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Fractures/Breaks

Is it broken or just fractured? This is a common question and what is the difference?As I read through the NHL injury reports this week I read about a lot of players out with fractures. With all this talk about reducung slashing and hacking there stil seem to be an ongoing problem, and we have one of our better defenceman out now with the Leafs with a fractured thumb. Your body has 206 bones. The function of bones is to protect the inner organs and act as levers for the muscles to work. The marrow in the centre of the bone functions to produce red blood cells. If enough force is applied to a bone it will break or fracture. There is no difference in a break or a fracture. Some people think that one is more serioius than another but this is not the case. The foerc required to break a bone can be a direct force like the two hander that broke Karpotsev?s thumb or an indirect force such a twisting fall in skiing that torque?s the bones until they fracture.

All bones have different shapes and configurations that make some more susceptible to fracture and there are parts to certain bones that are more prone to fracture. There are five types of fractures 1/Transverse Fractures- The bone is broken in a straight line across.These are the most common and caused by a direct blow. 2/Comminuted Fractures- The bone here is not broken cleanly in two but the x-ray shows the fracture site splintering in many pieces. In the worst case scenario the bone breaks through the skin which we call an open fracture. 3/Oblique Fracture-The fracture line is on a slant. These are caused by a combination of a direct blow and a torque. 4/Spiral Fracture- The fracture line here follows a long curved coil. This is caused by a torque to the bone. Both spiral and oblique fractures must be followed carefully as the can slide or slip to shorten the bone. 5/Greenstick Fractures- These occur in children because their bones are more flexible.

The bone is bent and may show a crack like you would find in bending a small sapling. These heal very quickly as the break is not complete. The amazing thing is how well and how quickly the body heals fractures. As soon as the fracture occurs a pool of blood forms at the ends of the fracture site. Within seven days it starts to organize into a semi-liquid. Then bone cells from the broken end of the bones reproduce in the hematoma. Within two weeks new bone is forming around the fracture and is called a callus. For a simple fracture the bone has regained most of it?s strength within six weeks. Over the next year the body converts the new bone to more mature bone and then to solid bone. Bones heal automatically but it is the doctor?s job to make sure the bone s heal straight while the repair process is going on.

It is also our job to advise people and athletes when it is safe to go back to their activity without risk of re-fracturing an already weakened bone The fracture is treated according to where the break occurs and the severity of the fracture. Some small fractures we leave alone, others we place in a cast, while others must be operated on to keep the bones in line. Fractures will heal from three weeks to three months. Complications may prolong the healing. It is crucial that I treat not only the fracture but also the surrounding tissues. The joints above and below the break will be stiff and the muscles will be weakened. The rehabilitation of these areas is as important as the bone healing. Athletes are always pushing to get back to play as son as possible. While I want to encourage that, it is important that we wait for the biology of healing to have time to do its job. We maintain the athletes complete physical conditioning, so that when they go back to play they are in as good as shape as possible.


Sick!!! Do You Exercise?

You come into my office and ask ""Doc, I have a cold. I feel terrible but I have a big game this weekend. Do you think I can play? I'll do anything to get me out there."" Well, do you think you are the only one asking me this qustion. Noooo, I get asked this a thousand times over the winter months. As we are now into the winter season, it is also the cold and influenza season. The cold winds seem to make us more vulnerable to illness. Colds are the greatest cause of absenteeism in North America. It is said that Canadians alone lose more than 60 million working days a year. The common cold is indeed common where the average person will have 2.5 colds per year. Most of these fall into the nuisance category.

The cause of the common cold is a virus. We have now isolated more than 200 of these viruses which cause the symptoms of the cold. Although we often visit a doctor for these colds there is really nothing that can be done but the usual symptomatic treatment that you can buy yourself at the drug store. Antibiotics will not do anything to help these viral infections. If the cold is relatively minor, there is very little reason to limit exercise. Last year Jim Courier won the French Open with a cold. Despite Courier's cold which you could easily hear on his interviews, he only lost one set in seven matches. I am often surprised by some of the individual Maple Leaf performances have when they are sick. Exercise does not seem to prolong these minor illness.

In fact people will tell you that they actually feel better immediately after exercise when they have a cold. The theory is that when you raise your body temperature you are creating a fever like effect which may help your body combat the infection by increasing the white blood cells which fight the infection. This post exercise feeling is usually short lived. Research has shown that acute febrile viral infections decrease muscle strength and reduce endurance performance. If you are going to exercise, take it easy and do not go as hard as you might normally go. Monitor how you feel more carefully. If after you start you do not feel too bad, then continue. If on the other hand you start to feel worse with your heart or head pounding, call it quits and take the needed rest.

On the other hand if you have a more serious illness it is advised that you do not exercise. There have been reported deaths from people who have exerted themselves when they were sick. The cause of death is Myocarditis where the infection spreads into the heart muscles. This occurs when the body is suffering a more severe infection such as influenza. Therefore if you have a more severe infection where you have muscle aches, diarrhea, high fever, or a hacking cough you should not exercise. A rule of thumb is that if the illness is above the neck such as only a runny nose then it is okay to exercise but if you have symptoms below the neck such as those mentioned above then you should wait until you feel better.

The other question about illnes I often get asked about is if regular exercise will reduce their immunity and make them more prone to colds or otherinfections. A recent study of people training for a marathon showed that they hadmore colds than other people. It was reported that runners that trained more than 60 miles per week had twice as many colds as those that averaged only 20 miles perweek. Also those that actually completed the marathon were six times more likelyto be sick the week following the marathon than those that trained and registered but did not run the marathon. Other studies have found other results. One study claimed that those runners who averaged more than 30 miles per week were less likely to ""catch the flu"". Therefore the answer to this question is not as clear and may be related to other individual factors such as stress. In summary it is wise to follow these common-sense tips.

1/ Avoid other people who have colds.

2/ Avoid getting chilled.

3/ Stress has been proven to lower your immunity-Avoid or reduce stress

4/ Vitamin C may play some role in preventing and treating colds.

5/ Maintain good health and nutrition

6/ Children, elderly, pregnancy and other medical illness need special care and should be advised by their individual doctor.

7/ Use disposable tissues as opposed to a handkerchief which can harbor the virus

8/ Do not share water bottles.

9/ Follow the neck check and exercise appropriately to your condition.

10/ You do not need to see your doctor for the common cold but if the symptoms become worse or are persistent then seek your physicians advice.

So, are you going to play this weekend? I hope this column has helped you answer the question for yourself.


Osteoporosis

Post menopausal women have a tendency to develop brittle bones or osteoporosis. Regular weight bearing exercise such as walking or jogging has been shown that along with a good calcium intake to help preserve bone density and strength. ELDERLY: Among the other benefits exercise helps preserve the blood flow to the brain in a similar way it improves the circulation to the heart. This helps to preserve intelligence and prevent strokes. CANCER: In many studies exercise has been shown to reduce the incidence of certain cancers. This has been shown mostly in colon cancer in men and breast cancer in women. In summary lack of exercise and low levels of physical activity are very important risk factors in disease and death. Next week I will discuss how much to exercise.


Imaging Tests In Sports Medicine

How often do you hear after a game""The player was injured tonight and they will go for x-rays or some other test tomorow to determine the extent of the injury.""? Not only do proffessional athletes have tests done quite often, but imaging of the body such as an x-ray are used to a great extent by Sport Medicine Physicians. I am often asked by the media of what the biggest advances in sport medicine are. One area where there have been major advances in the field of sport medicine is in imaging techniques. It is hard to read the sport pages today without reading about some athlete getting some test on some part of his body. Not only are the availability of tests available to us increasing but our ability to interpret the tests is growing as well. In fact sometimes we are seeing things so well that we do not know the significance of what we are seeing.

It is only with time that our knowledge and interpretation skills will match the technology of today. Whenever I see a patient, I have to decide if I need more information to help make a definitive diagnosis or confirm a diagnosis. I have to decide if this test is going to help me in the management of the patient. It has to be cost effective. Many people in Canada do not realize the cost of some of these tests which can be over $1,000. Some tests also have some risk because of the radiation or the dyes we inject to help image certain body parts. The following are a list of the most common tests used in sport medicine. THE PLAIN ROENTGENOGRAM By far the most common test ordered and the backbone in sport medicine is the plain x-ray. They provide information about soft tissue injuries, changes in the bone, the integrity and alignment of bony structures and abnormalities in the joint spaces.

The most common use is to visualize fractures, arthritis, and bone spurs. After the routine x-rays we can do stress x-rays where the bone is stressed while the x-ray is taken to look for abnormalities in the joint or growth plates. We can also do tomograms which are serial x-rays taken at special angles very close together so we can get a more clear picture of one certain part of that bone(ie. a fracture that is hard to see on regular x-rays). RADIONUCLIDE IMAGING(BONE SCAN) A bone scan is a common test. A bone scan is performed by injecting a small amount of technetium-99m diphosphate. This radioactive substance is taken up in areas of increased activity in the bone. After 2-3 hours the patient returns to the lab where a machine goes over the body and measures the amount of uptake in the bones in question.

The most common use for this test is to look for stress fractures. These are surface fractures which occur from too much stress on the bone. The are not visualized on regular x-rays for up to several weeks after the pain develops. It will show up on a bone scan usually within 24 hours. This allows us to treat the injury more definitively from an earlier stage before it gets worse. The bone scan is also effective as a screening procedure because it is so sensitive. It will often help us exactly locate where a problem is and then other techniques are used in the exact location of the problem. ARTHROGRAM This is a test where a radio-opaque dye is injected into the joint . It was commonly used in the knee to look for meniscal cartilage tears but other techniques are now more accurate and is rarely if ever used for this now. It is used in other joints as well for various problems, but the main use for this test is in the shoulder to look for rotator cuff tears. COMPUTERIZED TOMOGRAPHY(CAT SCAN) CAT scanning was the new innovation in the 1970's.

These scanners produce two and three dimensional pictures with contrast resolutions far superior to plain x-rays. It is particularly helpful in evaluating complex bony anatomy such as the spine, wrist, shoulder, hips, and face. It can also be combined with injecting a dye as in the arthrogram to help with certain problems. ULTRASOUND We use the same ultra sound technology that they use to look at babies in pregnant women to look at tissues to determine if they are damaged. Again one of the main uses is to look at the rotator cuff muscles to see if they are intact. These are the main imaging techniques used in Sport Medicine today. It is up to the physician to look at each case and determine what test should be done for each athlete. Sometimes an athlete will require two or more tests to be sure of the diagnosis.

But wait you say; I have not mentioned the MRI;The TEST of the 90's. Well just as you must wait for the following day to hear the extent of that famous athlete's injury, I am going to make you wait until next week where I will devote a whole article to Magnetic Resonance Imaging. MAGNETIC RESONANCE IMAGING(MRI) Matt Dunigen is once again injured in a game this weekend. The announcer on TV states "" Matt Dunigen has hurt his knee and the MRI will be done tomorrow to see if he can play next weekend."" Notice the announcer did not say that the doctor will examine the knee and determine if he can play but it is the MRI which will tell us if he can in fact play. Well, what exactly is an MRI and why is it so good that it over takes the roll of the doctor. Last week we talked about the major imaging tests that are done on athletes. I left this weeks column totally dedicated to the MRI.

The MRI is one of the greatest advances in the field of medicine let alone Sport Medicine. It is the best imaging device that we know have especially for structures in the body that are not bone.(soft tissues). We have for many years visualized bones very well, but know we have a great test that can show us the soft tissues without us having to open the body up to see them. This is definitely the test of the 90,s. The MRI image is created from the interaction between radio waves and hydrogen protons in body tissues aligned in a magnetic field. A computer generates a picture by reading the intensity of the MRI signal coming from that volume of tissue. Abnormal tissue has a different density of normal tissue and therefore show up as a different colour. The MRI is particularly good for imaging the bodies soft tissues which is something which we have not been able to do well before. This is what makes the MRI so valuable.

It is used for any soft tissue injury in sport medicine with it mostly being used for any joint especially the knee where we can visualize well the ligaments and meniscis. It also excellent for the spine and gives excellent pictures of the spinal discs and nerves. The problem in Canada is the availability of the MRI. While they are readily available in the United States you may wait several months or longer for a scan in Canada. The other problem is the public's perception of the MRI. While the MRI provides very clear images, it is not a photograph. The information that we get from the MRI or from any diagnostic test must be correlated with the doctor's examination. The doctor then assesses the situation and decides how to treat the injury. We are still on a learning curve on how to read the pictures on the MRI we are seeing.

Often we see things on the MRI, but we do not know the relevance of what we are seeing. On the other hand the MRI as they are not like a photograph may not show something which can be a problem. It will only be with experience over many years that we will have more of the answers to the questions that are raised by the pictures we are seeing on the MRI. The MRI's are also very expensive(up to $1,000) and thus we should only be using them when they will affect our management of the patient. Yes, athletes will still have their MRI's, but it is with our physical examination that we are going to base our treatment of our athletes. The MRI is used to confirm our diagnoses or maybe answer a small question about the injury which we are not quite sure about. No, the MRI is probably not as great as it is sometimes made out to be but nonetheless it is pretty fantastic and it is the best thing since sliced bread that we have to be excited about for a long time.


Cycling Injuries

A previous article talked about the various types of cycling and how to choose a bike for the type of cycling that you want to do. Cycling is one of the great sports as it is fun and easy on the body. We generally do not see a lot of injuries directly from cycling but there are certain problems that do occur with cycling. Cycling is a repetitive motion sport so that most of the problems are due to overuse. The other cause of problems are due to the opposite situation where other body parts are not moving enough and sustain constant pressure. FEET. The most common problems in the feet is from the pressure on the forefoot on the downstroke. Often the cyclist will feel numbness and tingling in the forefoot and the toes. This is caused by shoes being too tight or from pressure from a toe clip.

The treatment is to alter the shoe wear. ACHILLES. The Achilles is rarely injured in cycling but occasionally becomes inflamed when the cyclist starts ""ankleing"". This when the cyclist drops their heel down on the downstroke. This is not only inefficient for cycling but puts stress on the Achilles. The key is to change the technique where the heel is kept parallel to the rest of the foot and the cyclist pulls straight back when they get to the bottom of the downstroke of the cycling motion. KNEE. This is the most common joint causing pain in cyclists. Most of the problems are in behind the patella. On each stroke the patella moves up and down in a groove in the femur. If there is too much pressure or if the patella is off center there will be more stress on the back of the patella causing pain.

The two most common causes of knee pain are bike fit and your cycling technique. The key is a good bike fit. The first thing is to make sure that your seat is the right height. With your toe on the pedal, there should be about a 20 degree bend in the knee. Often raising your seat height will eliminate the pain. If there is a problem with unequal tracking of the patella in the groove in the femur you may have to change the angle of the lower leg. This is most easily accomplished by changing your foot position on the pedal. By various placements of the heel relative to the toes you can dramatically change the rotation of the lower leg and the angle of the knee. In resistant cases we can put an orthotic in the shoe or cant the shoe like we do to a ski boot. Knee pain can also be due to various muscle inflexibilities and strength imbalances.

BUTTOCKS The seat is often a source of discomfort both early in the season when you are not used to the seat and when you start to increase the length of your rides. Some of the pain is from direct pressure on the buttocks. Usually the cyclists adapt to the pressure with subsequent rides. Sometimes you have to change the type of seat or the position of the seat to relieve the pressure. The other common problem cyclists get is saddle soars from longer rides. This can range from simple chaffing to frank ulceration. The treatment for this is a combination of proper cycling shorts, different type of seat, and or a change in seat position. In the more severe cases the cyclists will have to avoid cycling while the skin heals. HEAD, NECK, AND SHOULDERS Pain in the neck and shoulders while cycling is quite prevalent.

This is from the constant stress from the hands up to the neck and shoulders supporting the body weight. This is most commonly caused from riding with the arms straight and rigid. The arms should be kept slightly bent and relaxed to absorb the shocks from the road or trail. Bike fit can also be a problem especially in females where the cyclists is reaching too far forward and again putting too much stress on the upper extremity. They say there are two kinds of cyclists. Those that have fallen and those that are going to fall. Although this is hopefully not always true, falls off bikes are very common. The most likely injuries are to the head and the shoulder. Always wear a helmet to prevent the head injuries. I see a lot of separated shoulders from cyclists going over the handle bars and landing directly on their shoulders. NERVES.

With the constant pressure on certain body parts, nerves can be compressed and cause numbness, pins and needles, and even weakness in the muscles that those particular nerves supply. The most common is in the hand where you will get symptoms in the last few digits. You can also get numbness in the groin area. This is almost only reported by males where they will get numbness in their scrotum and penis. Extreme cases have been reported where males have become impotent for six months after a long ride. SKIN. Since you are on the bike for an extended period of time you will have a lot of sun exposure. You have to be careful to avoid sun burn and also protect yourself from the long term effects of long term sun exposure such as skin cancer. The skin is also at risk with any fall. There is no mystique of why the most common problems exist in cycling. The majority of these problems can be prevented by a well fitted , well tuned bicycle and common sense. Make sure your bike is the right type and is fit properly to your body and keep on pedaling.


Cheer Leading

This might seem an unusual column to use with regards to sport medicine, but in fact cheer leading has become a sport unto itself. As the fall approaches we think of sports such as football and hockey. Now we are seeing less football played in Canada there is still a strong following. Along with football we associate cheer leading. In years gone by where females were not as encouraged to participate in sport, they would gravitate to cheer leading to become involved in extra-curricular activity. Today females want to become more active and cheer leading has not only become a more co-ed activity but a sport unto itself. There are competitions and national championships.

With this increase in competition, the nature of the activity has become more athletic with its roots in acrobatics and gymnastics. As teams do more difficult manoueveres the injury rate has increased. Supervision is limited with the perception that cheerleaders do not need the supervision due to old preconceived ideas of what cheer leading once was. Not only has the injury rate dramatically increased but there have been several incidences of quadriplegia and even death. The majority of the serious injuries have been a result of problems while performing the pyramid. The pyramid is one of the most basic manoueveres in cheer leading. Most gymnastics coaches would be surprised at some of the stunts that are performed by cheerleaders and shocked by the lack of supervision while training for these.

In the United States where cheer leading is a bigger activity several states have banned or limited the stunts that cheerleaders are allowed to perform. There is a large move in the States to recognize cheer leading as a sport with a governing body. There is a big push for safety certification programs. I already am starting to see kids in the clinic who are competing in cheer leading in Canada and similar programs should be implemented here. The National Center for Catastrophic Sport Injury Research in the United States has put out the following guidelines to help prevent cheer leading injuries.

1. Cheerleaders should have medical examinations before they are allowed to participate; a complete medical history would be included.

2. Cheerleaders should be trained by a qualified coach with training in gymnastics; the coach should be trained in the proper methods for spotting and other safety factors.

3. Cheerleaders should be exposed to proper conditioning programs and trained in proper spotting techniques.

4. Cheerleaders should receive proper training before attempting gymnastic stunts and should not attempt stunts they are not capable of completing. A qualification system demonstrating mastery of stunts is recommended.

5. Coaches should supervise all practice sessions in a safe facility.

6. Minitrampolines and flips or falls off of pyramids and shoulders should be prohibited.

7.Pyramids over two people high should not be performed; two high pyramids should not be performed without mats and other safety precautions.

8. If it is not possible to have a physician or athletic trainer at games and practice sessions, cheerleaders should be trained in emergency procedures.

9. Research should be continued concerning safety in cheer leading.

10. When a cheerleader has experienced or shows signs of head trauma( loss of consciousness, visual disturbances, headache, inability to walk correctly, obvious disorientation, and/or memory loss) she or he should receive immediate medical attention and should not be allowed to practice or cheer without permission from the proper medical authorities. I can only be excited that we have turned a relatively sedentary activity into a sport that requires regular training and a commitment to conditioning and development of skills. With careful observation and judicious supervision this will develop into a well participated activity


Summer Hockey Conditioning Program

The Leafs have now bowed out in the semi-finals for the second consecutive year. This is excellent considering the lack of play-off exposure for the several years previous. The goal now is to do better next year. In years gone by, hockey was a eight month sport. The players would finish their season in the spring and would barely think about hockey until late August. Those that trained in the summer were few and far between. They would play themselves into shape as the season progressed. This is not the case in todays game. The players are bigger and faster. Those that come in to camp in the fall having not trained will not only be far behind, but also risk not even making the team. This holds true for not only the processionals but for all levels of competitive hockey or any sport for that matter.

Chris Broadhurst and Brent Smith are the two Toronto Maple Leaf athletic therapists. They are responsible for getting and maintaining the conditioning of the players. The play offs end abruptly and the players disperse quickly. The therapists must give an individualized training program to the players which they must follow in the summer. This will accentuate their individual weaknesses. It is broken down on a daily basis so the player knows exactly what is required of them. When they show up for training camp in the fall, the first thing we do is fitness test the players so we will know who has maintained their program. The program is broken down into four phases. PHASE I RESTORATION The season is long which culminates in the playoffs where the players play at an intense level every other day(21 games in 42 days last year).

The body needs time to heal and regenerate the systems which have been overused. Not only have many of the players been injured but the body has taken a lot of abuse. All injuries are reviewed by the medical staff and a plan is made. Certain tests have to be done and often surgery is required for some injuries. The most important thing is a specific rehabilitation program to ensure that the injury is totally healed by the next season with full strength and flexibility in the area to avoid re-injury. The athlete concentrates on an aerobic and stretching program in the month following the season. The aerobic system is developed now as once the season starts their is little opportunity to work on this system. Hockey players generally use the bike to train on, but any other aerobic activity can be used such as running, stair machines, roller blading.

The aerobic system allows one to recover during stoppages in play, between shifts, periods and most importantly between games. The stretching exercises given are for body areas in hockey which are overstressed and prone to tightness during the season. The athletes are given advice on their nutrition in the summer. PHASE II CONDITIONING The second month will continue to build the aerobic base that we started in the first phase. This is now comprised of the constant aerobic work outs in the first phase with the introduction of interval type aerobic work outs which are more specific to hockey. The stretching program is continued. The injuries are reviewed by the medical staff to monitor their progress and make any alterations in the rehabilitation programs. Weight training is started in this phase as well.

We concentrate on the certain muscle groups which are used most in hockey. We also concentrate on areas in which hockey players are prone to injury such as the groin. PHASE III CONDITIONING In the third month we start a lot more intense hockey specific conditioning. The main energy source that is utilized in hockey is the Anaerobic System. This is the energy system which does not use the oxygen we breath, but uses the stored energy in muscle. This system provides energy for up to two minutes. The average shift in hockey is 45-90 seconds. This system provides short intense bursts of energy. Therefore; we train this system with what we call interval training where we train hard for a short period of time(30-90 seconds) with an equally short rest period between intervals.

The goal is to delay the build up of lactic acid in the muscles which cause your muscles to be painful and feel fatigued. The training program will allow the player to operate at a higher level while delaying the build up of lactic acid. The aerobic conditioning is maintained in this phase along with the stretching program. The rehabilitation for any injuries is monitored. PHASE IV FINAL PREPARATION The final phase maximizes the training of the anaerobic energy system which is the major system used in hockey. The program is designed so that the players are peaking when they arrive at training camp. The anaerobic system can only be trained hard for six to eight weeks before it undergoes a de-training effect. Other drills are added at this time to increase the athletes agility and power.

Plyometrics are added at this time. A general maintenance of the aerobic base and strength are continued until the Fall training camp. The NHL players maintain their fitness for a living but the principles should be followed by any athlete who expects to play well. Sport is most fun when you maximize your abilities. The best way to do this is to bring your body into optimal fitness specifically for the sport you are doing. Conditioning programs are best started in the off season and maintained during the season. Various sports will have times you need to ""peak"" for and the programs must be designed accordingly. Chris Broadhurst offers weekend seminars for young amateur hockey players so they too can have an efficient off season program to maximize their performance. What we learn from the professionals can be used by others.

Hopefully with these programs the team will perform at a higher level next year. Kevin , Here is the Lede and Closer for the Cheerleading column. Lede Julie, a 17 year old high school student came into to see me last fall with a leg that had too many colours to mention. I asked her what sport she had sustained an injury that would cause so much bruising in the leg. Her quick reply was ""I fell off the top of a pyramid while Cheerleading!!"" Then into previous text as subject. Closer I can only be excited that we have turned a relatively sedentary activity into a sport which requires regular training and a committement to conditioning and the development of skills. Julie had fallen off a pyramid, and while she did not have a major injury, she had a seriouis hamstring tear. With treatment it did heal and on a recent visit to the office, she happily told me that she was back cheerleading this year.


Slapshot Gut

What do Tom Fergus, Basil McRae, Mike McPhee, and Todd Gill all have in common. The have all had some form of the ailment called ""Slapshot Gut"" They were all off playing for an extended period of time and some of them even required surgery to help them get back on the ice. We have all heard of a hockey player or some athlete have a groin strain or pull. They are usually not too serious if treated properly and the athlete is back playing with only a short period of time off. Often players wityh this syndrome are diagnosed this way and every one is surprised when they can not play when expected. On further exqamination or as the symptoms progress we discover that there is more going on than what was origionally thought. The athlete is frustrated in that they can not go back to play when they had hoped to.

The cause of the now becoming famous ""slapshot gut"" is a tearing of the abdominal muscles as they enter the pelvis area. This is the same area where ther groin musclaes also insert which can lead to the confusion. This is usually a long process where the insertion of the abdominal muscles is weakened over many years. Finally the area is weakerned where it becomes inflamed as it can no longer handle the forces going through it or it can in fact tear. I have seen this injury in hockey players at all levels as they get older, mature long distance runners and it is apparently very common in Europe in soccor players. There are three main causes of this syndrome: 1/ It is called slapshot gut as we implicate the slapshot as one of the main causes. When one takes' a slapshot a player torques the torso to get the power behind the shot.

The buttock muscles on the opposte side pull that half of the body backwards while the other side of the body is forced forward as you bring the stick through to hit the puck. This puts enormous stress on the abdominal muscles on the side of the shot. Now imagine a player lining up rows of pucks to shoot day after day. The similar forces will apply to the soccor player on their main kicking leg. 2/ The skating motion in that it takes the body from side to side will constantly put stress on the abdominal muscles as well as the groin muscles. 3/ Muscle imbalances or weaknesses will put srtress on the abdominal muscles and will eventually lead to it breaking down where it will become inflamed and prone to tearing. This syndrome is very hard treat. I will tell patientas that they can expect a long course of recovery.

They have to avoid any side to side motion. We have them clcle or go on the stairmaster to maintain fitness. The inflamation is reduced with medication and physiotherapy. Once the therapuist has reduced the inflamation the next job is to strengthen the abdominal and pelvic muscles. We then gradually increase the athlete back to their sport. Due to the chronic and severity of this injury we take the athlete back extra slowly ot allow the injury to fully heal. In the more severe instances or if the injury is not responsive to conservative management, then surgery is required. Once back playing an extra long warm up and cool down are emphasized. As always the area is iced for 15-20 minutes after sport. Perhaps one of the benefits of the NHL lockout is thaat will allow some of the players with chronic injuries like the ""slapshot gut"" the time off to help heal their injuries. All the players mentioned are now back playing, but there are many others in the NHL or just playing old timers hockey who are now fighting the battle of the SLAPSHOT GUT.


Altitude

You have slaved away at your desk for the last several months and you are now going on a holiday. You relax on the plane in great anticipation for the slopes that await you. The plane lands in Denver and soon you are on the ski slopes. As quick as you can you strap on those new boards and hop on the chairlift. But something is not right. You have a headache, you feel fatigued and you can barely catch your breath. This is not a lot of fun. You with as many as 25% of the skiers that go to Colorado have some form of mountain sickness. The question is what happens to the body when it exercises at altitude? Is it able to do the same things at altitude that it could do at sea level and are there other factors which may effect the athlete.

The first thing is that there is less oxygen available at altitude. this results in a decreased VO2max(the standard measure of aerobic fitness). The more trained the athlete the more dramatic the effect. When a person exercises the body senses that it is getting less oxygen and starts to compensate by breathing faster. At the same time the heart beats faster in an attempt to deliver the extra oxygen needed by the exercising muscles. This is soon obvious to those who try to exercise after a sudden increase in altitude. I have seen many good athletes left gasping for air while their heart pounds away. Altititude sickness can occur at 10,000 feet. The initial symptoms can include headache, nausea, insomnia.

In more severe cases there can be swelling of the lungs and/or brain. As a person flies in to a high altitiude the above symptoms can ruin the plans. As a way to avoid these symptoms, skiers are advised to wait until the day after they arrive until they ski. Even after one day the body will start to adapt so you might enjoy your skiing more the next day with less chance of injury. Even flying in to 5000 feet can cause the mild symptoms. The symptoms can be accentuated by dehydration; therefore not only should you drink extra fluids, but you should avoid caffeine and alcohol which will make you even more dehydrated. If you are prone to this problem, your doctor may presribe a special medication to counter act the effects of the sudden exposure to altitude. Over the long term the body adapts to the altitude.

The negative effects last up to three weeks with impairment of the athletes VO2 max. After about three weeks the postitive things start to happen. There is an increased production of red blood cells to help transport the lack of oxygen. Due to this and other factors the athlete will have increased endurance. You can see why it would be important for an athlete who lives at sea level to train for at least three weeks at altitiude if that was the location of an important event such as the Olympics in Mexico City. There are others that believe that the effects of training at altitude will help them compete at events that are held at sea level but the evidence for this is controversial if it works. The are others that believe that the optimal way to train is to actually live at altitude but do go down to sea level to do their training. The bottom line for most of us who just want to enjoy a short holiday of skiing, hiking, or whatever is to be aware of the effects that a sudden rise in altitude may cause and to do the appropriate things to minimize the effects so as to enjoy our holiday time as much as possible.


Overtraining

Jane Smith is training for the Toronto Marathon. The training is going very well, when slowly but surely she starts to not feel so well. She finds that she is going slower and slower each day, It is hard to get motivated for her once energizing runs. She is dragging at work during the day and has caught several colds over the last couple of months. She is confused as to what has gone wrong. As an athlete strives to improve they will train harder and harder to obtain maximal performance. Often they will train on a fine line between training not hard enough and over training. Over training results in decreased performance while training harder and harder. Not only will the complaints affect these high level athletes, they can effect everyday active people as well especially when combined with other life stresses.

The over training syndrome is a vague series of complaints. The most common and disabling is the fatigue factor. The athlete will complain of tiredness during their sports participation and/or an inability to recover from the previous days work out. The other series of vague complaints include loss of appetite, insomnia, weight loss, decreased performance, muscle soreness, overuse injuries, elevated resting pulse rate, frequent infections, depression, and or mood disturbances. When an athlete complains of the above symptom complex it is important to make sure there is not another cause of the problem. Many medical conditions can cause the above from anemia to mononucleosis to cancer.

It is therefore very important for the individual to see their physician for a complete physical examination to make sure that there is nothing more serious going on. Unfortunately there is no specific tests to diagnose over training and therefore we can only label a person with this problem when all other causes are ruled out. I find that the best indicator is the resting morning pulse. The most reliable time to measure your pulse is first thing in the morning while you are still lying in bed. When your body is not recovering from the previous days activities the pulse will be around 5-10 beats faster than normal. This is also a good way to monitor your recovery from this problem. I find that people come to see me when they are feeling fatigued or run down both during exercise and during their normal daily activities.

They may find that they require more sleep than normal. Their bodies may start to break down and find they are running into a series of injuries that they are not usually prone to. Healthy people are fighting off numerous colds which previously were rarely a problem. Once a diagnosis of over training is made after making sure there is no other serious cause for the way you are feeling, the athlete needs a plan to get over the problem. The first and most obvious thing is to decrease the amount of activity to allow the body to recover. Since the body is so run down the decrease in activity will initially be quite significant.

Proper nutrition is often a factor in the over training syndrome, so the athlete is educated on a proper diet necessary to support not only their daily lives but the extra nutritional needs for their training. Jane Smith is not going to run the Toronto Marathon this year. The important thing is that she is now recovering from the over training syndrome. She is now slowly increasing her running with the appropriate rest days to allow her body to recover. She Not only is she back enjoying her runs like she used to but feels great during the day at work as well. Our nutritionist has analyzed her diet and made some significant recommendations. Her plans now are to run a marathon in the fall or wait for Toronto 1996 depending how her body responds.



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