Prevention and Care of Athletic Injuries

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Prevention and
Care of Athletic Injuries
E      xercise and sports can cause injury, but the fun and
       benefits of physical activity make it worth the risk.
Take steps to minimize the risk of athletic injuries, and
rehabilitate them fully when they occur. Sports and exer-
                                                               The personal trainer is in a similar position. Their profes-
                                                               sionalism and programming skill can make the difference
                                                               between a successful experience and one that ends in
                                                               injury. Most coaches and teachers are knowledgeable and
cise can have profound influences on your life, but an          extremely dedicated. They teach techniques that prevent
accumulation of athletic injuries can produce a lifetime of    injuries and encourage physical fitness.
chronically sore joints and lack of function. Make your            A good coach, teacher, or personal trainer can mini-
program safe by following a well-designed exercise pro-        mize even minor injuries by teaching proper sports fun-
gram and seeking advice from coaches, teachers, physi-         damentals. You will reduce the risk of shoulder and elbow
cians, and therapists. Make sports and exercise positive       injury when you learn proper throwing techniques and
experiences and avoid becoming an injured casualty. This       decrease or eliminate back pain when you learn correct
chapter presents the principles of prevention and treat-       lifting methods. Good sports fundamentals make move-
ment of athletic injuries.                                     ments more efficient and predictable because it is the
                                                               unexpected that often results in injury.
                                                                   Hundreds of studies show that adequate fluid intake is
PREVENTING INJURIES                                            essential for controlling body temperature during exer-
                                                               cise. Dehydration and rising body temperature will
Athletic injuries occur fairly often but they can be mini-     exceed the ability of thirst to detect water needs during
mized by taking precautions. Preventive measures               exercise. It is, therefore, important to drink plenty of
include proper coaching, good equipment, and adequate          water or athletic fluid replacement beverages.
medical supervision.

                                                               THE ROLE OF PHYSICAL FITNESS
PROPER COACHING                                                IN INJURY PREVENTION
                                                               Physical conditioning is one of the most important factors
Coaches and physical educators are in a unique position        in the prevention of athletic injuries. Teachers, personal
to help you improve physical fitness and promote well-          trainers and coaches can encourage students to remain fit
ness. They set the tone of the practices, games, or exercise   during the entire year. Frantic fitness programs two weeks
sessions and help you play sports with skill and finesse.       before the ski or tennis season begins will make you a

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     Visit the Fit and Well Online Learning Center for study aids, online labs, additional information about nutrition,
     links, Internet activities that explore the role of nutrition in wellness, and much more.
candidate for injury. At the very least, this last-minute fit-      Safety equipment is mandatory. Wear a helmet when
ness development strategy results in poor performance.          cycling and a life jacket when sailing, waterskiing, or river
    Continue the physical conditioning program through-         rafting. Do not tempt fate by performing foolhardy feats.
out the year. Immediately after the season, emphasize           Although this is part of being young and fearless, you
well-rounded general conditioning. Develop endurance,           should use safety equipment for your own good.
strength, power, flexibility, agility, and speed systemati-
cally. The intensity doesn’t have to be as severe as during
the actual season. Maintaining a written record (training
                                                                MEDICAL SUPERVISION
diary or work-out card) will help you set attainable,
short-term goals. People always work harder when they
                                                                Your physician should help you assess your suitability for
have realistic goals and can see their improvement.
                                                                sports and help treat injuries when they occur; physical
    Develop good posture. Poor posture is a cause of many
                                                                therapists or athletic trainers will help rehabilitate your
injuries, particularly to the back. With good posture, you
                                                                injuries; and the physical educator, coach, or personal
should be able to remain standing or seated for a long time
                                                                trainer will help supervise your exercise program on the
with little effort. Properly alligned bones and their liga-
                                                                field or in the health club. Each has definite responsibilities.
mentous attachments require little muscular exertion to
                                                                    Your physician should have a good knowledge of exer-
maintain efficient body positions. However, when you
                                                                cise and sport and a familiarity with sports medicine,
assume inefficient body postures, the muscles must assist
                                                                exercise physiology, and biomechanics. An orthopedic
the skeleton to maintain these unnatural positions. These
                                                                specialist should evaluate injuries involving bones and
overstressed muscles fatigue easily and stress the joints and
                                                                joints. Physicians with experience working with active
ligaments of major joints that are critical for maintaining
                                                                people and athletes are usually the best for treating ath-
painless postures. Although some bad postures are due to
                                                                letic injuries. They often have better perspective on when
structural and genetic abnormalities, most posture prob-
                                                                the active people should play and when they should rest.
lems stem from bad habits developed over a lifetime.
    People, particularly adolescents, assume postures that
                                                                When To Call The Doctor Strains, sprains, bumps,
reflect the way they feel about themselves. You may look
                                                                and bruises are common in people who exercise and play
slumped and dejected after losing a game or deal at work.
                                                                sports. It is impractical and unneccessary to visit the doc-
You may walk with a shuffle with your head bowed. This
                                                                tor every time this happened. Most minor injuries to
is the classic “agony of defeat” posture. People with nega-
                                                                muscles and joints do not require medical examination.
tive attitudes about themselves may develop this type of
                                                                People should “wait and see” before consulting a physi-
drooped stance as a chronic habit. Slouching postures
                                                                cian for most muscle and joint injuries. It’s difficult to list
cause fatigue quickly and stress the supportive structures
                                                                hard and fast rules for separating serious from relatively
of the back and neck. This is another example of the
                                                                benign athletic injuries, but there are some general guide-
importance of developing positive attitudes. Good self-
image is necessary for emotional and physical well-being.
    Following the wellness lifestyle is important for pre-        • Use the RICE principle to treat acute muscle and
venting injury. You need adequate rest and a well-bal-              joint injuries. RICE is an acronym that stands for
anced diet. Unfortunately, our fast-food society makes              rest, ice, compression, and elevation. Ice decreases
empty-calorie snacks look very desirable. Learn about the           inflammation. You can progress to heat after the
need for proper nutrition and the hazards of drugs, smok-           inflammation has subsided—usually within two or
ing, and alcohol. Avoid social pressures to smoke and eat           three days following the injury. Compression and
junk food.                                                          elevation minimizes swelling. See a doctor if the
                                                                    injury does not get any better after using the RICE
                                                                    principle to treat it.
GOOD EQUIPMENT                                                    • Treat overuse injuries, such as tennis elbow, shin-
                                                                    splints, and Achilles tendinitis, with RICE and then
Modern materials have revolutionized athletic equipment             gradually progresses to stretching, systematic
and facilities, from tennis racquets and skis to running            strengthening, and functional training. See a physi-
surfaces and playing fields. Unfortunately, many people              cian if the pain from an overuse injury does not
use inferior equipment to save money or because they                disappear after several weeks.
have nothing else available. Inadequate equipment may             • Injuries that require immediate medical attention are
decrease performance or even cause injury. Loose-fitting             those to the head and eye; “traumatic” injuries,
running shoes can cause knee, back, or foot injuries. Ski           caused by sudden blows or an overwhelming force,
bindings that don’t release can result in a broken leg. A           that will usually result in swelling—particularly to the
tennis racquet that is too heavy or has too large of grip           ankle and knee; injuries involving damage to the
may cause elbow or shoulder pain. Prevent injury by                 ligaments; injuries involving broken bones; and inter-
using good-quality equipment that fits properly.                     nally related disorders such as chest pains, fainting,

444    Chapter 17   Prevention and Care of Athletic Injuries
    and intolerance to heat. Unless the injury is obviously    a certain extent (using the RICE principle), but also
    minor, see a doctor as quickly as possible. Be careful     involves an attempt to regain and maintain full range of
    not to underestimate the seriousness of an injury.         motion as quickly as possible. In treating a sprained
  • Health clubs should have an emergency medical              ankle, for example, cryokinetic treatments involves
    plan.                                                      applying an ice pack, wrapping the ankle in an elastic
  • “Listen” to your body. If the pain from an injury is       bandage, and elevating the foot followed by range of
    beyond tolerance, get medical attention quickly. But,      motion exercises.
    if the pain is only caused by a spasm or cramp from            An injured person can quickly recover full range of
    overexertion, there is very little a doctor can do.        motion in the injured area and normal use of his body
    Think of how the injury happened: a back injury            through continued ice therapy. Also, continued ice treat-
    sustained after crashing into a tree requires an x-ray,    ment can prevent much of the deconditioning that often
    while a backache caused by hitting too many balls at       results from an injury, since the therapy will reduce pain
    the driving range may not.                                 and muscle spasms. Ice treatment does not eliminate all
                                                               pain sensations, so it promotes recovery and keeps you
   Specific treatment of athletic injuries is beyond the        from overdoing it and possibly making the injury worse.
scope of this course. However, it’s important that active          The most common types of ice treatment are the ice
people know the general principles involved in sports          massage, the ice bath, and the ice pack. The ice massage
injuries and disabilities.                                     is very effective for cooling a particular spot. Fill a paper
                                                               cup with water and freeze it. When the ice is formed, peel
                                                               away the upper half of the cup and hold the ice by the
INJURIES TO JOINTS AND MUSCLES                                 lower half of the cup. Using a circular motion, massage
                                                               the injured area for seven to ten minutes, or until numb-
Joint and muscle injuries are common during exercise           ness sets in. You can avoid numbing your fingers by plac-
and sports, but are usually relatively benign if cared for     ing a tongue depressor in the cup of water before making
properly. As discussed, the immediate care of these            the ice. This will create a large frozen lollipop with a con-
injuries involves rest, immobilization, ice, elevation, and    venient handle. Another good method is to freeze the
compression (RICE).                                            water in a Styrofoam cup. A word of caution: never use
   Very often after a person sustains an injury during         dry ice.
exercise such as a pulled muscle (muscle strain), sprained         An ice pack is valuable for immediate treatment of
ankle, or twisted knee, and function appears to be almost      muscle and joint injuries. Take a wet towel and place a
normal. The tendency is often to “run it off.” Because the     layer of crushed ice on it, then wrap or place the towel
muscle is warm and initial swelling is minimal, a person       directly on the injury. Another method of ice packing
can easily underestimate an injury. Continued activity         involves placing a plastic bag filled with ice directly on
with an injury is only going to make things worse and          the injury. However, this kind of ice pack is less effective
delay recovery. It is important that the injured area be       because the ice is often unevenly distributed. Carry com-
immobilized and weight bearing minimized or elimi-             mercially available ice packs in your athletic bag and use
nated. Although the person may want to maintain motion         when needed. Breaking a container inside the pack acti-
in the joint, they should try to do so without putting too     vates a chemical reaction that creates a cold ice pack,
much weight on it.                                             which lasts for 20 to 30 minutes.
                                                                   Immersion in ice water can be effective for injuries to
                                                               the ankles, hands, feet, elbows, and sometimes knees.
IMMEDIATE TREATMENT                                            The ice bath can also be used during the later stages of
                                                               injury rehabilitation, when it’s no longer necessary to ele-
Applying ice to the injured area is one of the best things     vate the injured muscle or joint. Add about two-dozen ice
you can do to speed recovery from an injury. Ice will          cubes to a sink or basin filled with cold water. Immerse
numb the area and block much of the pain by slowing            the injured area in the ice water and leave it there. If you
down the activity of the nerves that send pain sensations.     are only able to tolerate a few minutes, take the injured
Ice treatment will relax the injured area, reduce the inci-    part out of the water for about a minute, and then reim-
dence of muscle spasms, and increase the blood flow             merse it for seven to eight minutes. Keeping an injured
deep in the tissue without causing swelling.                   area in the ice water for more than ten minutes will do lit-
                                                               tle good. In fact, you risk developing frostbite by immers-
Cryokinetics involves moving an injured area after cool-       ing an area for too long.
ing it with ice. It has become an important treatment              Use heat to increase circulation and relax the muscles
method for athletic injuries. Until recently, the immediate    after the swelling of an injured area has subsided. Do not
treatment of an injury involved immobilization followed        use heat sooner than 48 to 72 hours after a muscle or
by heat treatment and massage. Cryokinetics requires the       joint injury because effective healing cannot progress
injured exerciser to take the weight off the injured area to   until swelling decreases. Premature heat therapy may                                                                               Immediate Treatment   445
actually increase swelling and retard the healing process.           sports; the old football maxim, “You’ve got to play
This is especially true in injuries that involve muscle pulls        with small hurts,” is true. However, the injury is not
and joint damage, which are usually accompanied by                   rehabilitated if pain is intolerable or significant.
damage to the blood vessels.
   Heat therapy includes hot baths, whirlpool, and hot
water bottles. The hot bath, or whirlpool, is probably the       OVERUSE INJURIES
easiest. Water temperature should be kept between 90°
and 105° Fahrenheit, with 104° being comfortable for             Many people can become over motivated and behave as
most people. Never use a hot whirlpool bath if you have          though they’re trying to make the Olympic team in a
lost any feeling in the injured area; in this kind of injury,    month. A variety of overuse injuries can occur when you
the body may be more susceptible to burns. Other kinds           train beyond your body’s tolerance for exercise. Examples
of heat treatment include hot water bottles, heating pads,       include shin splints, sore Achilles tendons, and tennis
hydrocollator packs, and heat lamps. Hydrocollator               elbow. These injuries result from overworking a relatively
packs silicone-filled canvas bags heated in water.                weak area and from improper sports techniques.
                                                                     Modern training methods have resulted in an increase
                                                                 of overuse injuries. It’s not uncommon for swimmers to
REHABILITATION                                                   put in as much as 15,000 meters per day or for distance
                                                                 runners to cover 100 miles a week. Non-athletes can also
Rehabilitation of muscle and joint injuries is critical. After   develop overtraining injuries by not providing enough
an injury, the body attempts to protect itself by producing      recovery time in their training program.
muscle spasms and adhesions in joints that restrict                  Brutal training programs do produce optimal results. It
motion. Psychologically, the natural tendency is to baby         is easy to push too far, too fast. Often, there is inadequate
the injury in an attempt to keep it from getting worse.          preparation or buildup for these difficult exercise pro-
Many people fail to restore normal function after an             grams. Overuse injuries can be tricky to deal with, partic-
injury and never seem to get any better. Work hard to            ularly because the ultimate responsibility for
restore as much strength, flexibility, endurance, and func-       rehabilitation lies with the individual, their families,
tional capacity as possible. Start gradually and systemati-      coaches, and personal trainer. Sometimes you must rest in
cally increase the intensity of rehabilitation exercises until   order to heal and improve performance.
normal function is restored.
   Rehabilitate the injury as much as possible before            Overtraining syndrome The overuse injury is part of
returning to full sports participation. When the injury is       the overtraining syndrome. This condition is particularly
serious, the physician should make the decision to return        prevalent in highly motivated people. Overtrained people
the exercise program. Rest from exercise sports is often         feel sluggish, tired, sore, and may lack enthusiasm. They
necessary for optimal healing; inadequately healed mus-          often perform well during practice but below expecta-
cles and joints are vulnerable to reinjury. There are some       tions during competition. Some people mistakenly call
general principles you can follow to help you decide             this the “choking,” but it may actually be caused by over-
when to return to sports:                                        training.
  • Do not return to sports you have recovered full                 Sports scientists have recently shown that overtraining
    range of motion—both actively and passively. Simply          is at least partially due to lack of an important muscle
    recovering the ability to move the knee, shoulder, or        fuel, glycogen. Overtraining depletes glycogen, the com-
    elbow is not enough rehabilitation. You must be able         plex carbohydrate that is so important for muscular exer-
    to withstand the rigors of exercise and sports as well       cise. When muscles run low on this fuel, they ache and
    as you did before the injury.                                don’t perform as well. Other chemicals and fuel, such as
  • Regain full strength and power before returning to           creatine phosphate, testosterone, and cortisol are also
    active sports. Compare the injured side with the             linked to overtraining. Overtraining increases the risk of
    uninjured side to see if size and strength are equal. If     overuse injuries. Injury is just around the corner when
    not, do more rehabilitation exercises before resum-          you are fatigued and run down.
    ing full activities.                                            Rest is very important for overtrained people. Rest is
                                                                 the only thing that can break the vicious cycle in which
  • Recover full range of motion before returning to             you train hard but performance decreases, so you trains
    sports. All compensating motions, such as limping            even harder and performance drops even more. The
    and favoring an injured area, should be eliminated.          harder you exercise, the more you get overtrained. The
    After a lower body injury, for instance, rehabilitation      best thing you can do for overtraining is to take a few days
    is not complete unless you can run forward, back-            off and increase the carbohydrate content of your diet.
    ward, and laterally and can start and stop quickly.          Anyone involved in vigorous training should include
  • You should be free from pain before returning to             large amounts of carbohydrates in the diet to maximize
    your exercise program. Some pain is a natural part of        muscle and liver fuel stores.

446    Chapter 17   Prevention and Care of Athletic Injuries
IMBALANCE INJURIES                                               which increases flexibility and muscle tone and protect
                                                                 your disks from loss of fluid. Emphasize three exercises
Imbalance injuries can be caused by poor posture, train-         following acute back pain: curl-ups, side-bridges, and
ing that overdevelops some muscle groups at the expense          back extensions (bird-dog exercise) (see chapter 4). Con-
of others, and anatomical weaknesses. Normal move-               sider the following principles when helping clients deal
ments usually don’t involve undue risk of injury. But            with back pain:
sports, by their very nature, require stretching a little fur-     • Do your back exercises every day.
ther or trying a little harder. Add fatigue, anxiety, anger,       • Emphasize muscle endurance rather than strength.
poor body mechanics, and bad luck and weak links in the              “No pain, no gain” does not apply to back exercises.
body’s structure can be overwhelmed. Injuries may be                 Most back injuries occur due to “motor errors”—
inevitable.                                                          your nervous system attempts complex trunk move-
   Muscle imbalances often cause injuries. Some people               ments (such as picking up a tissue paper from the
develop the muscles on the front of the thigh (quadri-               floor) but the movement fails because the muscles
ceps), for example, without also developing the muscles              are tired. This puts pressure on the nerve, so your
on the back of the thigh (hamstrings). This causes an                back hurts.
imbalance that may result in hamstring pulls. Back pain is         • Don’t do full range of motion spine exercises early in
also caused by muscle imbalances and lack of muscle                  the morning because your disks have a high fluid
endurance in the spine, abdomen, hips, and thighs. Cur-              content. This could lead to injury.
rent treatment for the prevention and treatment of many
                                                                   • Be patient and stick with the program. Increased
kinds of back pain involves spinal stabilization using
                                                                     back fitness and relief from pain may take as long as
exercises that increase muscle endurance in the abdomi-
                                                                     3 months.
nal muscles (crunches), spinal muscles (birddog exer-
cise), and lateral trunk muscles (side bridges to increase         • See your physician if the pain is severe or you feel
the endurance of the obliques and quadratus lumborum                 pain radiating down your leg. Usually, treating the
muscle). Treatment and prevention of back pain is dis-               inflammation with over-the-counter medicines, us-
cussed later in this section.                                        ing ice and heat, and doing moderate exercise will
   Our upright posture causes many aches and pains that              take care of the problem within a few days.
four-legged animals don’t have. Many people have minor
anatomical imbalances that throw their bodies out of bal-
ance and increase the risk of injury. For instance, if one       KNEE INJURIES
leg is longer than the other, problems may develop in the
back, knees, or hips. A podiatrist (foot doctor) may be          Knee Injuries are extremely common in sports and their
able to design orthotics to restore anatomical balance.          incidence has been increased during the past few
Orthotics are inserts that fit into shoes and place the feet      decades. Knee injuries represent 15-30% of all sports
and thus the legs in a better position. They have proven         injuries. Other than simple strains, the most common
valuable for many imbalance injuries. Orthotics can be           reason for seeing a physician include meniscus tears
expensive (around $200), but they often improve sore             (40%), acute traumatic hemarthrosis (22%), knee liga-
knees and hips within a few days.                                ment injuries (18%) and loose bodies (10%). Over 50%
                                                                 of sports injuries leading to permanent impairment and
                                                                 disability are knee injuries (5).
MANAGING ACUTE BACK PAIN                                            Anterior cruciate ligament (ACL) injury was found in
                                                                 85% of these knee injuries, with most sustained in soccer,
You’ve been working in the yard all day or playing a few         skiing, football, baseball and basketball. Thus, the rup-
sets of tennis when it happens—your back goes into               ture of ACL is the most common serious knee ligament
spasm when you did a simple movement, such as turn-              injury sustained in sports. ACL injuries are more com-
ing quickly to talk to a friend or picking up a tissue from      mon in women than in men. Some experts think gender
the ground (Prevention of back pain is discussed in              differences in ACL injuries are linked to weaker core mus-
Chapter 4 of Fit and Well. Sudden onset of back pain             cle strength in women. The core muscles are found in the
happens to most people at one time or another. How can           thorax and support the spine during movement.
you get rid of the pain and live a normal life as soon as           The combination ligamentous injuries together with
possible?                                                        the ACL rupture represent more than half of all ACL
   Bed rest—immediately after the onset of back pain—            injuries. The medial collateral ligament (MCL) is the most
will probably make you feel better. But, don’t overdo it.        often injured ligament with the ACL rupture. Of 450 ACL
While prolonged bed rest—5 days or more—was once                 injuries in Finland, 167 (37%) were isolated and 130
thought to be an effective treatment for back pain, most         (29%) were ACL-MCL injuries. The “unhappy triad”—
physicians now recommend moving promptly. Limit bed              injury to the ACL, MCL and medial meniscus injuries—
rest to one day and begin exercising quickly. Exercise           was found in 31 patients (7%).                                                                                      Knee Injuries   447
   To prevent knee ligament injuries in other sports, espe-     or during the days following the workout. As discussed,
cially that of the ACL, it is important to determine the        you may feel pain around the knee joint after sitting in a
mechanism of injury in specific sports. Tremendous               car, movie, or classroom, a condition called the “theater
decreases in injuries have occurred when attention has          sign.”
been focused on prevention of sports injuries, In Sweden,
for example, there was a 50% decline in soccer injuries         Deficiencies in the muscles and soft tissues around the
when coaches focused on preventing them.                        knee joint Athletics, power lifting in particular, may
   Improved fitness is the best way to reduce the risk of        cause muscle imbalances and deficiencies in flexibility
serious knee injuries—particularly in women. Active peo-        that can cause abnormal kneecap tracking. The quadri-
ple should develop the large muscles of the lower body as       ceps, the large muscle group on the front of the thigh, is
a unit by doing squats, lunges, and step-ups. Isolating         composed of four muscles _ the vastus lateralis, vastus
and developing lower body muscles by doing knee exten-          intermedius, vastus medialis, and rectus femoris. These
sions, leg curls, and calf raises also help. Maintaining flex-   muscles do not always contract equally. The vastus medi-
ible quadriceps, hamstring, calf, and iliopsoas muscles         alis, for example is much more active during the last 15
may also contribute to a reduced risk. Do not neglect           degrees of extension of the knee joint than the other mus-
dynamic stability of the knee—do agility drills and for-        cles. During the squat, the vastus medialis is much less
ward and backward sprints.                                      stressed than the other quadriceps muscles, which may
                                                                cause it to be relatively less developed than the other
                                                                quadriceps muscles. This may cause the kneecap to track
KNEECAP PAIN                                                    abnormally to the outside of the joint and result in
                                                                kneecap pain. If relative vastus medialis weakness is a
You just finished a heavy squat workout, so you go to a          problem, an obvious solution is to strengthen the muscle.
movie to relax. You are there for less than an hour when            Lack of flexibility in the quadriceps and hamstrings
your knees start to ache. Sound familiar? Kneecap pain is       can also cause increased pressure on the kneecap. When
extremely common in active people because of the                these muscles are tight, the kneecap tends to press harder
tremendous pressure they put on the kneecaps when               against the femur bone as the knee flexes and extends.
jumping, sprinting, or weight training. While it may be         This causes deterioration of the kneecap cartilage and
impossible to cure the problem, you may be able to min-         pressure on the underlying bone and surrounding tissue,
imize the pain if you know the causes of the pain and           which results in pain. The solution _ stretch your ham-
some simple remedies.                                           strings and quadriceps regularly.
   Pain under and around the kneecap is caused by
abnormalities in the patellofemoral joint (joint formed         Poor alignment of the knee joint A kneecap that does-
by the knee cap and the large thigh bone), deficiencies in       n’t track (ride) in the joint correctly can cause kneecap
the muscles and soft tissues around the knee joint, and         pain. There may be many reasons for poor tracking. Often
poor alignment of the knee joint. Each of these factors         the condition is congenital, which means it is present at
may be related to the others. For example, poor muscle          birth. Other times poor tracking may be due, as dis-
strength in the vastus lateralis muscle (inside quadriceps      cussed, to a weak vastus medialis muscle or pronated feet.
muscle) may make the knee cap ride toward the outside           In people with pronated feet, the foot rolls over exces-
of the knee joint, which places abnormal stresses on the        sively during walking, which causes excessive twisting
cartilage cells and bone on the under side of the knee cap.     forces in the lower body. Orthotics, rigid supports placed
                                                                in your shoes, may help correct problems associated with
Abnormalities in kneecap cartilage cells and underly-           pronated feet. A podiatrist or orthopedic specialist pre-
ing bone Damage to the cartilage cells is a condition           scribes orthotics.
called chondrosis. The condition begins as chondroma-              A common cause of abnormal tracking, particularly
lacia, where the cartilage cells soften. As the condition       among physically active women, is an abnormally large
worsens, the cartilage cells split and resemble peach fuzz      “Q angle.” The Q angle is the angle formed between the
or a shag rug. Eventually, large flaps of cartilage may          pull of the quadriceps muscle group and the insertion
break off and the fragments can catch or lock the knee.         point of the kneecap tendon on the tibia (the large bone
When the condition is advanced, the underlying bone             in the lower leg). If this angle is excessive, then the
will be exposed within the joint. While the apparent dam-       kneecap tends to track to the outside of the joint and
age occurs in the cartilage, the pain comes from the            causes pain around the kneecap.
underlying bone or surrounding joint tissues because car-          There are many abnormal kneecap-tracking patterns.
tilage has no nerve fibers.                                      An orthopedic specialist, preferably one with sports med-
    Grinding and grating in the knee joint accompanies all      icine experience, can only evaluate this effectively. Unfor-
stages of chondrosis. It is often difficult to go down stairs    tunately, if you have a serious kneecap tracking disorder,
because of the increased pressure put on the knee joint.        you may have to give up the sport or face permanent
Squatting and dead lifting may be painful during the lifts      damage to your kneecap. However there are several

448    Chapter 17   Prevention and Care of Athletic Injuries
strategies that will help most active people who have           condition worse. Doing straight leg raises (one leg at a
kneecap pain.                                                   time to protect the back) will help keep your muscles
                                                                from deteriorating too much if you have to take some
                                                                time off from lifting.
STRATEGIES FOR DEALING WITH                                        Stretching the quadriceps and hamstring muscles will
KNEECAP PAIN IN ACTIVE PEOPLE                                   help take pressure off the knee joint. Stretching the ham-
                                                                string muscles may be helpful in building strength in peo-
Most active people will have kneecap pain at some time.         ple with poor flexibility. Stretching will also prevent
However, if you have chronic kneecap pain, then you             kneecap pain. It may be helpful to stretch quadriceps and
should take positive steps to do something about it. These      hamstrings thoroughly before doing squats, dead lifts, or
steps include evaluating your training program, anatomi-        pulling exercises. Stretching after the workout will proba-
cal evaluation by an orthopedic specialist who is an            bly result in the greatest degree in flexibility in the long
expert in sports medicine, remedial exercises, and mask-        run because the tissues are warmed up.
ing the pain.                                                      As a last resort, try to decrease the pain by minimizing
   Medical history is one of the physician’s most impor-        inflammation in the joint. Nonsteroidal anti-inflamma-
tant tools in evaluating diseases and disabilities. The         tory drugs, such as ibuprofen (i.e., Motrin or Advil), may
training diary, which can be a valuable part of the medical     be very helpful in reducing the incidence of kneecap pain.
history of an active person, is a great source for evaluating   Applying an ice pack to your knee after a workout may
the cause and origin of weight lifting and running              also help lessen the pain. Remember though, masking the
injuries. Did the onset of kneecap pain coincide with a big     pain will not correct the underlying problem. You are bet-
jump in poundage or volume in your workouts? Did you            ter off to get to the root of the problem than to merely
stay on a high volume running or weight training cycle          treat its symptoms.
for 2 or 3 weeks too many? Did your technique break
down because you did too many exercises when fatigued?
The solution to your problem may be as simple as taking         ROTATOR CUFF INJURIES
some time off to let your tissues heal.
   You may be doing exercises or using techniques that          If you throw, hit a tennis racket, swim, or lift weights hard
aggravate your knee joints. Full range knee extensions on       enough and long enough, chances are you will develop
a knee extension machine are notorious for causing              shoulder rotator cuff problems. The cuff is made up of
kneecap pain or making the problem worse. Examine               four muscles—subscapularis, teres minor, infraspinatus
your squatting technique. If you take a narrow stance and       and supraspinatus—that cause the shoulder to rotate
point your feet excessively inward, this will place a lot of    inward and outward. In the same general area of the
stress on your knee caps. The solution may be to improve        shoulder you will find bursae, tendons, and ligaments, all
your squating technique so that you place less stress on        of which can become irritated or injured from trauma or
vulnerable knees and back.                                      overuse. Initial weakness of the cuff can lead to bursitis,
   Orthopedic evaluation may be useful. Ideally, go to an       tendonitis, bone spurs, tears, and ruptures. Conservative
orthopedic specialist who is physically active or who has       treatment—rest, ice, rehab exercises, and anti-inflamma-
experience dealing with active people or athletes. The          tory drugs—is best. However, chronic shoulder problems
physician may be able to provide specific advice about the       may require surgery to repair or prevent tendon tears and
nature of your problem and suggest corrective actions. He       ruptures. Results of shoulder surgery to repair tendon
or she might be able to give you a knee brace or pad that       ruptures, tears, and shoulder impingement are very
will cause the kneecap to track in the joint better. As dis-    good—92% of patients reported a good result 2 and 5
cussed, foot orthotics that correct problems of faulty foot     years after the procedure. Experts encourage patients to
alignment, may benefit people with kneecap pain. In              do shoulder rehab exercises religiously for 3-6 months
extreme cases, the physician may recommend surgical             before resorting to surgery.
procedures to realign the knee joint or correct local tissue        Do rotator cuff strengthening and stretching exercises
damage.                                                         regularly—for prevention and treatment of the problem.
   Exercises that strengthen the vastus medialis (VM)           Use weights or rubber tubing to do the following exercises.
muscle may help take care of the problem. The VM mus-
cle is one of the quadriceps muscle found on the upper            • Lateral raises: Do raises to the front, side, and back.
part of the thigh that is responsible for extending               • Empty can exercise. These are raises done with the
(straightening) the knee. Doing short-arc knee extension             thumb down (wrist pronated maximally) and shoul-
exercises on a knee extension machine best strengthens               der horizontally adducted to 45°.
the vastus medialis muscle. This means that you only              • Internal rotation: Laying on a bench on your side,
extend the knee through the final 20° of it’s range of                elbow at your waist and holding a dumbbell (arm on
motion. Do not do full range of motion knee extensions if            the downside of your body), internally rotate your
you have kneecap pain because this exercise will make the            shoulder by moving your forearm toward your body.                                                                                 Rotator Cuff Injuries   449
   You can do this exercise with rubber tubing (one end        BASIC STRUCTURE OF
   tied to a bar or doorknob): Standing with your el-
                                                               THE IMMUNE SYSTEM
   bow at your side fixed at 90 degrees and shoulder
   rotated outward. Grip the tube and pull your arm
                                                               The immune system works to rid itself of foreign material.
   across body keeping elbow at side. Return tubing
                                                               It recognizes material that is not its own. The immune
   slowly and controlled.
                                                               system can be subdivided into nonspecific and acquired
 • External rotation: Lie on a bench on your side, el-         immune mechanisms.
   bow at your waist and holding a dumbbell (arm on               Non-specific immune mechanisms include
   the upside of your body). Externally rotate your
                                                                 • Skin: resists penetration by foreign organisms and
   shoulder by moving your forearm away your body.
   You can do this exercise with rubber tubing (one end
   tied to a bar or doorknob): Standing with your el-            • Respiratory tract: filters particles entering from the
   bow at your side fixed at 90 degrees and shoulder                 air.
   rotated inward across your body. Grip the tube and            • Acidic digestive secretions in the stomach: kills in-
   pull your arm away from your body, keeping elbow                 gested organisms.
   at side. Return tubing slowly and controlled.                 • Capacity to lower iron levels in blood and intestinal
 • Stretching: Lie on a bench on your back and extend               fluid: affects growth of pathogens
   your shoulder upward at a 45° angle. Lower your               • Phagocytosis of bacteria and viruses
   arm until you feel a stretch in your shoulder. Hold           • Inflammatory response to infection and injury. Directs
   the stretch for 10-30 seconds. Repeat with your arm              cells (macrophages) and causes release of chemicals
   at approximately 80°.                                            (e.g., complement, histamine, bradykinin) in the area
                                                                    to rid body of foreign material or injured tissue.
                                                                 • Secretion of antibacterial substances (e.g., a-interfer-
SYSTEMIC PROBLEMS                                                   ons)
Active people can get diseases just like anyone else. Over-       Acquired immune mechanisms includes antibody
trained people are susceptible to upper respiratory infec-     based immunity and cell-based immunity. Antibody
tions. That’s why it is important to design the program        based immunity involves B and T lymphocytes which
intelligently. Your program should balance hard work and       produce antibodies when exposed to a foreign substance
rest. Also, you should take in enough nutrients to with-       The foreign substance is called an antigen. The classes of
stand a vigorous athletic lifestyle.                           antibodies include immunoglobulin M (symbolized as
    You are getting ready for a competition and you feel       IgM), IgA, IgG, IgE, and IgD. Antigen-antibody reactions
great. You have been training harder than ever before. All     are involved in destroying and removing invading
that hard work is about to pay off. Then, the bottom falls     microorganisms.
out from under your plans—you get the flu. Your nose               Cell-based immunity is centered on the T lymphocyte.
runs, your sinuses are stuffed up, and your muscles ache.      When exposed to an antigen, they may be involved with
Was this bad luck or could you have prevented it?              B-lymphocytes in the production of antibodies. They can
    Your immune system has failed to fight off the small        also attach themselves to antigens directly and destroy it.
organisms that make you sick. What has happened is just        Direct antigen destruction involves several sub-type T
as devastating as a strained muscle or a prolonged lay-off.    lymphocytes. These include cytotoxic T cells, helper T
Some experts feel immune system suppression may be             cells, and suppressor T cells.
the ultimate limiting factor of athletic performance. If you
are sick, you are unlikely to lift to your potential.
    Exercise and immunity has been the center of folklore      EXERCISE TRAINING
and home-remedy medicine for centuries. Popular senti-         AND IMMUNITY
ment is that regular exercise makes people more resistant
to disease. Many believe that getting chilled makes people     There is not enough evidence to state conclusively that
more prone to the common cold. What evidence do we             exercise training either improves or impairs immune
have for these and other popular beliefs? Researchers have     function. Several studies suggest that heavy training
increased the understanding of the human immune sys-           depresses the immune system. Moderate exercise may
tem. The process is extremely complex. The system              improve immunity.
attempts to maintain balance. Short-term changes are often
difficult to comprehend. The immune system works in             Moderate exercise In animal studies, moderate exer-
concert with the hormone systems. Exercise has profound        cise increased antibody levels and increased longevity. In
effects on secretion of hormones such as catecholamines        humans there is very little data available. There are many
(for example, adrenaline), insulin, and corticosteroids.       studies that have shown that components of the immune
These hormones influence immune function.                       system are affected by exercise. However, we don’t know

450    Chapter 17   Prevention and Care of Athletic Injuries
if people who exercise regularly are more resistant to dis-     may increase the risk of cardiac arrhythmias and sudden
ease. Moderate levels of physical activity may decrease the     death. Several clinical studies reported exercising with a
incidence of colon cancer. This disease is thought to be        viral illness may have contributed to bacterial meningitis
linked to immune function.                                      and acute rhabdomyolysis (muscle destruction). One
                                                                study reported worsened asthma symptoms in an asthma
Chronic intense exercise Several studies have                   victim.
reported increased incidence of upper respiratory infec-            Viral illnesses decrease physical performance. They
tion. Several measures of immune function are also              also affect muscle structure. Isometric strength decreases
depressed in people who exercise intensely. Immunoglob-         in patients with active viral infections. Recovery time may
ulin A is important in protecting against upper respiratory     take one month after the illness. Reduced levels of several
infections. It was found to be depressed in cross-country       muscle substrates and enzymes have been found in
skiers and emotionally stressed dental students. However,       patients with active viral illnesses. Muscle samples,
in the skiers, there was no report of increased incidence of    observed with an electron microscope, revealed cellular
illness. In another study athletes given antitetanus vac-       abnormalities. In racehorses, upper respiratory infections
cine immediately after running a marathon had a normal          have been associated with poor performance.
antibody reaction.                                                  Viral illnesses decrease performance and increase the
    Untrained subjects increase lymphocytes in reaction to      risk of sudden death. People experiencing a sudden loss
intense physical exercise. Trained subjects typically have      in performance without any symptoms of illness may
lower responses. Trained subjects have been found to            have a sub-clinical viral infection. Resumption of training
have transient reductions in T-helper cells, which could        after a viral illness depends on the symptoms. If symp-
suppress immune function. After vigorous exercise the           toms are limited to the upper respiratory track, then
ability of lymphocytes to react to specific antigens             training can resume in a few days. However, if symptoms
decreases. These changes are temporary. There effects on        are more general and severe, then more rest is needed. In
long-term immune function are not known.                        general, you should rest at least one day for every day of
    Over-training is often associated with increases in cor-    illness.
ticosteroid hormones, such as cortisone. Elevated corti-
costeroids have a depressive effect on the immune system.
For example, cortisone decreases the reaction of lympho-        STRATEGIES FOR PREVENTING
cytes to an antigen. It is probable that the effects of exer-   IMMUNITY PROBLEMS
cise on the immune system are small and transitory.
However, if the exercise program leads to over-training,        Howard Hughes (famous recluse billionaire), before he
suppression of the immune system may result. This is a          died, is said to have a phobia about germs and getting
critical consideration in the training of active people.        sick. He is said to have worn gloves and mask much of
Active people colds or flu are not any better off than those     the day. Even with all his money and extraordinary efforts
with muscle and joint injuries: neither are making              to avoid germs, Hughes could not escape illness. Unfor-
improvements in fitness.                                         tunately, it is impossible to avoid organisms that can
                                                                potentially make you sick. However, there are some pre-
                                                                cautions you can take to reduce the risk of illnesses that
COMMON VIRAL ILLNESSES                                          stall progress in your training routine.
Viral illnesses are extremely common. They affect the           Over-training Over-training suppresses the immune
average person 1-6 times a year. They typically cause           system. People who over-train secrete more corticosteroid
symptoms in the upper respiratory tract. However, they          and catecholamine hormones. These hormones are
can sometimes have systemic effects. They can have a far-       known to suppress the immune system. Over-training
reaching effects on organs and tissues. They can impair         increases cortisol and decreases testosterone—hormone
skeletal muscle and cardiac function. The severity of viral     conditions that increase the risk of illness. Structure your
infection can range from sub-clinical to death. The most        program so that you get enough rest. Adequate rest has
common viral groups are Rhinovirus, Coxsackie A and B,          two benefits—better immune function and enough
Echovirus, Adenovirus, and influenza.                            recovery to train hard. Remember, intensity is the most
                                                                important factor in improving strength.
Viral infections and Exercise The risk of cardiac
related sudden death increases during exercise in people        Diet Poorly balanced diets, particularly if low in calories,
with systemic viral infections. In a study of 78 people         can suppress your immune system and contribute to over-
who died during or shortly after exercise, 15 % recently        training. The diet should contain plenty of carbohy-
had an upper respiratory infection. The Coxsackie virus         drates—emphasizing fruits and vegetables—and adequate
has been shown to have a tendency to invade the heart           protein. Protein intake for physically active people is
muscle. Exercising with a systemic Coxsackie infection          approximately 0.8 to 1.5 grams per kilogram body weight.                                                           Strategies for Preventing Immunity Problems   451
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454      Chapter 17       Prevention and Care of Athletic Injuries
Walch, G., A. Boulahia, A. H. Robinson, and S. Calderone. 2001. Posttrau-        Imbalance injuries Injuries stemming from muscles on one
   matic subluxation of the glenohumeral joint caused by interposition of        side of the body having more strength or flexibility than oppos-
   the rotator cuff. J Shoulder Elbow Surg. 10: 85–91.                           ing muscles.
Wang, H. K., and T. Cochrane. 2001. A descriptive epidemiological study of       Immune system A body system that fights disease.
   shoulder injury in top level English male volleyball players. Int J Sports
   Med. 22: 159–163.                                                             Loose body A solid tissue fragment lying free in a joint
Wang, M. J., A. Garg, Y. C. Chang, Y. C. Shih, W. Y. Yeh, and C. L. Lee.         Nonsteroidal anti–inflammatory drugs Drugs that de-
   1998. The relationship between low back discomfort ratings and the            crease inflammation by blocking prostaglandins.
   NIOSH lifting index. Hum Factors. 40: 509–515.                                Obliques important muscles on the sides of the abdomen
Weaver, N. L., S. W. Marshall, and M. D. Miller. 2002. Preventing sports in-     that help rotate and bend the truck and stabilize the spine.
   juries: opportunities for intervention in youth athletics. Patient Educ
                                                                                 Orthotics Shoe inserts used to provide foot support and
   Couns. 46: 199–204.
                                                                                 correct anatomical defects.
Weldon, E. J., 3rd, and A. B. Richardson. 2001. Upper extremity overuse in-
   juries in swimming. A discussion of swimmer’s shoulder. Clin Sports           Overtraining An imbalance between training and recovery.
   Med. 20: 423–438.                                                             Overuse Injuries Injuries developed through excessive
Wilson, G. J., G. A. Wood, and B. C. Elliott. 1991. The relationship between     exercise or overtraining.
   stiffness of the musculature and static flexibility: an alternative explana-
                                                                                 Patellofemoral joint joint formed by the knee cap and the
   tion for the occurrence of muscular injury. Int J Sports Med. 12:
                                                                                 large thigh bone.
                                                                                 Phagocytosis Destruction of particulate material, such as
                                                                                 microorganisms or cell fragments, inside cells.
                                                                                 Podiatrist a physician who specializes in foot problems.
 GLOSSARY                                                                        Q angle The angle formed by lines drawn through the long
                                                                                 axes of the femur and tibia. Women have larger Q angles
   acquired immune mechanisms immunity that builds up                            because of their broader hips.
   after exposure to specific germs or environmental factors.                     Quadratus lumborum important spinal stabilizing muscles.
   Anterior cruciate ligament A ligament that stabilizes the                     Rehabilitation        The return of function after an injury,
   knee joint. The knee with an anterior cruciate ligament injury                often with the assistance of physical therapists or athletic
   will usually appear swollen, tender, and unstable.                            trainers.
   Chondromalacia patella Damage to the cartilage cells on                       RICE An accronym meaning rest, ice, compression, and
   the under side of the kneecap.                                                elevation. These procedures work best for management of
   Chondrosis       Damage to the cartilage cells.                               soft tissue injuries.
   Congenital      Present at birth.                                             Sprain   Injury to a ligament.
   Cryokinetics A rehabilitation technique that uses exercise                    Theater sign Kneecap pain experienced while sitting in
   and ice.                                                                      places such as theaters and classrooms caused by lack of
                                                                                 circulation of the joint fluid (synovial fluid).
   Deconditioning        Loss of fitness through rest or injury.
                                                                                 Traumatic Relating to or resulting from a trauma, wound or
   Hemarthrosis Blood within a joint space. Commonly seen
                                                                                 injury, that may be physical or psychological.
   after trauma to a joint.
                                                                                 Unhappy triad Injury to the ACL, MCL and medial meniscus
   Hydrocollator packs Canvas bags filled with silicon that are
   heated in water and used for heat therapy.
   Ice massage Massaging a body part with a small block of
   ice.                                                                                                                   Glossary    455

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