Answer: It appears that you have partially torn the medial collateral ligament, also called the MCL. Luckily, most people who injure their medial collateral ligament have a complete recovery once they have been properly rehabilitated. The MCL is one of the strongest ligaments in the body. It is most commonly injured when an athlete sustains a direct contact injury to the outside of their knee which stresses and ultimately tears the ligaments on the inside of the knee.

Injuries to the MCL are graded I, II and III. Grade I injuries are mild sprains, while grade II are partial tears to the MCL. Complete tears to the MCL are grade III. While the majority of the athletes who sustain MCL injuries do not require surgery, occasionally some athletes with a grade III MCL tear may need surgery if they do not go on to heal.

Our treatment protocol for these injuries at the University of Minnesota Sports Medicine Institute has been developed based upon basic research and the results that we have seen in our athletes. As with any initial injury, the initial treatment consists of a RICE protocol (Rest, Ice, Compression and Elevation). It is essential to get the swelling in your knee joint down as soon as possible, as this allows a quick return to activity. Ice, applied approximately 20 minutes out of each hour, is important within the first 48 hours of injury because it makes the diameter of the blood vessels shrink so there is less swelling in the injured area. A compression wrap will also help to decrease swelling. In addition, we occasionally use a hinged knee brace for these injuries to provide some stability to the healing ligament in some athletes.

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Wednesday, July 18, 2007

Q: When I run, my lower shin aches -- is this shin splints?

A: Also known as medial tibial stress syndrome, shin splints presents as a dull ache or pain on the inside of your lower shin, mostly over the muscle attachment to the bone.

Participants in soccer, cross country, track and field, marathons and the weekend 5K are all at risk. Most experience shin splints after a few workouts or after one "intense" workout.

The pain will occur early in a run, but if left untreated, over time the pain will last longer and increase in severity.

Each shin absorbs twice your body weight every time your foot hits the ground during running, leading to a thousand impacts per mile.

Some runners have weak ankle dorsiflexors. These muscles normally work to pull the foot upward and slow the foot as it drops.

Weak muscles lead to a "slapping" foot and "pulling" on the shin where these muscles attach to the bone. The injured area is most likely where these muscles connect to the bone.

Some athletes have a tendency to over-pronate (turn outward) where they often seem to have flat feet. This causes stress and pull of the muscles that connect to the shin.

The opposite is also a problem -- very rigid feet don't allow energy to be absorbed.

It is important to increase running mileage and intensity slowly.

Shoes should be of good quality and designed for your type of foot. They should be replaced about every 500 miles.

Run on softer surfaces. Decrease hill workouts when possible. A running analysis to avoid hard heel strike and improve running technique is often of value.

Rest and modified activity are important. Decrease workouts by 30 percent to 50 percent. Cross train by biking or swimming.

Initiate ice massage and stretching of the lower leg muscles. Strengthening of ankle muscles is vital. Compression wraps and taping can help.

Address any foot alignment problems with inserts or orthotics. Gel inserts or pads can help.

Severe pain, increasing pain, swelling over the shin bone and pain with walking can be signs of a stress fracture. Also, numbness and significant weakness of the leg can be a sign of exertional compartment syndrome. These should be evaluated by a physician.

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It's that four-part muscle in the front of your thigh. The one you rely on for the running sports. It gives you the push off, the stretch and glide movement and the control on impact.

Because it is used so often during sports competition, the muscle can be the one that is the most susceptible to injury. Adequate warm-up for this large muscle area is a must for prevention of quadriceps strain or tear.

There are two types of sports that seem to avoid strain or tearing to the quad area: ice-skating and bicycling.

The leg is usually slightly flexed in these sports during the weight-bearing portion of the leg movements. Thus, a slight softening bend to the leg puts less pressure on the quadriceps and helps prevent the muscle from overextension and a possible tear.

You'll know immediately if you have overworked your thigh. You will lose the ability to bend your knee. And the worse the strain or tear, the more the limitation of movement.

A charley horse, or muscle spasm, in the quadriceps area, can take a player off the field immediately and keep him off for an extended period of time. The muscle tightens and then is hit sharply creating a sudden reflex spasm that releases very slowly. Whether soccer, football, basketball or racket sports, the quadriceps are the key to successful play.

Putting yourself back together after a muscle strain or pull of the quadriceps area may take six to eight weeks.

The initial use of the RICE treatment, with rest, ice, compression and elevation, and a trip to your doctor can hasten your return to sports. But too often the return is too soon and re-injury occurs.

I haven't met a sports type yet who has a lot of patience for waiting out the healing period on any injury.

When you train with strength conditioning for the quadriceps injury, go slowly and use resistance exercises to build the area first.

Bicycling, water exercise or any form of isokinetic movements will help strengthen without full weight-bearing conditioning for the first six to eight weeks.

Prevention and proper warm-up for the legs, and keeping those legs warm during time-out periods is essential.

Also, something you don't consider, is the importance of ease. Learn to control impact movements. Lunging, wobbling and flopping add up to lack of body control. A little ease in movement can be important injury prevention.

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There are a few ways to help prevent sprains and strains and make the most of the sunshine and warm weather:

• Maintain a healthy weight and exercise regularly.
• Wear shoes that fit well, and replace them if they start to show wear.
• Warm up and stretch before all exercise, including hiking and biking.

Mild-to-moderate strains and sprains usually can be addressed with aggressive but conservative treatment. As a naturopathic physician, I often prescribe inflammation modulating and soft tissue supportive natural medicine to stimulate recovery from injury. This can be achieved through specific botanical medicine or nutrient supplementation. Additionally, physical medicine treatments such as hydrotherapy, therapeutic exercise or soft tissue sports massage may help to stimulate healthy tissue repair and restore function.

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Lateral epicondylitis is the fancy medical term for tennis elbow. This condition occurs when there is swelling and inflammation around the epicondyle of the humerus. This is believed to happen from injury (strain or possibly even small tears) of the tendons and/or muscles that anchor into the epicondyle, and is thought to be due to repetitive stress injury to these structures.

Tennis elbow is very common, and although it can affect either arm (or even both) it is most common in a patient's dominant arm. Epicondylitis is most common in people in their 30s to early 50s. More than 50 percent of people who play tennis regularly will get at least some symptoms of this at some time in their playing careers, and hence the name. However, only about 5 percent of all people diagnosed with tennis elbow get it from playing tennis. Other repetitive motions such as frequent hand shaking (such as in politicians running for re-election), other sports (such as a ``wristy'' backhand in squash), gripping tools tightly (such as in many construction or manufacturing jobs) or any other twisting or hand turning motions can contribute to this problem. Many people get this condition with no identifiable risk factors.

Tennis elbow is diagnosed by the patient's history, as well as an exam by their health care provider that will reveal tenderness by the lateral epicondyle as well as pain reproduced by extending (lifting up away from the palm) the wrist and/or fingers. No X-rays or other tests are typically needed at this point.

Patients with tennis elbow typically go to their doctor because of the elbow pain, often noting that it is worsened by gripping things in their hand or with certain lifting movement with their hand. They will sometimes describe it as a weakness, although it is not common for there to be true weakness, just limitation of use of the affected muscles due to pain. It will not usually limit the patient's range of motion (except as limited by the pain it causes), and elbow movement will not usually worsen the pain. The pain can be severe, and some patients may even say it is even too painful to pick up a cup of coffee. Although classically the symptoms start out mild and progress over time, some patients will complain of the acute onset of severe pain without noting a period of milder symptoms.

The initial treatment of tennis elbow is aimed at relieving the acute symptoms. This usually includes ``PRICE'': Protection, Rest, Ice, Compression and Elevation. Anti-inflammatory pain medications such as naproxen or ibuprofen are often recommended. Compression arm straps, and sometimes wrist braces (to minimize wrist motion to allow the injured tissues to rest), are often recommended. Phonophoresis (application of a steroid gel directly to the affected area) can also be helpful.

Acupuncture has also been shown to be beneficial for some patients, and can be utilized in addition to the conservative treatments outlined above.

Over 90 percent of people with tennis elbow will improve with these conservative measures, although it can take four to six weeks for this improvement to be significant. For those who do not improve with these treatments, the next step is often an injection of steroids to help decrease the inflammation. This treatment, in conjunction with continuing the above treatments, will help over 95 percent of patients. Some studies have shown that steroid injections are useful to help improve symptoms in the early period (first one to two months), but do not improve outcomes in the longer term (at one year).

For the minority of patients who do not benefit from any of the treatments discussed above, surgical intervention may be considered, although I could not find any controlled studies evaluating the benefit of surgical intervention. Before surgery, your health care provider may order an MRI to visualize the underlying structures to rule out subtle bone fractures, large muscle/tendon tears or other injuries.

Once the patient's acute symptoms have improved, the next phase of treatment is aimed at restoring normal function and preventing recurrence. Physical therapy may be recommended to help patients recover the strength they may have lost during the prolonged rest used to treat the tennis elbow flareup, as well as to help prevent recurrence. Exercises may include ball squeezing (to strengthen grip), and there are many other exercises your physical therapist may recommend. Recommendations will also include avoiding repetitive lifting or grasping, avoiding extremes of load (no heavy lifting when the elbow is almost straight or almost completely bent), using a two-handed backhand (for tennis players), using padded tools (to minimize gripping too tightly when using tools) as well as other strategies to minimize repetitive motions that may contribute to a recurrence of the condition.

If you have pain in your elbow, whether or not you play tennis, tennis elbow may be the cause. You should see your health care provider to be evaluated and to begin appropriate treatment since the chance of recovery is better when treatment is started within a couple of months.

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The quickest way to return to the court, gym or track is the RICE method, according to "Men's Health: Best Sports Injuries Handbook" (Rodale, 96 pages, $9.95). RICE stands for rest, ice, compression and elevation. Here's how it works:

Rest: Stop the activity. Get off your feet if there's swelling or black and blue coloration. Put some weight on minor sprains to test the level of pain. Try to move injured joints. If you can't or the pain is intense, see a doctor.

Ice: Apply ice to the swelling for 20 minutes every 4 to 6 hours for the first couple of days. Continue until the swelling subsides. Wrap the ice in a towel to protect the skin from frostbite.

Compression: Simply, it's pressure applied to the area of swelling. Bandages and tape can be used. Leave your shoe on if the sprain is to an ankle. Remove it when you can apply an ice pack.

Elevation: By keeping the injured area above your heart, you'll minimize swelling by heading off fluid buildup.

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Dr. William Levine, chief of sports medicine at NewYork-Presbyterian Hospital/Columbia University Medical Center, recommends the following rules of the game to avoid athletic injuries:

-- Your best bet is to prevent injuries before they happen. First of all, start slow. Don't expect to be in the same playing condition that you ended up in last fall, even if you have been maintaining your fitness level. New activities require muscles and joints to respond in a different way. This may result in minor soreness while your body adjusts. If you push yourself too hard too soon, that minor soreness could turn into something more serious.

-- Don't forget to warm up. Although you may feel warm in good weather, you still have to give your muscles a chance to go through the motions and get blood pumping to all the necessary areas. Gentle stretching before finishing your activity will help those hard-working muscles retain and improve flexibility.

-- For tennis elbow, runner's knee, and similar injuries, try R.I.C.E. -- rest, ice, compression, and elevation. Rest means that the injured area is not put through any undue strain. When icing a body part, apply the ice in a covering so that it is not in direct contact with the skin. A cotton handkerchief covering the ice is helpful. Ice the affected area several times a day, for about 20 minutes at a time. Compression is applying pressure to the injured area to stop bleeding (if any is occurring) or to reduce swelling. Elevation helps in these respects as well. Compression and elevation are to be used in the case of acute injuries, such as a twisted ankle.

-- Take frequent breaks. Even tennis pros rest between sets. Taking a rest doesn't mean that you have to completely stop all activity (although it may be advisable sometimes). Just rest the body parts that are working hard and are susceptible to injury.

-- The single most important thing you can do is pay attention to your body. Don't ignore the little aches and pains in the joints and muscles. They are early signals that could help you prevent more serious injuries.

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Commonly called fatigue fractures, the term originated with the military, and refers to small, hairline cracks that develop in heavily used bones -- such as metatarsal bones on the top of the foot, the heel bone and the bones along the front of the lower leg, he said.

"Everyone is at risk for developing these fractures," Holderness said. "When people try to do too much too quickly or don't warm up and stretch before exercising, these bones take on too much stress and they crack and can cause pain."

Young athletes are not immune -- in fact, they occur most in that age group. However, overweight and obese people and the elderly also are prone to such fractures, due to extra weight stress and weaker bones, he said.

Seniors are especially prone to hip bone stress fractures, because a minor "twisting episode" coupled with an unsteady balance and osteoporosis will sometimes cause the bone to crack, Holderness said. These types of stress cracks are often called insufficiency fractures.

The diagnosis isn't always easy, he added. Often, when in
the leg, stress fractures may be confused with shin splints, or pain along the shin bone.

These cracks won't always show up on X-rays until they begin to heal, he said, and sometimes alternative scan methods will be used to locate the fracture.

Without proper treatment, the cracked bone may heal improperly and cause chronic pain, he said.

Often referred to as a "nuisance injury," treatments often include mandatory rest of the injured area, and in some cases may require a brace or a cast until it heals, Holderness said.

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More than 3.5 million American children younger than 15 are treated for sports injuries every year, according to SafeKids USA. The nonprofit organization reports about half those injuries are the result of solo activities like biking or skateboarding. Team sports are the source of the rest. Of injuries that result in emergency room visits, 40 percent occur between May and August.

The prevalence of injury and the upcoming National Safe Kids Week have prompted Hughston Orthopedic Hospital to sponsor a lunchtime seminar on April 24 called "Safe or Sorry: Playing It Safe." Dr. Christopher Bowman, an orthopedist and sports medicine specialist, will share tips on playing safely and preventing basic sports injuries.

Should there be an injury whether on the playground or during a team sport, Dr. Bowman says if there is an obvious physical deformity the child should immediately be taken for treatment. For minor injuries he points to RICE -- Rest, Ice, Compression and Elevation.

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One of the most common injuries sustained in contact sports such as football and martial arts is a muscle contusion. This injury is caused by direct impact to a muscle from a blunt object, usually something like an opposing player's knee or a portion of their protective equipment. Common sites of contusion injuries include the upper arm, and the front, side and back of the thigh.

Frequently, these injuries are not taken serious. A delay in treatment or improper treatment can lead to a prolonged period of disability and, in some cases, a complication called myositis ossificans.

The injury causes soreness, pain and swelling at the site of impact. In more severe cases, there is significant loss of motion affecting the joints spanned by the injured muscles. For example, after sustaining a contusion to the front of the thigh, it may become very painful and difficult to bend and extend the knee.

The swelling is caused, in part, from injury to the small blood vessels and subsequent bleeding into the region. A collection of blood, called a hematoma, may be palpable at the site of injury.

Myositis ossificans, an abnormal growth of bone within the contused muscle, is a complication that develops in a small number of cases. The more severe the contusion is the greater the risk of developing this problem.

The treatment of a muscle contusion should begin immediately after the injury. Swelling is controlled with ice, elevation and compression wraps. The involved muscles should be immobilized in a stretched position for 24 to 48 hours. For example, if the muscles on the front of the thigh are injured, the leg should be immobilized with the knee in an almost fully bent position.

After the period of immobilization is over, the involved muscles should then be gradually stretched. A strengthening program is started only after full, pain-free motion is achieved. Athletes are allowed to return to full activity when strength and function are normal. This can sometimes take as long as three or four weeks.

You should consult with a physician. An X-ray and/or MRI should be performed to rule out complications such as a muscle tear, myositis ossificans or bone injury. In some cases, a structured rehabilitation program with a physical therapist may be the cure.

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Men who took such drugs for most days in a week were about one-third more likely to be diagnosed with high blood pressure than men not taking them, the researchers found.

Their findings, published in the Archives of Internal Medicine, reinforce a study published in 2002 that these commonly used drugs raise blood pressure in women.

"This is a potentially preventable cause of high blood pressure," Dr. John Forman of Brigham and Women's Hospital, who led the study, said in a statement.

Millions of people take the painkillers as pills every day to treat headaches, arthritis, muscle pulls, and other aches and pains.

"These are the three most commonly used drugs in the United States," Dr. Gary Curhan, who also worked on the study, said in a telephone interview.

"We advise physicians to start with non-pharmacologic treatments such as physical therapy and exercise, weight loss to reduce stress on joints, and heat or cold therapy," said Dr. Elliott Antman of the Heart Association and Brigham and Women's Hospital.

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Ice! What good could it be (besides cooling our drinks during the warmer months)? There are actually many studies showing the benefits of ice as therapy. We are frequently asked in our offices: "Should I put ice on it?"

Ice is one of the simplest, cheapest, safest and most effective self-care techniques for injury, pain or discomfort in muscles and joints. Ice is effective in decreasing muscle spasms, pain and inflammation in soft tissues. Ice can be used at the time of an initial injury and also during rehabilitation following injury. Some chronic problems are also effectively treated with ice therapy.

During an initial injury, ice can reduce the amount of swelling and thus reduce the initial damage. Ice causes constriction of the blood vessels decreasing the amount of blood flow, which can limit bleeding, bruising and cell death at the site of the injury. One study even showed a positive effect on the metabolism of bone which could significantly aid the healing process of an injury to a joint.

Ice should be used after exercise and not before. Cooling a body part before exercise can inhibit position sense, which might add to the risk of injury. However, using ice immediately following a workout, especially if there is pain or injury, can be helpful.

Ice should be used for the first two to three days after an injury and sometimes longer if there is persistent swelling. Ice packs are easily made by placing ice cubes in a plastic Ziploc-type bag. Frozen gel packs are available as well. To avoid frostbite do not put the ice pack directly on your skin. Instead place the pack over a wet washcloth or towel. (Dry cloth will inhibit the cooling effect).

Ice packs should be used for 20 to 30 minutes every three to four hours. When you first apply ice, you will feel coldness, then burning and then after several minutes the area will become numb. Stop icing once the skin is numb.

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By Brom Hoban
AMERICAN-STATESMAN CORRESPONDENT

In the final weeks before a marathon, runners can cross that fine line between optimal training and injury. As a friend recently said, "Marathon training seems to awaken all of the dormant injuries you've forgotten about."

Most of the time, your first thought is, "There goes the marathon." But often, it doesn't need to work out that way.

The New York Times recently reported that "the usual advice in treating injuries is to rest until the pain goes away. But a number of leading sports medicine specialists say that is outdated and counterproductive."

Runners should be overjoyed to hear that, and many of them suspected it intuitively anyway.

The article quotes Dr. William Roberts, a sports medicine specialist at the University of Minnesota, in a revealing statement. "We want to keep you moving. Injured tissue heals better if it's under some sort of stress," he said.

That's not to say you shouldn't address the problem, just that the old "rest, ice compression and elevation" may not be the best and only answer.

ED: Ice Right is only part of the solution to your running problems, and only some of the time. Please take the time to learn more about your injuries, and more importantly, how to prevent them.

Often, it's a question of a weak link that needs to be dealt with. During marathon training in particular, the hamstrings take a lot of abuse, due to the constant "eccentric" contractions that take place during the running gait.

Three weeks before the Houston Marathon, I noticed soreness in my left upper hamstring. I had a fairly strong commitment to run Houston, so I decided the best course was to aggressively massage it out. During a similar previous injury, I had discovered that rolling on a kid-sized soccer ball and zooming in on the painful area could work wonders.

Sure enough, by race day, the hamstring pain was mostly gone. It did get a bit sore by marathon's end, but by that time, I was hurting everywhere.

Other proactive measures for hamstrings include specific strengthening exercises. Writing in the January-February 2007 issue of Running & FitNews, John Cianca, a physical medicine and rehabilitation specialist from Houston, said that the hamstrings can become overused due to "underactive and weak pelvic stabilizers and hip extensors."

To counter this, Cianca prescribes a regimen that focuses on hip and trunk strengthening, using a full-length mirror to monitor your posture and maintain optimal balance. He recommends including single-leg stands and single-leg squats, as well as prone leg extensions for the hip and lower back stabilizers.

"Additionally, single-leg stands with opposite leg abduction (movement away from the body) are excellent for strengthening the pelvis. This exercise targets the gluteus medius, a stabilizing muscle that is notoriously weak in runners and leads to hamstring overuse," Cianca said.

Sports medicine doctors agree that if an injury is obviously severe, as in a broken bone or torn Achilles' tendon, see a medical professional and don't go out for a run.

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Athletes and younger individuals may tear the meniscus by twisting the knee, pivoting, cutting or decelerating. In athletes, meniscal tears often happen in combination with other injuries such as a torn ACL (anterior cruciate ligament). Older people can injure the meniscus without any trauma, as the cartilage weakens and wears thin over time, setting the stage for a degenerative tear. In my practice, I see many baby boomers and weekend warriors who have torn a meniscus in a knee that has also developed some arthritis (cartilage breakdown). I also see a lot of meniscus tears this time of year due to twisting injuries on icy surfaces.

SIGNS AND SYMPTOMS

You might experience a "popping" sensation when you tear the meniscus. Most people can still walk on the injured knee and many athletes keep playing. When symptoms of inflammation set in, your knee feels painful and tight. For several days you have:

* Stiffness and swelling.

* Tenderness in the joint line.

* Collection of fluid ("water on the knee").

Without treatment, a fragment of the meniscus may loosen and drift into the joint, causing it to slip, pop or even lock in one position.

DIAGNOSIS

We can get a good idea of what's going on just by talking to you and examining your knee. X-rays will show us if there's any arthritis; however, an MRI of the knee is almost always needed to confirm a torn meniscus.

TREATMENT

Initial treatment of a meniscal tear follows the basic RICE formula: rest, ice, compression and elevation, combined with nonsteroidal anti-inflammatory medications to reduce pain and inflammation. If your knee is stable and does not lock, this conservative treatment is occasionally all you need.

If your knee continues to be painful, stiff, gets locked, or if you have a certain type of tear, you may need surgical help. If you do need our help, don't panic -- it's minimally invasive, outpatient surgery. We are able to use an arthroscope (camera placed through poke holes) to trim or repair your knee's damaged shock absorber. Occasionally, we even do meniscal transplants.

Dr. Joseph Guettler is an orthopedic surgeon who specializes in sports medicine, as well as surgery of the knee, shoulder, and elbow. His practice, Performance Orthopedics, is located in Bingham Farms.

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So you just couldn't hold back. Despite pointed advice to ease back slowly into your exercise routine, you pushed too hard and are now limping, wincing, whining or worse. We feel for you. But we'll also exploit your pain as a chance to explain the fine art of self-treating minor injuries.

Rushing back into action can be a sure-fire way to make an injury worse.

First: Know when to head to the doctor.

Darryl Conway, assistant athletic director for sports medicine at the University of Maryland in College Park, cites four injury types that should prompt a visit to the doctor:

•Any pain in your back that extends into the buttocks or legs;

•A fracture or dislocation;

•Numbness or tingling in the extremities;

•Gross swelling – for example, Mr. Conway says, "if your ankle swells to the point where it looks like you have a grapefruit under your sock."

For more common episodes of minor pain or swelling or both, experts recommend self-care via the RICE treatment – rest, ice, compression and elevation.

Ideally, you can apply ice periodically throughout the day for about 20 minutes at a time. Yes, we know you have jobs, commutes and other annoyances to deal with. But the more consistently you ice, especially in the first 48 hours after injury, the quicker you heal, says Walter R. Thompson, a professor of kinesiology and nutrition at Georgia State University in Atlanta.

If your injury is swollen, do not apply heat, which can worsen swelling. Absent such distension, however, alternating heat and ice is fine, Dr. Thompson says.

"Compression" means a tight wrap during icing, then an Ace bandage or similar wrap during the rest of the day. Nothing that will cut off circulation, of course; you're looking to limit mobility, not cut off a spurting artery. Keep the site elevated above your heart as often as possible, to let gravity help reduce the swelling.

Do the RICE routine for at least five to seven days before testing the injury with exercise.

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