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The Charley Horse

As you drive toward the basket, the opponent cuts in to stop you from your lay up. Unfortunately, his knee drives into your thigh and you drop to the floor. You know you can not finish the game, but you limp off. It does not seem that bad, but after a restless sleep that night, you awake to find that you can barely bend your leg and the thigh is now quite swollen. You have a full fledged charley horse. Last season I got a frantic phone call from Hartford in the middle of the second period. Doug Gilmour was hit in the arm and they could feel bone moving and they were sure he had broken his arm.

We were all very relieved (especially Doug) when after an x-ray we saw that it was an old area of Myositis Ossificans in his arm that was actually cracked and not the main bone. He was back playing in the all star game three days later. He later did tell us of a previous severe contusion to his arm several years earlier. Once you want to go back to play it is important that you have full range of motion and strength in the leg or arm. The key thing is to protect the area from further injury. This is with proper equipement and extra protective padding. Good conditioning and an increased skill level will allow you to drive to the basket, avoid the opposing player, avoid a serious injury and score an easy two points


Stress Fractures

The Toronto Marathon is fast approaching on May 7. Your training is going extremely well. As you increase your mileage perhaps too quickly you develop a pain in your foot. Ininially the pain is not too bad and only there when you are running. After a couple of weeks the pain intensifies not only in your running but after you finish and even aches in bed at night. You go to your physician who tells you that you have a stress fracture. You know join the ranks of many athletes that 'have fallen victem to this small bone fracture that can occur in virtually any bone in the body. What is a stress fracture? When there is increased stress on a bone the body reacts to make the bone stronger. It does this by actually removing old bone at the point of maximal stress where it is breaking down. The body then makes new bone to make that part of the bone extra strong. Unfortunatly the building process goes more slowly then the breaking down process.

If you do not give your body a chance to catch up by an appropriate rest period the bone eventually breaks down and cracks. This initially is only a surface crack. A good analogy is if you take a soft piece of metal and bend it back and forth. Initially the metal holds up but with repetetive stress it starts to fatigue and eventually crackas at the surface. If you continue to stress the metal it eventually will break right through which will happen in the body as well where if you continue to exercise with a stress fracture the bone will break right through. Fortunately most people will listen to their body and seek the right treatment before it gets that bad. Stress fractures were first talked about in the United States army. New reqruits were asked to walk miles a day. Many developed stesss fractues in their feet.

At that time they were appropiately called ""March Fractures"" Although most stress fractures occur in the lower leg in the foot and the leg, they can occur throughout the body where there is repetitive increased stress on a bone. I have seen them in ribs, the spine and even in a finger of a tennis player. Stess fractures are much more common in females. Some studies have shown women to be ten times more prone to developing a stress fracture. This is due to several factors. The most important factor is a females hormonal balance. Females who do not menstrate regularily or have the female athlete triad of eating disorders, irregular or loss of menstration and osteoporosis will have weaker bones that are more prone to developing stress fractures. If you have what you think is a stress fracture you should see your physician. Because it is only a surface crack in the bone the fracture will usually not be visible on a regular x-ray.

On examining you the doctor will be highly suspicious of a stress fracture if you have exquisite tenderness when he/she pushes on the site of the fracture. The best way to diagnose the fracture is with a bone scan. A nuclear tracer is injected into a vein. The tracer is picked up in areas of increased bone activity such as a stress fracture and gives a charachteristic appearance on the screen to confirm the diagnosis. The main form of treatment for stress fractures is rest. You must give the bone a chance to heal the fracture and allow the body to build the new bone at this point of stress. Calcium supplements are given to ensure there is enough calcium to build the new bone. Although you can not continue your activity that caused the fracture, you can always do some other activity to maintian your fitness.

A runner can swim, run in the water or cycle. You then must correct any of the predisposing factors so you do not get a recurrence. The most common causes are overuse or training errors(usually increasing your training too fast), improper shoes, muscle weakness or imbalance, inflexibility, biomechanical factors such as flat pronated feet and, hormonal and nutritional factors. All of these must be adressed and corrected if necessary. Once the fracture is healed and the athlete is pain free for a minimum of two weeks there is a VERY slow return to activity. Usually the athlete is only off for 4-6 weeks but is suprised by how slowly they have to back to their training. So, you saw your doctor and confirmed your stress fracture. You corrected the predisposing causes and the most important thing is that you maintained your fitness with cycling and swimming and you are now back into your marathon training and sure to be there on the start line on May the 7th.


 

Hamstring Tears

The Super Bowl is played tomorow although many think the real Super Bowl was Is Dallas not playing in the Super Bowl tomorrow because San Francisco is a better team or because of that old finicky hamstring of Emitt Smiths.


Prevention

What is the most important concept in Sport Medicine? Without a doubt the most important thing is prevention. It is always advantageous to prevent an injury than to deal with the injured athlete after the event has occurred. Unfortunately, Sport Medicine is no different than most medicine in that we are much more geared to dealing with illness and injury than we are with preventing it. I can recall very little time in medical school spent on the prevention of disease. It now seems that in the 90's that we are becoming more interested in prevention. We are all familiar with the concept of trying to prevent heart attacks by living a healthy lifestyle with proper nutrition and exercise. We now realize that as individuals rather than getting sick or injured, but there may be things we can do to avoid these problems.

We constantly hear about controlling escalating health care costs. It is always much cheaper to prevent injury or illness than it is to treat it. Now, how does this apply to sports. Recently my friend Dr. David Janda was in town to speak at our annual Sports Medicine meeting. Dr. Janda is the director of The Institute for Preventative Sport Medicine. He does extensive research on ways to prevent sports injuries. Once he has proven methods he is diligent to get the public to comply. His most important contribution so far is the use of break away bases in baseball. He has shown that there is a huge reduction in injury in leagues that use break away bases as compared to ones that use the traditional nailed in bases.

An independent analysis by the Centers for Disease Control projected that break away bases would prevent 1.7 million injuries in recreational baseball with an estimated savings in health care of $2 billion per year. Although he has convinced many leagues to change to break away bases it is a crime that any one at all still uses break away bases. We are even worse in Canada where the use of these bags is even less. Closer to home, Dr. Tom Pashby has almost single handedly been responsible for the virtual elimination of eye injuries in minor hockey with advent of the face mask. Even Don Cherry would have a hard time criticizing Dr. Pashby for saving so many eyes in players. In Canada CSA approved helmets and facemasks are mandatory in all minor hockey, thanks again to all the hard work of Dr. Pashby.

Sometimes it is rule changes in sport that lead to the prevention of injuries. A study in the United States in the 1970's showed that cross-body blocking was a major cause of knee injuries. When they eliminated that kind of blocking the injuries went substantially down. We have all heard of athletes becoming quadriplegic in sports. Rule changes to not permit spear tackling with the head in rugby and football have helped to greatly reduce these catastrophic injuries. We are very hopeful that trying to eliminate the checking from behind will have the same effect in hockey players. Do not think that the pro leagues are not concerned with the rate of growth of injuries within the sport.

It does not help a sport when more and more players especially the stars are off for extended periods of time or even have their careers ended by injury. Although, through better techniques we are able to treat injuries much better than even several years ago, we can not keep up to the rate of growth of injuries both in the profressional and amateur ranks. Dr. Pashby and Dr. Janda are truly inspirational. We must follow their lead to make the practice of prevention the rule not the exception. Although we are taught and it is easier to treat athletes ""reactively"" when they already injured, it is far better to be ""proactive"" and prevent injury. Whether you are a sport medicine specialist, a coach, a parent, an educator, or a player, let us all collectively emphasize the development of preventative techniques that would lead to a reduction of injuries.


Osteoporosis

We hear a lot in the media lately of this dreaded problem of osteoporosis. What was once considered to be an ""old ladies disease"" it is affecting not only the old ladies but the younger ones as well. Not only that many women are predisposing themselves to having osteoporosis at an earlier age than expected or to a problem that they might avoid totally. The sad thing is that many women don't think about doing something about this until it is too late. Osteoporosis refers to premature bone loss and/or inadequate bone formation, resulting in low total bone mass. The key factor is that you are then more prone to fractures, including stress fractures that we so commonly see in the athlete. In 1989 the Health Protection Branch reported that over 800,000 Canadians suffering from fractures of the hips, spine, ribs, and wrists.

Research indicates that at least 60-70% of a women's peak bone mass is acquired during the adolescent growth spurt. Bone loss starts at around age 35 unless there are problems at an earlier age. There is then a gradual decline until menopause when the loss is more rapid with the change in hormones. If a women does do her utmost to optimize her bone density in adolescence and early adulthood she may begin to lose her bone mass prematurely. Once she is at an older age the loss may be irreversible and she will be prone to the typical curved spine we so often see as well as the other fractures (the most common are in the wrist and hip). These can seriously affect not only the quality of your life but the length of your life as well. Death results from 15% of hip fractures.

The reason I am talking about women in this article is that women are much more prone to osteoporosis than men because they have lower peak bone mass in their thirties. This is compounded by an inadequate replacement of calcium lost during pregnancy and breast feeding and finally the change in hormone status as women go through menopause. There are other important risk factors as well. They are: 1/Heredity 2/ Small thin statures 3/ Dietary factors- low dietary intake of calcium, excess protein, high fat, high salt, 4/ Not having born a child 5/ Immobilization of a part of your body or total immobilization with illness 6/ Prolonged loss of menstruation at a young age(even temporarily for a year) Osteoporosis is too often only diagnosed once a fracture occurs.

Regular x-rays only reveal the problem after significant bone loss and are therefore unreliable in diagnosing this problem. There are now specific tests that we can do to determine your bone density. As usual the best treatment is prevention. To keep your bones strong enough so they will not fracture you have to not only increase your peak bone density in early years but decrease the amount of bone loss in later years as much as possible. The following are tips to prevent osteoporosis: 1/ You have to have sufficient Calcium in your diet. Often Calcium supplements have to be used if your diet is deficient. Adolescents and post menopausal women require about 1500 mg per day while adults need about 800 mg.

2/ Young dancers, models, gymnasts, runners, or other athletes whose need to be thin, or excessive training causes them to not menstruate need professional help. Changes in diet and training or even hormone replacement therapy may be required. 3/ Post menopausal women may also consider hormone replacement therapy. 4/ Moderate weight bearing exercise increases bone mass and reduces the rate of loss in aging females. Childhood physical activity has a significant positive effect on bone mass. 5/ Researchers are looking at many other ways to prevent and treat osteoporosis. So, do not wait until it is too late. Be aware of this serious problem and do your best to maintain your bones and lifestyle


Marathon Sunday

Tomorrow is the Toronto Marathon. Several thousand runner's will embark on the 26 mile course that starts in front of city Hall and winds it's way around the city to finish in front of Metro Hall on Wellington Street. At the same time many thousand more runners will complete a 10 k run through downtown Toronto with the same start and finish line. For those of you who have trained hard this is your big day. You know that some where along the run it is going to be painful, the joy of setting a goal and completing it will be well worth it. Just keep thinking of how good you are going to feel when you actually cross the finish line. For the winners it will be around 2 hours and 10 minutes for the men and 2 hours and thirty minutes for the women. The rest of the pack will finish between then and five hours.

The following are a few tips for those who are going to run the marathon tomorrow or are planning to run another race this year. 1/ Make sure you are ready for the race and have trained sufficiently for the distance and type of event. Do not try to be hero and injure yourself. There are always more events you can enter in the future when you are ready. 2/ Watch the weather. This is especially true for the spring marathon. Most of your training has been in the winter and cool spring. If it is a hot day your body will not have time to adjust. Therefore you have to run at a pace that is appropriate for the weather. If it is a hot day it is not the day to run your personal best or at the pace that you might have wanted to. Slow down to avoid over heating which will make the day quite uncomfortable or even serious problems.

The temperature will be announced at the start line. Watch for temperature markers along the course. Green means no problem. Yellow means caution and red means that the heat is a serious concern. It is also important to dress appropriately. Dress in layers and shed clothes along the course if you have to. 3/ If you have been sick the week prior to the event with fevers, muscle aches, or diarrhea and/or vomiting DO NOT RACE. This can lead to a more severe illness which can be life threatening. I know you have trained long and hard, this is not the time to put your body and life in jeopardy. The Marathon will guarantee a spot for next years race. 4/ Always print your name, address, phone number, and emergency contact on the back of your number.

If you have any medical problems and/or are taking medications, write those as well on the back of your number. Inform the marathon committee before the race if you have a medical problem which might be affected by the race. 5/ Protect your skin in problem areas. Use lubrication between your thighs and around your toes where you are prone to blisters. This is not the time to use new shoes or inserts. Shoes should have at least 60-80 miles of running on them. 6/ Drink plenty of fluids. Try to drink 2 cups before the race and a cup at every 5k station. Electrolyte drinks are excellent if you are used to them. If you do not know how your body will respond, this is not the time to try something new. Remember that you are already dehydrated well before you feel thirsty. Be aware of the signs of dehydration and heat problems.

They are excessive sweating, headache, nausea, dizzyness, cramps, possible cessation of sweating, and gradual loss of consciousness. 7/ We have a medical team of over 150 doctors, nurses, therapists, podiatrists, and other volunteers to help you on marathon day. For those of you who are not participating tomorrow, think of this as inspiration to make goals for yourself. Good luck to the runners and I will see you at the finish line.


Chronic Injuries

The last two columns talked about acute injuries which occur suddenly through a specific event. Chronic injuries occur over a time period, not obviously related to a single isolated event. The symptoms develop slowly and will gradually worsen with continued use. Poor treatment or incomplete rehabilitation of acute injuries may lead to chronic injuries. As the end of baseball season approaches, we hear of many pitchers who either can not pitch or are not pitching effectively due to pain in their shoulder or elbow. this is most commonly caused by tendinitis in the affected area. Tendinitis is the most common of the chronic injuries. Consistent microtrauma to a tendon will lead to inflammation which will cause pain using that structure. The pain can occur during the sport or after.

The pain may even be worse the morning after such as in Achilles tendinitis. It may also cause pain during daily activities such as lifting a coffee cup when you have tennis elbow.(tendinitis in the elbow) In Sports Medicine we are dealing mostly with this overuse syndrome. Whenever we see a patient with an overuse injury we must look at the predisposing and precipitating factors. Unless we can isolate these factors we can not effectively treat the injury and allow the athlete to continue training at his/her appropriate level. Once you have decided what these predisposing and precipitating factors are for the injury, the treatment is fairly easy. The main priority is to correct any and all of these factors. The most important thing is to seek appropriate advice from your physician or a Sports Medicine Physician and therapist. The next column will discuss the most common predisposing and precipitating factors


Chronic Injuries II

The last column talked about what chronic sports injuries were. I mentioned that the most important step in beginning to treat these injuries was to determine the main predisposing and precipitating factors for the particular injury. 1/ TRAINING -The most common cause of overuse injuries are in fact training errors. Most of us have fallen victim to the ""TOO MUCH- TOO SOON"" adage. The most common and exaggerated example of this is what I call the CLUB MED syndrome. This is where the people do very little during the year and then go and play 5 hours of tennis a day for 6 days straight and then wonder why their elbows are sore. On a smaller scale a people may develop an injury by increasing their training too quickly such as increasing the volume or intensity of their running too quickly while training for a race.

2/BIOMECHANICS- Unfortunately, very few of us are blessed with perfect bodies. Inherent structural imbalances may lead to unusual stresses on parts of our body and cause it to break down. The most common examples of this are runners with flat feet or a bit of a torsion in their legs which may cause a lower limb injury as they increase their distance. Muscle imbalances, weakness, or inflexibilities can also lead to injury. 3/ EQUIPMENT-Overuse injuries can come from faulty, worn out, and/or improper equipment. Running with the wrong or worn out shoes can lead to biomechanical problems and overuse injuries. The wrong or inappropriate tennis racquet can cause a tennis elbow. 4/ PREVIOUS INJURY- A previous injury which is not totally healed and rehabilitated to full strength and flexibility can lead to re-injury or a new injury to another body part. The next column will discuss how to treat these chronic overuse injuries


Chronic Injuries III Treatment

The last column discussed the most common predisposing and pre- cipitating factors leading to overuse chronic injuries. This column will tell you how to treat these injuries. 1/MODIFY- It is important that you not continue to aggravate your injury. There are very few injuries where you can not do some form of alternate activity to stay active. This may be as simple as modifying a part of your sport such as avoiding the backhand in typical tennis elbow. If you are a runner then you may have to decrease the amount you are running but augment your training with cycling or swimming which will not affect your injury. 2/ICE-Ice your injured area several times a day for 15-20 minutes and after doing any activity, to control and limit the inflammation. 3/MEDICATION-Anti -inflammatory medication can be used to help to reduce the inflammation.

4/SPORTS PHYSIOTHERAPY-This perhaps is the most important part of the treatment. The initial therapy is very basic with the main goal is to reduce the inflammation and pain. The second phase which overlaps with the first phase is called the recovery phase. The goal here is to return the athlete to normal strength and flexibility of the injured tissues and the surrounding areas. Throughout the first two stages the athletes maintain their fitness as much as possible. The third and final phase prepares the athletes to return to their sports at a high level. At this phase we progress the athlete to maximal strength, flexibility and agility appropriate for the sport an athlete is participating in. Sport specific exercises and drills are given to the individual. Although this third and final phase is equally if not more important than the first two, it is often neglected by the athlete and the therapist. It is this final third phase that will allow the athlete to return to their previous level of play with the least risk of re-injury The next column will discuss the prevention of injuries


Detraining

NHL players are out of shape. This is the result of the long work stoppage now into the second month. We have all heard about training for a sport, but what is detraining. Basically, when an athlete stops playing a sport and working out, there is a detraining process. How bad are the NHL players out of shape? One of the main tragedies of the delayed season is that the players will be starting to play when not in peak condition. In the old days the players would do relatively little in the summer and collectively work themselves into shape as the season went on. In today's world hockey is a 12 month sport. The players are given detailed training schedules in the summer so when they arrive in training camp they are close to peak shape. To ensure this all clubs fitness test the players on the first day of camp.

There is no escaping. The players will then only have to work themselves into ""game"" shape which they can only do by playing. There are four areas of concern when it comes to detraining. They are: 1/MUSCLE STRENGTH AND POWER Muscle strength has found to be significantly decreased in well trained athletes after only 15 days of inactivity. This is especially true in the totally immobilized limb(such as in a cast). Fortunately an athlete can maintain most of their strength and power by maintaining infrequent workouts. The important factor is the athlete must have the muscular strength and power before hand to maintain it with these weekly infrequent work outs.

2/MUSCULAR ENDURANCE Muscular endurance will start to decrease after only two weeks of inactivity. The anaerobic capacity of an athlete(the ability to do short sprints) is maintained much better than the aerobic capacity(endurance of long exercise). This is mostly due to the loss of muscle glycogen(the energy). 3/LOSS OF SPEED AND AGILITY, AND FLEXIBILITY Training speed and agility is very hard; therefore the loss with inactivity is not as great. Also, peak levels of both can be maintained with limited amounts of training. It is important to realize that success on the ice relies on factors other than basic speed and agility. No amount of off-ice conditioning can substitute on ice training. Performance qualities such as form, skill, and timing can only be improved by actual on ice practice. Flexibility is lost quickly if not maintained. We can never stress the importance of maintaining flexibility to improve performance and prevent injury.

4/CARDIORESPIRATORY ENDURANCE This is where the most detraining occurs. The fitter you are, the quicker and greater is the loss. Not only that, it will the well conditioned athlete much longer to regain the loss that developed with inactivity. The longer the rest the harder it will be to get back into shape. Studies have shown an 8% loss in as little as two weeks. There are other factors to keep in mind. The players motivation is diminished. In preparation for training camp, they have a set date to prepare for. Now, they do not know when they will be playing so it is hard to motivate themselves to train. It is easier to train as a team than as an individual. Normally they would be training as a team with the coach pushing them. Now they are still on their own without the motivation of team mates and coach.

They are also not in game competition and players need that training to maximize their playing ability. Diet is also important. The potential to gain weight and body fat is greater when not in season. Poorly conditioned players are setting themselves up for potential injuries. So, how out of shape are the players? This will depend on how much each individual player is doing to maintain their fitness and skills. No matter how much they can do it can not match what they would be doing if they were in full season. The longer the delay in the season goes on the worse it is going to get. When it comes to detraining; the bigger you are or the more fit and skilled you are, the harder you will fall out of shape.



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