The Achilles tendon has 2 major functions during running. The calf muscles (1) lower the forefoot to the ground after heel strike; and (2) raise the heel during "toeing off". Achilles tendonitis is caused by a force on the tendon greater than its inherent strength.
Most runners land on their heels with their forefoot still 2 in from the ground. Running fast and up and down hills places extra force on the Achilles tendon. During downhill running, the forefoot strikes the ground with greater force than on level ground, since it drops further and has more distance to accelerate. During uphill running, the heel is much lower than the forefoot, so it takes a much greater force by the calf muscles to raise the heel before toeing off.
A soft heel counter allows excessive movement of the heel in the shoe. The rear foot is not as stable and the Achilles tendon has to pull on a wobbly insertion. This places uneven force on the tendon and increases its chance of being torn. Stiff-soled shoes that do not bend just behind the first metatarsophalangeal joint place great stress on the Achilles tendon just before toeing off.
Achilles Tendon Injury At Its Insertion Onto The Heel Bone
The tendon can be strained, or suffer a minor tear, at or close to its point of insertion on the heel. Or the bursa between the tendon and the upper part of the bone may become inflamed. The condition may be complicated by small bony outgrowths (spurs) forming on the heel bone. The spur sometimes becomes detached, formed a focal point of pain.
The pain usually comes on gradually, but it can be sudden. You feel it tiptoeing or running, and the tendon feels tender over the heel when you press on it. The cause is usually excessive use of the calf in extreme ranges of movement, as, for instance, when you run fast up a steep hill. Rough, protruding linings in your shoes can also be a cause, producing bruising and tenderness over the heel.
Specialist treatment may consist of an injection, or physiotherapy treatment. Your doctor may have X-rays taken, to make sure that there is no damage to the heel bone, or spur formation. It may be necessary to line the backs of your shoes with felt or padding, to create a smooth surface. This injury is slow to heal, so you must rest it.
Achilles Tendon Injury Just Above The Heel Bone
The tendon may become sore, thickened, and tender to touch at any point up to about five centimeters above the top of the heel bone. Some of its fibers may be torn or degenerated, while the tendon's covering becomes thickened. The tendon feels stiff first thing in the morning, and on starting exercise. When you stand on your toes barefoot, the tendon hurts at first, but then eases. However, it remains very sore to touch.
The cause is almost invariably friction from shoes with high backs, or heel-tabs. The first priority is to remove the cause: cut down the heel-tabs with two vertical slits on either side of where the tendon lies, to the level of the back of your ankle, usually about five centimeters above the upper edge of the sole. If there is no spasm causing pain higher up where the tendon joins the calf muscle, you can safely resume running and sports provided you warm-up and warm-down thoroughly. The tendon may remain thickened and sore to touch for months, possibly years, but provided you feel no pain during exercise, it is safe for you to continue your sport.
Achilles Tendon Rupture
This may happen at any level in the tendon. A sudden severe pain occurs, which often feels like a violent blow to the calf. Swelling and bruising may appear, and the two broken ends of the tendon often leave a visible gap. Usually, you fall at the moment of injury, and walking is then too painful to try.
The cause can be a blow to the muscle or tendon when they are tensed. More often, the injury is caused by strenuous activity involving the calf, such as sprinting or playing squash. The injury may occur at the beginning of the activity, when the muscles are 'cold' and tight.
At the moment of injury, it may not be clear whether the tendon is completely torn. One test for this is to lie on your stomach, and have someone squeeze the calf muscle bulk gently: if the tendon is partly intact the foot will move to point downwards, but if the tear is complete, the foot will remain still.
This injury requires specialist treatment, which may consist of surgery, to stitch the two tendons ends together, or immobilization in a plaster cast, allowing the tendon to heal naturally. After surgery, you can usually resume sport within three to four months. If your leg is immobilized, the plaster will be on for eight to twelve weeks, so, after rehabilitation, you will probably resume sport about six months after the injury.
The many joints which comprise the foot are all bound together by ligaments, or thickened protective parts of the joint coverings. Any of these ligaments may be damaged by abnormal strains. Usually, the strain is the result of a sudden twist. The strain may occur gradually, from repeated over-stretching, if, for instance, you wear unsuitable or unaccustomed shoes. In either case, once a ligament is damaged, it will set up a painful spot which will be aggravated each time you subsequently over-stretch that point, or apply pressure over it. Even a tiny ligament can give severe pain when strained, and the pain can persist for some months.
Treatment may consist of an injection from your doctor; rest; supportive strapping; underfoot supports to prevent stress over the damaged ligament; or electrical and exercise therapy from a physiotherapist. Any painful activities increase the damage and prolong the injury: the more you can rest the foot, the quicker it recovers.
The plantar fascia may be strained by a change in shoes. When the fascia is strained, it usually becomes painful where the fascia is attached to the heel bone, and the front of the heel bone feels tender when you press it. The heel hurts on walking and running, and on standing up after you have been sitting down. It also hurts when the sole of your foot is put on the stretch, for instance if you pull your foot and toes backwards towards you with your hands. Specialist treatment may consist of an injection and/or electrotherapy. A soft arch support will take the pressure off the fascia. Painful activities should be avoided. You can resume sport when the tenderness to pressure under the heel has disappeared.
This is a general term to describe pain in the forefoot, between the metatarsal heads. The pain may be associated with, or caused by, structural defects such as an excessively high arch. Treatment aims to correct the defects and improve overall foot function, usually by exercises to improve the balanced working of all the muscles in the food, and by foot supports to improve the mechanical alignment of the joints.
In this condition, technically known as hallux valgus, the big toe is pulled towards the second toe, causing the big toe joint with the first metatarsal to form an angled protrusion on the inner side of the foot. The condition is caused by excessive pull inwards from the tendons acting on the toe. Shoes with pointed toes can contribute to the problem. The deformity may become severe, but it is not necessarily very painful. If it does cause pain, pads are used around the protruding bone, to try to prevent friction from shoes over it. Underfoot support, to try to rebalance the weight-bearing load, may be tried. If the joint becomes very painful, and especially if the second toe is crushed by the sideways drift of the big toe, an operation is needed to remove the protruding part of the bone and straighten the joint.
The tendons over the top of the foot are vulnerable to this condition. A direct blow, friction from tight shoelaces, or overuse strain, can cause irritation between these tendons and their covering sheaths. Over-stretching the tendons, by extending the ankle and pointing your foot down, is painful. If you touch the tendons and move your foot, you will feel a slight 'grating' sensation. Specialist treatment may include an injection, or various forms of physiotherapy treatment. You should check your shoes for tightness over the mid-foot, hard lacing eyelets, or roughness on the shoe tongues. If necessary, you should place a padding along the whole tongue. Painful activities and over- stretching should be avoided until the pain and grating have subsided.
These occur because of a direct blow to the nail, or through friction from tight shoes, or from disruption of the nail, for instance if an inner seam in a shoe catches on the toe and lifts the nail away during movement. The blackness is blood and bruising under the toenail. If the nail is painful, with a feeling of excessive pressure, you can ease it by boring through the nail with a sterilized needle, to release some of the blood. If the nail is persistently painful, you should ask your doctor either to treat it, or to refer you to a chiropodist or podiatrist (foot specialist). You should take care to trim all your toenails evenly, straight across the top of the toes, to avoid the further problem of ingrown toenails.
Runners push off from their toes, putting great stress on the metatarsal heads. The 1st metatarsal is usually immune to fracture because it is much thicker and stronger than the others. The 5th metatarsal is relatively immune because the major force of "toeing off" comes from the first 2. The 2nd, 3rd and 4th metatarsals are usually susceptible because of their thin diaphyses.
Symptoms, Signs and Diagnosis
Patients usually present with forefoot pain, often during a long or intense workout, which disappears within seconds of stopping exercise. On successive exercising, the pain returns earlier than previously, ultimately becoming so severe that it may prohibit exercise and persist even with the patient lying in bed. Palpating the swollen area causes pain at the facture site. An x-ray usually is not sensitive enough to diagnose the fracture until a callus forms 2 to 3 wk after the injury.
Treatment includes stopping all sports that require running. Healing usually takes 3 to 12 wk (it may take longer in elderly and in debilitated patients). Women with recurrent stress fractures and oligomenorrhea or amenorrhea may need to be treated with calcium, estrogen and progesterone.
Anterolateral Shin Splits
The anterior compartment muscles (tibialis anterior, extensor hallucis longus and extensor digitorum longus) hold the forefoot up during foot descent and contract eccentrically immediately after the heel strikes the ground. They are opposed by the much larger gastronomies and soleus muscles, which pull the forefoot down. The tremendous force of eccentric contractions can damage the anterior compartment muscles
Symptoms and Signs
Pain occurs in the anterior compartment muscles, at first only immediately after the heel strikes the ground during running. If running is continued, the pain will occur throughout each step, eventually being felt constantly. By the time advice is sought, there is usually severe point tenderness over the anterior compartment muscles.
Treatment includes stopping running, trying an alternate exercise, stretching the calf muscles, and doing exercises to strengthen the anterior compartment muscles after they start to heal.
Posteromedial Shin Splints
The main function of the posteromedial compartment muscles is to supinate the foot and raise and avert the heel just before "toeing off". Increased traction on the muscles is caused by excessive pronation and by running on banked tracks or crowned roads (exacerbated by wearing shoes that do not effectively restrict pronation). Excessive pronation causes the arch to drop lower than normal, increasing the force necessary to lift the arch during supination.
Symptoms, Signs and Diagnosis
Pain usually starts in the postremedial compartment muscles; 2 to 20 cm above the medial malleolus. It becomes more severe when the athlete rises up on his toes or averts the foot. If he continues running, the pain then moves forward to involve the medial aspect of the tibia, and can then move up the medial side of the tibia, to reach within 5 to 10 cm of the knee.
Pain location and severity depend on injury progression. First, there is a tendonitis of the muscles of the deep posterior compartment. If the athlete continues to run, the pain may progress into the muscle bodies themselves; then traction on the tibialis posterior tendon can lift the muscle from its bony origin, causing subperiosteal hemorrhage and periostitis. With continued traction, part of the tibia can be torn away.
Treatment is to stop running, until it causes no pain, choose an alternate exercise, wear shoes with rigid heel counters and special arch supports to limit pronation, avoid future running on banked tracks and crowned roads, and strengthen the injured posteromedial muscles.
An acute hamstring injury can happen in a variety of different ways, with the one common factor that there is a sudden pain in the muscles, which is directly related to a particular movement or incident.
The hamstring muscles or their tendons may tear as a result of an over-stretch injury, for instance if you have to sprint suddenly when you are cold, or when your muscles are tightened because of a previous strain, or fatigue from training hard the previous day. Over-stretching may happen if your foot slips forward when your leg is straight in front of you, for instance as you land during hurdling. A direct blow to the hamstrings while they are contracting can tear the muscles. You may be hit by a hockey ball or a squash racket while you are running fast. Inefficient muscle function can also contribute to sudden tears in the hamstrings.
What you feel is a sudden pain in the hamstrings, which may be no more than a twinge, up to a searing pain. You may see bruising, immediately, or some time after the injury has happened, and the bruising, with perhaps swelling, will tend to track downwards towards the knee. If there is a severe tear, you may see a knot of tissue forming a bump on the thigh, especially if you work the hamstrings by trying to bend your knee. After the initial pain, the torn part feels sore to touch, and gives pain in the same area whenever you contract the hamstrings, either by extending your hip or bending your knee; and when you stretch the muscles, by keeping your leg straight and bending forwards at the hips.
A severe tear, involving a lot of muscle tissue, may need to be stitched together again by a specialist surgeon. However, if the tear is more minor, your doctor may decide that you need no more than a conventional rehabilitation program, which you must follow completely.
A gradual pain in the hamstrings, directly related to a particular movement or activity, is usually termed a hamstring 'pull' or 'strain'. This injury happens for similar reasons to the acute tear. The muscles are tight, fatigued, or weakened, and are then strained by overwork. Over training, especially if this involves repetitive movements, is a common cause of hamstring overuse strains.
By definition, the overuse strain starts with only a very slight pain, which gradually gets worse, as you continue with the activity which caused the problem. Occasionally, the pain is only evident when you work the hamstrings against resistance in their least efficient range, lying on your stomach with your knee held bent to a right angle, and extending your leg backwards at the hip.
The problem with overuse injuries to the hamstring is that they tend to recur. Even if they do not develop to the stage of an acute tear, they limit your ability to run, sprint, hop, and stretch your leg out. Specialist treatment may include injections, and various forms of physiotherapy. But the most important factor in recovery is regaining full flexibility in the muscles, and efficient function. If you try to resume your sport before you have completed the whole recovery process, you are making a recurrence of the problems inevitable.
A mild hamstring injury may recover within ten days to two weeks, but a more severe problem can last for over three months. If your hamstring injury does not improve, despite careful rehabilitation, it may be that there is an underlying problem. Hamstring pain and spasm can be caused by a stress fracture in the thighbone.
Exposure to high ambient temperature may lead either to excessive fluid loss and dehypovolemic shock (heat exhaustion) or to failure of heat mechanisms and dangerous hyper pyrexia (heatstroke)
Common sense is the best preventive; strenuous exertion in a very hot environment and insulating clothing should be avoided, and an adequate fluid intake is important.
An abrupt onset is sometimes preceded by prodromal headache, vertigo, and fatigue. Sweating is usually but not always decreased, and the skin is hot, flushed, and usually dry. The pulse rate increases rapidly and may reach 160; respirations usually increase, but the blood pressure is seldom affected. Disorientation may briefly precede unconsciousness or convulsions. The temperature climbs rapidly to 41C and the patient feels as if burning up. Circulatory collapse may precede death; after hours of extreme hyperpyrexia, survivors are likely to have permanent brain damage.
Old age, debility, or alcoholism worsens the prognosis.
Heroic treatment measures must be instituted immediately. If distant from a hospital, the patient should be wrapped in wet bedding or clothing, immersed in a lake or stream. The temperature should be taken every 10 minutes and not allowed to fall below 38C to avoid converting hyperpyrexia to hypothermia.
The patient should be taken to hospital as soon as possible after the emergency methods have been instituted for further management.
Bed rest is desirable for a few days after severe heatstroke, and temperature liability may be expected for weeks.
Because of excessive fluid loss, this disorder gives adequate warning by increasing fatigue, weakness, anxiety, and drenching sweats, leading to circulatory collapse with slow thready pulse; low or imperceptible BP; cold, pale, clammy skin; and disorientation followed by a shock-like unconsciousness.
Syncope (faint) is a mild form of heat exhaustion and is precipitated by standing or a long time in a hot environment, e.g. the soldier on the parade ground, and is due to pooling of blood in the heat-dilated vessels of the lower extremities.
Heat exhaustion is more difficult to diagnose than heatstroke, but its prognosis is far better unless circulatory failure is prolonged.
Treatment is aimed at restoring normal blood volumes and improving brain perfusion, thus the patient should be placed flat or with their head slightly down. When they start responding, small amounts of sugar water should be given.
The knee is not simply a hinge joint: you bend and straighten it, but you can also turn it slightly in a twisting movement, when the knee is bent. This rotary movement automatically accompanies the bending and straightening movements. As you bend your knee, the shinbone turns inwards slightly relative to the thigh bone. As you straighten, the shinbone rotates outwards. You can only rotate the knee actively and voluntarily when the knee is bent. When you bend your knee against gravity or a resistance, the muscles at the back of the knee contracts to perform the movement. The hamstrings do the main work of bending the knee, but the gastrocnemius tendons help, especially if the movement takes place against a strong resistance. When you straighten your knee in the direction of gravity, for instance while you are lying on your stomach, the hamstrings pay out to control the movement. The quadriceps muscles on the front of the thigh straighten your knee against gravity or a resistance, but they also act to control the movement, when the knee bends in the direction of gravity's influence.
The structure of the knee-joint has two effects. Firstly, the knee is a very stable joint, by virtue of its strong binding ligaments and the protective effect of the muscles which control the joint's movements. Secondly, the joint has quite a wide freedom of movement, because the bones are not closely bound within their own configuration. The knee is one of the three major joints in the leg which transmit loading forces between one's body and the ground. Its stability helps to keep us upright on our feet when we are standing, walking, hopping or jumping.
This can arise from various causes. The knee can be affected by a spontaneous inflammatory arthritis. Or it can be one of many joints involved in a multiple inflammatory arthritis. Pain referred from the hip or back may be felt as a simple knee pain. Problems in the thighbone may cause knee pain. In older age, the knee, like the hip, may be affected by osteoarthritis, or wear- and-tear degeneration. In children, unexplained knee pain can be a sign of a very serious hip condition, the slipped epiphysis.
Joint swelling is an important symptom in knee conditions. Because of the complex and extensive synovial lining in the knee, the joint may distend alarmingly, with swelling right round the joint, reaching about seven centimeters above the knee onto the front of the thigh. However, it can also be more subtle. You may also see a small pocket of swelling, perhaps on one or the other side of the joint; or there may be just a slight puffiness on the front of the joint, on either side of the kneecap. Swelling may occur at the back of the joint, without any visible signs of it at the front. Joint swelling always indicates inflammation. As in the ankle, knee swelling can be caused by gravity bringing the fluid down from some higher tissues: the swelling may track down from the hip joint or some part of the thigh muscles. However, unlike the situation in the ankle, if you have persistent swelling in the knee, which delineates the joint's shape, it is unlikely to be gravitational swelling, and it is very likely to mean that there is something wrong inside your knee.
If the swelling has appeared for no obvious reason, it may indicate that you have an inflammatory or degenerative condition. Your doctor will probably arrange blood tests and X-rays, to decide whether this is so. If the swelling occurs as the result of an injury to the knee, and you are aware of having wrenched it, or fallen on the joint, it is likely that you have damaged one or more of the knee's internal structures, with irritation or damage to the synovial lining. The swelling may come on at the moment of injury, or some hours afterwards.
The knee is very prone to injury, because of its mobility and the variety of stresses we subject it to. The most common type of traumatic injury to the knee is the twisting or wrenching injury. This happens most frequently when your knee is bent, while carrying your body-weight, and you twist awkwardly or unexpectedly. Skiers and footballers are most susceptible to this type of injury, but it can happen to you while walking or running, if you trip and catch your foot, or fall while turning. Any of the knee's structures may be damaged in this type of injury. The full extent of the damage may be impossible to assess immediately after the injury, and may only become evident when the knee subsequently fails to recover its full function.
The knee is also vulnerable to overuse injuries: gradual pains brought on by an activity, which progressively get worse, if you continue the activity. These are the injuries which must be distinguished from the other, more serious, medical conditions which can cause similar pain.
Frontal Knee Pain
1) Patellar Tendon Strain
The patellar tendon is very short, extending only between the pointed lower end of the kneecap and the tibial tubercle, the prominent bump of bone at the top of the shinbone. However, it acts as the concentrating point for the pull exerted by the quadriceps muscle group during knee movements, so it is an extremely powerful tendon. The tendon works hard whenever the knee bends and straightens under load. It works hardest when knee movements involve a full bend under your body weight and gravity, for instance if you do a full squat exercise in weightlifting, or when you take off from one leg in high jumping or long jumping. The tendon also generates a strong pull when you go up and down stairs, when you run on hilly ground, and when you kick a football.
Because the tendon plays such an important part in all movements at the knee, it may be strained simply by overwork. This type of overuse strain is usually due to a repetitive activity, such as long-distance running, or extended sessions of hill running, hopping and bounding, kicking, or squatting exercises. An overuses strain is more likely to occur if the tendon is working inefficiently, because it is fatigued through overwork, or tight due to cold or previous excessive exercise. Bad shoes can contribute to changing the tendon's angle of pull. This is especially true if children and adolescents wear shoes with little support underfoot, or high-heels, during their growth years. The tendon may also be subject to sudden injury.
When the patellar tendon is strained, a few of its many fibers may be torn. This causes pain when you use the tendon, but it does not necessarily stop the tendon from working through its normal range of movement. As a result of a strain, or partial tear, the tendon may become thickened, and tight, because of scar tissue forming in the torn fibers. This limits the tendon's function, and the tendon becomes more painful on movement.
The tendon may tear completely, causing immediate functional disability. When the tendon tears right through, the whole of the quadriceps muscle group on the front of the thigh is incapacitated, as its lower attachment point is destroyed. The kneecap rides upwards over the thigh, as it is no longer held tethered over the front of the knee-joint. There is of course severe pain, and it is impossible to take weight through the leg. A normal patellar tendon can only tear completely if a sudden enormous force is applied to it. However, it may give way under less pressure, if it has been previously weakened by repeated strains which have made its center degenerate. Steroid injection into the center of the tendon can result in severe weakening of the fibers. Following inexpert injections to 'cure' a strain, the tendon may tear under minimal pressure, for instance if you squat down, or if you try to climb onto a higher step.
When the patellar tendon tears completely, you must refer for specialized treatment as a casualty. The tendon will have to be repaired surgically, as quickly as possible after the accident. You will not be able to put weight through your leg, and you should be transported to hospital, keeping the leg as still as possible.
Osteochondritis, a form of degeneration in a bone's growth point, can occur in the lower part of the kneecap, where the patellar tendon attaches to the bone. This complication is called Sinding- Larsen-Johnson syndrome, and it causes severe pain when the tendon is stressed during activity, as well as soreness if you press over the point of the kneecap, or if you try to kneel on it.
2) Prepatellar Bursitis ('Housemaid's Knee")
The front of the kneecap is protected by a fluid-filled pouch, or bursa, which lies between the bone and its covering skin. When the bursa is inflamed, it swells up, forming a large egg-like protrusion over the kneecap. The condition is called 'housemaid's knee', identified in women who had to kneel down constantly to scrub floors and so were particularly prone to suffer from it. The damaged the bursa has a cumulative effect from the repeated pressure on the front of the knee. The bursa can easily be damaged by a single hard blow on the kneecap, for instance if someone kicks your knee, or if you fall onto your knees from a height. The bursa may also swell because of a medical inflammatory condition. Your doctor will be able to differentiate between the various possible causes of the bursitis, if you can give him an accurate account of exactly when and how it first occurred.
Although the bursa may become large and unsightly, it is not necessarily very painful or functionally disabling. It hurts when you press it, and possibly when you stretch the skin on the front of the knee, by bending your knee fully, or squatting down. If it does become painful enough to interfere with your normal activities, it will need specialized treatment. Your doctor may drain off the extra fluid in the bursa, although the swelling may recur after this is done. Otherwise, the bursa may be removed completely by surgery to eliminate the problem and the possibility of recurrence. After surgery, the knee is usually kept immobilized in a plaster, to prevent a secondary bursa from forming in place of the original one. About four weeks after the operation, the surgeon normally allows rehabilitation to start, following removal of the plaster.
3) Knee-cap dislocation
This is a problem which can occur at any age, but which often happens to children. If it starts in pre-teen years, it tends to be a continuing problem, with episodes that gradually get worse over the years. Girls are particularly vulnerable to the problem. When the dislocation is a continuing, chronic problem, the episodes tend to be relatively mild, so that the dislocation is hardly recognizable as such. However, in the older sportsman especially, the dislocation can be severe, with the kneecap remaining out of alignment until it is manipulated back into place.
Specialist care will aim to correct the mechanical defects that contribute to, and are caused by, the kneecap dislocation. You will be set a program of exercises to strengthen the inner part of the quadriceps. If your foot mechanics have contributed to the weakness in your knee, a podiatrist will make up special orthotic foot-supports for you. If the dislocation problem is severe, you may be referred to an orthopedic surgeon for an operation that would aim to strengthen the kneecap from its inner side, and perhaps correct the 'Q-angle' at the knee. In the worst of cases, the surgeon may recommend removing the kneecap to eliminate the problem.
Pain in the back of the knee
There are many bursea, or fluid-filled sacs for friction-free movement, at the back of the knee.
Any of these bursae may become inflamed and swollen. If an inflamed bursae becomes very enlarged, it may push sideways into the space at the back of the knee called the popliteal fossa. You will then be able to see a defined, soft swelling protruding from the back of the knee. It need not necessarily be very painful, but by taking up space it may limit full movement at the knee. You should refer to the doctor for an assessment of the swelling, as this type of swelling can be disease-related. If it does prove to be simply a bursitis caused by friction, perhaps because you have changed your style in distance running, or changed boats in rowing, it may not be necessary to have any treatment for the swelling. The definitive cure is to have the swollen sac removed surgically by an orthopedic surgeon. After surgery, your knee is usually kept held still in plaster for some weeks, after which you have to re-strengthen the muscles, and then regain full movement.
Pain inside the knee joint
Any of the knee's internal tissues can be damaged by a severe injury, but the cartilage (menisci) and the cruciate ligaments are those most commonly harmed in sportsmen.
1) Cartilage tears
The knee's soft-tissue cartilages can be damaged by pressure from the bones of the joint when an abnormal force twists the bones against each other unusually. In the normal way, the cartilages move slightly, backwards and forwards, during knee movements. In this way, the cartilages act as buffers throughout the whole movement, although the joint surface of the thighbone is bigger than the receiving surface on the shinbone. However, with abnormal pressure, the cartilages may be jammed between the two bones: if the bones then twist on each other and apply a shearing stress on the cartilage, the tissue splits.
The most common cause is an abnormal twist in your knee while your weight is on the leg. In each case, your knee is bent at the moment of injury. A sudden stress with the knee bent, even when you are not standing on the leg, can be enough to tear the cartilage. Cartilage tears can also be caused by a sudden over- stress when your knee is straight, for instance if you miss a drop kick in rugby.
This injury gives instant pain, to the extent that you may not be able to move the knee at all, let alone take weight through your leg. Immediate swelling will inhibit movement further, although the swelling may not appear until some hours later, in which case the knee will feel weak rather than stiff in the first instance. Visible swelling may extend right round the knee, making the joint look bloated, or it may be only a small patch, barely visible over the line of the joint. At the moment of injury, it is impossible to tell, from the outside; exactly how much damage has been done. First aid for the swollen knee must be applied (see "treatment of acute sports injury").
The only external sign that you might have torn a cartilage is the so-called 'locked' knee. More often, the knee is too painful to move immediately, and this 'locking' feeling only becomes evident when the knee has recovered enough for you to be moving it. Once you have applied first-aid measures and made the knee comfortable, you must be taken for specialist help as quickly as possible.
The sooner an accurate assessment of the extent of the damage is done; the better off you will be in the long-term. If you are taken to a casualty department in a hospital, your knee will probably be X-rayed, to see whether there is any bone damage. You may also have arthrograms done, in which dye is injected into your knee, so that soft-tissue damage shows up on X-ray. You may even be admitted to hospital so that an orthopedic surgeon can perform arthroscopy.
Once a specialist has diagnosed a cartilage tear in the knee, there are two possible courses of action. Either the torn part of the cartilage must be removed surgically, or the problem must be treated with rehabilitation only. The one certainty is that the torn cartilage will not heal, or mend itself, naturally. If the specialist decides on immediate surgery, it is because he deems that the torn cartilage will create functional problems in the knee.
The cartilage removal operation is called a meniscectomy. Recovery from the surgery can take a varying time, according to individual circumstances. It is possible to be back to full sporting activities within two weeks of removal of the cartilage through the arthroscope.
If a specialist decides not to remove the torn cartilage, after diagnosing the tear, it is because he believes that the damage is slight, and the knee can recover functionally without any need for surgery. Your leg may be immobilized in plaster, to protect the knee, if the injury was severe; or you may simply be given a supporting bandage to control the swelling.
In either case, you must start straight-leg exercises immediately, to maintain knee stability. You progress to gentle mobilizing exercises to bend the knee as soon as your specialist allows, when the knee is no longer acutely painful and swollen.
2) Cruciate Ligament Tears
The cruciate ligaments are two strong bands that bind the shin- bone to the thighbone, across the center of the knee. It takes a strong force to damage them; they can be torn in a severe twisting injury, for instance in a blocked kick or a sliding fall in a tackle during football; or by excessive pressure forcing the knee to 'bend backwards' when it is straight, for instance if an opponent falls across your extended leg in rugby or hockey.
A major shearing force can tear both cruciates together, usually tearing one or both of the cartilages at the same time. A moderate injury may tear one of the cruciates completely, without damaging the second, and with or without accompanying cartilage damage. At the moment of injury, it is totally impossible to assess the extent of the internal damage through outward signs. The only certainty is that, if your knee has swollen painfully, some of its internal structures have been damaged. If you do not have an accurate diagnosis at the time of injury, it may only become apparent that the cruciate ligaments have been damaged much later when you have started doing sport again. Then you may find that in certain positions your knee feels loose and instable. It may feel as though it is 'rolling' on itself, backwards or forwards, usually giving a 'clunking' sound, with a sharp pain. This makes running and turning difficult. This unstable feeling is an external indication that there is some damage to the cruciates. If your knee locks as well, then there is also likely to be cartilage damage.
At the moment of injury, the knee should be made comfortable in applying the first-aid measures for the swollen knee. It is essential to obtain a specialist opinion as quickly as possible. If the surgeon finds that both cruciate ligaments are completely torn, he will probably perform an immediate operation to try to repair the damage. If there is partial damage to one or both of the cruciates, the surgeon will choose whether to operate, or whether to allow the knee to recover enough for you to resume sport, and see whether there is any residual disability when you use the knee.
Whether the repair is done straight away, or after residual disability has shown up, there are various methods that the surgeon may choose to mend the damage. Some procedures involve mending the cruciates themselves, either by re-attaching a torn end to the bone from which it has snapped off, or by replacing the whole ligament with a synthetic substance. Other methods of stabilizing the knee involve tightening up the capsule and tissues around the joint, to compensate for the internal instability. Whichever method the surgeon chooses, rehabilitation is a slow process; full recovery may take up to a year. It is vital to follow the surgeon's rehabilitation program to the letter, as recovery phases differ according to the particular operation done.
The knee joint is the most complicated joint in the body. It consists of three joint surfaces that are covered with articular cartilage. There are two menisci (cartilages) between the joint surfaces, and four ligaments that stabilize the joint. When a person walks, the load exerted on the knee joint is approximately four times the body weight; with running it is eight times the body weight.
The Clinical Examination
In order to make an accurate diagnosis it is important to have a complete medical history of the knee problem. This includes the details of the mechanism of injury, the type and location of the discomfort and symptoms such as swelling, giving way, locking, etc. The medical history is followed by a careful clinical examination of the joint, after which the surgeon should be able to make a provisional diagnosis. This provisional diagnosis is further confirmed by diagnostic tests.
Routine X-rays should show any abnormality in the bone itself and will also show up wear and tear on the joint surface. It is, however, not possible to see soft tissue structures such as cartilage and ligaments on X-rays. In special cases MRI (magnetic resonant imaging) is done, as this does show up soft tissue. An arthroscopic examination can also help with the diagnosis.
An arthroscope is an instrument similar to a telescope. It is approximately as thick as a pencil, and has a lens on the one end. The arthroscope is placed into the joint through a small puncture wound. A small video camera is attached to the back of the arthroscope, allowing one to visualize the inside of the joint.
This is usually done on an outpatient basis. The patient would come to the hospital on the day of the operation and be discharged on the same day. No food or drink may be taken in for six hours before the operation. On the morning of the operation, the patient should report to the hospital reception, from where he or she would be directed to the outpatient department.
Three small puncture wounds are made in the joint while the patient is under general anesthesia. The scope and other necessary instruments are inserted into the joint through these wounds, and the necessary procedure is performed. Surgical procedures such as the removal of loose bodies, meniscectomies, repair of joint surfaces and even ligament reconstructions can be performed through the scope.
In most cases the patient will be able to take full weight on the joint by the time he or she leaves the hospital. In a small percentage of cases it might be necessary to use crutches for a day or two.
REMEMBER: One is not allowed to drive a car for the first 12 hours after anesthesia.
The following should be observed after arthroscopic examination/surgery:
- It will usually be possible to walk without crutches. However, if the joint causes discomfort, crutches should be used for as long as necessary.
- The sutures are soluble and beneath the skin, and do not have to be removed.
- The bandage around the joint can be removed after three days, by which time the wounds should have healed to such an extent that baths or showers would be possible.
- If the knee is pain-free after four weeks, it is not necessary to make a follow-up appointment, unless the doctor has indicated otherwise. It will be approximately four to six weeks before the knee is completely pain-free.
- The doctor will be available to discuss any questions or problems.
- There are a number of exercises that could be done at home. The exercise routine should be started as soon as the knee is pain-free. If physiotherapy is indicated, the doctor will prescribe it.
- There should not be severe discomfort. Light analgesics will be prescribed, and they should control any pain. If there is severe pain, swelling of the calf or any other problems, the doctor should be contacted.
Rehabilitation Exercises for the Knee
In the case of a knee problem it is of the utmost importance that the hamstring and quadriceps (upper leg) muscles should be as strong as possible. There are a number of exercises to strengthen these muscles. An iron shoe weight or a shopping bag filled with sand can be used for the exercises. The patient should start with a light weight (or even no weight) and slowly increase it weekly until his or her maximum is reached.
Do the quadriceps isometric exercises as indicated, i.e., contract the muscles maximally for five seconds with minimal knee movement. The knee must not move more than five degrees during the exercise and the muscle should be maximally contracted while the knee is kept completely straight.
Repeat ten times, rest for two minutes and then do ten more. Do the whole exercise three times, with two-minute rest periods in between.
Isotonic exercises are indicated for the hamstring. The knee is brought from full extension to full flexion in a slow movement with a weight on the foot.
Do in succession and then rest for two minutes. Do another ten. Repeat the whole exercise three times, with two-minute rest periods in between.
III. Side Muscle
For the muscle on the side of the leg, the patient must lie on his or her healthy side while keeping the knee straight. Lift the leg sideways, using the same technique as in II, but with a light weight.
Do ten in succession, rest for two minutes and then do ten more. Repeat the whole exercise three times, with two-minute rest periods in between.
These exercises should be done at least twice a day for six weeks.
Any movement, or series of movements, which places abnormal stress or abnormal loading on the spine can injure it. This may be a sudden overload, if, for instance, you overbalance while lifting a very heavy weight. Or it may be a cumulative overload, if you repeatedly pull or lift a weight at an awkward angle.
In principle, your back is a very strong structure. It can withstand a great deal of pressure. Equally, in certain situations, it can become vulnerable to strains. Often, the strain is caused by pressure or loading that seems trivial, and below the normal strength of your back. Sports which combine twisting movements in the spine with heavier compressive loading, like rowing, judo and rugby, carry the double risk of sudden, traumatic, back injuries, or the more gradual kind.
It is usually possible to identify a triggering factor for your back pain, even when the injury appears to have no particular cause at first sight. You may have changed your equipment, or your style of play; you may have been doing more of your sport than you were used to; you may have been feeling back stiffness due to fatigue; you may have over-twisted or over-loaded your back without a preparatory warm-up; you may have developed a faulty technique through carelessness in handling, lifting or carrying heavy weights; or a leg injury may have affected your back posture.
Back pain, whether sudden or gradual, may be felt in one localized area of your back, or it may feel widespread over the whole lower back. If the injury is sudden, it is likely to cause a severe stab of pain, which may subside quickly or may persist. A more gradual pain usually starts mildly, but builds up to the stage of causing real discomfort. You may find that certain movements or positions aggravate your pain, while others relieve it. You may feel that your back hurts, whatever you do, but careful analysis may show that in certain positions you can relieve your pain. You have to be aware of cause and effect: poor posture may ease your pain temporarily, but make it worse as soon as you straighten up. Easing pain through twisting your back is likely to make your pain progressively worse over a space of time. Your back may hurt when you are at rest; when you cough; when you turn over in bed at night. But it may stop hurting when you lie flat; when you are walking around; when you bend forwards, backwards of sideways; or if you hang from a bar by your hands, and take the weight off your feet.
You may also feel pain in one or both legs, associated with your back pain, and which gets worse when your back is moved in certain ways, for instance when you are sitting in an easy chair, or when you bend forwards. The leg pain may be directly traceable to your back, so that you feel a line of pain spreading down from your lower back into your groin, or down the back of your leg. The pain may spread only to your knee, or it may go right down to your foot. This kind of leg pain may come on without an obvious link to your back, making you think that you have a localized muscle strain in your leg. Although referred pain in the leg related directly to a back strain, or sometimes to a hip problem, it can come on when you do not have noticeable pain in your back. Because of the complex structure of your spinal joints, there are many different tissues that can be damaged in a back injury. A severe compression injury, like a fall from a height, can crush the body of a vertebra. A severe twisting injury can fracture the bony arch at the back of one of the vertebrae. Abnormal movements can strain any of the ligaments guarding the spinal joints. Over-stretching or over-contraction may strain the small or larger muscles in your back. If a spinal joint is damaged, the muscles over it usually go into spasm, to fix the joint in a kind of natural splint. This stiffens that part of your back, creating even more pain if you then try to move it against the limiting factor of the tightened muscles. If you try to force movement, you may tear the muscles, adding to the original damage done in the injury.
The discs between your vertebral bones can be damaged in a variety of different ways. The danger of disc damage increases as you get older, because the strong outer part, the annulus fibrosis, begins to degenerate at any time after twenty-five years, while the nucleus pulposus begins to lose its pliability and water-holding capacity as early as in middle age. Minor damage to the outer part of the disc can be no worse in its effect than a strain to the ligaments covering the joints. But major disc damage is a much more serious problem. A rise in pressure over a degenerated disc can push the disc out from between the vertebrae, or it can create enough pressure to push the nucleas through the annulus, cracking its outer ring. Usually the broken disc protrudes backwards, so that it encroaches into the spinal canal, and lodges against the nerves there. This can cause severe and unremitting pain in your leg, in the pathway of the pressurized nerves, although the pain may be milder and intermittent. The cause of this major injury can be minor; a degenerated disc may be disrupted by simple activities like coughing when you are bending forward, or lifting even a light weight with your back bent.
It is totally impossible for you to identify which of the various spinal structures has been damaged in any particular injury. This is a matter of specialist diagnosis.
- If there is any danger at all that your back might have been broken in a very severe, traumatic injury, you should not be moved at all until specialist help arrives and you can be transported to hospital. Apart from back pain, the main signs that your back may have been broken are numbness, tingling or pain in your legs, and a feeling of total weakness in your trunk and legs.
- If the injury is less drastic, but very painful, ice can be applied to your back. You should refer to your local casualty department or your doctor as quickly as possible, in case you need X-rays or other investigations.
- In the initial stages of a painful back injury, the more you lie down and keep the weight off your feet, the better. If possible, lie flat, and avoid propping your head up on pillows, or curling up on your side.
- If you have to sit down, especially at work, you must make sure that your back is well supported, preferably on soft cushions.
- You must avoid any activities that cause pain in your back.
- General exercising is best started with swimming.
- Your return to your sport should start with gentle jogging, building up to sprinting, and then sprinting and turning, and shuttle running.You must always remember to warm-up thoroughly before any exercise session; warm-down afterwards, and shower quickly, rather than sitting around getting chilled.
1) Tennis Elbow (Lateral Epicondylitis)
This is an overuse syndrome caused by continued stress on the grasping muscles and supination muscles, which originate on the lateral epicondyle of the elbow. First, there is pain in the extensor tendons when the wrist is extended against resistance. With continued stress, the muscles and tendons hurt even at rest, and there is progression to subperiosteal hemorrhage, periostitis, calcification and spur formation on the lateral epicondyle.
During a backhand return, the elbow and wrist are extended, causing the extensor tendons, particularly the extensor carpi radialis brevis, to be damaged when they roll over the lateral epicondyle and radial head. Contibuting factors are poor backhand technique and weak shoulder and wrist muscles. Other factors include using a too-tightly-strung racket, using too small a handle, hitting heavy wet balls, and hitting "off-center" on the racket.
The first symptom is pain along the lateral epicondyle when the patients hits a backhand shot. Often this is ignored and exercise is continued. Eventually, the pain becomes constant and can extend from the lateral epicondyle to the wrist.
On examination, if the patient is asked to extend his fingers against resistance when the elbow is held straight, pain will occur along the common extensor tendon. Alternatively, the patient sits on a chair with the arm resting on a table. The hand is held palm downward, and the elbow is straight. The examiner places a hand firmly on top of that of the patient, who is asked to try to raise the hand by bending the wrist. The same pain will occur. Treatment is to avoid any activity that hurts on extending or pronating the wrist, and to substitute any exercise that does not cause pain, e.g., jogging, cycling, basketball (even racquetball or squash, as the force of the ball on the rackets is less than in tennis). With healing, exercises to strengthen the wrist extensors can be started. Generally, exercises to strengthen the wrist flexor pronators are also recommended.
2) Golfers Elbow (Medial Epicondylitis)
Forceful wrist flexion and pronation can damage the tendons that attach to the medial epicondyle; e.g., serving in tennis (with too heavy a racket, heavy balls, an undersized grip, a spin serve, or having too much tension on the strings, together with weak shoulder and hand muscles), pitching in baseball, throwing the javelin, and carrying a heavy suitcase or playing golf. If the athlete continues to stress the wrist flexors, the tendon can be pulled from the bone, causing subperiosteal hemorrhage, periostitis, spur formation and tearing of the medial collateral ligament.
The patient complains of pain in the flexor pronator tendons (that attach to the medical epicondyle) and in the medial epicondyle when the wrist is flexed or pronated against resistance or when a hard rubber ball is squeezed.
To confirm the diagnosis, the patient sits in a chair with his arm from the elbow to the wrist resting on a table. The hand is supinated, and the patient is asked to try to raise his fist by bending the wrist, while the examiner holds it down. Pain will be elicited on the medial epicondyle and in the flexor pronator tendons.
The patient should avoid performing any activity that hurts on flexing or pronating the wrist and should try an alternative sport, as for lateral epicondylitis, above. Later, he should learn how to hit the ball by applying more force from the wrist and shoulders and do exercises to strengthen the muscles in the hand, wrist, elbow and shoulder. Generally, exercises to strengthen the wrist extensors should also be done.
Groin pain may be caused by internal problems, for instance bladder or prostate problems. It may be referred from your back or hips, without necessarily causing symptoms in the joint which is the source of the pain. An inguinal hernia injury to an adductor tendon or a stress fracture in one of the pubic bones, can all cause pain in the groin region.
As soon as you have noticeable pain in your groin, you should refer to your doctor with details of how it came on, what makes the pain worse, whether it eases at all, and whether it is aggravated by such movements as coughing, sneezing, or passing water. To make an accurate diagnosis of your problem, your doctor will probably want to do investigations such as X-rays, bone scans, blood tests and internal checks, as appropriate to your symptoms.
The pubic symphysis is such a strongly bonded joint that it is rarely injured on its own. In a severe injury involving shearing stresses, for instance a fall in which a motorcycle or a horse rolls across your pelvis, you are as likely to fracture the pelvic bones as to disrupt the symphysis pubis.
However, the pubic joint can be damaged by repetitive stress. If a particular movement or activity causes a continual slight separation or shearing in the symphysis, the joint surfaces can be eroded, causing a kind of roughening in the cartilage and bones forming the joint. This condition is called osteitis pubis, meaning inflammation of the pubic bone.
Footballers can suffer this injury, simply from the cumulative effect of the shearing movement involved in kicking the football. Rest is an essential part of the cure for this problem. You have to avoid any pain-causing activities for anything up to six months. If the problem is severe enough, your doctor may refer you to an orthopedic surgeon, with a view to your having an operation to fuse the two bones in the symphysis together.
An uncomfortable condition, which can happen to cyclists, is friction directly under the groin from the saddle. The friction may cause pain, numbness or tingling. A very uncomfortable secondary effect in men can be a constant, painful erection, due to pressure on the nerves in the groin.
Specialist treatment may be needed, but analyzing the cause of the problem is essential to avoid recurrences. The saddle may be too wide, so it should be changed for a narrower one, preferably with furrowed edges. Some soft padding along the edges of the saddle may help. The cyclist should avoid pressing inwards against the saddle with his or her thighs. Standing up in the pedals whenever possible can help to relieve the constant pressure on the seat and groin.
Your neck can move freely forwards, backwards and sideways. Twisting is the only limited movement in the neck (cervical) region, and this is compensated for by the freedom of rotation in the thoracic region immediately below. The necks forms the main support for your skull, so its movements allow you to turn your head, so that you can see in various directions, or move your head away from danger. Your shoulder movementís co-ordinate with your neck movements, because of the muscular links. The muscles may hold your neck still, for instance when you extend your arms in shaping up for a dive. Or your neck may move at the same time as your shoulders, as when you serve in tennis, turning your head to watch the ball as you throw it up.
Like the rest of the spine, your neck encloses and protects your spinal cord, which emerges from your brain through a hole in your skull, and then extends downwards in the canal formed by the bone struts at the back of the vertebral blocks.
Inflammatory joint disease can cause pain in the neck joints. You can have neck pain related to certain viral infections. Influenza often causes aching and stiffness on one or both sides of your neck. Pain can be referred to your neck from internal regions, such as your diaphragm or breathing muscle.
You can hurt your neck through a sudden traumatic injury, for instance if you hit your head in a fall from a height, or if your head or neck is wrenched. This type of accident can happen in sports like riding, gymnastics, diving, rugby, judo and boxing. If the injury is severe, and there is a chance that the neck might have broken, the victim must be kept still, as there is a risk of total paralysis. For less severe strains, you can apply ice to relieve the worst of the discomfort. If possible, the neck should be supported, for instance by a folded newspaper wrapped around it and held in place by a towel or scarf. You should then refer to your doctor or local casualty department as quickly as possible, in case you need to have X-rays taken.
Your neck can also be injured by gradual, overuse strains. Too much strain on your neck muscles through a long bout of tennis practice, throwing the javelin, archery or hand-stands in gymnastics can cause this type of gradually increasing pain. The actual damage may vary from an injury to one or more of the neck joints, involving a strain or tear in ligaments, joint capsule, or small muscle, to gross damage to one or more of the discs. The muscles over the damaged joint usually go into spasm to protect the joint from more harm, and you feel tightness and soreness in the trapezius on the injured side. Occasionally, neck joint problems happen following an injury to the neck muscles, because the injured muscle, becoming taut, pulls against the joints and distorts them. Accurate diagnosis of neck injuries is a matter for the specialists, and the problem should be treated, before you try to resume your sport.
Following an injury, your specialist may recommend you to do specific neck exercises, to make your neck joints stronger and more flexible. Once you have recovered, you should include some neck exercises in your warm-up before doing sport, and, if possible, as a general daily routine. At no stage should you do any movements that cause pain, during or after the exercise.
While your neck is painful, your specialist may give you a supporting collar to wear, made of hard or soft material.
As in the rest of the spine, a neck problem can cause referred symptoms. You may feel pain, tingling or numbness down your arm into your hand. The symptoms may form a continuous line down your arm to your hand, or only one part of your arm may be affected, in which case it may be more difficult to relate the symptoms to your neck problem. A ligament strain, or minor damage to a disc, will cause intermittent referred symptoms, which you can relieve by altering the position of your neck, perhaps stretching your neck away from the affected arm. A major disc problem causes unremitting pain. In either case, you should ask your doctor for specialist help, and you should not do any sport or strenuous activities until you have recovered.
Headaches and dizziness can also be caused by neck problems, either through spasm in the neck muscles, or because your injury is interfering with the flow of your circulation between your vertebrae.
Wear-and-tear arthritis can happen in the neck joints, causing pain in your neck, with or without referred symptoms in your arms. It is important to maintain as much mobility and strength in your neck as you comfortably can, while avoiding stressing the joints with heavy loading or strenuous sports. Your doctor will advise you on the type and amount of exercise you should be doing, on the basis of your symptoms and the changes visible on your X-rays.
Rotator Cuff Tendonitis
The rotator cuff (supraspinatus, infraspinatus, subscapularis, and teres minor) holds the humeral head tightly in the glenoid fossa of the scapula. Tearing and inflammation of the tendons of these muscles often occur in sports requiring the arm to be moved over the head repeatedly; e.g., pitching in baseball; moving the arm forward when swimming the free style, backstroke, and butterfly; lifting a heavy weight over the head in weightlifting; and serving in racket sports. Reaching forward causes the humeral head of the anteriorly flexed shoulder to abut the acromium and carocoacromial ligament, which in turn is rubbed by the tendon of the supraspinatus. Chronic irritation can cause subacromial bursitis, inflammation of the tendons, and tearing of the rotator cuff. If exercise continues in spite of the pain, the lesion progresses to a periostitis and then avulsion of the tendons from their attachments on the humeral tuberosities.
Signs, Symptoms and Diagnosis
Initially, pain occurs only when the athlete participates in any sport that requires him to hold his arm over his head and forcibly bring it forward. Later, pain may occur when the arm is moved forward to shake hands. Usually, pain will be elicited by pushing things away, with little or no pain on pulling objects in. To palpate the rotator cuff, abduct the arm backward and away from the body in internal rotation with the elbow straight. The patient will complain of tenderness over the tendons, especially when the arm is raised above the shoulder, but often not when the arm is held down by the side. Severe pain is caused by adduction of the arm across the chest. Shoulder abduction will be weak, usually due to under use atrophy of the deltoid. An arthrogram is usually not sensitive enough to diagnose a partial tear of the rotator cuff but not demonstrate a complete tear.
First, the injured tendons should be rested and the uninjured shoulder muscles strengthened. The patient should avoid exercises that push things away and do ones that bring things towards him, provided there is no pain; e.g., upright rows and downward "lat pulls".
Surgery may be necessary if the injury is particularly severe, if there is a complete tear of the rotator cuff, or if the tendons do not heal within 1yr.
A slight strain in the ankle can be extremely painful, whereas more severe damage, such as bone fractures or ligament ruptures, may not be evident in the first instance. After an ankle injury, if there is any danger that the damage might be severe, you must attend a hospital casualty department or see your doctor, as quickly as possible. You may need X-rays and a specialist opinion.
The ankle tendons can be damaged when you have a severe ankle sprain. However, during the time in which the joint structures heal and are rehabilitated, the tendon strain usually heals naturally, without needing specific treatment.
When the tendons around the ankle are strained, you feel pain when you use the affected tendon. The strained tendons may feel tight when you put on the stretch, but they will probably not feel particularly painful.
Tendon strains can last for some time. You must try to work out the cause of the problem, and avoid any activities that bring on, or aggravate, the pain. Meanwhile, you should gently stretch the affected tendon passively, and you should do alternative training for fitness, such as swimming.
Treating Acute Sport Injuries
Immediate treatment for almost all acute athletic injuries is Rest, Ice, Compression, and Elevation (RICE). Rest is instituted immediately to minimize hemorrhage, injury and swelling. Ice causes dermal vasoconstriction and helps limit inflammation and reduce pain. Compression and elevation help limit edema.
The injured part should be elevated. A bag that is chemically cooled or filled with chipped or crushed ice (which will conform better than ice cubes to body contours) should be placed on a towel over the injured part. An elastic bandage should be wrapped over the ice bag and around the injured part, loosely enough to permit blood flow. After 10 min, the wrapping and the ice bag should be removed, but the injured part should be kept elevated. After a further 10 min, the ice bag and the wrapping should be replaced. Ten minutes with and without ice should be alternated for 60 to 90 mi. This procedure can be repeated several times during the first 24h.
Pathology of ice application
Cold limits swelling by vasoconstrictions and reduction in capillary permeability. It helps to limit pain by reducing impulse transmission from pain receptors. It limits muscle spasm by reducing impulse transmission from tendon receptors to muscles. It limits tissue destruction by decreasing cellular metabolism.
Prolonged application of ice, however, can cause vasodilation, increased swelling, pain, and tissue destruction.
Supports and splints
In most injuries, pain is greatly reduced if the injured part is immobilized correctly. Supportive bandaging or splinting reduces stress, prevents painful movements, and helps control the swelling that is produced when tissues of any kind are damaged. Inflatable splints are a very convenient method of providing a comfortable, removable, adjustable support to a led or an arm.
A simple splinting method is to tie one injured part to a neighboring uninjured part, with crepe bandages, cotton bandages, or scarves and towels.
Splints and bandages should never be tight, as they can constrict the blood flow and cause further damage. To check the circulation, you should press on the thumbnail or toenail on the bandaged limb, to see whether the blood returns to the nail immediately after the pressure has turned it white. If the blood return is sluggish, the bandage must be loosened or removed immediately. It is best not to use non-stretch strapping as a first-aid binding.
Whereas cold therapy can be applied immediately to an injury, and continued through the rehabilitation phases for as long as there is swelling, bruising and pain, heat should only be applied, if at all, in the recovery phases of rehabilitation. Applying heat draws blood to the skin under the heat source. This tends to increase internal bleeding or fluid exudate (swelling) in an immediate injury. Therefore heat is not appropriate in first-aid.
Heat is used later on to relieve muscle tension, promoting relaxation.
Massage, like heat, aggravates the situation when an injury has just happened. Any cream applied must be laid gently on the skin and allowed to soak in. If you rub it in, not only do you risk increasing internal bleeding, but also you could stimulate blood clotting and bone formation in torn muscle fibers.
Acute Mountain Sickness
Atmospheric pressure decreases as altitude increases, but the percentage of O2 in air remains constant; thus, the partial pressure of O2 decreases with altitude and at 18,000 ft (5500 m) is about Ĺ that at sea level. About 20% of persons ascending above 9000 ft (2700 m) in less than one day will develop symptoms and signs of altitude sickness. Persons who have had one attack are slightly more susceptible to a recurrence. Children under 6 years and women that are premenstrual may be especially vulnerable.
Hypoxia stimulates breathing, which increases tissue oxygenation but also causes respiratory alkalosis, which contributes to the symptomatology until it is partially compensated by loss of HCO3 in urine. Hypoxia may impair the O2-dependent "sodium pump," resulting in the accumulation of Na and water within, and the movement of K out of cells; it is thought that the resultant swelling of cells is the basic pathophysiology of altitude illnesses. ADH secretion is increased by hypoxia in some individuals, causing further water retention. The roles of atrio- natriuretic peptide (ANP), aldosterone, and renin-angiotensin remain unclear.
Hypoxia from any cause increases pulmonary vascular resistance and pulmonary artery pressure; systemic resistance and arterial pressure usually are little changed. Cerebral blood flow is decreased by hypercapnia and increased by hypoxia; consequently, it varies with the balance between arterial CO2 and O2. Its role in symptomatology is unclear. In High- Altitude Cerebral Edema (HACE), the CSF pressure may be elevated, but the fluid is normal. CT brain scans of patients with High-Altitude Pulmonary Edema (HAPE) and HACE often show diffuse cerebral edema, and edema and hemorrhages are found on autopsy. HAPE is considered to be a high-pressure edema with increased microvascular permeability. Platelet and fibrin emboli and venous thromboses often occur in cerebral, pulmonary, and peripheral vessels. Stretching of distended pulmonary arterioles releases biologically active substances (arachidonic acids, prostaglandins, thromboxanes), which may cause the distended capillaries to leak, causing bloodstained, sometimes grossly bloody sputum. Discrepancy between perfusion and ventilation in portions of the lung is considered the most likely pathophysiology in HAPE. Endocrine glands are normal, though their function is often altered. Liver, kidneys, and heart are normal, and passive congestion is not seen.
Symptoms, Signs, and Diagnosis
The various forms of altitude illness are not separate entities but a continuum in which now one, now another may dominate. Acute mountain sickness (AMS) is the most common and may appear at altitudes as low as 6500 ft (2000 m). It is characterized by headache, fatigue, nausea, dyspnea, sleep disturbance, and rapid, forceful heartbeat. Exertion aggravates the symptoms. Unless dehydration is severe or hyperventilation is excessive, AMS usually subsides within a few days. Laboratory studies are nonspecific and rarely required for diagnosis.
High-altitude pulmonary edema (HAPE) is less common but more serious, usually developing 24 to 96 h after rapid ascent above 9000 ft (2700 m). Long time high-altitude residents, returning after a brief stay at low altitude appear to be at a slightly greater risk, as are children. HAPE is characterized by increasing dyspnea; irritative cough that becomes productive of frothy, often bloody sputum; weakness; ataxia; and later coma. Cyanosis, tachycardia, and low-grade fever are common, and together with fine and coarse rales (often audible without a stethoscope) may lead to a misdiagnosis of pneumonia. Even a minor respiratory infection appears to increase the risk of HAPE.
HAPE may worsen rapidly, and coma and death may occur within hours. High-altitude cerebral edema (HACE) is believed present to some degree in all forms of altitude illness. The severe form presents with ataxia, headache, mental confusion, and hallucinations. Coma and death may develop within a few hours of the first symptoms; gait ataxia is a reliable early warning sign.
Retinal hemorrhages appear as low as 9000 ft (2700 m) in severe cases; they are common above 16,000 ft (5000 m). They are usually asymptomatic unless in the macular region and clear rapidly without sequelae. Splinter hemorrhages beneath nail beds are often seen above 16,000 ft (5000 m), but nosebleed is rare.
Peripheral or facial edema may be due to altitude or to strenuous exertion. Thrombophlebitis may occur at extreme altitude, especially with dehydration and inactivity. Transient dimmed vision or even total blindness is a rare complication at very high altitude.
Altitude illness is best prevented by slow ascent, taking 2 days from sea level to 8000 ft (2500 m) and 1 day for every 2000 ft (600 m) above this. Physical fitness and climbing experience, though they enable greater exertion for less O2 consumption, do not protect against any form of altitude illness. Strenuous effort should be avoided for several days, but bed rest is less beneficial than mild exercise. Because of great individual variation, those going to altitude should learn how fast they could ascend without symptoms; a climbing party should be paced at the rate of its slowest member.
Water loss is greatly increased by over breathing the dry air at altitude, and dehydration with some degree of hypovolemia aggravates symptoms. Drinking much more water than usual is important, but additional salt should be avoided. Alcohol seems to worsen AMS. Frequent small meals, high in easily digested carbohydrates (fruits, jams, starches), improve altitude tolerance and are recommended for the first few days.
Acetazolamide is an effective prophylactic for AMS. Recent work suggests that 50 to 125 mg orally q 8 h is protective without causing diuresis. It is administered on the day ascent is started and for 2 days after reaching altitude. Acetazolamide inhibits carbonic anhydrase and allows increased ventilation and better O2 transport with less alkalosis; it halts periodic breathing (almost universal during sleep at altitude), thus preventing sharp falls in blood O2. Low-flow O2 during sleep accomplishes the same but is inconvenient. Aspirin may relieve headache and possibly decrease the risk of HAPE by preventing platelet emboli.
Acclimatization: Persons exposed to altitude gradually develop an integrated series of responses that restore tissue oxygenation toward normal. Full acclimatization takes more time the higher the altitude, and above 18,000 ft (5500 m) deterioration is more rapid and there are no permanent residents. Major features of acclimatization include sustained hyperventilation with persistent partially compensated alkalosis, normal or low cardiac output, increased RBC mass, and increased tolerance for anaerobic work.
AMS seldom requires treatment other than fluid, analgesics, light diet, mild activity, and (rarely) descent. Acetazolamide 250 mg orally q 4 h is helpful in AMS and HAPE. When HAPE is suspected, bed rest and O2 may be tried, but if the condition worsens, immediate descent is essential. Placing the victim in a large bag in which the pressure is then increased, thus simulating descent, has proved as effective as supplementary O2. When promptly treated, recovery from HAPE is usual within 24 to 48 h. Persons who experience one episode of HAPE are likely to have another and should be warned. Dexamethasone 8 mg IV q 4 h is used to treat severe HACE, though its effect is not dramatic. Retinal hemorrhages require no treatment, generally resolving during stay at altitude.
Feeling It In the Right Spot
You may feel a little discomfort in your joints on the first set of an exercise. But the discomfort should disappear on subsequent sets, says Dr. Scott Reale, a sports-medicine specialist in Manhattan.
After that, you should notice it right in the belly of the muscle. Here are the exercises youre likely to feel in the wrong places:
Feel it in your&Midsection
But not in your&Lower back, neck
Feel it in your&Chest, triceps
But not in your&Shoulder joints
Feel it in your&Upper arms
But not in your&Elbows, wrists
Feel it in your&Shoulders, upper back
But not in your&Elbows, neck
Feel it in your&Upper back
But not in your&Shoulder joints, arms
Feel it in your&Hamstrings
But not in your&Lower back, gluteals
Feel it in your&Quadriceps
But not in your&Knees
Feel it in your&Upper back
But not in your&Lower back, arms
Feel it in your&Thighs, gluteals
But not in your&Knees, lower back
Feel it in your&Upper arms
But not in your&Elbows