolic Bone Disease Service. He specializes in malignant and benign bone tumors; metabolic bone disease; and fractures, non-unions and delayed healing.

• Keep items that you use frequently during the day in a place where you can easily reach them. This includes items such as the phone, stapler, and reading and writing materials.
• Try to maintain a “neutral” posture as you work, with your head level or tilted slightly downward, shoulders relaxed and elbows close to your sides, and your body leaning slightly back. Use the chair’s backrest.
• Keep your feet flat on the floor or flat on a footrest. Your feet should be supported when you are seated in your chair. Do not wrap your feet around the base of the chair or cross your legs.
• Do not use your shoulder to cradle the phone against your ear. Using a headset can be helpful if you use the phone frequently or for an extended length of time.
• When using a laptop for an extended length of time, you should use an external keyboard and mouse. Enlarging the font can also help prevent eyestrain.
• Make sure whatever you’re working on is placed directly in front of you. Your monitor and keyboard should be located ahead of you, not off to the side. When you are seated, your monitor should be located 18-24 inches away. A glare filter is recommended if there is glare on the monitor.
• Keep your wrists straight when using the keyboard and mouse. The keyboard and mouse should be located on the same level and right next to each other.

You can see demonstrations of these tips and more in our Ergonomics video on the HSS YouTube channel.

Remember that each person is unique and there is no single “correct” posture or arrangement of components that will fit everyone. If you find that you’re having aches and pains throughout the day, you may want to schedule an ergonomic evaluation with a specially trained therapist who can help you optimize the fit of your specific workstation.

Julia Doty is an occupational and hand therapist at the Joint Mobility Center at Hospital for Special Surgery. Julia has completed the Matheson Ergonomic Certification Program and offers complete ergonomic evaluations by appointment. 

Some people turn to elimination diets in an effort to target certain foods that may be making their RA symptoms worse. However, none of these diets have been proven effective for the treatment of RA. In addition, these diets often end up cutting out key nutrients that your body needs to maintain good health. Therefore, I encourage all patients to follow a well-balanced diet, including all major food groups, and maintain a healthy weight as obesity can exacerbate arthritis.

Below are some key points to remember when planning a well-balanced diet:

Variety: Aim to eat a variety of foods. Focus on lean protein, whole grains, low-fat dairy, fruits and vegetables.

Limit bad fat: Limit foods high in saturated fat and trans fat. Saturated fat is found in red meat, processed meats, sausage, bacon and high-fat dairy. Trans fat is typically founds in commercial pastries, cookies, cakes and donuts.

Limit refined sugar: Try to limit refined sugar from processed foods and sweets such as candy, soda and fruit juices.

Alcohol in moderation: Alcohol should only be consumed in moderation; this means one drink per day for women and 1-2 drinks per day for men at most.

Calcium: Calcium is important for bone health and regulation of essential nutrients in your body. While calcium is most commonly found in dairy products such as low-fat cheese, skim milk and low-fat yogurt, it can also be found in spinach, cooked greens, broccoli, soy milk, soy beans and tofu. Individuals should take in approximately 1000-1200 mg of calcium per day. Talk to your doctor to see if you should be taking a calcium supplement.

Omega-3:  Omega-3 fatty acids have been shown to have anti-inflammatory properties. Aim to eat a 3-5 oz serving of fatty fish such as herring, mackerel and salmon, at least 2-3 times per week.

Laura Gibofsky, MS, RD, CDN, is a clinical nutritionist in the Hospital for Special Surgery Department of Food & Nutrition Services.