The Anatomy of Sports Injuries, Your Illustrated Guide to Prevention, Diagnosis, and Treatment

TheAnatomyofSportsInjuries

YourIllustratedGuidetoPrevention,Diagnosis,andTreatment

SecondEdition

BradWalker

Copyright©2007,2013,2018byBradWalker.Allrightsreserved.Noportionofthisbook,exceptforbriefreviews,maybereproduced,storedinaretrievalsystem,ortransmittedinanyformorby any means – electronic, mechanical, photocopying, recording, or otherwise – without thewrittenpermissionofthepublisher.Forinformation,contactLotusPublishingorNorthAtlanticBooks.

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TheLibraryofCongressCataloguing-in-Publicationhascataloguedthefirsteditionasfollows:Walker,Brad,1971-Theanatomyofsportsinjuries/BradWalker.p.;cm.Includesbibliographicalreferencesandindex.ISBN978-1-55643-666-6(NorthAtlanticBooks:pbk.)1.Sportsinjuries--Atlases.I.Title.[DNLM:1.AthleticInjuries--Atlases.2.AthleticInjuries--Handbooks.3.AthleticInjuries--therapy--Atlases.4.AthleticInjuries--therapy--Handbooks.QT29W177a2007]RD97.W352007

http://www.northatlanticbooks.com

617.1’027--dc222007010564

VD1

Contents

Introduction

AnatomicalDirections

CHAPTER1

ExplanationofSportsInjury

WhatConstitutesaSportsInjury?

WhatisAffectedinaSportsInjury?

IstheSportsInjuryAcuteorChronic?

HowAreSportsInjuriesClassified?

HowAreSprainandStrainInjuriesClassified?

CHAPTER2

SportsInjuryPrevention

IntroductiontoSportsInjuryPrevention

Warm-up

Cool-down

TheFITTPrinciple

Overtraining

FitnessandSkillDevelopment

StretchingandFlexibility

Facilities,RulesandProtectiveDevices

CHAPTER3

SportsInjuryTreatmentandRehabilitation

IntroductiontoSportsInjuryManagement

RegainingtheFitnessComponents

CHAPTER4

SportsInjuriesoftheSkin

001:Cuts,Abrasions,Chafing

002:Sunburn

003:Frostbite

004:Athlete’sFoot(TineaPedis)

005:Blisters

006:Corns,Calluses,PlantarWarts(Verrucae)

CHAPTER5

SportsInjuriesoftheHeadandNeck

Acute007:HeadConcussion,Contusion,Haemorrhage,Fracture

008:NeckStrain,Fracture,Contusion

009:CervicalNerveStretchSyndrome

010:Whiplash(NeckStrain)

011:Wryneck(Torticollis)

012:CervicalDiscInjury(AcuteCervicalDiscDisease)

013:PinchedNerve(CervicalRadiculitis)

014:SpurFormation(CervicalSpondylosis)

015:Teeth

016:Eye

017:Ear

018:Nose

RehabilitationExercises

CHAPTER6

SportsInjuriesoftheHandandFingers

Acute019:MetacarpalFractures

020:ThumbSprain(UlnarCollateralLigament)

021:MalletFinger(LongExtensorTendon)

022:FingerSprain

023:FingerDislocation

Chronic024:Hand/FingerTendinitis


CHAPTER7

SportsInjuriesoftheWristandForearm

Acute025:WristandForearmFracture

026:WristSprain

027:WristDislocation

Chronic028:CarpalTunnelSyndrome

029:UlnarTunnelSyndrome

030:WristGanglionCyst

031:WristTendinitis


CHAPTER8

SportsInjuriesoftheElbow

Acute032:ElbowFracture

033:ElbowSprain

034:ElbowDislocation

035:TricepsBrachiiTendonRupture

Chronic036:TennisElbow

037:Golfer’sElbow

038:Thrower’sElbow

039:ElbowBursitis


CHAPTER9

SportsInjuriesoftheShoulderandUpperArm

Acute040:Fracture(Collarbone,Humerus)

041:DislocationoftheShoulder

042:ShoulderSubluxation

043:AcromioclavicularSeparation

044:SternoclavicularSeparation

045:BicepsBrachiiTendonRupture

046:BicepsBrachiiBruise

047:MuscleStrain(BicepsBrachii,Chest)

Chronic048:SubacromialImpingement

049:RotatorCuffTendinitis

050:ShoulderBursitis

051:BicipitalTendinitis

052:PectoralMuscleInsertionInflammation

053:FrozenShoulder(AdhesiveCapsulitis)


CHAPTER10

SportsInjuriesoftheBackandSpine

Acute054:MuscleStrainoftheBack

055:LigamentSprainoftheBack

056:ThoracicContusion

Chronic057:DiscProlapse

058:DiscBulge

059:StressFractureoftheVertebra


CHAPTER11

SportsInjuriesoftheChestandAbdomen

Acute060:Broken(Fractured)Ribs

061:FlailChest

062:AbdominalMuscleStrain


CHAPTER12

SportsInjuriesoftheHips,PelvisandGroin

Acute063:HipFlexorStrain

064:HipPointer

065:AvulsionFracture

066:GroinStrain

Chronic067:OsteitisPubis

068:StressFracture

069:PiriformisSyndrome

070:IliopsoasTendinitis

071:TendinitisoftheAdductorMuscles

072:SnappingHipSyndrome

073:TrochantericBursitis


CHAPTER13

SportsInjuriesoftheHamstringsandQuadriceps

Acute074:FemoralFracture

075:QuadricepsStrain

076:HamstringStrain

077:ThighBruise(Contusion)

Chronic078:IliotibialBandSyndrome

079:QuadricepsTendinitis182


CHAPTER14

SportsInjuriesoftheKnee

Acute080:MedialCollateralLigamentSprain

081:AnteriorCruciateLigamentSprain

082:MeniscusTear

Chronic083:Bursitis

084:InflammationoftheSynovialPlica

085:Osgood-SchlatterDisease

086:OsteochondritisDissecans

087:PatellofemoralPainSyndrome

088:PatellarTendinitis(Jumper’sKnee)

089:ChondromalaciaPatellae(Runner’sKnee)

090:PatellarDislocation


CHAPTER15

SportsInjuriesoftheShinandCalf

Acute091:Fractures(Tibia,Fibula)

092:CalfStrain

093:AchillesTendonStrain

Chronic094:AchillesTendinitis

095:MedialTibialPainSyndrome(ShinSplints)

096:StressFracture

097:AnteriorCompartmentSyndrome


CHAPTER16

SportsInjuriesoftheAnkle

Acute098:AnkleFracture

099:AnkleSprain

Chronic100:TibialisPosteriorTendinitis

101:PeronealTendonSubluxation

102:PeronealTendinitis

103:OsteochondritisDissecans

104:Supination

105:Pronation


CHAPTER17

SportsInjuriesoftheFoot

Acute106:FractureoftheFoot

Chronic107:RetrocalcanealBursitis

108:StressFracture

109:FlexorandExtensorTendinitis

110:Morton’sNeuroma

111:Sesamoiditis

112:Bunions

113:HammerToe

114:TurfToe

115:FlatFeet(PesPlanus)

116:ClawFoot(PesCavus)

117:PlantarFasciitis

118:HeelSpur

119:BlackNail(SubungualHaematoma)

120:IngrownToenail


GlossaryofTerms

Resources

Index

A

Introduction

s sports participation rates increase, so does the occurrence ofsport-related injury. As a consequence, there is a need fordetailed,easy-to-understandreferencebooksontheprevention,

treatmentandmanagementofsportsinjury.

Whilsttherearemanybooksdealingwiththissubject,veryfewpresentdetailedanatomical informationinawaythat iseasytounderstandforeveryonefromtheweekendwarriortotheprofessionalathlete;fromthefirst-yearpersonaltrainertotheseasonedsportscoachorfromtherecentuniversitygraduatetotheaccomplishedsportsdoctor.

Combining real-life practical experience with detailed theory, BradWalker presents complex prevention, treatment and managementstrategiesinawaythateveryonecanunderstand.Full-colorillustrationsprovide a visual aid to the workings of the human body during thesports injury management process. The expert yet easy-to-followinformationwillhelp thereaderpreventsports injury,and in theeventthataninjurydoesoccurhelptotreatiteffectively,allowingareturntoactivityinaslittletimeaspossible.

TheAnatomy of Sports Injuries looks at sport-related injury from everyangle.Chapter1 introduces theconceptof sports injury. It explains thedifferent classifications and grades of sports injury and describes thestructures and tissues involved. InChapter 2 key prevention strategiesare explained to help reduce the occurrence of sport-related injury. InChapter 3 a comprehensive treatment and rehabilitation process is

outlinedtoensureaquickandcompleterecovery.

Chapters 4–17 provide a detailed overview of 120 sports injuries in aneasy-to-locate format. Divided into key areas of the body, each sportsinjury is described by: the anatomy and physiology involved, possiblecauses, signs and symptoms, complications, immediate treatment,rehabilitationproceduresandlong-termprognosis.

Aimed at fitness enthusiasts and health-care professionals of all levels,The Anatomy of Sports Injuries also provides strength and flexibilityexercises to aid with sports injury prevention, treatment andrehabilitation. These exercises are by nomeans exhaustive andmerelyprovide guidance. Consult a healthcare professional for a tailor-madeprogrammetosuityourindividualneeds.

AnatomicalDirections

Abduction Amovementawayfromthemidline(ofthebodyorfoot/hand).

Adduction Amovementtowardthemidline(ofthebodyorfoot/hand).

Anatomicalposition

Thebodyisuprightwiththepalmsofthehandsturnedforward.

Anterior Towardthefrontofthebody(asopposedtoposterior).

Circumduction Movementinwhichthedistalendofabonemovesinacirclewhiletheproximalendremainsstable.

Contralateral Ontheoppositeside.

Coronalplane Averticalplaneatrightanglestothesagittalplanewhichdividesthebodyintoanteriorandposteriorportions.

Deep Awayfromthesurface(asopposedtosuperficial).

Depression Movementofabodypartdownward.

Distal Awayfromthepointoforiginofastructure(asopposedtoproximal).

Dorsal Relatingtothebackorposteriorportion(asopposedtoventral).

Elevation Movementofapartofthebodyupwardinthecoronalplane.

Eversion Toturnthesoleofthefootoutward.

Extension Amovementatajointresultinginseparationoftwoventralsurfaces(asopposedtoflexion).

Flexion Amovementatajointresultinginapproximationoftwoventralsurfaces(asopposedtoextension).

Horizontalplane

Atransverseplaneatrightangletothelongaxisofthebody.

Inferior Beloworfurthestawayfromthehead.

Inversion Toturnthesoleofthefootinward.

Lateral Awayfromthemidlineofthebodyororgan(oppositetomedial).

Medial Towardthemidlineofthebodyororgan(oppositetolateral).

Median Centrallylocated,situatedinthemiddleofthebody.

Opposition Amovementspecifictothesaddlejointofthethumbthatenablesthethumbtotouchthetipsofthefingersofthesamehand.

Palmar Anteriorsurface(palm)ofthehand.

Plantar Thesoleofthefoot.

Posterior Relatingtothebackorthedorsalaspectofthebody(asopposedtoanterior).

Pronation Toturnthepalmofthehanddowntofacethefloororawayfromtheanatomicalposition.

Prone Positionofthebodyinwhichtheventralsurfacefacesdown(asopposedtosupine).

Protraction Movementforwardinthetransverseplane.

Proximal Closertothecentreofthebodyortothepointofattachmentofalimb.

Retraction Movementbackwardinthetransverseplane.

Rotation Movementaroundafixedaxis.

Sagittalplane Averticalplaneextendinginananteroposteriordirectiondividingthebodyintoequalrightandleftparts.

Superficial Onornearthesurface(asopposedtodeep).

Superior Aboveorclosesttothehead.

Supination Toturnthepalmofthehanduptofacetheceilingortowardtheanatomicalposition.

Supine Positionofthebodyinwhichtheventralsurfacefacesup(asopposedtoprone).

Ventral Referstotheanteriorpartofthebody(asopposedtodorsal).

N

CHAPTER1ExplanationofSportsInjury

o one doubts the benefits of regular structured exercise:elevated cardiovascular fitness, improved muscular strengthandincreasedflexibilityallcontributetoanenhancedqualityof

life.However,oneoftheveryfewdrawbacksofexerciseisanincreasedsusceptibilitytosportsinjury.

Whilesportandexerciseparticipationratesareincreasing(agoodthing!)injuryratesarealsoontherise.InfacttheUSConsumerProductSafetyCommission estimates: “between 1991 and 1998, golf and swimminginjuries increased 110 percent; ice hockey andweightlifting injuries, 75percent; soccer injuries, 55 percent; bicycling, 45 percent; volleyball, 44percent;andfootball43percent”(ConsumerProductSafetyReview,2000).

WHATCONSTITUTESASPORTSINJURY?

Physical injurygenerally canbedefinedas any stresson thebody thatpreventstheorganismfromfunctioningproperlyandresultsinthebodyemployingaprocessofrepair.Asportsinjurycanbefurtherdefinedasany kind of injury, pain or physical damage that occurs as a result ofsport,exerciseorathleticactivity.

Although the term sports injury can be used to define any traumasustained as a result of sport and exercise, it usually describes injuries

that affect the musculoskeletal system. More serious injuries, such ashead, neck and spinal cord trauma, are usually considered separate tocommonsportsinjurieslikesprains,strains,fracturesandcontusions.

WHATISAFFECTEDINASPORTSINJURY?

Sports injuriesaremost commonlyassociatedwith themusculoskeletalsystem,whichincludesthemuscles,bones, jointsandassociatedtissuessuch as ligaments and tendons. Below is a brief explanation of thecomponentsthatmakeupthemusculoskeletalsystem.

MusclesMuscle is composed of 75%water, 20% protein and 5%mineral salts,glycogenand fat.Thereare three typesofmuscle: skeletal, cardiacandsmooth. The type of muscle involved with movement is skeletal (alsoreferred to as striated, somatic or voluntary). Skeletal (somatic orvoluntary)musclesmakeupapproximately40%ofthetotalhumanbodyweight.Skeletalmusclesareundervoluntarycontrol,andattachto,andcover over, the bony skeleton. They are capable of powerful, rapidcontractionsand longer, sustainedcontractions.Skeletalmusclesenableus to perform both feats of strength and controlled, fine movements.Theyareattachedtobonebytendons.Theplacewhereamuscleattachestoarelativelystationarypointonabone,eitherdirectlyorviaatendon,iscalledtheorigin.Whenthemusclecontracts,ittransmitstensiontothebones across one ormore joints andmovement occurs. The end of themusclethatattachestothebonethatmovesiscalledtheinsertion.

OverviewofSkeletalMuscleStructure

Thefunctionalunitofskeletalmuscleisknownasamusclefiber,whichisanelongated,cylindricalcellwithmultiplenuclei,rangingfrom10–100micronsinwidth,andafewmillimetresto30+centimetresinlength.Thecytoplasm of the fiber is called the sarcoplasm, which is encapsulatedinside a cell membrane called the sarcolemma. A delicate membraneknownastheendomysiumsurroundseachindividualfiber.

Muscle fibers are grouped together in bundles covered by theperimysium. These bundles are themselves grouped together, and thewholemuscleisencasedinasheathcalledtheepimysium.Thesemusclemembranesrunthroughtheentirelengthofthemuscle,fromthetendonof origin to the tendon of insertion. Thiswhole structure is sometimesreferredtoasthemusculo-tendinousunit.

NOTE:Astheycontract,allmuscletypesgenerateheat,andthis

heat is vitally important in maintaining a normal body

temperature.Itisestimatedthat85%ofallbodyheatisgenerated

bymusclecontractions.

Majormusclesincludethequadricepsofthethighandthebicepsbrachiioftheupperarm.

BonesWe are born with approximately 350 bones, but gradually they fusetogetheruntilbypubertywehaveonly206.Bonesformthesupportingstructure of the body and are collectively known as the endoskeleton.(The exoskeleton iswell developed inmany invertebrates but exists inhumans only as teeth, nails and hair). Fully developed bone is thehardesttissueinthebodyandiscomposedof20%water,30–40%organicmatterand40–50%inorganicmatter.

BoneDevelopmentandGrowthThemajority of bone is formed from a foundation of cartilage, whichbecomes calcified and then ossified to form true bone. This processoccursthroughthefollowingfourstages:

1. Bone building cells called osteoblasts become active during thesecondorthirdmonthofembryoniclife.

2. Initially, the osteoblastsmanufacture amatrix ofmaterial betweenthe cells, which is rich in a fibrous protein called collagen. Thiscollagen strengthens the tissue. Enzymes then enable calciumcompoundstobedepositedwithinthematrix.

3. This intercellularmaterial hardens around the cells,whichbecomeosteocytes, living cells that maintain the bone but do not producenewbone.

4. Othercellscalledosteoclastsbreakdown,remodelandrepairbone.This process continues throughout life but slows down withadvancingage.Consequently,thebonesofelderlypeopleareweakerandmorefragile.

Thestructureofmuscletissuefrommicroscopictogrossanatomy.

Bonedevelopmentandgrowth.

Inbrief,osteoblastsandosteoclastsarethecellsthatlaydownandbreakdownbone respectively, enabling bones to very slowly adapt in shapeandstrengthaccordingtoneed.

Bonecellssitincavitiescalledlacunae(singular:lacuna)surroundedbycircularlayersofveryhardmatrixthatcontainscalciumsaltsandlargeramounts of collagen fibers. Bones protect internal organs and facilitatemovement. Together they form a rigid structure called the skeleton.

Majorbonesincludethefemurinthethighandthehumerusintheupper

arm.

TypesofBoneAccordingtoDensityCompactBoneCompactboneisdenseandlookssmoothtothenakedeye.Throughthemicroscope, compact bone appears as an aggregation of Haversiansystems called osteons. Each system is an elongated cylinder orientedalong the longaxisof thebone, consistingof a centralHaversian canalcontaining blood vessels, lymph vessels and nerves surrounded byconcentricplatesofbonecalledlamellae.Inotherwords,eachHaversiansystemisagroupofhollowtubesofbonematrix (lamellae)placedoneinside the next. Between these lamellae there are spaces (lacunae) thatcontainlymphandosteocytes.Thelacunaearelinkedviahair-likecanalscalledcanaliculitothelymphvesselsintheHaversiancanal,enablingtheosteocytestoobtainnourishmentfromthe lymph.This tubulararrayoflamellaegivesgreatstrengthtobone.

Structureofcompactbone.

Structureofspongy(cancellous)bone.

Othercanalscalledperforating,orVolkmann’s,canalsrunatrightanglesto the long axis of the bone, connecting the blood vessels and nervesupplywithinthebonetotheperiosteum.

SpongyBone(CancellousBone)Spongy bone is composed of small, needle-like trabeculae (singular:trabecula; literally, ‘little beams’) containing irregularly arrangedlamellae and osteocytes interconnected by canaliculi. There are noHaversiansystemsbutratherlotsofopenspaces,whichcanbethought

of as largeHaversian canals, givingahoneycombedappearance.These

spacesarefilledwithredoryellowmarrowandbloodvessels.

This structure forms a dynamic lattice capable of gradual alterationthrough realignment in response to stressesofweight,postural changeand muscle tension. Spongy bone is found in the epiphyses of longbones,thebodiesofthevertebraeandotherboneswithoutcavities.

TypesofBoneAccordingtoShapeIrregularBonesIrregularboneshavecomplicatedshapes;theyconsistmainlyofspongyboneenclosedby thin layersof compactbone.Examples include: someskullbones,thevertebraeandthehipbones.

FlatBonesFlatbonesarethin,flattenedbonesandarefrequentlycurved;theyhavealayerofspongybonesandwichedbetweentwothinlayersofcompactbone. Examples include: most of the skull bones, the ribs and thesternum.

ShortBonesShort bones are generally cube-shaped; they consist mostly of spongy(cancellous) bone. Examples include: the carpal bones in thewrist andtarsalbonesintheankle.

SesamoidBonesFromtheLatin,meaning‘shapedlikeasesameseed’,sesamoidbonesarea special type of short bone that are formed and embedded within amuscle tendon. Examples are: the patella (kneecap) and the pisiformboneofthewrist.

LongBonesLongbonesarelongerthantheyarewide;theyhaveashaftwithheadsatbothends,andconsistmostlyofcompactbone.Examplesinclude:thebones of the limbs, except those of the wrist, hand, ankle and foot(althoughthebonesofthefingersandtoesareeffectivelyminiaturelongbones).

ComponentsofaLongBoneThetransformationofcartilagewithinalongbonebeginsatthecentreoftheshaft.Secondarybone-formingcentresdeveloplater,acrosstheendsof the bones. From these growth centres the bone continues to growthroughchildhoodandadolescence,finallyceasingintheearlytwenties,whereuponthegrowthregionsharden.

DiaphysisThediaphysis(fromGreek,meaning‘aseparation’)istheshaftorcentralpart of a long bone. It has a marrow-filled cavity (medullary cavity)surrounded by compact bone. It is formed from one ormore primarysitesofossificationandsuppliedbyoneormorenutrientarteries.

EpiphysisTheepiphysis (fromGreek,meaning ‘excrescence’) is theendofa longbone, or any part of a bone separated from the main body of animmature bone by cartilage. It is formed from a secondary site ofossification.Itconsistslargelyofspongybone.

EpiphysealLineTheepiphyseallineistheremnantoftheepiphysealplate(aflatplateofhyalinecartilage)seen inyoung,growingbone.Theepiphysealplate is

the site of growth of a long bone. By the end of puberty, long bonegrowthstopsandtheplate iscompletelyreplacedbybone, leaving justthelinetomarkitspreviouslocation.

ArticularCartilageArticular cartilage is the only remaining evidence of an adult bone’scartilaginouspast.Itislocatedwheretwobonesmeet(articulate)withinasynovialjoint.Itissmooth,slippery,porous,malleable,insensitiveandbloodless. It ismassagedbymovement,whichcirculatessynovial fluid,oxygenandnutrients.

NOTE:Thedegenerativeprocessofosteoarthritis(andthe latter

stages of some forms of rheumatoid arthritis) involves the

breakdownofarticularcartilage.

PeriosteumTheperiosteumisafibrousconnectivetissuemembraneenvelopingtheouter surface of bone. It is vascular and provides a highly sensitive,double-layeredlifesupportsheath.Theouterlayerismadeupofdenseirregular connective tissue. The inner layer, which lies directly againstthebonesurface,mostlycomprisesthebone-formingosteoblastsandthebone-destroyingosteoclasts.

The periosteum is supplied with nerve fibers, lymphatic vessels andbloodvesselsthatenterthebonethroughnutrientcanals.Itisattachedtothe boneby collagen fibers knownas Sharpey’s fibers. Theperiosteumalsoprovidestheanchoringpointfortendonsandligaments.

MedullaryCavityThemedullarycavityisthecavityofthediaphysis(i.e.thecentralsection

ofalongbone).Itcontainsmarrow:redintheyoung,turningtoyellowinmanybonesinmaturity.

Componentsofalongbone.

Structureofcartilage;a)hyalinecartilage,b)whitefibrocartilage,c)yellowelasticcartilage.

RedMarrowRedmarrow is a red, gelatinous substance composedof redandwhitebloodcellsinavarietyofdevelopmentalforms.Redmarrowcavitiesaretypicallyfoundwithinthespongyboneoflongbonesandflatbones.Inadultstheredmarrow,whichcreatesnewredbloodcells,occursonlyinthe head of the femur and the head of the humerus and, much moreimportantly, in the flat bones such as the sternum and irregular bonessuchasthehipbones.Thesearethesitesroutinelyusedforobtainingredmarrow samples when problems with the blood-forming tissues aresuspected.

YellowMarrow

Yellowmarrowisafattyconnectivetissuethatnolongerproducesbloodcells.

CartilageCartilageisaspecializedfibrousconnectivetissue.Itsmainpurposeistoprovideasmoothsurfaceforthemovementofjoints,andabsorbimpactand friction when bones bump and rub together. It exists either as atemporary formation that is later replaced by bone, or as a permanentsupplementationtobone;itisnotashardorasstrongasbone.Cartilagestrength comes mainly from the strength of the collagen it contains.Cartilageisrelativelynon-vascular(notpenetratedbybloodvessels)andismainlynourishedbysurroundingtissuefluids.Typesinclude:hyalinecartilage,fibrocartilageandelasticcartilage.

Themostimportantishyaline(articular)cartilage,whichismadeupofcollagen fibers and water. Hyaline cartilage forms the temporaryfoundation of cartilage from which many bones develop, thereafterexistinginrelationtoboneas:

• Thearticularcartilageofsynovialjoints.• Cartilage plates between separately ossifying areas of bone during

growth.• The xiphoid process of the sternum (which ossifies late or not at all)

andthecostalcartilages.

Thekneejoint;rightleg,mid-sagittalview.

Hyaline cartilage also exists in thenasal septum,most cartilagesof thelarynx,andthesupportingringsofthetracheaandbronchi.

LigamentsLigamentsare the fibrousconnective tissues thatconnectbone tobone.Composed of dense regular connective tissue, ligaments contain more

elastinthantendonsandsoaremoreelastic.Ligamentsprovidestabilityforthejointsand,withthebones,eitheralloworlimitmovementofthelimbs.

TendonsTendonsarethefibrousconnectivetissuesthatconnectmuscletobone.Their collagen fibers are arranged in a parallel pattern, which enablesresistancetohigh,unidirectionaltensileloadswhentheattachedmusclecontracts.Tendonswork togetherwithmuscles to exert force onbonesandproducemovement.

JointsJoints(alsocalledarticulations)enablemovement,givingtherigidbony

skeleton mobility. They are also sites where forces are absorbed andtransmittedandwheregrowthtakesplace.Therearethreemaintypesofjoint:fibrousjoints,whichhaveverylittleornomovement;cartilaginousjoints, which are either immovable or only slightly movable; and

synovialjoints,whicharefreelymoveable.

As synovial joints are freely movable, they are the joints most ofteninvolvedwithsportsinjuries.Majorsynovialjointsinclude:theknee,hip,shoulder and elbow. Synovial joints share the following features, all ofwhichcanbedamagedinasportsinjury:

ArticularCapsuleThearticularcapsulesurroundsandenvelopestheentiresynovial joint.It consists of an outer layer of fibrous tissue and an inner layer, thesynovial membrane, which secretes synovial fluid to lubricate andnourish the joint. The joint capsule is strengthened by strong bands ofligament(seeabove).

JointCavityNeitherfibrousnorcartilaginousjointshaveajointcavity,whilesynovialjointspossessajointcavitythatcontainssynovialfluid.

HyalineArticularCartilageHyaline cartilage covers the end of bones and provides a smooth,slipperysurfacethatallowsthejointtomovefreely.Thejobofarticularcartilageistoreducefrictionduringmovementandabsorbshock.

BursaAbursa(pluralbursae)isasmallsacfilledwithviscidfluid.Bursaearemost commonly found at the point in the joint where themuscle and

tendonslideacrossthebone.Thejobofabursaistoreducefrictionandprovidesmoothmovementforthejoint.

TheSevenTypesofSynovialJointPlaneorGlidingMovement occurs when two generally flat or slightly curved surfacesglideacrossoneanother.Examples: theacromioclavicular jointand theintercarpaljointsofthewrist.

HingeMovementoccursaroundatransverseaxis,asinthehingeofthelidofabox.Aprotrusionofonebonefitsintoaconcaveorcylindricalarticularsurface of another, permitting flexion and extension. Examples: theinterphalangealjointsofthedigitsandtheelbow.

PivotMovementtakesplacearoundaverticalaxis,likethehingeofagate.Amore or less cylindrical articular surface of bone protrudes into androtateswithinaringformedbyboneorligament.Example:theproximalradioulnarjointattheelbow.

SpheroidalorBall-and-SocketConsistsofa‘ball’formedbythesphericalorhemisphericalheadofonebone which rotates within the concave ‘socket’ of another, allowingflexion, extension, adduction, abduction, circumduction and rotation.Thus, theyaremulti-axialandallowthegreatestrangeofmovementofalljoints.Examples:theglenohumeraljointandthehip.

EllipsoidHave an ellipsoid articular surface that fits into amatching concavity,which permits flexion, extension and some abduction and adduction.Example: the metacarpophalangeal joints of the hand (but not thethumb).

SaddleArticulating surfaces have convex and concave areas, and so resemble

two‘saddles’thataccommodateeachother’sconvextoconcavesurfaces.Similar to ellipsoid joints, they allow flexion, extension, abduction andadduction but more rotational movement, for example, allowing the‘opposition’ of the thumb to the fingers. Example: the carpometacarpaljointofthethumb.

Condylar/bicondylarReciprocal convex/concave joint surface(s) allow flexion, extensionandlimited rotation around a longitudinal axis. Example: the tibiofemoraljointoftheknee.

ISTHESPORTSINJURYACUTEORCHRONIC?

Regardlessofwheretheinjuryoccurswithinthebody,ortheseriousnessoftheinjury,sportsinjuriesarecommonlyclassifiedinoneoftwoways:acuteorchronic.

AcuteInjuriesTheserefertosportsinjuriesthatoccurinaninstant.Commonexamples

ofacuteinjuriesarebonefractures,muscleandtendonstrains,ligamentsprains and contusions. Acute injuries usually result in pain, swelling,tenderness, weakness and the inability to use or place weight on theinjuredarea.

ChronicInjuriesTheserefertosportsinjuriesthatoccuroveranextendedperiodoftimeandaresometimescalledoveruseinjuries.Commonexamplesofchronicinjuriesaretendinitis,bursitisandstressfractures.Chronicinjuries, likeacuteinjuries,alsoresultinpain,swelling,tenderness,weaknessandtheinabilitytouseorplaceweightontheinjuredarea.

HOWARESPORTSINJURIESCLASSIFIED?

Aswellasclassifyingasports injuryasacuteorchronic,sports injuriesarealsoclassifiedaccordingtotheirseverity.Injuriesaregradedintooneofthreeclassifications:mild,moderateorsevere.

MildAmildsportsinjurywillresultinminimalpainandswelling.Itwillnotadversely affect sporting performance and the affected area is neithertendertotouchnordeformedinanyway.

ModerateAmoderate sports injurywill result in somepain and swelling. Itwillhavealimitingaffectonsportingperformanceandtheaffectedareawillbemildlytendertotouch.Somediscolorationattheinjurysitemayalso

bepresent.

SevereAseveresports injurywillresult in increasedpainandswelling. Itwillnot only affect sporting performance but will also affect normal dailyactivities. The injury site is usually very tender to touch, anddiscolorationanddeformityarecommon.

HOWARESPRAINANDSTRAININJURIESCLASSIFIED?

The term sprain refers to an injury of the ligaments, as opposed to astrain, which refers to an injury of the muscle or tendon. Rememberligamentsattachbonetobone,whereastendonsattachmuscletobone.

Injuries to the ligaments,muscles and tendons are usually graded intothreecategories.Thesetypesofinjuryarereferredtoas:first-,second-orthird-degreesprainsandstrains.

First-degreeA first-degree sprain/strain is the least severe. It is the result of someminor stretching of the ligaments, muscles or tendons and isaccompanied bymild pain, some swelling and joint stiffness. There isusually very little loss of joint stability as a result of a first-degreesprain/strain.

Second-degreeAsecond-degreesprain/strainistheresultofbothstretchingandsometearingoftheligaments,musclesortendons.Thereisincreasedswelling

andpainassociatedwithasecond-degreesprain/strainandamoderatelossofstabilityaroundthejoint.

Third-degreeA third-degree sprain/strain is the most severe of the three. A third-degreesprain/strainistheresultofacompletetearorruptureofoneormore of the ligaments, muscles or tendons and will result in massiveswelling,severepainandgrossinstability.

One interestingpoint tonote about a third-degree sprain/strain is thatshortlyaftertheinjurymostofthelocalizedpainmaydisappear.Thisisaresultofthenerveendingsbeingsevered,whichcausesalackoffeelingattheinjurysite.

CHAPTER2SportsInjuryPrevention

INTRODUCTIONTOSPORTSINJURYPREVENTION

In a recent article titled ‘ManagingSports Injuries’, the author estimatedthateverydaymorethan27,000Americansspraintheirankle.Ontopofthis,SportsMedicineAustraliaestimatesthat1 in17participants insportandexercisesufferasportsinjuryplayingtheirfavoritesport.Thisfigureis even higher for contact sports like football. However, the trulydisturbingfact isthatupto50percentoftheseinjuriesmayhavebeenprevented.

Ifimprovingsportingperformanceisthegoal,thenthereisnobetterwaytodothatthanbystayinginjuryfree.Tofollowareanumberoftipsandstrategies that will help prevent sports injury. When properlyimplementedand routinely followed, theyhave thepotential to reducetheincidenceofsportsinjurybyupto50percent.

Before moving on, please note that any single injury preventiontechniquediscussedinthischapterisjustonecomponentthatcanhelptoreduce theoverall riskof injury.Thebest resultsareachievedwhenallthetechniquesareusedincombinationwitheachother.Whenitcomestosportsinjury,preventionisbetterthancure.

WARM-UP

Warm-upactivities are a crucialpartof anyexerciseor sports training.The importance of a structured warm-up routine should not beunderestimatedwhenitcomestothepreventionofsportsinjury.

Aneffectivewarm-uphasanumberofkeyelements.Theseelements,orparts, should all work together to minimize the likelihood of sportsinjuryfromphysicalactivity.

Warming-uppriortoanyphysicalactivityhasanumberofbenefits,butitsmain purpose is to prepare the body andmind formore strenuousactivity. One of theways it achieves this is by helping to increase thebody’scoretemperaturewhileincreasingthebody’smuscletemperature.Increasingmuscletemperaturewillhelptomakethemuscles looseandsupple.

Aneffectivewarm-upalsohastheeffectofincreasingbothheartrateandrespiratory rate. This increases blood flow,which in turn increases thedeliveryofoxygenandnutrients totheworkingmuscles.All thishelpstopreparethemuscles,tendonsandjointsformorestrenuousactivity.

HowShouldtheWarm-upBeStructured?It is important to start thewarm-up routinewith the easiest andmostgentle activity, building upon each part with more energetic activitiesuntilthebodyisataphysicalandmentalpeak.Thisisthestateinwhichthebody ismostpreparedfor thephysicalactivity tocome,andwherethe likelihood of sports injury has been minimized. To achieve thesegoals,thewarm-upshouldbestructuredasfollows:

There are four key elements, or parts, which should be included toensureaneffectiveandcompletewarm-up.Theyare:

1.Thegeneralwarm-up

2.Staticstretching3.Thesport-specificwarm-up4.Dynamicstretching

All four parts are equally important and any one part should not beneglectedorthoughtofasunnecessary.Allfourelementsworktogetherto bring the body andmind to a physical peak, ensuring the athlete isprepared for the activity to come. This process will help ensure theathletehasaminimalriskofsportsinjury.

1.GeneralWarm-upThegeneralwarm-upshouldconsistoflightphysicalactivity.Thefitnesslevelof theparticipatingathlete shouldgovernboth the intensity (howhard)andduration(howlong)ofthegeneralwarm-up.Ageneralwarm-upfortheaveragepersonshouldtake5–10minutesandresultinalightsweat.

The aim of the general warm-up is to elevate the heart rate andrespiratoryrate.Thisinturnincreasesthebloodflowandhelpswiththetransportation of oxygen and nutrients to theworkingmuscles. It alsohelps to increase themuscle temperature, allowing foramoreeffectivestaticstretch.

2.StaticStretchingStatic stretching isaverysafeandeffective formofstretching.There islimited risk of injury (when performed correctly) and it is extremelybeneficial for overall flexibility.During thispart of thewarm-up, staticstretchingshouldincludeallthemajormusclegroupsandshouldlast5–10minutes.

Staticstretchingisperformedbyplacingthebodyinapositionwherebythemuscle (orgroupofmuscles) tobestretched isunder tension.Both

the opposing muscle group (the muscles behind or in front) and themusclestobestretchedarerelaxed.Thenslowlyandcautiouslythebodyismovedtoincreasethetensionofthemuscle,orgroupofmuscles,tobestretched.At this point the position is held ormaintained to allow themusclesandtendonstolengthen.

Thissecondpartofaneffectivewarm-upisextremelyimportant:ithelpstolengthenboththemusclesandtendons,whichinturnallowthejointsagreaterrangeofmovement.Thisisveryimportantinthepreventionofmuscleandtendoninjuries.

Theabovetwoelementsformthebasisorfoundationforacompleteandeffectivewarm-up.It isextremelyimportantthatthesetwoelementsbecompleted properly before moving on to the next two elements. Theproper completionof elementsone and twoprepare the athlete for themore specific and vigorous activities necessary for elements three andfour.

Recent studies have shown that static stretchingmay have an adverseaffectonmusclecontractionspeedandthereforeimpairperformanceinathletes involved in sports requiring high levels of power and speed(Crameretal,2005).Itisforthisreasonthatstaticstretchingisconductedearly in thewarm-up routine and is always followed by sport-specificdrillsanddynamicstretching.

Anexampleofstaticstretching.

3.Sport-specificWarm-upWith the first two parts of the warm-up carried out thoroughly andcorrectly,itisnowsafetomoveontothethirdpartofaneffectivewarm-up. In this part, the athlete is specifically preparing their body for thedemandsoftheirparticularsport.Duringthispartofthewarm-up,morevigorousactivityshouldbeemployed.Activitiesshouldreflectthetypeof movements and actions that will be required during the sportingevent.

4.DynamicStretchingFinally, a correct warm-up should finish with a series of dynamicstretches.Anoteofcaution:thisformofstretchingcarrieswithitahighrisk of injury if used incorrectly. Dynamic stretching is for muscularconditioning as well as flexibility and is really only suited for well-trained,highlyconditionedathletes.Dynamicstretchingshouldonlybeusedafterahighlevelofgeneralflexibilityhasbeenestablished.

Dynamic stretching involves a controlled, soft bounce or swingingmotion to move a particular body part to the limit of its range ofmovement.Theforceof thebounceorswingisgradually increasedbutshouldneverbecomeradicaloruncontrolled.

Duringthislastpartofaneffectivewarm-upitisalsoimportanttokeepthedynamicstretchesspecifictotheathlete’sparticularsport.Thisisthefinal part of the warm-up and should result in the athlete reaching aphysicalandmentalpeak.Atthispointtheathleteismostpreparedfortherigoursoftheirsportoractivity.

Anexampleofdynamicstretching.

Theaboveinformationformsthebasisofacompleteandeffectivewarm-up.However, the process described above is somewhat of an ideal orperfectwarm-up. This is not always possible or convenient in the realworld. In practice the individual athlete must be responsible forassessingtheirowngoalsandadjustingtheirwarm-upaccordingly.

For instance, the time committed to thewarm-up shouldbe relative tothelevelofinvolvementintheathlete’sparticularsport.Forpeopleonlylookingtoincreasetheirgenerallevelofhealthandfitness,awarm-upof5–10 minutes would be enough. However, if involved in high-levelcompetitive sport the athlete will need to dedicate adequate time andefforttoamoreextensiveandcompletewarm-up.

COOL-DOWN

Many people dismiss the cool-down as a waste of time. In reality thecool-downis justasimportantasthewarm-up,andifyouaretryingtostayinjuryfreeitisvital.

Although thewarm-up and cool-down are equally important, they areimportantfordifferentreasons.Whilethemainpurposeofwarming-upis to prepare the body andmind for strenuous activity, cooling-downplaysaverydifferentrole.

WhyCool-down?Themain aim of the cool-down is to promote recovery and return thebodytoapre-exerciseorpre-workoutstate.Duringastrenuousworkout,the body goes through a number of stressful processes; muscle fibers,tendonsandligamentsgetdamaged,andwasteproductsbuildup.Thecool-down,whenperformedproperly,will assist the body in its repairprocess,andonearea thecool-downwill specificallyhelpwith ispost-exercisemuscle soreness.Another common termused forpost-exercisemusclesorenessisdelayed-onsetmusclesorenessorDOMS.

This is the soreness that is usually experienced the day after a toughworkout.Mostpeopleexperiencethisafterhavingabreakfromexerciseoratthebeginningoftheirsportsseason.Anexamplewouldberunninga 10 km fun run or half marathon with very little preparation, andfinding it difficult to walk down steps the next day because thequadriceps muscles are sore. This discomfort is post-exercise musclesoreness.

Post-exercise muscle soreness is caused by a number of factors. First,during exercise, tiny tears calledmicrotears developwithin themusclefibers. Thesemicrotears cause swellingwhich in turnputspressure onthenerveendingsandresultsinpain.

Post-exercisemusclesoreness.

Second,whenexercising,theheartpumpslargeamountsofbloodtotheworkingmuscles. This blood carries the oxygen and nutrients that theworkingmusclesneed.Whenthebloodreachesthemusclestheoxygenand nutrients are used up and the force of the contracting (exercising)muscles pushes the blood back to the heartwhere it is re-oxygenated.However, when the exercise stops, so does the force that pushes the

blood back to the heart. This blood, aswell aswaste products such aslacticacid,staysinthemuscles,whichinturncausesswellingandpain.Thisprocessisoftenreferredtoasbloodpooling.

Thecool-downhelpskeep thebloodcirculating,which in turnhelps toprevent blood pooling and also removes waste products from themuscles.This circulatingbloodbringswith it theoxygenandnutrientsneededbythemuscles,tendonsandligamentsforrepair.

TheKeyPartsofanEffectiveCool-down

Now that the importanceof the cool-downhasbeen established, letushavealookatthestructureofaneffectivecool-down.Therearethreekeyelements,orparts,whichshouldbeincludedtoensureaneffectiveandcompletecool-down.Theyare:gentleexercise,stretchingandre-fuel.

Allthreeelementsareequallyimportantandanyonepartshouldnotbeneglectedorthoughtofasunnecessary.Theyworktogethertorepairandreplenishthebodyafterexercise.

To follow are two examples of effective cool-downs. The first is anexample of a typical cool-down that would be used by a professionalathlete. The second is typical of someone who simply exercises forgeneralhealth,fitnessandfun.

Cool-downRoutinesfortheProfessional• Startwith10–15minutesofeasyexercise.Besurethattheeasyexercise

resemblesthetypeofexercisethatwasdoneduringtheworkout.Forexample,iftheworkoutinvolvedalotofrunning,cool-downwitheasyjoggingorwalking.

• Include some deep breathing as part of the easy exercise to helpoxygenatethebody.

• Follow with 20–30 minutes of stretching. Static stretching andproprioceptiveneuromuscularfacilitation(PNF)stretchingarebestforthecool-down.

• Re-fuel.Bothfluidandfoodareimportant.Drinkplentyofwater,plusagood-qualitysportsdrink.Thebesttypeoffoodtoeatstraightafteraworkoutisthatwhichiseasilydigestible.Fruitisagoodexample.

Cool-downRoutinesfortheAmateur• Startwith3–5minutesof easyexercise.Be sure that theeasyexercise

resemblesthetypeofexercisethatwasdoneduringtheworkout.Forexample, if the workout involved swimming or cycling, cool-downwithafeweasylapsofthepooloraslowridearoundtheblock.

• Include some deep breathing as part of the easy exercise to helpoxygenatethebody.

• Follow with 5–10 minutes of stretching. Static stretching and PNFstretchingarebestforthecool-down.

• Re-fuel.Bothfluidandfoodareimportant.Drinkplentyofwater,plusagood-qualitysportsdrink.Thebesttypeoffoodtoeatstraightafteraworkoutisthatwhichiseasilydigestible.Fruitisagoodexample.

AnexampleofPNFstretching.

THEFITTPRINCIPLE

TheFITTprinciple(orformula)isagreatwayofmonitoringanexerciseprogram. The acronym outlines the essential elements of an effectiveexerciseprogramandtheinitialsstandfor:

F:Frequency I:Intensity T:Time T:Type

FrequencyFrequency refers to the frequency of exercise undertaken or how thenumber of times the athlete exercises per week. Frequency is a keycomponent of the FITT principle. Frequency needs to be adjusted toreflect:theathlete’scurrentfitnesslevel;thetimetheathleterealisticallyhasavailable(consideringothercommitmentslikefamilyandwork);and

thespecificgoalsthattheathletehassetforthemself.

IntensityIntensity refers to the intensityof exerciseundertakenorhowhard theathlete exercises. This is an extremely important aspect of the FITTprincipleandisprobablythehardestfactortomonitor.Thebestwaytogaugetheintensityofanyexerciseperformedistomonitorheartrate.

Thereareanumberofwaystomonitorheartratebutthebestwayistouseanexerciseheartratemonitor.Thesecanbepurchasedatmostsportsstoresandconsistofanelasticbeltthatfitsaroundthechestandawristwatchthatdisplaystheexerciseheartrateinbeatsperminute.

TimeTimereferstothetimespentexercisingorhowlongtheathleteexercisesfor. The time dedicated to exercise usually depends on the type ofexerciseundertaken.

Forexample,atleast20–30minutesofnon-stopexerciseisrecommendedtoimprovecardiovascularfitness.Forweightloss,moretimeisrequired– at least 40 minutes of moderate weightbearing exercise. However,when talking about what exercise is required for muscular strengthimprovement, this is often measured as a number of sets and reps(repetitions). A typical recommendation would be three sets of eightreps.

TypeTyperefers to the typeofexerciseundertakenorwhatkindofexercisethe athlete does. Like time, the type of exercise chosenwill have a bigeffectontheresultsachieved.

Forexample,ifimprovingcardiovascularfitnessisthegoal,exerciseslikewalking, jogging, swimming, bike riding, stair climbing, aerobics androwing are very effective. For weight loss, any exercise that uses themajority of our large muscle groups will be effective. To improvemuscular strength the best exercises include the use of free weights,machineweightsandbodyweightexerciseslikepush-ups,chin-upsanddips.

HowDoesAllThisRelatetoInjuryPrevention?The two biggest mistakes people make when designing an exerciseprogramaretotraintoohardandtonotincludeenoughvariety.

Theproblem,mostcommonly,isthatpeopletendtofindanexercisetheylikeandveryrarelydoanythingotherthanthatexercise.Thiscanresultinlong-term,repetitivestraintothesamemusclegroupsandneglect,orweakening, of other muscle groups. This will lead to an unbalancedmuscularsystem,whichisasure-firerecipeforinjury.

WhenusingtheFITTprinciple todesignanexerciseprogram,keepthefollowinginmind:

FrequencyAfterexercisethebodygoesthroughaprocessofrebuildingandrepair.Itisduringthisprocessthatthebenefitsofexerciseareforthcoming.

However,ifstrenuousexerciseisconductedonadailybasis(5–6timesaweek)thebodyneverhasachancetorealizethebenefitsandgainsfromtheexercise.Inthiscase,whatusuallyhappensisthattheathleteendsupgettingtiredorinjured,orjustquits.

To avoid this scenario, allow more rest and relaxation time, and cutdownthefrequencyofstrenuousexercisetoonly3–4timesaweek.

This may sound strange and a little hard to do at first, because mostpeople have been conditioned into believing that they have to exerciseeveryday,butafterawhileexercising like thisbecomesveryenjoyableandsomethingthatcanbelookedforwardto.

Exercising this way also dramatically reduces the likelihood of injurybecause the body has more time to repair and heal. Many elite levelathleteshaveseenbigimprovementsinperformancewhenforcedtotakeanextendedbreak.Mostneverrealizetheyaretrainingtoohardor toooften.

IntensityandTimeThe key here is variety. Do not get stuck in an exercise rut. Dedicatesome of the workouts to long, easy sessions like long walks or light,repetitiveweights.Othersessionscanbemadeupofshort,high-intensityexercisessuchasstairclimbingorintervaltraining.

TypeThetypeofexerciseundertakenisalsoveryimportant.Manypeoplegetintoaroutineofdoingthesameexerciseoverandoveragain.Ifloweringtheriskofinjuryisthegoal,doavarietyofdifferentexercises.Thiswillbenefitallthemajormusclegroupsandwillalsohelptomaketheathletemoreversatileandwell-rounded.

OVERTRAINING

There isabigdifferencebetweenbeing justa little tiredoronadown-cycleandbeinglegitimatelyrundownorovertrained.Itisimportanttobeabletotellthedifferencesoastoremaininjuryfree.Nothingwillput

a stop to improved sporting performancemore quickly than not beingable to recognize the signs of being legitimately run down andovertrained.

Oneofthebiggestchallengestoachievingfitnessgoalsisconsistency.Ifthe athlete is repeatedly getting sick, run down and overtrained itbecomesverydifficulttostayinjuryfree.Thefollowinginformationwillhelpathleteskeeptheconsistencyofregularexercise,withoutoverdoingitandbecomingsickorinjured.

Amateurandprofessionalathletesalikeareconstantlybattlingwiththeproblem of overtraining. Being able to juggle just the right amount oftrainingwithenoughsleepandrestandtherightnutritionisnotaneasyacttomaster.Throwinacareerandafamilyanditbecomesextremelydifficult.

WhatisOvertraining?Overtrainingistheresultofgivingthebodymoreworkorstressthanitcan handle. Overtraining occurswhen a person experiences stress andphysical trauma from exercise faster than their body can repair thedamage.

Thisdoesnothappenovernightorastheresultofoneortwoworkouts.In fact, regular exercise is extremely beneficial to general health andfitness, but the athlete must always remember that it is exercise thatbreaksthebodydown,whileitisrestandrecoverythatmakethebodystrongandhealthy.Improvementsonlyoccurduringthetimesofrest.

Stresscancomefromamultitudeofsources.Itisnotjustphysicalstressthat causes overtraining. Sure, excessive exercise coupled withinadequate restwill lead to overtraining, but do not forget to considerotherstressessuchasfamilyorworkcommitments.Remember:stressis

stress.Whetheritisaphysical,mentaloremotionalstress,itstillhasthesameeffectonthehealthandwellbeingofthebody.

ReadingtheSignsAt this point in time there are no tests that can be performed todeterminewhetheranathleteisovertrainedornot.Theathletecannotgotoalocaldoctororeventoasportsmedicinelaboratoryandaskforatestforovertraining.However,whiletherearenotestsforovertraining,thereare a number of signs and symptoms that need to bewatchedout for.These signs and symptoms will act as a warning bell giving advancenoticeofpossibledangerstocome.

Therearequiteanumberofsignsandsymptomstobeonthelookoutfor.To make them easier to recognize they are grouped below into eitherphysicalorpsychologicalsignsandsymptoms.

Sufferingfromoneortwoofthefollowingsignsorsymptomsdoesnotautomaticallymeananathleteissufferingfromovertraining.However,ifanumber(sayfiveorsix)arepresent,itmaybetimetotakeacloserlookatthevolumeandintensityofthecurrentworkload.

PhysicalSignsandSymptoms• Elevatedrestingpulse/heartrate• Frequentminorinfections• Increasedsusceptibilitytocoldsandinfluenza• Increasesinminorinjuries• Chronicmusclesorenessorjointpain• Exhaustion• Lethargy• Weightloss• Appetiteloss

• Insatiablethirstordehydration• Intolerancetoexercise• Decreasedperformance• Delayedrecoveryfromexercise

PsychologicalSignsandSymptoms• Tired,drainedorlackingenergy• Reducedabilitytoconcentrate• Apathyorlackofmotivation• Irritability• Anxiety• Depression• Headaches• Insomnia• Inabilitytorelax• Twitchy,fidgetyorjittery

Asseenbythenumberofsignsandsymptoms,thereisalottolookoutfor.Generallythemostcommonsignsandsymptomsofovertrainingarealossofmotivationinallareasoflife(workorcareer,healthandfitness,etc.)plusafeelingofexhaustion.Ifthesetwowarningsignsarepresent,plusacoupleoftheotherlistedsignsandsymptoms,thenitmaybetimetotakeashortrestbeforethingsgetoutofhand.

TheAnswertotheProblemLet us consider the following example. We feel run down and totallyexhausted.Wehavenomotivationtodoanything.Wecannotgetridofthat niggling knee injury.We are irritable, depressed and have totallylost our appetite. Sounds like we are overtrained, but what dowe donow?

Aswithmostthings,preventionisbetterthancure.Tofollowareafewmeasuresthatcanbetakentopreventovertraining.

• Onlymakesmallandgradual increasestoanexerciseprogramoveraperiodoftime.

• Eatawell-balanced,nutritiousdiet.• Besuretogetenoughrelaxationandsleep.• Be prepared to modify the training routine to suit environmental

conditions. For example, on a very hot day go to the pool instead ofrunningonthetrack.

• Monitorotherlifestressesandmakeadjustmentstosuit.• Avoidmonotonous training by varying exercise routines asmuch as

possible.• Donotexerciseduringanillness.• Beflexibleandhavesomefunwiththeexerciseundertaken.

While prevention should always be the aim, therewill be timeswhenovertrainingwilloccurandthefollowinginformationwillhelptogettheovertrainedathletebackontrack.

Thefirstpriorityistotakearest;anywherefrom3–5daysshoulddothetrick,dependingonhowseveretheovertrainingis.Duringthistimetheathleteneedstoforgetaboutexercise,andthebodyneedsaresttoo,sogiveitone–aphysicalrest,aswellasamentalrest.

Trytogetasmuchsleepandrelaxationaspossible.Gotobedearlyandcatch a napwheneverpossible. Increase the intake of highlynutritiousfoodsandtakeanextradoseofvitaminsandminerals.

Aftertheinitial3–5daysresttheathletecangraduallygetbackintothenormalexerciseroutine,butstartoffslowly.Mostresearchstatesthatitisfinetostartoffwiththesameintensityandtimeofexercisebutcutbackon the frequency.So if theathletewouldnormallyexercise3–4 timesa

week,cutthatbacktoonlytwiceaweekforthenextweekortwo.Afterthattheathleteshouldbesafetoresumethenormalexerciseregime.

Sometimes it isagood idea tohavea rest, like theoneoutlinedabove,whetherfeelingrundownornot.Itwillgiveboththemindandbodyachance to fully recover from any problems that may be building upwithout the athlete even knowing it. It will also freshen up themind,givearenewedmotivation,andhelptheathletelookforwardtoexerciseagain.Donotunderestimatethebenefitsofagoodrest.

FITNESSANDSKILLDEVELOPMENT

An individual’s physical fitness ismade up ofmany components. Themain ones are strength, power, speed, endurance, flexibility, balance,coordination, agility and skill. Although particular sports requiredifferentlevelsofeachfitnesscomponentitisessentialtoplanaregularexerciseortrainingprogramthatcoversallofthemaincomponents.

A common mistake made by athletes is to excessively focus on thecomponents thatareeasilyrecognizedwithin theirparticularsportandneglect the others. Although one component may be used more thananother, it is importanttoseeeachcomponentasonlyonespokeinthefitnesswheel.Animbalanceinonecomponentmaycontributetosportsinjury.

Forexample,footballreliesheavilyonstrengthandpower;however,theexclusionofskilldrillsandflexibilitytrainingmayleadtoseriousinjuryandpoorperformance.Strengthandflexibilityareofprimeconcerntoagymnast but a sound training program would also improve power,speedandendurance.

The same is true for each individual. While some people seem to benaturallystrongorflexible,itwouldbeveryunwiseforsuchapersontocompletelyignoretheothercomponentsofphysicalfitness.Thisiswhyathletes such as ironmen and triathletes are often referred to as beingtotally fit; their sportsdemand an evendistribution of the componentsthatmakeupphysicalfitness.

Definingtheappropriatebalanceisthekeytohealthandfitnesssuccessand staying injury free. This may require the assistance of a qualifiedprofessional trainer.Tohelpwith the implementationof an exercise ortrainingprogram,fourcommontrainingmethodsarediscussedindetailbelow. They are strength training, circuit training, cross training andplyometrictraining.

Fitness1:StrengthTrainingStrengthtraininghasbeenapartofsportsconditioningformanyyears.Itistoutedforitseffectsonspeed,strength,agilityandmusclemass.Oftenoverlookedthoughareitsbenefitsforinjuryprevention.

WhatisStrengthTraining?Strengthtrainingismovingthejointsthrougharangeofmotionagainstresistancerequiringthemusclestoexpendenergyandcontractforcefullytomovethebones.Strengthtrainingcanbedoneusingvarioustypesofresistance andwith orwithout equipment. Strength training is used tostrengthen the muscles, tendons, bones and ligaments and to increasemusclemass.

Strengthtrainingshouldbeimplementedintheconditioningprogramofallsports,notjuststrengthsports.Theincreaseinspeed,strength,agilityandmuscularendurancewillbenefitathletesofeverysport.

TypesofStrengthTrainingStrength training comes in a variety of formats. The formats aredescribedbythetypeofresistanceandequipmentused.

MachineWeightsMachinestrengthtrainingincludesresistanceexercisesdoneusinganyofthe various machines designed to produce resistance. These includemachineswithweight stacks, hydraulics, resistance rodsor bands, andeventheuseoftherabandorresistancetubing.

Theresistance,orweight,maybechangedtoincreasetheintensityoftheexercise.Therangeofmotionandpositionofmovementiscontrolledbythemachine.Theresistancemaybeconstant throughout themovementor may change due to the set-up of the pulley or hydraulic systems.Machines often add a degree of safety but neglect the stabilizer, orhelper,musclesinamovement.

FreeWeightsFreeweightstrengthtraininginvolvesusingweightsthatarenotfixedina movement pattern by a machine. These include barbells anddumbbells. Also included in this group are kettlebells, medicine balls,ankleandwristweightsandweightliftingchains.

Examplesofmachineweights.

Theweightused,aswiththemachines,maybechangedtoincreasetheresistance of an exercise. The resistance at different points along therange of motion transfers to different muscles and due to angles maylessen at times. At the limit of a joint’s range ofmotion theweight istransferredtothejointasthemusclessimplystabilizethejoint.

The range of motion and path of movement is not limited so thestabilizing muscles must work to keep the joints in line during themovement.Duetothefactthatthemovementisnotfixed,poorformcanbecomeanissue.

OwnBodyweightExercisesBodyweight exercises utilize the athlete’s bodyweight as resistanceduringtheexercise.Aswithfreeweights,therangeandpathofmotionisnotfixedbyamachine.Exercisessuchasplyometricjumping,push-ups,pull-ups,abdominalexercises,evensprintingandjumpingrope,fallintothiscategory.

Examplesoffreeweights.

Theweightusedintheseexercisesisconstantandonlychangeswhentheathlete’sbodychanges.Thechangesinresistanceduringthemovementaresimilartothoseoffreeweightexercises.

Therangeofmotionandpathofmovementdoesnotfollowafixedpathsostabilizingmusclescomeintoplay.Formisagainanissuewiththeseexercises. The inability to change the weight used does limit theeffectiveness for some athletes. Larger athletes will be limited in the

exercises they can perform and the number of repetitions. Smallerathleteswillquicklygobeyondthedesiredrepetitionrangeforstrengthbuilding.

HowDoesStrengthTrainingPreventInjury?Strengthtraininginathleticsiscommonpracticetoday.Thebenefitsareobvious and the immediate crossover of those benefits to the playingfieldmakesitidealforoff-seasonconditioning.Injurypreventionisonebenefitthatisoftenoverlooked.Strengthtrainingisaveryeffectivetoolforinjurypreventionforavarietyofreasons.

Examplesofownbodyweightexercises.

Strengthtrainingimprovesthestrengthofthemuscles,tendonsandeventheligamentsandbones.Thestrongermusclesandtendonshelptoholdthe body in proper alignment and protect the bones and joints whenmoving or under impact. The bones become stronger due to the loadplacedonthemduringtraining,andtheligamentsbecomemoreflexibleand better at absorbing the shock applied to them during dynamic

movements.

Whenanareaofthebodyisusedlessduringanactivityitmaybecomeweakerthantheotherareas.Thiscanbecomeaproblemwhenthatarea(whether amuscle, ligament, joint or specific bone) is called into play

suddenly. If the area cannot handle the sudden stress placed on it aninjurymay occur. Strength training, using a balancedprogramme,willeliminate theseweak areas and balance the body for the activities it iscalledontodo.

Muscle imbalances are one of the most common causes of injuries inathletics.Whenonemuscle,ormusclegroup,becomesstrongerthanitsopposinggroup,theweakermusclesbecomefatiguedquickerandmoresusceptible to injury.A forceful contraction nearmaximal output fromthe stronger muscle can also cause damage to the weaker opposingmuscleduetoitsinabilitytocountertheforce.

Muscleimbalancesalsoaffectthejointsandbonesduetoabnormalpullcausingthejointtomoveinanunnaturalpattern.Thestrongermuscleswill cause the joint topull in thatdirection, causinga stretchingof theopposing ligaments and a tightening of the supporting ones. This canleadtochronicpainandanunnaturalwearingofthebones.Abalancedstrength training program will help to counter these effects bystrengthening the weaker muscles to balance them with theircounterparts.

PrecautionsforStrengthTrainingStrengthtrainingisagreattoolforinjuryprevention.Becominginjuredduringstrengthtrainingobviouslydefeatsthispurpose.Toavoidinjuryitisessentialthatproperformbeusedinallexercises.Keepingthebodyinproperalignmentwhileexercisingwillminimizethechancesofinjury.

Starting with light weights or resistance and developing proper formbefore increasing the resistance is important. When increasing theresistanceitisimportanttodosoinsmallincrementsandonlywhenthedesirednumberofrepetitionscanbeperformedincorrectform.

Rest plays a crucial role in the efficiency and safety of a trainingprogram. Remember:muscles repair and become stronger during rest,not during theworkout. Performing strength training exercises for thesamemusclegroupswithoutadequaterestbetweentrainingsessionscanleadtoovertraining.Overtrainingwillresultinthemusclesbeingunabletorepairproperlyandnotbeingreadyforadditionalwork.Thiscanleadtoacuteorchronicinjuries.

Fitness2:CircuitTrainingCircuittrainingroutinesareafavoritetrainingsessionformanycoachesandathletes.Circuittrainingcanbeusedaspartofinjuryrehabilitationprograms, for conditioning elite level athletes, or to help with weightloss.Circuitscanbeusedforjustabouteverything.

Circuit training consists of a consecutive series of timed exercisesperformedoneaftertheotherwithvaryingamountsofrestbetweeneachexercise.

Forexample,asimplecircuittrainingroutinemightconsistofpush-ups,sit-ups,squats,chin-upsandlunges.Theroutinemightbestructuredasfollows,andcouldbecontinuallyrepeatedasmanytimesasisnecessary.

• Do as many push-ups as possible in 30 seconds, then rest for 30seconds.

• Doasmanysquatsaspossiblein30seconds,thenrestfor30seconds.• Doasmanysit-upsaspossiblein30seconds,thenrestfor30seconds.

• Doasmanylungesaspossiblein30seconds,thenrestfor30seconds.• Doasmanychin-upsaspossiblein30seconds,thenrestfor30seconds.

WhatMakesCircuitTrainingSoGood?Thequickpaceandconstantchangingnatureofcircuittrainingplacesaunique type of stress on the body,which differs from normal exerciseactivitiessuchasweighttrainingandaerobicexercise.

The demands of circuit training prepare the body in a very even, all-roundmanner.Circuit trainingisanexceptional formofexercisetoaidin thepreventionof injuryand isoneof thebestways tocondition theentirebodyandmind.

Therearemanyotherreasonswhycircuittrainingisafantasticformofexerciseandwhatmostof these reasonscomedown to is flexibility. Inother words, circuit training is totally adaptable to the specificrequirementsoftheindividual.

• Circuit trainingcanbe totallypersonalized.Whetherabeginneroraneliteathlete, circuit training routines canbemodified togive thebestpossibleresults.

• A circuit training routine can bemodified to give the athlete exactlywhattheywant.Whetherforanall-overbodyworkout,orjustworkingon a specific body area or aspect of the chosen sport, this can all beaccommodated.

• Itiseasytochangethefocusofthecircuittrainingroutinetoemphasizestrength, endurance, agility, speed, skill development,weight loss oranyotheraspectoffitnessthatisimportanttotheindividual.

• Circuittrainingistimeefficient.Withnowastedtimeinbetweensets,itgivesmaximumresultsinminimumtime.

• Circuit trainingcanbedone justaboutanywhere.Circuit trainingisafavoriteformofexerciseforBritishRoyalMarinescommandosbecause

theyspendalotoftimeonlargeships.Theconfinedspacemeansthatcircuit training is sometimes the only form of exercise available tothem.

• Noexpensiveequipmentisneeded–notevenagymmembership.Itisjustaseasytoputtogetheragreatcircuittrainingroutineathomeorina park. By using some imagination it is easy to devise all sorts ofexercises using things like chairs and tables, and even children’soutdoorplayequipmentlikeswingsandmonkeybars.

• Anotherreasonwhycircuittrainingissopopularisthatitisgreatfuntodo inpairsorgroups.Half thegroupperforms theexerciseswhiletheotherhalfrestsandmotivatestheexercisingmembersofthegroup.

TypesofCircuitTrainingAsmentioned before, circuit training can be totally customized,whichmeans there are an unlimited number of ways to structure a circuittrainingroutine.Hereareafewexamplesofthedifferenttypesavailable:

TimedCircuitThis type of circuit involvesworking to a set timeperiod for both restandexerciseintervals.Forexample,atypicaltimedcircuitmightinvolve30secondsofexerciseand30secondsofrestinbetweeneachexercise.

CompetitionCircuitThis issimilartoatimedcircuitbuteachindividualpushesthemself toseehowmanyrepetitionscanbedoneinasettimeperiod.(Forexample,complete12push-upsin30seconds.)Theideaistokeepthetimeperiodthesamebuttrytoincreasethenumberofrepetitionsachievedwithinit.

RepetitionCircuitThis typeof circuit isgreatwhenworkingwith largegroupsofpeople

whohavedifferentlevelsoffitnessandability.Theideaisthatthefittestgroupmightdo 20 repetitions of each exercise; the intermediate groupmight only do 15 repetitions; while the beginners might only do 10repetitionsofeachexercise.

Sport-specificorRunningCircuitThis type of circuit is best done outside or in a large, open area withexercises that are specific to the participants’ sport, or emphasize anaspect of the sport that needs improvement. Then instead of simplyrestingbetweenexercisesruneasyfor200–400metres.

SomeImportantPrecautionsCircuit training is a fantastic form of exercise. However, the mostcommonproblemisthatpeopletendtogetoverexcited,becauseofthetimed nature of the exercises, and push themselves harder than theynormallywould.This tends to result in soremusclesand jointsandanincreased likelihood of injury. Below are two precautions to take intoconsideration:

LevelofFitnessIf the athletehasneverdoneany sort of circuit trainingbefore, even ifthey are considered quite fit, start off slowly. The nature of circuittrainingisquitedifferenttoanyotherformofexercise.Itplacesdifferentdemandsonthebodyandmindand,iftheathleteisnotusedtoit,itwilltakeafewsessionsforthebodytoadapttothisnewformoftraining.

Warm-upandCool-downDonoteverstartacircuittrainingroutinewithoutathoroughwarm-up

thatincludesstretching.Asmentionedpreviously,circuittrainingisverydifferent fromother forms of exercise. The bodymust be prepared forcircuittrainingbeforestartingasession.

Fitness3:CrossTrainingCrosstraining,althoughithasbeenusedforyears,isrelativelynewasatrainingconcept.Athleteshavebeenforcedtouseexercisesoutsidetheirsport for conditioning for many reasons, including: weather, seasonalchange, facility and equipment availability, and injuries. These athleteswere cross trainingwhether they knew it or not. The benefits of crosstraining are beginning to get more press and one of those is injuryprevention.

WhatisCrossTraining?Cross training is the use of various activities to achieve overallconditioning.Crosstrainingusesactivitiesoutsidethenormaldrillsandexercises commonly associated with a sport. The exercises provide abreak from thenormal impact of training in aparticular sport, therebygiving themuscles, tendons, bones, joints and ligaments a brief break.These exercises target themuscles from a different angle or resistanceand work to balance an athlete. Cross training is an effective way ofresting the body from the usual sport-specific activities whilemaintainingconditioning.

Anyexerciseoractivitycanbeusedforcross training if it isnotaskillassociatedwiththatparticularsport.Weighttrainingisacommonlyusedcross training tool. Swimming, cycling, running and even skiing areactivitiesusedforcrosstraining.Plyometricsarebecomingpopularagainascrosstrainingtools.

CriticsofCrossTrainingCrosstrainingdoeshelpachievebalanceinthemusclesduetoworkingthemfromvariousanglesandindifferentpositions.Crosstrainingdoesnot, however, develop skills specific to the sport or sport-specificconditioning.A footballplayerwho jogs three to fivemilesall summerand liftsweightswill still not be in football shapewhen thepreseasonstarts.Crosstrainingcannotbeusedasthesoleconditioningtool.Sport-specificconditioningandskilltrainingisstillrequired.

High-impactsportssuchasbasketball,gymnastics,footballandrunningcausealotofjarringtotheskeletalsystem.Crosstrainingcanhelplimitthe jarring but some sport-specific impact is necessary to conditionathletes for their activity. A runner who runs in water as their onlyconditioning routinemaydevelop shin splints andother injurieswhentheyarerequiredtorunonhardsurfacesforracesortraining.Theirbodyis not conditioned to the forces it is subjected to and will reactaccordingly.

Jumpingintoanintensecrosstrainingschedulewithoutprogressingintoit properly can also lead to problems. It is important to progressivelyincreasetheintensity,durationandfrequencyinsmallincrements.

CrossTrainingExamplesCross training can take many forms. The key to a successful crosstrainingprogramisthatitmustaddressthesameenergysystemsusedinthesportandmustallowabreakfromsport-specificactivities.Trainingthe same major muscle groups in a different way keeps the athleteconditionedbuthelpspreventoveruseinjuries

• A cyclist may use swimming to build upper body strength and tomaintaincardiovascularendurance.Theymayusecross-countryskiingtomaintain legstrengthandendurancewhensnowand iceeliminate

bikingtime.• Swimmers may use free weight training to develop and maintain

strength levels. They may incorporate rock climbing to keep upperbodystrengthandenduranceup.

• Runners may use mountain biking to target the legs from a slightlydifferent approach. They can use deep water running to lessen theimpactwhilestillmaintainingaconditioningschedule.

• AshotputtermayuseOlympicweightliftingexercisestobuildoverallexplosiveness. They may use plyometrics and sprinting to developexplosivenessinthehipsandlegs.

HowDoesCrossTrainingPreventInjury?Cross training isan important tool in the injurypreventionprogramofathletes. Cross training allows coaches and athletes the opportunity totrain hard all year round without running the risk of overtraining oroveruse injuries. The simple process of changing the type of trainingchangesthestressonthebody.

Crosstraininggivesthemusclesusedintheprimarysportabreakfromthe normal stresses put on them each day. The muscles may still beworked, even intensely, but without the normal impact or from adifferent angle. This allows themuscles to recover from thewear andtear that builds up over a season. This active rest is a much betterrecovery tool than total rest and forces the body to adapt to differentstimuli.

Cross trainingalsohelps toreduceorreversemuscle imbalances in thebody.Apitcherinbaseballmaydevelopanimbalancelaterallybetweenthe two sides of the body as well as in the shoulder girdle of thethrowingarm.Thousandsofpitchesoveraseasonwillcausethemusclesdirectly involved in throwing to become stronger while supportingmusclesandthoseunaffectedbythrowingwillbecomeweakerwithout

training.Cross trainingcanhelpbalance thestrength in themusclesonbothsidesaswellas thestabilizingmuscles.Thisbalancingof strengthand flexibility helps to prevent one muscle group, due to a strengthimbalance, from pulling the body out of natural alignment. It alsoprevents muscle pulls and tears caused by one muscle exerting moreforcethantheopposinggroupcancounter.

PrecautionsforCrossTrainingWheneverstartinganewactivityitisimportanttogetinstructioninthepropertechniquesandsafetymeasures.Forexample,oceankayakingcanbe a great cross training activity for tennis players to develop andmaintain upper body endurance but without instruction on propertechniquesitcanbedangerous.

Equipment used for cross training activities should be fitted properlyanddesignedfor theactivity.Unsafeor ill-fittedequipmentcanleadtoinjury.

Crosstrainingisagreatwaytoavoidoveruseinjuriesandovertraining.Unfortunately, these same pitfalls can be an issue in a cross trainingprogramme.Varyingworkouts,adequaterestbetweenworkouts,useofproper form and gradual increasing resistance are important in anyprogramme. Many athletes simply add cross training to their currentprogrammerather than substituting.This leads toovertrainingand theoppositeoftheinjurypreventiongoal.

Examplesofplyometrictraining.

Fitness4:PlyometricTrainingThepreviousthreesectionslookedatthreeverygoodtrainingtechniquestohelpdevelopandconditionathleticability,whichinturnwillhelptopreventsportsinjury.Thissectionwillbuildonthelastthreetechniquesby discussing a slightly more advanced form of athletic conditioningcalledplyometrics.

WhatarePlyometricExercises?Inthesimplestofterms,plyometricsareexercisesthatinvolveajumpingmovement.Forexample,side-to-sidejumping,bounding,jumpingrope,punchbagpush,hopping,lunges,trunkcurlandthrow,jumpsquats,andclappush-upsareallexamplesofplyometricexercises.

However, for amoredetaileddefinition somebackground informationabout muscle contractions is needed. Muscles contract in one of threeways:

1.EccentricMuscleContractionAn eccentricmuscle contraction occurswhen themuscle contracts andlengthens at the same time. An example of an eccentric musclecontractionisloweringanobjectheldinthehanddowntoyourside.The

biceps brachii (upper arm) muscle contracts eccentrically to enablecontrolledloweringofthearm.

2.ConcentricMuscleContractionA concentricmuscle contraction occurswhen themuscle contracts andshortensatthesametime.Anexampleofaconcentricmusclecontractionisliftingthebodyupintoachin-upposition.Thebicepsbrachiimusclecontractsandshortensasthebodyisraiseduptothechin-upbar.

3.IsometricMuscleContractionAn isometricmuscle contraction occurswhen themuscle contracts butdoes not change in length. An example of an isometric musclecontraction is holding a heavy object in the handwith the elbow heldstationaryandbentat90degrees.Thebicepsbrachiimusclecontractsbutdoesnotchangeinlengthbecausethebodyisnotmovingupordown.

Gettingbacktotheformaldefinition,aplyometricexerciseisanexercisein which an eccentric muscle contraction is quickly followed by aconcentricmusclecontraction.Inotherwords,whenamuscleisrapidlycontracted and lengthened, then immediately followed with a furthercontractionandshortening,thisisaplyometricexercise.Thisprocessofcontract-lengthen, contract-shorten is often referred to as the stretch-shorteningcycle.

Hereisanotherexampleofaplyometricexercise.Considerthesimpleactof jumping off a step, landing on the groundwith both feet and thenjumpingforward,allinoneswiftmovement.

Whenjumpingoffthestepandlandingontheground,themusclesinthelegs contract eccentrically to slow the body down. When jumpingforward the muscles contract concentrically to spring off the ground.

Thisisaclassicexampleofaplyometricexercise.

WhyArePlyometricExercisesImportantforInjuryPrevention?Athletesoftenuseplyometrics todeveloppowerfor theirchosensport,andalothasbeenwrittenabouthowtoaccomplishthis.However,fewpeople realize how important plyometrics can be in aiding injuryprevention.

Essentially, plyometric exercises force the muscle to contract rapidlyfromafullstretchposition.Thisisthepositioninwhichmusclestendtobeattheirweakest.Byconditioningthemuscleatitsweakestpoint(fullstretch)itisbetterpreparedtohandlethistypeofstressinarealorgameenvironment.

WhyArePlyometricExercisesImportantforInjuryRehabilitation?Most injury rehabilitation programs fail to realize that an eccentricmuscle contraction can be up to three times more forceful than aconcentric muscle contraction. This is why plyometric exercises areimportantinthefinalstageofrehabilitation,toconditionthemusclestohandletheaddedstrainofeccentriccontractions.

Neglectingthisfinalstageoftherehabilitationprocesscanoftenleadtore-injury, because themuscles have not been conditioned to copewiththeaddedforceofeccentricmusclecontractions.

Caution,Caution,Caution!

PlyometricsareNOT for everyone.Plyometric exercisesarenot

for the amateur and theyarenot for theweekendwarrior.They

are an advanced form of athletic conditioning and can place a

massivestrainonunconditionedmuscles,jointsandbones.

Plyometric exercises should only be used by well-conditioned athletesand preferably under the supervision of a professional sports coach.When adding plyometric exercises to a regular training routine, pleasetakecarefulnoteofthefollowingprecautions.

• Children or teenagers who are still growing should not use intense,repetitiveplyometricexercises.

• Asolidbaseofmuscularstrengthandenduranceshouldbedevelopedbefore starting a plyometrics program. In fact Better-Body.comrecommends:“Itisagoodruleofthumbthatbeforewestartusinganyplyometricexercisesweshouldbeable to squatat least1.5 timesourownbodyweight,andthenfocusondevelopingcorestrength.”

• Athoroughwarm-upisessentialtoensuretheathleteisreadyfortheintensityofplyometricexercises.

• Donotperformplyometricexercisesonconcrete,asphaltorotherhardsurfaces.Grassisoneofthebestsurfacesforplyometricexercises.

• Techniqueisimportant.Assoonasformdeterioratesortheathletefeelstired,backoff.

• Do not overdo it. Plyometrics are very intense. Allow plenty of restbetweensessions,anddonotperformplyometricexercisestwodaysinarow.

STRETCHINGANDFLEXIBILITY

1:HowDoesStretchingPreventSportsInjury?

Stretchingisasimpleandeffectiveactivitythathelpstoenhanceathleticperformance, decrease the likelihood of injury and minimize musclesoreness.Buthowspecificallydoesstretchingpreventsportsinjury?

ImprovedRangeofMovement

http://Better-Body.com

Byplacingparticularpartsofthebodyincertainpositions,weareabletoincrease the length of our muscles. As a result of this, a reduction ingeneralmuscletensionisachievedandournormalrangeofmovementisincreased.

Byincreasingourrangeofmovementweareincreasingthedistanceourlimbscanmovebeforedamageoccurs to themusclesand tendons.Forexample, themusclesand tendons in thebackof the legareputundergreat strain when kicking a football. Therefore, the more flexible andpliablethosemusclesare,thefurtherthelegcantravelforwardbeforeastrainorinjuryoccurstothem.

The benefits of an extended range of movement include: increasedcomfort; a greater ability to move freely; and a lessening of oursusceptibilitytomuscleandtendonstraininjuries.

Improvedrangeofmovementwhenkickingafootball;a)limitedrangeofmovement,b)improvedrangeofmovementafterconditioning.

ReducedPost-exerciseMuscleSorenessWehaveallexperiencedwhathappenswhenwegoforarunor to thegymfor the first time ina fewmonths.The followingdayourmusclesaretight,soreandstiff,anditisusuallyhardtoevenwalkdownaflightof stairs. The soreness that usually accompanies strenuous physicalactivity is often referred to as post-exercise muscle soreness. Thissoreness is the result of microtears, (minute tears within the musclefibers), blood pooling and accumulated waste products such as lacticacid.Stretching,aspartofaneffectivecool-down,helpstoalleviatethissoreness by lengthening the individualmuscle fibers, increasing bloodcirculationandremovingwasteproducts.

ReducedFatigueFatigueisamajorproblemforeveryone,especiallythosewhoexercise.Itresultsinadecreaseinbothphysicalandmentalperformance.Increased

flexibility through stretching can help prevent the effects of fatigue bytakingpressureofftheworkingmuscle(theagonist).Foreverymuscleinthebodythereisanoppositeoropposingmuscle,(theantagonist).Iftheopposingmusclesaremoreflexible,theworkingmusclesdonothavetoexert as much force against the opposing muscles. Therefore eachmovementoftheworkingmusclesactuallytakeslesseffort.

AddedBenefitsAlongwith thebenefits listed above, a regular stretchingprogramwillalso help to improve posture, develop body awareness, improvecoordination, promote circulation, increase energy and improverelaxationandstressrelief.

2:TheRulesforSafeStretchingAswithmostactivitiestherearerulesandguidelinestoensurethattheyare safe. Stretching is no exception. Stretching can be extremelydangerousandharmfulifdoneincorrectly.Itisvitallyimportantthatthefollowing rules be adhered to, both for safety and formaximizing thepotentialbenefitsofstretching.

There is often confusion and concerns aboutwhich stretches are goodandwhichstretchesarebad.Inmostcasessomeonehastoldtheenquirerthattheyshouldnotdothisstretchorthatstretch,orthatthisisagoodstretchandthisisabadstretch.

Are there only good stretches and bad stretches? Is there no middleground?Andifthereareonlygoodandbadstretches,howdowedecidewhichonesaregoodandwhichonesarebad?Letusputanendtotheconfusiononceandforall…

ThereisNoSuchThingasaGoodorBadStretch!

Just as there are no good or bad exercises, there are no good or badstretches–onlywhat isappropriateforthespecificrequirementsoftheindividual.Soastretchthatisperfectlygoodforonepersonmaynotberightforsomeoneelse.

Letmeuse an example: a personwith a shoulder injurywouldnot beexpectedtodopush-upsorfreestyleswimming,butthatdoesnotmeanthat these are bad exercises. Now, consider the same scenario from astretching point of view. That same person should avoid shoulderstretches,butthatdoesnotmeanthatallshoulderstretchesarebad.

The stretch itself is neither good nor bad. It is the way the stretch isperformedandbywhomthatmakesstretchingeithereffectiveandsafeorineffectiveandharmful.Toplaceaparticularstretchintoacategoryofgoodorbad isunwise andpotentiallydangerous.To label a stretch asgoodgivespeopletheimpressionthattheycandothatstretchwheneverandhowevertheywantanditwillnotcausethemanyproblems.

TheSpecificRequirementsoftheIndividualareWhatisImportant!Remember,stretchesareneithergoodnorbad.However,whenchoosinga stretch there are a number of precautions and checks we need toperformbeforegivingthatstretchthego-ahead.

1.First,makeageneralreviewoftheindividual.Aretheyhealthyandphysicallyactive,orhavetheybeenleadingasedentarylifestyleforthe past five years? Are they a professional athlete? Are theyrecovering from a serious injury? Do they have aches, pains ormuscleandjointstiffnessinanyareaoftheirbody?

2. Second,make a specific review of the area ormuscle group to bestretched.Arethemuscleshealthy?Isthereanydamagetothejoints,ligamentsortendons?Hastheareabeeninjuredrecentlyorisitstillrecoveringfromaninjury?

If themuscle group being stretched is not 100 per cent healthy, avoidstretching this area altogether. Work on recovery and rehabilitationbefore moving on to specific stretching exercises. If however, theindividualishealthyandtheareatobestretchedisfreefrominjury,thenapplythefollowingtoallstretches.

Warm-upPriortoStretchingThis first rule is often overlooked and can lead to serious injury if notperformed effectively. Trying to stretch muscles that have not beenwarmedisliketryingtostretchold,dryrubberbands:theymaysnap.

Warming-upprior to stretchingdoes anumberof beneficial thingsbutprimarily its purpose is to prepare the body and mind for morestrenuous activity. One of the ways it achieves this is by helping toincrease the body’s core temperature while also increasing the body’smuscletemperature.Byincreasingmuscletemperaturewearehelpingtomake the muscles loose and supple. This is essential to ensure themaximumbenefitisgainedfromstretching.

Thecorrectwarm-upalsohastheeffectofincreasingbothheartrateandrespiratory rate. This increases blood flow,which in turn increases thedeliveryofoxygenandnutrients totheworkingmuscles.All thishelpstopreparethemusclesforstretching.

Acorrectwarm-upshould consistof lightphysical activity.The fitnesslevel of the participating athlete should govern both the intensity anddurationof thewarm-up, althougha correctwarm-up formostpeopleshouldtakeabouttenminutesandresultinalightsweat.

StretchBeforeandAfterExerciseThequestionoftenarises:“ShouldIstretchbeforeorafterexercise?”Thisisnotaneither/orsituationasbothareessential.Itisnogoodstretching

afterexerciseandcountingthatasthepre-exercisestretchfornexttime.Stretching after exercise has a totally different purpose to stretchingbeforeexercise.Thetwoarenotthesame.

The purpose of stretching before exercise is to help prevent injury.Stretchingdoes this by lengthening themuscles and tendons,which inturn increasesourrangeofmovement.Thisensures thatweareable tomovefreelywithoutrestrictionorinjuryoccurring.

However,stretchingafterexercisehasaverydifferentrole.Itspurposeisprimarily toaid in therepairandrecoveryof themusclesandtendons.By lengthening the muscles and tendons, stretching helps to preventtight muscles and delayed muscle soreness that usually accompaniesstrenuousexercise.

Afterexerciseourstretchingshouldbedoneaspartofacool-down.Thecool-downwillvarydependingonthedurationandintensityofexerciseundertaken, but will usually consist of 5–10 minutes of very lightphysical activity and be followed by 5–10 minutes of static stretchingexercises.

An effective cool-down involving light physical activity and stretchingwillhelptoridwasteproductsfromthemuscles,preventbloodpoolingandpromotethedeliveryofoxygenandnutrientstothemuscles.Allthisassists in returning the body to a pre-exercise level, thus aiding therecoveryprocess.

StretchAllMajorMusclesandTheirOpposingMuscleGroupsWhen stretching, it is vitally important thatwepayattention to all themajormuscle groups in the body. Just because a particular sportmayplacealotofemphasisonthelegs,forexample,doesnotmeanthatonecanneglectthemusclesoftheupperbodyinastretchingroutine.

Allthemusclesplayanimportantpartinanyphysicalactivity,notjustaselect few. Muscles in the upper body, for example, are extremelyimportantinanyrunningsport.Theyplayavitalroleinthestabilityandbalanceofthebodyduringtherunningmotion.Thereforeitisimportanttokeepthembothflexibleandsupple.

Everymuscleinthebodyhasanopposingmusclethatactsagainstit.Forexample, the muscles in the front of the thigh (the quadriceps) areopposedbythemusclesinthebackofthethigh(thehamstrings).Thesetwogroupsofmusclesprovidearesistancetoeachothertobalancethebody.Ifoneofthesegroupsofmusclesbecomesstrongerormoreflexiblethantheothergroup, it is likelyto leadto imbalancesthatcanresult ininjuryorposturalproblems.

For example, hamstring tears are a common injury in most runningsports.Theyareoftencausedbystrongquadricepsandweak,inflexiblehamstrings. This imbalance puts a great deal of pressure on thehamstringsandcanresultinamuscletearorstrain.

StretchGentlyandSlowlyStretchinggently and slowlyhelps to relax ourmuscles,which in turnmakesstretchingmorepleasurableandbeneficial.Thiswillalsohelptoavoid muscle tears and strains that can be caused by rapid, jerkymovements.

StretchONLYtothePointofTensionStretching isNOT an activity that ismeant to be painful; it should bepleasurable,relaxingandverybeneficial.Manypeoplebelievethattogetthemost from their stretching theyneed tobe in constantpain.This isone of the greatest mistakes we can make when stretching. Let meexplainwhy.

Whenthemusclesarestretchedtothepointofpain,thebodyemploysadefense mechanism called the stretch reflex. This is the body’s safetymeasure to prevent serious damage occurring to themuscles, tendonsand joints. The stretch reflex protects the muscles and tendons bycontractingthem,therebypreventingthemfrombeingstretched.

Thestretchreflexarc.

Sotoavoidthestretchreflex,avoidpain.Neverpushthestretchbeyondwhatiscomfortable.Onlystretchtothepointwheretensioncanbefeltinthemuscles.Thisway,injurywillbeavoidedandthemaximumbenefitsfromstretchingwillbeachieved.

BreatheSlowlyandEasilyWhileStretchingMany people unconsciously hold their breath while stretching. Thiscauses tension in ourmuscles,which in turnmakes it very difficult tostretch.Toavoidthis,remembertobreatheslowlyanddeeplyduringallstretchingexercises.Thishelpstorelaxourmuscles,promotesbloodflowandincreasesthedeliveryofoxygenandnutrientstoourmuscles.

AnExampleBy taking a look at one of the most controversial stretches everperformed, we can see how the above rules are applied. The stretchpicturedoppositecausesmanyapersontogointocompletemeltdown.It

hasareputationasadangerous,badstretchthatshouldbeavoidedatallcost.SowhyisitthatateveryOlympicGames,CommonwealthGamesand World Championships, sprinters can be seen doing this stretchbeforetheirevents?Letusapplytheabovecheckstofindout.

First, consider the person performing the stretch. Are they healthy, fitandphysicallyactive? Ifnot, this isnotastretch theyshouldbedoing.Aretheyelderly,overweightorunfit?Aretheyyoungandstillgrowing?Dothey leadasedentary lifestyle? If so, theyshouldavoid thisstretch!This first consideration alone would prohibit 50 per cent of thepopulationfromdoingthisstretch.

Second, review the area to be stretched.The stretch overleaf obviouslyputsalargestrainonthemusclesofthehamstringsandlowerback.Soifour hamstrings or lower back are not 100 per cent healthy, do notperformthisstretch.

Thissecondconsiderationwouldprobablyruleoutanother25percent,which means this stretch is only suitable for about 25 per cent of thepopulation: in other words the well-trained, physically fit, injury-freeathlete.

Apply the six precautions above and the well-trained, physically fit,injury-freeathletecanperformthisstretchsafelyandeffectively.

Remember, the stretch itself is neither good nor bad. It is theway thestretch is performed and by whom it is being performed that makesstretchingeithereffectiveandsafeorineffectiveandharmful.

3:HowtoStretchProperlyWhentoStretchStretchingisas importantastherestofanexerciseprogramme.Forthe

athleteinvolvedinanycompetitivetypeofsportorexerciseitiscrucialtomaketimeforspecificstretchingworkouts.Settimeasidetoworkonparticularareasthataretightorstiff.Themoreinvolvedandcommittedyouare toyour exercise and fitness, themore timeandeffort youwill

needtocommittostretching.

As discussed earlier it is important to stretch both before and afterexercise.Butwhenelseshouldyoustretchandwhattypeofstretchingisbestforaparticularpurpose?

Choosing the right typeof stretching for the rightpurposewillmakeabigdifferencetotheeffectivenessofyourflexibilityprogram.Tofollowaresomesuggestionsforwhentousethedifferenttypesofstretches.

For warming-up dynamic stretching is the most effective, while forcooling-down static, passive andPNF stretching is best. For improvingrange of movement try PNF and active isolated stretching, and forrehabilitationacombinationofPNF,isometricandactivestretchingwillgivethebestresults.

So when else should we stretch? Stretch periodically throughout theentireday. It isagreatwaytokeeplooseandtohelpeasethestressofeverydaylife.Oneofthemostproductivewaystoutilizeourtimeis tostretch while we are watching television. Start with five minutes ofmarchingorjoggingonthespotthentakeaseatonthefloorinfrontofthetelevisionandstartstretching.

Hold,Count,RepeatForhowlongshouldIholdeachstretch?HowoftenshouldIstretch?Forhow

longshouldIstretch?

These are the most commonly asked questions about stretching.Althoughthereareconflictingresponsestothesequestions,theanswers

given here are based on my study of research literature and personalexperienceand, Ibelieve, reflectwhat is currently themostcorrectandbeneficialinformation.

Thequestionthatcausesthemostdisagreementis:“ForhowlongshouldIhold each stretch?” Some sources state that as little as 10 seconds isenough.This isabareminimum.Tenseconds isonly justenough timefor the muscles to relax and start to lengthen. For any real benefit toflexibilityeachstretchshouldbeheldforatleast20–30seconds.

The time an individual commits to stretching will be relative to theirlevelofinvolvementinaparticularsport.Forpeoplelookingtoincreasetheirgenerallevelofhealthandfitnessaminimumofabout20secondswillbeenough.However,anathlete involved inhigh-levelcompetitivesportwillneed toholdeach stretch for at least 30 secondsand start toextendthatto60secondsandbeyond.

“HowoftenshouldIstretch?”Howoftenan individual commits to stretchingeachmusclegroupwillalso be relative to their level of involvement in a particular sport. Forexample, the beginner should stretch each muscle group 2–3 times.However, the athlete participating at an advanced level in their sportshouldstretcheachmusclegroup3–5times.

“ForhowlongshouldIstretch?”The same principle applies. For the beginner, about 5–10 minutes isenough,andfor theprofessionalathleteanythingup to twohours.Theindividual participating somewhere between the beginner and theprofessionalshouldadjustthetimetheyspendstretchingaccordingly.

Pleasedonotbeimpatientwithstretching.Nobodycangetfitinacoupleof weeks so do not expect miracles from a stretching routine. Somemuscle groups may need a minimum of three months of intense

stretchingtoseeanyrealimprovement.Stickwithit;itiswellworththeeffort.

SequenceWhenstartingastretchingprogramitisagoodideatostartwithgeneralstretchesfortheentirebodyinsteadofjustaselectfew.Theideaofthisistoreduceoverallmuscletensionandtoincreasethemobilityofthejointsandlimbs.

The next step should be to increase overall flexibility by starting toextend the muscles and tendons beyond their normal range ofmovement. Following this, work on specific areas that are tight orimportant for a particular sport. Remember, all this takes time. Thissequence of stretches may take up to three months to yield realimprovement, especially for individualswithnobackground inagility-basedactivitiesorwhoareheavilymuscled.

Nodataexistsonwhatorderstretchesshouldbecompletedin.However,it is recommended to start with sitting stretches, because there is lesschanceofinjurywhilesitting,beforemovingontostandingstretches.Tomakeiteasieryoumaywanttostartwiththeanklesandmoveuptotheneck or vice versa. It really does not matter as long as all the majormusclegroupsandtheiropposingmusclesarecovered.

Once you have advanced beyond improving overall flexibility and areworking on improving the range of movement of specific muscles, ormusclegroups,itisimportanttoisolatethosemusclesduringstretchingroutines.Todothis,concentrateononlyonemusclegroupatatime.Forexample, insteadof trying to stretchbothhamstringsat the same time,concentrateononlyoneatatime.Stretchingthiswaywillhelptoreducetheresistancefromothersupportingmusclegroups.

PosturePosture or alignment while stretching is one of the most neglectedaspectsofflexibilitytraining.Itisimportanttobeawareofhowcrucialitcan be to the overall benefits of stretching. Bad posture and incorrecttechniquecancauseimbalancesinthemuscleswhichcanleadtoinjury;properposturewill ensure that the targetedmuscle group receives thebestpossiblestretch.

Major muscle groups are made up of a number of different musclesworking together. If posture is sloppy or incorrect, stretching exercisescanputmorestrainononeparticularmuscleinthatmusclegroup,thuscausinganimbalancethatcouldleadtoinjury.

Thedifferencebetweengoodandbadposture.Notetheathleteontheleft,feetuprightandbackrelativelystraight.Theathleteontherightisatgreaterriskofcausingamuscularimbalancethatcouldleadtoinjury.

Forexample,whenstretchingthehamstrings(themusclesatthebackofthelegs)it is imperativetokeepbothfeetpointingup.Ifthefeetfalltoone side this will put undue stress on one particular part of thehamstrings,whichcouldresultinamuscleimbalance.

FACILITIES,RULESANDPROTECTIVEDEVICES

A number of less obvious prevention techniques are often overlookedbutareequallyimportantinhelpingtopreventsportsinjury.

PlayingAreasandFacilitiesTheseareas,designedspecificallyforsportandathleticactivity,areoftenasourceofunnecessarysportsinjuries.Broken,faultyorpoorlydesignedequipmentcanleadtoinjury,andplayingsurfacesthataredamagedorpoorlymaintainedputathletesatunnecessaryrisk.

Beforeparticipation,ensurethatplayingareasarefreefromobstructionand in good condition. Spectators should also be made aware of theimportanceofstayingwellbackfromplayingareas.

RulesSportingrulesarespecificallydesignedfortheprotectionofplayersandensureasafeplayingareaboth forparticipantsandspectators. It is theresponsibilityofcoachingstaff,playersandrefereestofullyunderstandandabidebyalltherulesoftheirparticularsport.

Emphasis should also be placed on good sportsmanship, fair play andthediscouragementofdangerousorviolentbehavior.

ProtectiveDevicesProtectivedevicesaredesignedtoaidperformanceandreduce injuries,withallsportsparticipationbenefitingfromtheuseofprotectivedevices.Even the sport of running is greatly enhanced with good supportivefootwearandswimmersbenefitfromprotectiveeyegoggles.

Other important protective devices include: mouth guards; individualplayer pads; helmets; shin guards; eye protection; wetsuits; goalpost

pads; andmatting for sports that require a cushioned landing such as

gymnastics.

CHAPTER3SportsInjuryTreatmentandRehabilitation

INTRODUCTIONTOSPORTSINJURYMANAGEMENT

Sports injurymanagement encompasses the entireprocessof treatingasports injury, right from the time the injuryoccurs through to the timethe injured player is fully recovered and 110 per cent stronger andhealthier than they were before the injury occurred. No, that is not atypo!Thegoalis110percentbecausesportsinjurymanagementshouldalways aim to rehabilitate the injured area to the point where it isstrongeraftertheinjurythanitwasbeforetheinjury.

Thetypesofsportsinjurythatthismanagementprocessisdesignedforare the soft tissue injuries,which are very common inmost, if not all,sports.Theseinjuriesincludesprains,strains,tearsandbruisesthataffectthemuscles,tendons,ligamentsandjoints–thesofttissuesofthebody.

Examples of common soft tissue injuries include hamstring tears,sprained ankles, pulled calf muscles, strained shoulder ligaments andcorkedthigh(bruisedquadriceps).Remember,asprainreferstoatearorruptureoftheligamentswhileastrainreferstoatearorruptureofthemusclesortendons.

Thetypesofsports injurythatthismanagementprocessdoesnotcoverare injuries that affect the head, neck, face or spinal cord; injuries thatinvolve shock, excessive bleeding, or bone fractures and breaks. The

treatment needed for these types of injury is beyond the scope of the

relatively simple soft tissue injuries that discussed here. Although thistypeofserioussportsinjuryisrare,immediatemedicalattentionmustbesought.

Softtissuesportsinjurymanagementinvolvesfourphases:

1.Firstaid:thefirstthreeminutes2.Treatment:thenextthreedays3.Rehabilitation:thenextthreeweeks4.Conditioning:thenextthreemonths

1.FirstAid:TheFirstThreeMinutesThefirstthreeminutesafteraninjuryoccursarecrucial.Thisisthetimewhenan initial assessmentof the injury ismadeandappropriate stepsare taken tominimize trauma andprevent further damage. This is thefirstprioritywhentreatinganysportsinjury.

Before treating any injury, whether to yourself or someone else, firstSTOPand takeaccountofwhathasoccurred.Ask thequestions: Is theareasafefromotherdangers?Isthereathreattolife?Istheinjuryseriousenoughtoseekemergencyhelp?

Then,usingthewordSTOP,asanacronym:

Stop:Stoptheinjuredathletefrommoving.Considerstoppingthe

sportorgameifnecessary.

Talk: Ask questions like:What happened?How did it happen?

Whatdiditfeellike?Wheredoesithurt?Haveyouinjuredthis

areabefore?

Observe: Look for signs like swelling, bruising, deformity and

tenderness.

Prevent:Preventfurtherinjury.

Next,makeanassessmentoftheseverityoftheinjury.

Is it a mild injury? Is it a bump or bruise that does not impair theathlete’s physical performance? If so, play on. Provide a fewwords ofencouragementandmonitortheinjury.ApplythetreatmentproceduresdescribedinChapters4–17justtobeonthesafeside.

Isitamoderateinjury?Isitasprain,strainorseverebruisethatimpairstheathlete’sabilitytoplayon?Ifso,gettheplayeroffthefieldandapplythetreatmentproceduresdescribedinChapters4–17assoonaspossible.

Isitasevereinjury?Doestheinjuryaffectthehead,neckorface?Istherea possibility of spinal cord damage? Does it involve shock, excessivebleeding,orbone fracturesandbreaks?The treatmentof these typesofinjuryrequiresmuchmorethansimplesofttissueinjurytreatment.Seekprofessionalhelpimmediately.

Onceafewmomentshavebeentakentomakesuretheinjuryisnotlifethreatening,itistimetostarttreatingtheinjury.Thesoonertreatmentisstarted, themore chance the injured athlete has of a full and completerecovery.

2.Treatment:TheNextThreeDaysWithout a doubt, the most effective initial treatment for soft tissueinjuries is theRICER regimen.This involves theapplicationof (R)rest,(I) ice, (C) compression, (E) elevation and obtaining a (R) referral forappropriatemedicaltreatment.

Where the RICER regimen has been used immediately after theoccurrence of an injury, it has been shown to significantly reduce

recovery time. RICER is the first and perhapsmost important stage ofinjury rehabilitation, providing a basis for the complete recovery ofinjury.

Whenasofttissueinjuryoccursthereisinflammationaroundtheinjurysite. Inflammation causes swelling thatputspressureonnerveendingsandresults in increasedpain. It isexactly thisprocessof inflammation,swellingandpainthattheRICERregimenwillhelptoalleviate.Thiswillalsolimittissuedamageandaidthehealingprocess.

RestIt is important that the injured area be kept as still as possible. Ifnecessary,supporttheinjuredareawithaslingorbrace.Thiswillhelptoslowbloodflowtotheinjuredareaandpreventanyfurtherdamage.

IceThisisbyfarthemostimportantpart.Theapplicationoficewillhavethegreatest effect on reducing inflammation, bleeding, swelling and pain.Applyiceassoonaspossibleaftertheinjuryhasoccurred.

How do you apply ice? Crushed ice in a plastic bag is usually best.However,blocksof ice,commercialcoldpacksandbagsof frozenpeaswillalldofine.Evencoldwaterfromatapisbetterthannothingatall.

Whenusing ice,be carefulnot toapply itdirectly to the skin.This cancause ice burns and further skindamage.Wrapping the ice in a damptowelgenerallyprovidesthebestprotectionfortheskin.

How long for and how often? There is much debate about this. Thefollowing are figures should beused as a roughguide, and then someadvice from personal experience will be offered. The most commonrecommendationistoapplyicefor20minutesevery2hoursforthefirst

48–72hours.

Thesefiguresareagoodstartingpoint,butrememberthattheyareonlya guide. A number of precautions must be taken into account. Somepeople are more sensitive to cold than others. Children and elderlypeople have a lower tolerance to ice and cold, and people withcirculatoryproblemsarealsomoresensitivetoice.

Thesafestrecommendationisthatpeopleusetheirownjudgementwhenapplyingicetotheinjuredarea.Forsomepeople,20minuteswillbewaytoolong.Others,especiallywell-conditionedathletes,canleaveiceonforalotlonger.

The individualshouldmakethedecisionas tohowlongthe iceshouldstay on. People should apply ice for as long as it is comfortable.Obviously,therewillbeaslightdiscomfortfromthecold,butassoonaspainorexcessivediscomfortisexperienceditistimetoremovetheice.Itismuchbetter to apply ice for 3–5minutes a coupleof timesperhourthannotatall.

CompressionCompression actually achieves two things. First, it helps to reducebleeding and swelling around the injured area; second, it providessupportfortheinjuredarea.Simplyuseawide,firm,elasticcompressionbandage to cover the injured part. Bandage both above and below theinjuredarea.

ElevationRaise the injured area above the level of the heart whenever possible.Thiswillfurtherhelptoreducethebleedingandswelling.

Referral

If the injury is severe enough, it is important that the injured athleteconsultaprofessionalphysical therapistoraqualifiedsportsdoctorforan accurate diagnosis of the injury. With an accurate diagnosis, theathletecan thenmoveon toaspecific rehabilitationprogramto furtherreduceinjurytime.

AWordofWarning!Beforemovingon,thereareafewthingsthatmustbeavoidedduringthefirst48–72hoursafteraninjury.Besuretoavoidanyformofheatattheinjury site. This includes heat lamps, heat creams, spas, Jacuzzis andsaunas.Avoidallmovementandmassageoftheinjuredarea.Alsoavoidexcessive alcohol. All these things will increase the bleeding, swellingandpainofyourinjury.Avoidthematallcosts.

3.Rehabilitation:TheNextThreeWeeksWhenamuscleistornordamageditwouldbereasonabletoexpectthebodytorepairthatdamagewithnewmuscle,orwithnewligamentifaligament is damaged, and so on. In reality, this does not happen. Thetear,ordamage,isrepairedwithscartissue.

When theRICERregimen isused immediatelyaftera soft tissue injuryoccurs, it will limit the formation of scar tissue. However, some scartissuewillstillbepresent.

Thismightnotsoundlikeabigdeal,butanyonewhohaseversufferedasoft tissue injurywillknowhowannoying it is tokeep re-injuring thatsame old injury, over and over again.Untreated scar tissue is amajorcauseofre-injury,usuallymonthsafteryouthoughtthatinjuryhadfullyhealed.

Scar tissue ismade from an inflexible, fibrousmaterial called collagen.

Thisfibrousmaterialbindsitselftodamagedsofttissuefibersinanefforttodrawthedamagedfibersbacktogether.Whatresultsisabulkymassof fibrous scar tissue completely surrounding the injury site. In somecasesitisevenpossibletoseeandfeelthisbulkymassundertheskin.

Whenscartissueformsaroundaninjurysite,itisneverasstrongasthetissue it replaces. It also has a tendency to contract and deform thesurroundingtissues,sonotonlyisthestrengthofthetissuediminishedbutflexibilityofthetissueisalsocompromised.

Sowhatdoesthismeanfortheathlete?First,itmeansashorteningofthesofttissuesresultinginalossofflexibility.Second,itmeansaweakspothas formedwithin the soft tissueswhich could easily result in furtherdamageorre-injury.

Theformationofscar tissuewill result ina lossofstrengthandpower.For a muscle to attain full power it must be fully stretched beforecontraction. Both the shortening effect and weakening of the tissuesmeansthatafullstretchandoptimumcontractionisnolongerpossible.

GettingRidofScarTissueTospeeduptherecoveryprocessandremoveorre-aligntheunwantedscartissue,twovitaltreatmentsneedtobeinitiated.

The first is commonlyusedbyphysical therapists (orphysiotherapists)andprimarily involves increasing theblood supply to the injuredarea.The aim is to increase the amount of oxygen and nutrients to thedamaged tissues. Physical therapists accomplish by using a number ofactivitiestostimulatetheinjuredarea.Themostcommonmethodsusedareultrasound,TENSandheat.

Ultrasound uses high-frequency soundwaves to stimulate the affectedarea.TENS(orTranscutaneousElectricalNerveStimulation)usesalight

electricalpulsetogivepainreliefandincreasebloodflow.Whileheatintheformofaraylamporhotwaterbottleisveryeffectiveinstimulatingbloodflowtothedamagedtissues.

Thesecondtreatmentusedtoreduceunwantedscartissueisdeeptissuesportsmassage.While ultrasound and heat will help the injured area,theywillnotreducescartissue.Onlymassagewilldothat.

Eitherfindsomeonewhocanmassagetheaffectedareaor,iftheinjuryisaccessible,massagethedamagedtissuesyourself.Doingthisyourselfhasthe advantage of knowing just how hard and how deep you need tomassage.

Tostartwith,theareawillbequitetender.Startwithalightstrokeandgradually increase the pressure until deep, firm strokes can be used.Massage in thedirectionof themuscle fibers and concentrate themosteffort at thedirectpointof injury.Use the thumbs toget inasdeepaspossibletobreakdownthescartissue.

Recommended for improved soft tissue recovery is a remedy calledArnica.Arnica isextremelyeffective in treatingsoft tissue injuriessuchassprains,strainsandtears. It isavailable inavarietyofformssuchasmassagegelsandlotions.

Besuretodrinkplentyoffluidduringtheinjuryrehabilitationprocess.The extra fluid will help to flush the waste products of injury andinflammationfromthebody.

ActiveRehabilitationAspartoftherehabilitationphasetheinjuredathletewillberequiredtodo exercises and activities that will help to speed up the recoveryprocess. Somepeople refer to thisphaseof the recoveryprocess as theactive rehabilitation phase because during this phase the athlete is

responsiblefortherehabilitationprocess.

The aim of this phase of the recovery is to regain all the fitnesscomponents that were lost during the injury process. Regainingflexibility, strength, power, muscular endurance, balance andcoordinationistheprimaryfocus.

Without this phase of the rehabilitation process there is no hope ofcompletely and permanentlymaking a full recovery from your injury.Dornan and Dunn in Sporting Injuries (1988) emphasize the value ofactiverehabilitation:

“Theinjurysymptomswillpermanentlydisappearonlyafterthe

patient has undergone a very specific exercise program,

deliberately designed to stretch and strengthen and regain all

parameters of fitness of the damaged structure or structures.

Further,itissuggestedthatwhenaspecificstretchingprogramis

followed,thusmorepermanentlyreorganizingthescarfibersand

allowingthecirculationtobecomenormal,thepainfulsymptoms

willdisappearpermanently.”(Ibid,42-3)

Thefirstpointtomakeclearishowimportantitistokeepactive.Oftentheadvicefromdoctorsandsimilarmedicalpersonnelwillbesimplytorest. This can be one of the worst things an injured athlete can do.Withoutsomeformofactivitytheinjuredareawillnotreceivethebloodflowitrequiresforrecovery.Anactivecirculationwillprovideboththeoxygenandnutrientsneededfortheinjurytoheal.

Anyformofgentleactivitynotonlypromotesbloodcirculationbutalsoactivatesthelymphaticsystem.Thelymphaticsystemisvitalinclearingthe body of toxins and waste products that accumulate in the tissuesfollowing a serious injury. Activity is the only way to activate the

lymphaticsystem.DornanandDunnalsosupportthisapproach:

“One does not need to wait for full anatomical healing before

starting to retrain the muscle. The retraining can be started,

graduallyatfirst,duringthehealingperiod.Thissameprinciple

appliesalsotoligamentousandtendoninjuries.”(Ibid,39)

AWordofWarning!Never do any activity that hurts the injured area or causes pain. Ofcoursesomediscomfortmaybeexperienced,butneverpushtheinjuredarea to the point where pain is felt. The recovery process is a longjourney.Donottakeastepbackwardsbyoverexertingtheinjuredarea.Beverycarefulwithanyactivity.Painisawarningsign:donotignoreit.

REGAININGTHEFITNESSCOMPONENTS

Nowisthetimetoworkonregainingthefitnesscomponentsthatwerelostasaresultof the injury.Themainareasthatneedtobeworkedonarerangeofmotion,flexibility,strengthandcoordination.Dependingonthebackgroundoftheathletetheseelementsshouldbethefirstpriority.As the athlete starts to regain rangeofmotion, strength, flexibility andcoordination they can then start towork on themore specific areas oftheirchosensport.

RangeofMotionRegainingafullrangeofmotionisthefirstpriorityinthisphaseoftherehabilitationprocess.Afullrangeofmotionisextremelyimportantasitlays the foundation formore intense and challenging exercises later in

theactiverehabilitationprocess.

Whileworkingthroughtheinitialstagesofrecoverytheinjurywillbeginto heal and the athlete should start to introduce some very gentle,movement-based exercises. First bending and straightening the injuredarea, then as this becomes more comfortable, starting to incorporaterotation exercises. Turn the injured area from side to side, and rotateclockwiseandanti-clockwise.DornanandDunnemphasize:

“Itisimportantthatgentlestretchingexercisesbeinitiatedearly

if normal flexibility is to be regained. For example, by actively

stretching bruises of the thigh to their fullest pain-free extent,

adhesion formationwas limitedand the thighmuscleswereable

toreturntothepre-injuryrangeofmotion.”(Ibid,39)

When these rangeofmotionexercisescanbeperformedrelativelypainfree, it is time tomoveon to thenextphaseof theactive rehabilitationprocess.

StretchandStrengthenAt this point increased intensity is added to the range of motionexercises.Theaimhereistograduallyre-introducesomeflexibilityandstrengthintotheinjuredstructures.

While attempting to increase the flexibility and strength of an injuredarea,besuretoapproachitinagradual,systematicwayoflightlyover-loadingthe injuredarea.Becarefulnot toover-dothis typeof training.Patienceisrequired.

The use of machine weights can be very effective for improving thestrengthofaninjuredareaastheyprovideacertainamountofstabilityto the joints and muscles as the athlete performs the rehabilitation

exercises.

Another effective and relatively safe way to start is to begin withisometric exercises. These are exercisewhere the injured area does notmove, yet force is applied and the muscles of the injured area arecontracted.

For example: imagine sitting in a chair while facing a wall and thenplacing the ball of your foot against thewall. In this position you canpush against thewall with your foot and at the same time keep yourankle joint frommoving.Themuscles contract but the ankle jointdoesnotmove.Thisisanisometricexercise.

It is also important during the active rehabilitation stage to introducesomegentle stretchingexercises.Thesewillhelp to further increase therangeofmotionandpreparetheinjuredareaformorestrenuousactivity.

Examplesofbalanceandproprioceptionexercises.

Remember,whileworkingonincreasingtheflexibilityofaninjuredareaitisimportanttoincreasetheflexibilityofthemusclegroupsaroundit.In the example above, these would include the calf muscles and themusclesoftheshin.

BalanceandProprioceptionImpairedbalanceandproprioception(thesenseofmovementandwherethebodyisinspace)commonlyoccuraftersofttissueinjury.Thisaspectof the rehabilitationprocess isoftenoverlookedand isoneof themainreasonswhyoldinjuriesreoccur.

Withsofttissueinjurythereisalwaysacertainamountofdamagetothenerve endings and pathways around the injured area. With lessproprioceptive information, the brain has less information about thepositionofthejointsandlimbsaroundtheinjuredareaandthemusclesare lessable toworkeffectively.The resultsofa lossofproprioceptionincludereducedbalance,coordination, strengthandstability.Local softtissuesaremorevulnerabletostrainsandsprains,eventoareoccurrenceofthesameinjurylongafteritwasthoughttohavecompletelyhealed.

Whenimprovedflexibilityandstrengthhasreturnedtotheinjuredareait is time to incorporate some balancing drills and exercises. Balancingexercisesare important tohelpre-train thedamagednervesaroundtheinjuredarea.Startwithsimplebalancingexercisessuchaswalkingalongastraightline,orbalancingonabeam.Progresstoone-legexercisessuchas balancing on one foot. Then try the same exercises with your eyesclosed.

Addsomemoreexplosiveexercisestoaidrecovery.

When comfortable with the above activities, try some of the more

advanced exercises like wobble or rocker boards, Swiss balls, stability

cushionsandfoamrollers.

FinalPreparationThis last part of the rehabilitation process will aim to return theindividual to a pre-injury state. By the end of this process the injuredarea should be as strong, if not stronger, than itwas before the injuryoccurred.

This is the time to incorporate somedynamic or explosive exercises toreallystrengthenupthe injuredareaand improveproprioception.Startbyworkingthroughalltheexercisesdoneduringthepreviousstagesofrecovery,butwithmoreintensity.

For example, if you were using light isometric exercises to helpstrengthen the Achilles tendon and calf muscles, start to apply moreforce,orstarttousesomeweightedexercises.

Next,gradually incorporatesomemore intenseexercises.Exercises thatrelatespecifically to theathlete’schosensportareagoodplace tostart.Activitieslikeskilldrillsandtrainingexercisesareagreatwaytogaugethefitnesslevelandstrengthoftheinjuredarea.

To put the finishing touches to the recovery, incorporate simpleplyometric drills. Plyometric exercises are explosive exercises that bothlengthen and contract a muscle at the same time. These are calledeccentric muscle contractions and are used in activities like jumping,hopping,skippingandbounding.

Theseactivitiesarequiteintense,soremembertoalwaysstartoffslowlyand gradually applymore andmore force.Do not get too excited andover-doitaspatienceandcommonsensearerequired.

4.Conditioning:TheNextThreeMonthsWhere the above treatment procedures have been diligently applied,most soft tissue injuries will have completely healed. However, eventhoughtheinitialinjurymayhavehealedandtheathleteisabletoreturnto normal activities, it is important to continue further strength andconditioningexercisestopreventarepeatoftheinitialinjury.

Thegoalofthenextthreemonthsistoidentifytheunderlyingcausesorreasons why the injury occurred in the first place. Once identified,employconditioningexercisesortrainingaidsthatwillhelptopreventareoccurrenceoftheinitialinjury.

Toaccomplish thisphase effectively it is important tounderstandwhysports injuries happen. Broadly speaking there are threemain reasonswhy sports injuries occur. The first is accident, the second is overloadandthethirdisbiomechanicalerror.

AccidentAccidents include things like stepping into a pothole and spraining anankle, tripping over and falling onto the shoulder or elbow, or beingstruck by sporting equipment.While there is little that can be done topreventsomeaccidentsitisimportanttoreduceriskasmuchaspossible.AlittlecommonsenseanddiligentlyemployingsomeofthepreventiontechniquesdescribedinChapter2willhelptominimize injuriescausedbyaccidents.

OverloadOverloadiscommoninsportandoccurswhenthestructureswithinthebody become fatigued and overworked. The structures then lose theirability to adequately perform their required task, which results inexcessivestrain(oroverload)onotherpartsofthebody.

For example, when the tensor fasciae lataemuscle and iliotibial band,located in the thigh, become fatigued and overloaded, they lose theirabilitytoadequatelystabilizetheentireleg.Thisinturnplacesstressontheknee joint,which results inpain anddamage to the structures thatmakeupthekneejoint.

Mostoverloadsymptomscanbequicklyreversedwithadequaterestandrelaxation.However,thereareanumberofthingsthatwillcontributetooverloadandshouldbeavoided.Theyinclude:

• Exercisingonhardsurfaceslikeconcrete• Exercisingonunevenground• Beginninganexerciseprogramafteralonglay-offperiod• Increasingexerciseintensityordurationtooquickly• Exercisinginwornoutorill-fittingshoes• Excessiveuphillordownhillrunning

BiomechanicalErrorBiomechanical errors are commonly responsible for many chronicinjuries and occur when the structures within the body are notfunctioningastheyshould.

Acommonbiomechanicalerror ismuscle imbalance.This iswhereonemuscle,orgroupofmuscles, iseitherstrongerormore flexible than itsopposingmuscles.Thiscanoccurontheleftandrightsidesofthebodyorthefrontandbackofthebody.

For example, a right-handed baseball pitcher will commonly haveoverdeveloped shoulder and arm muscles on the right hand sidecomparedwith their lefthandside.This can contribute toapullingontherightofthespineandresultinchronicpainintheshoulders,neckorback.

Another common example of muscle imbalance relates to hamstringstrain.Thiscanoccurwhenthemusclesofthequadriceps(thighmuscles)arestrongandpowerfulwhilethehamstringmuscles(locatedatthebackofthethigh)areweakandinflexible.

Otherbiomechanicalerrorsinclude:

• Leglengthdifferences• Tightorstiffmuscles• Footstructureproblemssuchasflatfeet• Gaitorrunning-styleproblemssuchaspronationorsupination

Once theunderlyingcauseor reasonwhy the injuryoccurredhasbeenidentified,aconditioningprogramortrainingaidcanbeusedtocorrectthe problem. This may involve strength or flexibility exercises in theeventofweakortightmuscles.Itmayinvolveorthoticsorshoeinsertsinthe case of pronation, supination or leg length difference. Or it mayinvolve the modification of the athlete’s current training program topreventoverload.

CHAPTER4SportsInjuriesoftheSkin

ANATOMYANDPHYSIOLOGY

Theskinisthelargestorganofthebody.Ithasmanyfunctions.Itsmainroleistoprovidethebodywithaprotectiveoutercovering.Theskinhasthreemainlayers:epidermis,dermisandsubcutaneouslayer.

Theepidermisistheoutercoveringoftheskinanditismadeupofmanylayersofcells.Thethicknessoftheselayersvaries,dependingonwhereitisonthebody,rangingfromthethickestparts,whicharetobefoundonthepalmsofthehandsandthesolesofthefeettothethinnestoneyelidsand lips. This layer has no blood vessels or nerve endings, but it isextremelysensitivetotouch.

Cellrenewaltakesplaceintheepidermis.Livingcellsareformedinthebasallayerandmaketheirwaythroughthelayersoftheepidermisandfinally reach the corneal layer.While going through these layers, cellsslowly die – their nuclei break down and they lose their fluid – and

instead they fill with keratin. The outermost cells are constantly beingwornawayandreplacedbythenewcellsgrowingupfrombelow.Thisisa continuous process. It takes the skin approximately 28 days tocompletelyrenewitself.

Thedermis is the thickest layer and is foundbeneath the epidermis. Itsupportsandnourishestheepidermis.Itismadeupofdenseconnectivetissue, which is tough, highly elastic and flexible. The tissue is highlysensitive and fibrous. The dermis also contains: collagen fibers, elastinfibers,bloodvessels,lymphvessels,nervesupply,sensorynerves,motornerves, hair follicles, sweat glands, sebaceous glands and erector pilimuscles.

Thesubcutaneouslayerisfoundbelowthedermisanditsfunctionistoproduceandstorefat.Itconsistsoftwolayers,adiposetissueandareolartissue.Itisthickerinwomenthaninmen.Asfatisapoorconductorofheat, this layerhelps toreduceheat loss throughtheskinandsokeepsthebodywarm.Italsoprotectsthenervesandbloodvessels.

001:CUTS,ABRASIONS,CHAFING

Skincuts,abrasionsandchafingarecommonafflictionsamongabroadvarietyofathletes.Such injuries involvesuperficialdamageto theskin.Theskinisbrokeninthecaseofcutsandsometimesinabrasions,whilechafingisgenerallyasurfacephenomenon.Whilecutsareoftencausedby impact to the skin, chafing and abrasions are forms of superficialinflammatorydermatitis.Frictiontoskinleadstoincreasedmoistureandmaceration. This causes a separation of keratin from the granularsublayer in the epidermis, sometimes resulting in an inflamed, oozinglesion.Generally,cuts,chafingandabrasionstotheskindonotpenetratebelowtheepidermis,unlikeexcoriationoftheskin,whichaffectsdeeperlayers. Cuts and abrasions can however cause bleeding, depending ontheseverityofinjury.Deepabrasionscanalsoproducescarring.

CauseofInjuryFriction fromathletic equipment, includingpadding and footwear. Fallonto a hard surface. Collision with another athlete. Friction of skinagainstclothing,combinedwithsweatandothermoisture.

SignsandSymptomsRedness,painandirritation.Itchingorburningsensation.Bleeding.

ComplicationsifLeftUnattendedSkininjuriesthatarenotproperlytreatedcanleadtopotentiallyseriousinfections. Cuts, abrasions and chafing combined with moisture fromsweat produce an ideal medium for bacteria and viruses. Infection is

furtherencouragedwhenathleticequipmentobstructstheskin.

ImmediateTreatmentCleantheaffectedareawithsoapandwater,anddrythoroughly.Applyatopicalsteroidasneeded.Bandageopenwounds.

RehabilitationandPreventionCuts often result from sudden accidents such as falls and are notpreventable.Wearingproperlyfittingclothingandfootwearanddryingareaspronetosweatwithtalcumoralumpowderscanminimizechafingandabrasions.Mostchafing,cutsandabrasionsoftheskinhealnaturallywithminimalcareandattention,providinginfectionisavoided.

Long-termPrognosisInmore severe cases, performancemay be detrimentally affected. Fullrecoveryfollowinghealingoftheskinisexpectedinmostcases.

002:SUNBURN

Ultraviolet (UV) radiation from the sun can cause damage to the skin,typically sunburn which can range from mild to severe. All athletesengagedinoutdoorsportsarevulnerabletosunburn,particularlythoseperformingathigheraltitudeswhereatmosphericprotectionagainstUVrays ismore limited. Skiers andmountaineers arehenceatgreater riskfromsunburnthanathletesclosertosealevel.Inthebasalregionoftheskin’s epidermis are dentritic cells known asmelanocytes. Exposure tosunlight causes activity in these cells and the release of melanin, apigment responsible for skin coloration. While gradual or less severeexposure produces tanning, excessive exposure causes damage tomelanocytes, sometimes leading to a cancer of the skin known asmelanoma.

CauseofInjuryExcessiveexposuretosunlight.Failuretocoverexposedskin.Failuretoapplysunscreenduringextendedexposure.

SignsandSymptomsRedness,painandinseverecasesblisteringoftheskin.Skinishottothetouch.

ComplicationsifLeftUnattendedThemostseriouscomplicationduetosunburnismelanoma,apotentiallyfatal cancer of the skin. Less severe complications involve damage to

bloodvessels,prematureagingoftheskinandlossofskinelasticity.

ImmediateTreatmentGetoutofthesunassoonaspossible.Coolbathsasneededandtopicalmoisturizers,includingaloevera.

RehabilitationandPreventionSunburnisusuallytreatedwithoutprofessionalattention,providingitisnotsevere.Moisturizermaybeappliedtohelppreventover-drynessandpeeling of the skin, but the skin should not be covered with suchproducts in the early phase of the injury while the body attempts toradiateheat.PreventsunburnwithSlip,Slop,Slap!Sliponashirt,Sloponsomesunscreen,andSlaponahat.

Long-termPrognosisMost sunburn heals in a matter of days, though damaged layers mayblisterandpeelaway,withfreshskinreplacingthedeadlayers.Thisnewskin is particularly vulnerable to damage from the sun, and exposureshouldbeavoided.Repeatedoverexposuretothesunincreasestheriskofskincancerormelanoma.

003:FROSTBITE

Athletes engaged in outdoor activities in cold weather are at risk offrostbite, an injury caused by a freezing of body tissue, resulting indamage to the skin and subcutaneous layers. Skiers andmountaineersare particularly prone to frostbite,which tends to affect exposed areassuchasthenoseandears,aswellasthebody’sextremities.Anyathleteimproperly protected against severe or prolonged exposure to lowtemperatureisvulnerable.

Frostbitereferstotheclinicalconditioninwhichwatermoleculeswithinhuman tissue freeze and crystallize, causing cellular and tissue death.Earlystagesof frostbitearecausedby ice formation in theextracellulartissue,causingdamagetocellmembranesandeventuallycellandtissuedeath. Further freezing causes a shift in intracellular water to theextracellularspaceleadingtodehydrationandfurther,oftenirreversibledamage.

CauseofInjuryProlonged exposure to the cold. Tissue getting wet and then freezing.Impededbloodflowincoldweather.

SignsandSymptomsSkin iswhite.Numbnessor tingling,often in thehandsandfeet.Looseandblackenedskin.

ComplicationsifLeftUnattendedSevere frostbite causes permanent damage to tissue andmay result ingangrene,insomecasesrequiringamputation.

ImmediateTreatmentImmerse frozen areas in warm water or apply warm compresses.Analgesicsforpain.

RehabilitationandPreventionThawingofseriousfrostbitemustbedonecarefully.Avoidrubbingtheaffectedarea.Ifblisteringhasoccurred,theareashouldbewrappedinasterilebandage.Donot thawareasatriskofrefreezingasmoreserioustissuedamagemayresult.Frostbiteispreventedbyavoidingprolongedexposuretothecoldandactivitiesatextremelylowtemperatures.

Long-termPrognosisMild tomoderate frostbitemay leave theathleteatsome increasedriskfor future cold sensitivity and re-injury. Severe frostbite can causeirreversible damage requiring amputation, though such injuries areusually restricted to those engaged in high-altitude sports, particularlymountaineering.

004:ATHLETE’SFOOT(TINEAPEDIS)

Athlete’s foot is causedbya fungal infectionof the footproducedbyaclassofparasitesof the skinknownasdermatophytes.Theaffliction iscommon among athletes and thrives in moist conditions produced bysweat.Theailmentcausesared,itchyrash-likeconditiononthefeetandmay be spread to others. The most common form of the condition isknownaschronicinterdigitalathlete’sfoot.

Thesitemostcommonlyaffectedisbetweenthespacesofthefourthandfifthtoeswhereitcausesirritation,maceration,fissuresandscalingoftheouterlayerofskin.Infectioncanspreadtothedorsalandplantarsurfacesofthefootandintothenails,whereitstartsasayellowingofthedistalmarginand/oralongtheedgeofanail.Thefungiresponsibleareplantorganisms(tineapedis),andbacteriamayproducesecondaryinfectionswhichworsensthesymptoms.

CauseofInjuryExcessive sweating. Contagious transmission. Failure to wash and

properlydrythefeet.

SignsandSymptomsReddened,crackedandpeelingskin.Itching,burning,stingingsensation.Badodour.

ComplicationsifLeftUnattendedWithoutpropercare,athlete’sfootcanworsen,deepeningthefissuresintheskin,spreadingacrossthefootsurface,affectingthesolesandtoenailsand occasionally spreading to the palms of the hands as well. Theburninganditchingsensationincreasesalongwithodour,andtheriskofspreadingtheinfectiontoothersincreases.

ImmediateTreatmentWashandthoroughlydrythefeet.Applytopicalantifungalmedication.

RehabilitationandPreventionAthlete’s foot is a common occurrence, affecting 70 per cent of thepopulation at various times. Generally, it responds well withminimalcare–washingthefeetoftenandseeingthat theyarethoroughlydriedand,wheneverpossible,keptdryduring theday. If thenail is infectedthe condition can be difficult to treat, requiring aggressive care.Chronicallyaffectedtoenailsmayneedtoberemovedbyapodiatrist.

Long-termPrognosisMost cases of athlete’s foot are resolved with proper hygiene andapplicationof anti-fungalmedication.More severe casesmay require along-termregimenoforalmedicationandnail removal to fully resolve

theissue.

005:BLISTERS

Blistersareacommoninjury inmanysportswheretheskinencountersfriction, either from footwear (during running events, skating, skiing,etc.)orsportingapparatus,forexample,ingymnastics,baseballorracketevents.Small,fluid-filledbubblesorvesiclesformontheskininresponsetofriction.Generally,thefluidisclearbutoccasionallybleedingintotheblistercausesredorbluediscoloration.

Blisters occur when there is a separation of the epidermis from thedermal layer of skin or a separation within the multiple layers of theepidermisitself.Serum,lymph,bloodorextracellularfluidfillsthespacebetween layers. Thin, translucentwalls are formed and the area swellsandmaybecomesensitiveorpainful.

CauseofInjuryFriction to feet fromrunningsports.Friction to fingersandpalms fromgolf clubs, tennis rackets, etc. Friction to hands from acrobatics andgymnasticsactivities.

SignsandSymptomsRaised,translucentbubblesofskinintheareaofwear.Pain,stingingandsensitivity at the site of injury. Leakage of fluid should the blister bedisturbed.

ComplicationsifLeftUnattendedIf athletic activities are continuedwithout attention to the blisters theymay become torn, resulting in further irritation to the skin and pain.Improperly treated blisters also run the risk of infection as the openwoundisapointofentryforbacteriaandothergerms.

ImmediateTreatmentWash the blister(s) gently with soap and warm water. If needed,carefullydrainfluid.Coverwithsterilebandage.

RehabilitationandPreventionBlistersgenerallyhealwithminimalcareandproperattention,providingno infectionhasoccurred.Properly fitting socksand footwear canhelpavoid blisters among runners.Other athletesmay chalk their hands tolessen blister-causing friction, particularly in the case of gymnasts.Properattentiontoathletictechniquemayalsohelpminimizeblisters.

Long-termPrognosisBlisters heal in a few days to a week, providing there is no seriousinfection. Until they have healed however, blisters can sometimesinterferewithperformanceduetopainanddiscomfort.

006:CORNS,CALLUSES,PLANTARWARTS(VERRUCAE)

Cornsandcallusesarebothcausedbyfrictionandpressure–inathletesthisisoftenduetopressurefromshoesorweightbearing.Plantarwarts(verrucae)resultfromthehumanpapillomavirus(HPV).

Acorn isahorny thickeningof thestratumcorneumof the skinof thetoes.Acallusisalocalizedthickeningofthehornylayeroftheepidermisduetophysicaltrauma.

Callusesoftenoccuronweightbearingareasoftheplantarsurface(sole)of the foot, andmay result fromabnormal alignment of themetatarsalbones in the ball of the foot. Corns and calluses may have a deepercentralcore,ornucleation,whichtendstobeextremely tender,andarecharacterized by a gradual thickening and toughening of the skin,eventuallyleadingtoirritation.

WartsaretheresultofaninfectionbythehighlycontagiousHPV.Wartsareepidermallesionswithahornysurface.Theyoccuronmanypartsofthebody,includingthesolesofthefeet,wheretheyareknownasplantarwartsorverrucae.

CauseofInjuryRepeated friction. Weightbearing. Contagious transmission (plantarwarts).

SignsandSymptomsThickened skinwhere prominent bones press against the shoe (corns).Tough or thickened skin on the soles of the feet (calluses). Raised,disfigured areas of skin on the ball, heel and bottom of the big toe(plantarwarts).

ComplicationsifLeftUnattendedIn the caseof corns and calluses the conditionmayworsen, eventuallycausingpainrequiringmedicalattention.Wartscanspreadtootherbodyareasaswellastoothers.

ImmediateTreatmentInthecaseofcornsandcalluses,alleviatethesourceofpressureonthefoot. Inthecaseofplantarwarts,applyanti-viralmedicationandcoverthearea.

RehabilitationandPreventionCorns and calluses are injuries directly related to pressure on the footandare resolvedbyaddressing the sourceofpressure,whetherdue tofootwear or weightbearing. Corns and calluses respond well totreatment,whilewartshaveatendencytorecur.Properathleticfootwearand attention to technique can help prevent corns and calluses whileverrucaemaybepreventedwithattention tohygieneandavoidanceofenvironmentspronetotheHPV.

Long-termPrognosisCornsandcallusesareusuallyaminorinconveniencetotheathleteandclearupthoroughlyoncetheirsourcehasbeenaddressed.Whentheyarea source of pain or continuing discomfort, they may be addressedthroughcryotherapy,excision,lasersurgeryorothermethods.

CHAPTER5SportsInjuriesoftheHeadandNeck

THEHEAD

The cranium (Greek: kranion) is made up of eight large flat bonescomprising two pairs plus four single bones. These form a box-likecontainerthathousesthebrain.Thesebonesare:

Frontal: which forms the forehead, the bony projections under theeyebrowsandthesuperiorpartoftheorbitofeacheye.

Parietal:apairofbonesthatformmostofthesuperiorandlateralwallsofthecranium.Theymeetinthemidlineatthesagittalsuture,andmeetwiththefrontalboneatthecoronalsuture.

Temporal:apairofbonesthatlieinferiortotheparietalbones.Therearethreeimportantmarkingsonthetemporalbone:(a)thestyloidprocess,asharp,needle-likeprojectiontowhichmanyof theneckmusclesattach;(b) the zygomatic process, a thin bridge of bone that joins with thezygomaticbonejustabovethemandible;(c)themastoidprocess,aroughprojection posterior and inferior to the styloid process (just behind thelobeoftheear).

Occipital:themostposteriorboneofthecranium.Itformsthefloorandback wall of the skull, and joins the parietal bones anteriorly at thelambdoidsuture.Inthebaseoftheoccipitalboneisalargeopening,theforamenmagnum,throughwhichthespinalcordpassestoconnectwith

thebrain.Toeachsideoftheforamenmagnumaretheoccipitalcondyles

whichrestonthefirstvertebraofthespinalcolumn(theatlas).

Sphenoid:abutterfly-shapedbonethatspansthewidthoftheskullandformspartofthefloorofthecranialcavity.Partsofthesphenoidcanbeseenformingpartoftheeyeorbitsandthelateralpartoftheskull.

Ethmoid: a single bone in front of the sphenoid bone and below thefrontal bone. Forms part of nasal septum and superior and medialconchae.

TheFacialBonesFourteenbonescomposetheface,twelveofwhicharepaired.Themainbonesofthefaceare:

Nasal:apairofsmallrectangularbonesthatformthebridgeofthenose(thelowerpartofthenoseismadeupofcartilage).

Zygomatic: a pair of bones commonlyknownas the cheekbones. Theyalsoformalargeportionofthelateralwallsoftheeyeorbits.

Maxillae:thetwomaxillarybonesfusetoformtheupperjaw.Theupperteethareembeddedinthemaxillae.

Mandible:thelowerjawboneisthestrongestboneintheface.Itjoinsthetemporalbonesoneachsideoftheface,formingtheonlyfreelymovablejointsintheskull.Thehorizontalpartofthemandible,orthebody,formsthe chin. Two upright bars of bone, or rami, extend from the body toconnect the mandible with the temporal bone. The lower teeth areembeddedinthemandible.

a)Theskull,anteriorview,andb)lateralview.

TeethTeeth are hard, calcified structures set in the alveolar processes of themandibleandmaxilla.Eachtoothconsistsofacrown,aneckandaroot.

The solidpart includesdentin,which formsmostof the tooth; enamel,whichcoversthecrown;andcementumcoveringtheroot.Inthecentreisthesoftpulpcontainingarteries,veins,andlymphaticandnervetissue.

EyesThe eyes, among the body’smost delicate structures, are protected bydesign from injury. The eyeball is a large sphere, and is recessed in asocketsurroundedbyastrong,bonyridge,withthesegmentofasmallersphere,thecornea,infront.Theeyelidscanclosequickly,protectingtheeyeball from foreign objects. Furthermore, the eye is designed towithstandsomeimpactwithoutseriousdamage.

EarsTheearistheorganresponsibleforhearing,alsoplayingacriticalroleinbalance(equilibrium).Injurytotheearcanaffecteitherorbothofthese

senses. The outer ear consists of the outer cartilage (pinna) and theauditory canal. Themiddle ear consists of the tympanicmembrane (oreardrum);theauditoryossiclesorbonesoftheear;themiddleearcavityandtheEustachiantube.

NoseThenose iscomprisedofboneandcartilage.Thenasal septumisofteninjured in sports. It consists of the vomer, a perpendicular plate of theethmoid,andthequadrangularcartilage.Apairofprotrusionsfromthefrontal bones and the ascending processes of themaxilla complete thebonycomponent,whiletheupperlateralandlowerlateralcartilages,aswellasthecartilaginousseptum,makeupthenon-bonyportion.

THENECK

Thecervicalspine(neck)ismadeupofsevenvertebrae,whichbeginatthebaseoftheskull(C1)andangledownwardslightlyastheyreachthechest region and connectwith the thoracic vertebrae.Muscles runningfromtheribcageandclavicle(collarbone)tothecervicalvertebrae, jawand skull appear on the front or anterior cervical area. The posteriorcervicalmusclescoverthebonesalongthebackofthespineandmakeupthebulkofthetissuesonthebackoftheneck.

Thebrachialplexus is a collectionof nerves supplying theupper limb.They exit the cervical vertebrae, extending to peripheral structuresincludingmuscles and the skin (transmittingmotor and sensory nerveimpulses).Cervicalnerverootswithinthebrachialplexussendfiberstotheshoulder,thearmandforearm,theelbow,wrist,handandfingers.

Between the cervical vertebrae, intervertebral discs absorb shock,facilitate movement and provide support for the spinal column. SuchdiscsconsistofacentralregionornucleuspulposusandasurroundingannulusfibrosisseparatingeachsegmentalvertebrabetweenfromC2toT1 (the first thoracicvertebra). (Only ligamentsand joint capsules existbetweenC1andC2).

Theheadandneck,lateralview.

Theneckmuscles,lateralview.

Theneckmuscles,anteriorview.

Most anterior neck muscles flex the cervical spine, bringing the headdownward. When standing or sitting, gravity assists and the heavyweight of the head helps. This can cause weakness in the antagonistmuscles,theextensors,ifitbecomeshabitual.Thestrongpullofthelargesternocleidomastoid muscle, along with small deeper muscles (longuscolli,longuscapitisandrectuscapitisanterior)canpulltheheaddownaswellassupportit.

Theextensorsonthebackoftheneckmustconcentricallycontracttoliftthehead. Straightening theupper spine iswork formanymuscles: thesplenii, scalenes, upper erector spinae, semispinalis, deep posteriormusclesandobliquuscapitis,eventhetrapezius.Thesemusclesalsodoeither lateral flexion (alongwith the levator scapula) or rotation of theneck, so they are easy to strengthen because of themany actions theyperform.

007:HEADCONCUSSION,CONTUSION,HAEMORRHAGE,FRACTURE

Traumas to the head are amongst the most serious injuries facing anathlete.Among these are: concussion, involving sudden acceleration ofthe head; contusion or bruising of the brain tissue; haemorrhage orbleeding inside the skull, and fracture or breaking of the bones of theskull.Athletesengagedincontactsportssuchasboxing,football,rugby,lacrosseandhockeyarethemostvulnerabletosuchinjuries.

If the force is sufficient, bones of the skull can fracture, sometimesimpingingonbraintissue.Bleedingorhaemorrhageinsidetheskullcanoccur(withorwithoutfracture).Ifabloodvessellyingbetweentheskulland the brain ruptures it may form a clot or haematoma, which maypress on the underlying brain tissue.A clot forming between the skulland the brain’s protective covering or dura mater is known as anepiduralhaematomawhileaclotbelowtheduraisknownasasubduralhaematoma. Haemorrhage in deeper layers may cause a contusion orbruisingtothebraintissue.

CauseofInjuryForcefulcollisionwithanotherathleteduringcontactsports.Seriousfallwithimpacttothehead.Traumafromblowinboxing.

SignsandSymptomsLossofconsciousness.Confusionandmemoryloss.Shock.

ComplicationsifLeftUnattendedHead injuries require immediate medical attention. Failure to seekprompt,professionalcarecanresultinpermanentbraindamageand,inmoreseverecases,fatality.

ImmediateTreatmentImmobilize patient (with head and shoulders raised) in a quiet place.Staunchtheflowofbloodifnecessaryandseekimmediatemedicalcare.

RehabilitationandPreventionRehabilitationfromheadinjuriesvarieswidelydependingonthenatureandextent.Evenmildconcussionsresultinapost-concussionsyndromein many patients, which can persist for six months to a year. Moreserious injuries can cause a broad array of permanent symptoms.Helmets or other appropriate headgear in sports where the skull isvulnerablehelppreventsuchinjuries.

Long-termPrognosisPrognosis for a head injurymay not be fully known formonths or, insomecases,years.Inthecaseofamildinjury,theprognosisisgenerallygood,thoughsymptomsincludingheadache,dizzinessandamnesiamaypersist. Blood clots, haemorrhaging and fractures of the skull oftenrequiresurgery.

008:NECKSTRAIN,FRACTURE,CONTUSION

Injuries to theneckcanbeserious,particularly in thecaseofbrokenorfracturedvertebrae.Neckstrainsarelessseriousandfarmorecommon,andinvolveinjurytothemusclesortendonsoftheneck.Contusionsarebruisestotheskinandunderlyingtissueoftheneck,usuallytheresultofadirectblow.

CauseofInjurySuddentwistingoftheneck.Seriousfall.Directblowtotheneck,inthecaseofcontusion.

SignsandSymptomsHead,neckandshoulderpain.Cracklingsensation in theneck.Lossofneckstrengthandmobility.

ComplicationsifLeftUnattendedInjuries to theneckarepotentiallyseriousanddeservepromptmedicalattention. Long-term paralysis, loss of motion and coordination,calcification and osteoporosis are possible side-effects. In the case offracture,theinjurycanleadtoparaplegiaandisalsosometimesfatal.

ImmediateTreatmentImmobilizationtoprotectthespinalcord.Analgesicsforpain.

RehabilitationandPreventionForneckstrains,immobilizationforaperiodofweekswithabracemaybe recommended. In cases of fracture, the broken vertebrae may besurgicallypinnedtogetherwithscrewsandthepatientmaybeplacedina neck cast. Physical therapy following healing will attempt to re-establish range of motion, flexibility and strength. Helmets or otherathletic headgear as well as attention to proper technique can helppreventsomeneckinjuries.

Long-termPrognosisOutcomes for neck injury vary widely depending on the nature andseverity. In cases of fracture, the prognosis is generally worse withinjuriesoccurringhigherupthecervicalspine.

Neckstrainsandcontusionsarefarlessseriousandtheiroutcomegivenproper treatment and rehabilitation is usually good. Severe strains inwhich the muscle–tendon–bone attachment is ruptured may requiresurgicalrepair.

009:CERVICALNERVESTRETCHSYNDROME

Cervical nerve stretch syndrome, also referred to as burner syndrome,results from the stretching (or compression) of the brachial plexus, acomplex of nerves in the lower neck and shoulder area. The injury iscommon in contact sports including hockey, football, wrestling andrugby. Sports injuries to the brachial plexus are characterized by aburning sensation that radiates down an upper extremity. Symptomsmaylastanywherefromtwominutestotwoweeks.

CauseofInjuryBlow to the head or shoulder, especially in a football tackle. Ear-to-shoulderbendingwithrotation(causingcompressionofcervicalnerves).Hyperextensionoftheneck.

SignsandSymptomsSevere,burningpain,radiatingfromthenecktothearmand/orfingers.Paraesthesia or numbness, tingling, pricking, burning or creeping

sensationoftheskin.Muscleweakness.

ComplicationsifLeftUnattendedBurning and stinging symptomswill persist andoftenworsen. Furtherdamage to peripheral nerves can result should the injury be ignored.Symptomsmayalsoindicatespinalcordinjury,withpotentiallyseriouscomplications.

ImmediateTreatmentIceand immobilize theneck region.Anti-inflammatorymedicationandanalgesicsforpain.

RehabilitationandPreventionRehabilitation for cervical nerve stretch syndrome usually entailsphysical therapy. Following a healing phase, therapy seeks to improvecervical range of motion and to strengthen cervical muscles, withparticularattentiontothemusclessupportingtheinjuredbrachialplexusnerve. Proper protective gear, appropriate technique and upper-extremitystrengthtrainingcanhelppreventtheinjury.

Long-termPrognosisPrognosisfortheinjuryisgenerallygood,thoughsomeathletesdevelopachronicformoftheconditionandahighrateofre-injuryhasalsobeennoted. In rare cases,nerve injury requiresmicrosurgery to repairnervedamage.

010:WHIPLASH(NECKSTRAIN)

Whiplashinjuryoccurswhenthereissuddenflexionand/orextensionoftheneck,usuallywhentheathleteisstruckfrombehindduringcontactsports,andtheheadisrapidlythrownbothforwardandbackward.Softtissues of the neck including intervertebral discs, ligaments, cervicalmusclesandnerverootsmaybe injured,producingneckpain, stiffnessandlossofmobility.

The hips, back and trunk are the first body segments and joints toexperience movement during a whiplash. Forward motion in thesestructuresisaccompaniedbyupwardmotion,whichactstocompressthecervicalspine.Thiscombinedmotioncausestheheadtomovebackwardinto extension, producing tension where the lower cervical segmentextends and theupper cervical segment flexes.With thismovement ofthecervicalvertebrae,theanteriorstructuresareseparatedandposteriorcomponentsincludingfacetjointsareseverelycompressed.

CauseofInjuryTacklefrombehind,e.g.football.Sharpcollisionwithanotherathleteorpieceofequipment.Blowtothehead,e.g.boxing.

SignsandSymptomsPainandstiffnessintheneck,shoulderorbetweentheshoulderblades.Ringingintheearsorblurredvision.Irritabilityandfatigue.

ComplicationsifLeftUnattendedLeftuntreated,whiplash injurycanproducechronicsymptomsofpain,inflexibility and loss of movement, along with the continuation orworsening of associated symptoms of fatigue, sleep loss, memory and

concentration loss and depression. Symptoms may also suggest moreserious injury to the spinal vertebrae with potentially serious

consequences.

ImmediateTreatmentTheRICERregimen.Immobilizationwithacervicalcollar.

RehabilitationandPreventionTheneckwillusuallybe immobilizedwithsomeformofbrace, thoughearlymovementisusuallyencouragedtopreventstiffening.Low-impactstrength and flexibility training and rehabilitation should followcompletehealingof the tendons,discsand ligaments.Riskofwhiplashmaybeminimizedwithprotectivegearaswellasathoroughwarm-uproutine, though prevention in rough contact sports may not beguaranteed.

Long-termPrognosisThe long-term prognosis for most whiplash injuries is good, givenadequatecare,thoughsymptomsmaypersistandtheneckmaybepronetore-injury.

011:WRYNECK(TORTICOLLIS)

Wryneck or torticollis is a painful neck injury that usually follows asudden rotational movement of the head. Nerves in the neck arecompressed,resultinginmusclespasms,accompanyingpainandlossofmovement. While irritation of the discs of the cervical spine, or discprolapse(rupturing),canleadtothecondition,suddeninjury,asduringsportsactivity, isusually the resultof compressionof thenerves in theneckorasprainofoneofthefacetjoints.Typicallytheneckisfrozeninone position, often rotated to one side and bent forward by thecontractionofthecervicalmuscles.

Manysportscancausetheinjury.Symptomsareoftenfirstexperiencedin the morning on waking. Immediate-onset torticollis is usually facetjointrelated;slow-onsettorticollis(asaftersleep)isoftendiscrelated.

CauseofInjurySuddenrotationoftheheadincontactsports.Afallthatcausesasuddentorsionintheneck.Directblowtothehead,causingsuddentwisting.

SignsandSymptomsPainandstiffness.Lossofmotion.Neckmaybestuckor frozen inoneposition.

ComplicationsifLeftUnattendedWryneck can worsen, in some cases becoming chronic if ignored. Theconditionmayindicatedamagetothecervicalvertebrae,cervicaldiscsorassociatednervesandjoints,requiringmedicalattention.

ImmediateTreatmentImmobilization of the injured neckwith a brace or supportive cervicalcollar.Anti-inflammatorymedicationandicetoreduceswelling.

RehabilitationandPreventionIt is critical to determine the cause of the injury and rule out seriousunderlying conditions requiring surgeryormajormedical intervention.Following this, a physical therapist may use an infrared heat lamp aswell as massage of the cervical muscles in order to restore range ofmotion in the injured neck. Protective headgear, upper body and neckstrength training and attention to proper athletic technique may helpreducethelikelihoodofthisinjury.

Long-termPrognosisWryneckusually resolves inaweekor less, though thepainful spasmscan be temporarily debilitating.While a chronic form of the conditionexists, for most a full recovery can be expected, barring more seriousunderlyingconditions.

012:CERVICALDISCINJURY(ACUTECERVICALDISCDISEASE)

Cervicaldiscsareshock-absorbingpadsoftissuecushioningthebonesofthecervicalspine.Avarietyofinjuriestothesediscscancausepainandhamper movement and flexibility of the neck. Herniated discs occurwhenthegel-likesubstanceofthenucleuspulposusbulgesorleaksfromthedisc’sinterior,followingasplitorrupturetothedisc.Thissubstancecanthenexertpressureonthespinalcordornervesofthecervicalspine.Disc degeneration and/or herniation (disc rupture) can cause injury tothespinalcordornerveroots.Bulgingdiscsoccurwhenthediscextendsoutsideitsnormalboundarybutnoruptureortearhasoccurred.

CauseofInjuryDisc degeneration and loss of elasticity. Repetitive stress, particularlyfromexcessiveorimproperweightlifting.Sudden,forcefultraumatothecervicalvertebrae.

SignsandSymptoms

Tinglingandweakness.Numbnessorpainintheneck,shoulder,armorhand. Loss of strength in the muscles supplied by the affected spinalnerve.

ComplicationsifLeftUnattendedHerniatedorslippeddiscscanimpingeonthespinalcord,anextremelydelicatestructure.Evenminordamagetothespinalcordcanbeseriousandisgenerallynotreparable.Ignoringcervicaldiscinjuriescanleadtofurtherdegenerationandassociatedpainandmobilityloss.

ImmediateTreatmentDiscontinueactivitycausingstress tocervicalvertebraeanddiscs.Rest,iceanduseofanti-inflammatorymedication.

RehabilitationandPreventionFormostdiscinjuries,aconservativecourseoftreatmentisundertaken.The neckmay be immobilized for a period in a cervical collar duringhealing.Physical therapy includesmobilizing, stretching, strengtheningand proprioceptive exercises and sometimes efforts to adjust posture.Upperbodyexercisemayhelppreventdischardeninganddegeneration,whilestrengtheningsupportingmuscleswilllowertheriskofrupture.

Long-termPrognosisThemajorityofdiscinjuriesimprovewithoutrecoursetosurgery.Mostathletes can expect a full return to normal performance following restandrehabilitation,thoughsymptomsoftheinjuryoccasionallyrecuranddegenerateddiscsarepronetore-injury.

013:PINCHEDNERVE(CERVICALRADICULITIS)

Nerves controlling the shoulder, arm and hand originate in the spinalcordintheneck.Inflammationorcompressionofoneofthesestructuresis knownas apinchednerveor cervical radiculitis and results inpain,weaknessandlossofmovement.

Cervicalradiculitisoccurswhenadiscfromoneofthecervicalvertebraepressesagainstoneof thespinalnervesemergingfromthespinalcord.Suchnervesbranchtonumerousareasof thebodyandsymptomsmayradiatefromthesourcealongthenervetoareaswherethenervetravels.Dependingontheaffecteddisc,painmayoccurinthehand,arm,neckorshoulder.

CauseofInjuryHerniated disc pressing on a nerve. Irritation of the nerve due torepetitive stress. Bone spurs or degenerating vertebrae impinging on anerve.

SignsandSymptomsPain, weakness and loss of movement in the neck. Numb fingers.Weaknessinthehand,arm,shoulderorchest.

ComplicationsifLeftUnattendedInflammationandpainassociatedwithpinchednervesmaycontinueorworsenshouldthesourceoftheinjurynotbeaddressed.Thenervemaybecome permanently damaged through continued pressure and stress,and the condition may point to other (potentially serious) underlyinginjuriestothevertebraeorspinalcord.

ImmediateTreatmentCeaseactivitystressfultothecervicalspine.Rest,ice,analgesicsandanti-inflammatorymedication.

RehabilitationandPreventionGivenpropertreatment,theprognosisforcervicalradiculitisisgenerallygood.Mildcasesusuallyrespondtophysicaltherapyinconjunctionwithmedicationssuchasnon-steroidalanti-inflammatorydrugs(NSAIDs)orsteroids. Following healing, a program of physical therapy andflexibility/strengthening exercises can help restore the athlete’s formercondition. Attention to proper technique, particularly during weighttraining/weightliftingcanhelppreventpinchednerveinjury.

Long-termPrognosisMostcervicalpinchednerveinjuriesresolvethemselveswithoutseriousmedical intervention. More serious or prolonged cases may requiresurgerytorelievecompressionofthenerveroot.

014:SPURFORMATION(CERVICALSPONDYLOSIS)

Cervical spondylosis is a chronicdegenerative conditionof the cervicalspineandtheintervertebraldiscs.Agingandrepetitivestresscausediscsto become drier, thinner and less elastic. When the surroundingligamentsbecomelesssupportive, thevertebraedevelopbonespurs,orosteophytes,whicharebonyprojectionsthatformalongjoints.

Bonespursarethebody’sattempttostabilizedegenerativejointsandareoften associatedwith arthritis or advancedwear and tear such as thatexperiencedbyathleteswhoplayhigh-impactsportssuchasrugby.Suchspurs themselves can rub against nearby nerves or occasionally on thespinalcord,causingpain,neurologicalsymptomsandlimitationsinjointmotion.

CauseofInjuryRepetitive wear on cervical vertebrae. Excessive or improperweightlifting.Bulgingorherniatedcervicaldisc.

SignsandSymptomsNeckpainradiatingtoshouldersandarms.Lossofbalance.Headachesradiatingtothebackofthehead.

ComplicationsifLeftUnattendedCervical spondylosis is a common cause of spinal cord dysfunction inolderadults. If the condition isn’t treated, the injurymayprogress andbecomepermanent.Bonespursorherniateddiscscan impingeandput

pressureontherootsofoneormorenervesofthespinalcordintheneck,producing tingling, burning, weakness or numbness in the arms orhands. Displaced spurs can also float in the system, periodically

interferingwithjoints.

ImmediateTreatmentNeckbraceorcervicalcollartohelplimitneckmotion.NSAIDs.

RehabilitationandPreventionLessseriouscasesofcervicalspondylosisrespondtoexercisesprescribedby a physical therapist aimed at strengthening and stretching neckmuscles.Low-impact aerobic exercises includingwalkingor swimmingmayalsohelp.Whileage-relatedspondylosismaybedifficulttoprevent,minimizing high-impact activity, engaging in upper body training andattentiontoposturemayhelpavoidtheinjury.

Long-termPrognosisMildcasesof cervical spondylosis respondwellafter immobilizationofthe area and appropriate physical therapy. More serious cases mayrequireinjectionsofcorticosteroidsbetweenthevertebralfacetjointsor,in some cases, surgery to remove bone spurs, particularly if they havebrokenofffromlargersectionsofbonetobecomeloosebodies.

015:TEETH

Injury to the teeth is a particular risk for athletes involved in sportswhereaprojectilesuchasaballorpuckcanstriketheplayer’sface.Suchsports includehockey, lacrosseandfootball.Themostcommoninjuriesof this sort are a fractured, displaced or avulsed (knocked out) tooth.Injuries to the teeth often accompany other head and neck injuries,including fractured facial bones, concussions, abrasions, bruises, softtissuelacerationswithbleedingandjaw-jointproblems.

Teeth can be chipped or in some cases knocked out altogether, givensufficient force from a bat or ball. The avulsed tooth runs the risk ofbeing rejected by the body as a foreign object and should therefore becleaned and replaced firmly in its socket as soon after the injury aspossible.

CauseofInjuryTeethstruckwithaball,puckorotherprojectile.Directblowinboxing.Teethstruckbyequipmentincludingbats,sticks,racquets,etc.

SignsandSymptomsMouthpain.Looseteeth.Bleedingfromthemouth.

ComplicationsifLeftUnattendedInjurytotheteethshouldreceivepromptmedicalattention.Swallowingatoothafterinjuryisadanger,asisinfectioninthemouthiftheinjuryisnotproperlycleanedandattendedto.

ImmediateTreatmentIf the toothhasbeenknockedout,wash insalineandreplace firmly inthesocket.Rinsemouthanduseanalgesicsandiceforpainrelief.

RehabilitationandPreventionRehabilitation from injury to the teeth is dependent on the nature andseverity. Chipped or fractured teeth can be repaired and bonded by adentistandlostteethreplaced.Theathleteshouldrefrainfromactivitiesthatputtheteethatriskuntilthoroughhealinghasbeenaccomplished.Useofamouthguard,particularlyacustom-fittedone,helpsprotecttheteethduringhigh-riskandcontactsports.

Long-termPrognosisMost injuries to the teeth, while painful, do not threaten an athlete’scareer or future performance, particularly provided they are givenpropermedical and dental attention. A knocked out tooth has a goodprognosis for replanting, providing this is done within the first thirtyminutesof the injury.Aftermore than twohours theprognosis ispoorfor toothreplacementdue torejectionof the toothandre-absorptionoftheroot.

016:EYE

Injuriestotheeyearealwayspotentiallyserious.Manysportsentailrisktotheeyes,particularlythoseinvolvingaball,puck,stick,batorracquetorotherapparatus,suchasafencingfoil.Basketball,hockey,netballandbaseballcausethemosteye injuries,whilesportscarryinga lowriskofinjury to the eye include track and field, swimming, gymnastics andcycling.Exposureoftheeyestoexcessultraviolet(UV)radiationcanalsocausedamage, necessitatingprotection of the eyes in sports like skiingand mountaineering. Even minor eye injuries can impair vision andcomplicationscanresultinvisualdeficitorloss.

CauseofInjuryBlunttraumatotheeyefromequipmentordirectcontact,e.g.wrestling.Penetrating injury to the eye. Radiation damage due to sunoverexposure.

SignsandSymptomsBlurredorabsentvision.Painorsensitivityintheeye.Obvioustrauma,includingbruisingorbleeding.

ComplicationsifLeftUnattendedEyeinjuriesrequireimmediatemedicalattention.Failuretoseekmedicaltreatment can result in visual impairment, deficit or permanent loss,particularlyifocularhaemorrhagingresultsfollowingtheinjury.

ImmediateTreatmentCold compress.Avoidpressureon the eye. Seek immediate emergencymedicalcare.

RehabilitationandPreventionRehabilitationforaneyeinjuryvariesbroadlydependingonthenatureand severity. Minor injuries are generally self-healing, while seriousinjuriesmayrequireophthalmicsurgeryandconsiderablerehabilitation.Eye protection including safety goggles, helmets with eye shields andothereyeprotectionforsportssuchascricket,wrestling,football,soccer,hockey,lacrosse,paintball,basketballandracquetsportsincludingtennisshouldbewornwhenpossibletopreventsuchinjuries.

Long-termPrognosisPrognosis for eye injuries varies according to the nature and severity.Minor injuries that do not damage underlying structures in the eyegenerallyhealgivenproperattention.Moreseriousinjuries,particularlypenetratinginjuries,runtheriskofproducingpermanentvisualloss,andmustbetreatedaggressivelyassoonaftertheinjuryaspossible.

017:EAR

Injuries to the ear can occurwhen the ear is exposed to direct trauma(fromaball,puck,stickorotherobject)orthroughablowinboxingorasaresultofinfection,asinthecaseofswimmer’sear.Cutsandlacerationstotheeararepossibleinavarietyofathleticevents,particularlycontactsports,asarebruisesandswelling.Theeardrumcanberuptured,thoughthisinjuryinsportsisuncommon.

Sports injuries tend to involve the outer ormiddle ear, rather than theinner ear where the cochlea and other structures reside. For example,cauliflowerear(illustrated)iscausedbyrepeatedblunttrauma,whereahaematoma forms between the cartilage of the ear and theperichondrium(itsfibrouscovering).

CauseofInjuryBlowto theear fromaballorotherprojectile.Suddenpressurechangeresultinginarupturedeardrum.Traumafromboxingblow.

SignsandSymptoms

Bleedingandswelling.Hearinglossorringingintheears.Dizzinessandlossofbalance.

ComplicationsifLeftUnattendedEarinjurieshavepotentiallyseriousconsequencesforlong-termhearingandshouldnotbeignored.Rupturedeardrumscanalsoleadtoinfection,withpotentiallyseriousimplications.

ImmediateTreatmentApplydirectpressureshouldbleedingoccur.Sterilecotton in theoutereartokeeptheinsideoftheearclean.

RehabilitationandPreventionCutsandabrasionstotheearaswellascauliflowerearusuallyhealwithminimalmedicalattention.Arupturedeardrumrequiresparticularcareto avoid infection. Ear infections common to swimmers may requireantibiotics and usually a period out of thewater until the condition isfullyresolved.Useofhelmetsorotherheadgearincontactsportshelpstopreventdirecttraumatotheear.

Long-termPrognosisMost athletes experiencing injury to the ear can expect a full recovery,though in thecaseofarupturedeardrumpartialor insomecases totalhearing loss may result. Prompt medical attention is critical for suchinjuries.

018:NOSE

Nasalinjuriesareamongthemorecommonsportinginjuries,partlyduetotheprotrusionofthenasalbonesfromtheface.Injuriestothenosearegenerally due to direct blows in contact sports, from cricket balls,basketballs and other athletic equipment or from a fall on the face. Inaddition to surface cuts, bruising and lacerations to the skin, the nasalbonesmaybefractured.Bloodclottingbeneaththemucousmembranesoftheseptumisalsopossibleandisknownasaseptalhaematoma.

Epistaxis, or nosebleed, occurs when superficial blood vessels on theanteriornasalseptumarelacerated.

CauseofInjuryBlowtothenosefromabaseball,basketballorsimilarobject.Blowtothenosefromboxingorduringcontactsports.Fallontheface.

SignsandSymptomsNasal deformity. Bleeding, pain, or difficulty breathing. Swelling andskinlaceration.

ComplicationsifLeftUnattendedInjuries to the nose are potentially dangerous and require promptmedical attention. Collections of clotted blood can accumulate in thespace between the nasal cartilage and its fibrous covering, forming aseptal haematoma. Resulting pressure on the underlying cartilage canproduceirreversiblenecrosisoftheseptum.Thereisalsosignificantrisk

for infection. If the injury involves damage to the cribriform plate, theathletecanlosecerebrospinalfluid,placingthematriskfrommeningitisorotherseriouscomplications.

ImmediateTreatmentApply ice to thenoseandelevate thehead.Usenasaldecongestants toreduceswellingandmucosalcongestion.

RehabilitationandPreventionMost injuries to the nose heal well, though the athlete should avoidcontactorotherhigh-risksportsduringthisphase.Fracturesneedtobereset butdonot inmost cases require surgery.Helmetswith adequatefaceprotectionshouldbeusedwherethenoseisatrisk,tohelppreventsuchinjuries.

Long-termPrognosisLess serious nasal injuries usually allow the athlete to return to non-contactsportswithintwoweeks.Fullhealingoffracturesusuallyoccursinthreeweekswithoutlastingcosmeticorfunctionaldeformity.

REHABILITATIONEXERCISES

LateralNeckStretch

Look forward while keeping your head up. Slowly move your eartowardyourshoulder.Keepyourhandsbehindyourbackanddonotliftyourshoulderuptoyourear.

NeckExtensionStretch

Standuprightandliftyourhead,lookingupwardasiftryingtopointupwithyourchin.Relaxyourshouldersandkeepyourhandsbyyourside.

ForwardNeckStretch

Stand upright and let your chin fall forward toward your chest. Relaxyourshouldersandkeepyourhandsbyyourside.

SingleArmDumbbellRow

Placeyour leftkneeonaweightbenchandbendover to restyour left

handonthebenchaswell.Leavingyourotherfootontheground,gripadumbbell with your right hand. Lift the dumbbell by bending yourelbow toa90-degreeangleas ifyouare startinga lawnmower.Slowlyreleaseandrepeat.

IsometricLateralNeckExercise

Withboth feet firmlyon theground,raiseonehandandplace itaboveyourearonthesideofyourhead.Pushyourheadgentlyintoyourhanduntilyoufeeltensioninyourneck.Releaseandrepeatontheothersideofyourhead.

IsometricRotationNeckExercise

Withbothfeetfirmlyontheground,raiseonehandandplaceitslightlyforward of your ear. Rotate your head, pushing gently into your hand

untilyoufeeltensioninyourneck.Releaseandrepeatontheothersideofyourhead.

IsometricForwardNeckExercise

Withbothfeetfirmlyontheground,placebothhandsonyourforeheadandgentlypushyourheadintoyourhandsuntilyoufeeltensioninthe

frontofyourneck.

IsometricRearwardNeckExercise

Clench your hands together and place them behind your head. Pushyourheadgentlybackwardintoyourhandsuntilyoufeeltensioninthebackofyourneck.

CHAPTER6SportsInjuriesoftheHandandFingers


Thefivemetacarpalbonesofthepalmrunfromthecarpalbonesofthewrist to the base of the fingers. (The knuckles are the heads of themetacarpals where they articulate with the phalanges of the fingers.)Each metacarpal bone comprises a base, shaft, neck and head (fromproximaltodistalend).

Thefirstmetacarpalboneistheshortestandconnectswiththetrapeziumatthebaseofthethumb.Theotherfourmetacarpalsofthehandconnecttothetrapezoid,capitateandhamate,andlateral/medialsurfacesoftheadjoining metacarpals. Each finger has three phalanges, whereas thethumbonlyhastwo,makingatotaloffourteenphalanges.

Eachfingerofthehandhasthreejointstoenablefinemotorcontrol.Themetacarpophalangeal(MCP)orknucklejointsarecondyloidjoints,eachofwhich is enclosed in a capsule that is reinforcedby strong collateralligaments. The carpometacarpal (CMC) joint of the thumb is a saddlejoint but the CMC joints of the fingers are plane joints. Theintermetacarpal (IM) jointsarealsoplane jointsandboth theCMCandIM joints are surrounded by a joint capsule. The interphalangeal (IP)joints,bothdistal(DIP)andproximal(PIP),arehingejoints.

Thestrongulnar(medial)collateralligamentofthemetacarpophalangeal

jointconnectsthefirstmetacarpalbonetothefirstphalanxatthebaseof

the thumb. Its function is toprevent the thumb fromstretching too farawayfromthehand.Theligamentisrequiredforpinchingandgraspingactivities.

Thebonesoftherightwristandhand,anteriorview.

Extensor tendons are small muscle tendons in the hand and fingerswhich enable delicate finger movements and hand coordination. Theyare located on the dorsal aspect of the hand and fingers, allowing theathletetoextendandstraightenthefingersandthumb.Extensortendonsattachtomusclesintheforearm.

Themuscles of the hand can be grouped as: 1) the ‘intrinsic’muscles,consistingoftheinterossei,locatedbetweenthemetacarpalstoactonthefourfingersandthumb,andthelumbricals,whicharisefromthetendonsofflexordigitorumprofundusinthepalmandactonthefourfingers;2)themuscles of the hypothenar eminence; 3) the muscles of the thenareminence;and4)theadductorpollicismuscle.

Musclesofthehand.

019:METACARPALFRACTURES

Breaks or fractures in one ormore of themetacarpal bonesmay resultfrom a variety of events. They are common in football and basketballplayers.Metacarpalsarevulnerable todirect forceandcanbe fracturedwhen a closed fist strikes another person or hard object, such injuriesbeing referred to as a boxer’s fracture. Metacarpal bones can fractureeitheratthebase,shaftorneck.Themostcommonfractureisoftheneckofthefifthmetacarpal.

CauseofInjuryAdirectblowto thehand.Fallingdirectlyonto thehand.Longitudinalforcetransmittedthroughaclosedfistwhenpunching.

SignsandSymptomsLocalpainandswelling.Bruisinganddeformityof thebrokenboneorknuckle.Lossofhandmovementandfunction.

ComplicationsifLeftUnattendedUse of a handnot properly immobilized followingmetacarpal fracturemay lead to lastingdeformityandreduced functionaswellaspossibledamage to surrounding nerves, muscles, tendons, blood vessels andligaments.

ImmediateTreatmentWash any associated cuts to prevent infection and apply ice to reduce

swelling.Elevatetheinjuredhandandavoidusingit.

RehabilitationandPreventionPreventionofmetacarpalfracturesrequiresavoidanceofactivitieslikelyto produce them, particularly striking hard objects with the hand.Preventing further injury to already fractured metacarpals is usuallyaccomplished by immobilizing the hand, eitherwith a finger splint orshortcast,dependingonthenatureofthemetacarpalfracture.Exercisesdesigned to gradually increasemovement, flexion and extensionof thewristorfingerswillhelprestorefulluse.

Long-termPrognosisFull recovery from most metacarpal fractures can be expected withaggressiveearlyattention,whichmayincluderesettingoftheboneandimmobilization of the hand. Surgery may be required in the case ofdisplacedbones,withtheaffectedmetacarpalrealignedandheldfastbymeansofremovablepins.

020:THUMBSPRAIN(ULNARCOLLATERALLIGAMENT)

Manyactivitiescanpull the thumbsuddenlyaway fromtherestof thehand, stretching or occasionally tearing this ligament. The injury isprevalentamongskiersandisoftenreferredtoasskier’sthumb,thoughrepetitive activities that gradually wear and irritate the collateralligaments,fibrousbandsoftissuelyingoneithersideofthethumb,canproduceachronicformofinjury.

CauseofInjuryThumb being jammed into another player, piece of equipment or theground. Repetitive wear of the ulnar collateral ligament throughgrippingbetweenthethumbandindexfinger.Anyactivitythatviolentlyseparatesthethumbfromtherestofthehand,suchasaskiingfall.

SignsandSymptomsLocal pain and swelling over the torn ligament. Difficulty graspingobjects or holding them firmly. Instability of the thumb which mayrepeatedlycatchonobjectsorclothing.

ComplicationsifLeftUnattendedIf a torn ulnar collateral ligament is left untreated it may result in apainful,unstablethumbwithlossofmobility.Continuedsorenessandapropensityforre-injuryarealsopossible.

ImmediateTreatmentElevate and ice for thirtyminutes every two hours. Immobilizewith asplint.

RehabilitationandPreventionBuddy taping the thumb to its neighbouring digit, especially duringcontact sports, may help prevent re-injury. Gradual use of motionexercisestorestorethumbmovementshouldbeundertakenastheulnarcollateralligamentundergoesfinalrepair.

Long-termPrognosisNon-contact sports may usually be permitted six weeks following theinjury,andareturntocontactsportscanbeexpectedafterthreemonths,dependingontheseverityoftheoriginalsprain.

021:MALLETFINGER(LONGEXTENSORTENDON)

Extensor tendons are vulnerable to injury, lying just below the skinsurfacedirectlyon thebonesof thebackof thehandand fingers.Suchtendons may be torn apart when a finger is jammed, separating thetendonsfromtheirattachmenttobone.Theinjuryiscommonatthestartoftheseasonforsportslikebaseball,basketballandnetball,oftencausedbyaballhittingthefingertip.Whenanobjecthitsthefingertipitpushesit sharply down. The forceful flexion avulses the lateral bands of theextensortendonfromitsattachmenttothephalanx.Cutstothehandorfingerscanalsodamagetheextensortendons.

CauseofInjuryCutsorlacerationsaffectingthebacksofthefingersandhands.Baseball,volleyball,football,basketballorotherobjectstrikingthefingertipswhilethe extensor tendon is taut. Jamming the finger against awall, doororotherimmovableobject.

SignsandSymptomsInability to straighten the finger. Bruising, pain and swelling of theaffectedfinger.Droopingfingertip.

ComplicationsifLeftUnattendedLeftuntreated,malletfingermaycausepermanentcosmeticdeformityinthefinger,thoughoftenwithoutfurthercomplication.Withoutsplinting,someresidualstiffnessand lossof fingerextensionmayresult.Surgicalintervention is typicallynot advised in simple cases ofmallet finger assurgicalcomplicationsmayincludestiffness,nailbeddamage, infectionandchronictenderness.

ImmediateTreatmentRICER regimen for the first two days, followed by heat treatment.Immobilizationwithasplintpendingmedicalconsultation.

RehabilitationandPreventionGenerallyasplintmustbeworncontinuouslyuntiltheextensortendonisfullyhealed.Itwilloftenrequireseveralmonthsforlocalswellingandredness to fully subside.Special carewith the fingertips shouldalwaysbetakeninsportsinvolvingfast-movingballs,aswellaswhenhandlingcuttingimplements.

Long-termPrognosisWithattentiontopost-injurycareincludingimmobilizationoftheinjuredfinger, most athletes achieve full restoration of movement andappearanceofthedigit.

022:FINGERSPRAIN

Finger sprains are injuries to a joint that cause a stretch or tear in aligament.Thesesprainsarecommoninawidevarietyofsportsincludingfootball, basketball, cricket and handball. They include MCP and IPsprains,Boutonnièredeformityandmalletfinger.

InjuriestothePIPjoint(themiddlejointofthefinger)aremostcommon,andmay resultwhen the joint is bent back (hyperextension). This cancause rupture or tearing of the volar plate (see page 85), a ligamentconnectingtheproximalandmiddlephalangestothecollateralligamentsfoundoneithersideofthePIPjoint.

CauseofInjuryBlowtothehandat theregionof the joint.Hyperextensionof the joint,damaging the volar plate ligament. Collateral ligaments areoverstretchedinaside-to-sidedisplacement.

SignsandSymptomsPain and tenderness in the finger. Pain whenmoving the finger joint.

Swelling of themiddle finger joint,with deformity in the case of jointdisplacement.

ComplicationsifLeftUnattendedShould a deformity associated with finger sprain become chronic, thechances of successful surgical correction are reduced. Potential forpermanentfunctionaldeficitintheinjuredfingerexists.

ImmediateTreatmentUse of anti-inflammatory or other painmedication to reduce swelling.Applyicepackstotheinjuredfingerfor20–30minutesevery3–4hoursfor2–3daysoruntilpainsubsides.

RehabilitationandPreventionMost finger sprain injuries, depending on severity, will be splinted orbuddy taped to neighbouringdigits in order to immobilize the area oftrauma.Fingerstrainstendtobeunforeseenandunpreventableinjuries,though proper sports technique and equipment may reduce thelikelihoodofsomesprains.Strengtheningandmobilityexercisesforthefingersmaybeundertakenfollowinginitialhealing.

Long-termPrognosisFullrecoveryandrestorationoffunctionintheinjuredfingerislikelyinmostcasesoffingersprains.

023:FINGERDISLOCATION

Fingerdislocationsaremoresevereinjuriesthansprainsandinvolvethedisplacementof the joint,altering thealignmentof the finger.The jointmust therefore be reset before the finger is immobilized with casting,splintortaping.Splintsallowtheligamentsandjointcapsuletoproperlyheal.Suchdislocationsarecommoninmanysports,particularlycontactsportsinwhichtheathlete’shandscomeintodirectphysicalcontactwithother players (football, wrestling) and sports emphasizing use of thehands(volleyball,baseball,basketball,gymnastics,karate,etc.).

Dislocation of a joint involves the tearing of ligaments and the jointcapsule surrounding theaffected joint.Dislocationmayoccur inanyofthe joints of the fingers. Dislocation of the IP joints occurs mostcommonlyinbasketballandfootball.DislocationsoftheMCPandCMCjointscanoccurduringfallsontotheoutstretchedhand.

CauseofInjuryFingersbeingstruckbya football,baseball,basketball, etc.Fallingontothe outstretched hand. Abduction force applied to the thumb, as in askier’sfall.

SignsandSymptoms

Immediate pain and swelling. Finger appears crooked. Inability tostraightenorbendthedislocatedjoint.

ComplicationsifLeftUnattendedDeformity of the joint, loss of function and early-onset arthritis canaccompany an untreated finger dislocation. While some dislocationscorrectthemselveswithoutmedicalintervention,generallythedisplacedjointmustberesetbyaphysician,followedbyimmobilizationduringthehealingoftheinjury.

ImmediateTreatmentRICER treatment should immediately follow the injury. Avoid allunnecessarymovementoftheinjuredfinger.

RehabilitationandPreventionLigamentsoccasionallydonothealadequatelyfollowingdislocation,andsurgerymayberequiredtorepairdamagedstructures.Generallyfingerdislocationsaresuccessfullytreatedbyresettingthemisalignedjointandholdingthearearigidbymeansofasplintuntilthoroughhealingoftheligamentandjointcapsulehastakenplace.Stretching,strengtheningandmobilityexercisesmayfollowtoavoidstiffeningormobility loss intheaffectedjoint.

Long-termPrognosisMost finger dislocationsdo not result in long-term finger deformity orloss of function, and a full recoverymay be expected given aggressiveearlytreatment.

024:HAND/FINGERTENDINITIS

Tendinitismeansirritationandinflammationoftendonsandmayaffectanyofthetendonsofthewristorfingers.Theafflictioniscommonwhereoveruseoroverworkingofthetendonsisinvolvedbutcanalsoberelatedto various underlying diseases including diabetes and rheumatoidarthritis.

Tendonsareresilientcordsoftissueconnectingmuscletobone,andactto transmit forces between themuscle and the skeletonwhich requiresthemtobearconsiderablemechanicalloads.Overworkingofthetendonscan lead to inflammation of the tendons and their tendon sheaths.Tendinitismaybe accompaniedby fibrinoidnecrosis andmyxomatousdegeneration (a condition where mucus accumulates in connectivetissue).

CauseofInjuryIntenseorsustainedexertioninvolvingthetendonsofthewristorhand.

Lack of adequate recovery time between athletic exertion. Coldtemperaturesorconstantvibrationinthehand.

SignsandSymptomsTenderness.Inflammation.Cracklingorgratingsensationundertheskin(crepitus).

ComplicationsifLeftUnattendedShouldathleticactivitycontinuedespiteexistingtendinitis,theafflictioncan become chronic and permanent damage to the structure of thetendonsmayresult.

ImmediateTreatmentAnti-inflammatorymedication.Iceforthefirst24–48hoursafteronsetofthecondition.

RehabilitationandPreventionFollowingrestandmeasurestoreduceinflammation,strengtheningandstretching exercises targeting the affected tendons can be undertaken,providedpainhassubsided.Avoidanceofrepetitivestresstothetendonsand ensuring proper recovery time following physical activitiesinvolving the wrist and hands can help prevent recurrence of thecondition.

Long-termPrognosisProper care of tendinitis usually results in reduction of inflammation,alleviationofpainandfullrecoveryofmovement,thoughtheconditioncan become chronic, particularly in elite athletes whose schedule

demandsrepeatedover-stressoftendons.


FingerSquashing(Flexion)

Grip the ringwith four fingers on top andyour thumbon thebottom.Closeyourhandsothatyourthumbmeetsyourmiddlefinger.Repeat.

FingerOpening(Extension)

Put your hand inside the ring, but do not push it past your knuckles.Stretchyour fingers apartbyattempting togetyourmiddle finger andthumbasfarawayfromeachotheraspossible.

Palms-outForearmStretch

Interlock your fingers in front of your chest and then straighten yourarmsandturnthepalmsofyourhandsoutward.

FingerStretch

Placethetipsofyourfingerstogetherandpushyourpalmstowardeachother.

ThumbStretch

Startwithyourfingerspointingupandyourthumbouttooneside,thenuseyourotherhandtopullyourthumbdown.

CHAPTER7SportsInjuriesoftheWristandForearm


Thewristhelpsorientandsupportthehand.Thewristcanbethoughtofas a multi-articular complex. Most wrist movement occurs at theradiocarpaljoint,anellipsoidjoint.Thedistalsurfaceoftheradiusandafibrocartilagediscarticulatewith theproximal rowofcarpalbones: thescaphoid,lunateandtriquetrum.

Movements at the radiocarpal joint occur in combination with themidcarpaland intercarpal joints.Theseareaseriesofplane joints,witharticulationsbetweenthetwocarpalrows–themidcarpaljoint–forminga compound saddle joint. There are numerous intercarpal articulationsbetween the bones of the proximal and distal carpal rows. The distalradioulnar joint is immediately adjacent to the radiocarpal joint. Acartilaginous disc separates the distal ulna and radius from the lunateand triquetrum.An elaborate complex of ligaments holds the bones ofthewrist togetherandallows for theirpropercoordination.Tendonsofmusclespassingacrossthewristareencasedintendonsheathsknownasthetenosynovium.

Threemajor nerves supply the skin andmuscles of the forearm, handand fingers: the median, radial and ulnar nerves. These nerves arevulnerabletoinjuryandcompressionatseveralpointsontheirpaths.

The carpal tunnel is a narrow, rigid space formed by the shape of thecarpal bones and ligaments at the base of the hand.Themediannerveand the tendons of the flexor muscles of the hand and fingers runthroughit.Themediannerveisvulnerabletocompressioninthecarpaltunnel. It transmits sensory information from the palmar aspect of thethumb and first two or three fingers aswell as supplying some of themusclesofthehand.

The elbowhas twobonypoints frequently associatedwithulnarnervecompression (ulnar tunnel syndrome): the olecranon process and themedial epicondyle of the humerus. The space between these bonyprotrusions is known as the ulnar tunnel and the ulnar nerve passesthroughit,runningdowntheforearmandintothehand.Theulnarnerveactson theadductorpollicismusclewhichpulls the thumb toward thepalmofthehandandcontrolssmallintrinsicmusclesofthehand.Italsotransmits sensory information from themedial border of thehandandthefourthandfifthfingers.

The anterior forearm contains three functional muscle groups: thepronators of the forearm; thewrist flexors; and the long flexors of thefingers and thumb. They are arranged in three layers: the superficiallayer comprises four muscles: pronator teres, flexor carpi radialis,palmarislongusandflexorcarpiulnaris.Themiddlelayercontainsonlyflexor digitorum superficialis. The deepest layer consists of: flexordigitorumprofundus,flexorpollicislongusandpronatorquadratus.Onthe back of the forearm there are two muscle groups. The superficialgroup contains, from the radial to ulnar side: brachioradialis, extensorcarpi radialis longus, extensor carpi radialisbrevis, extensordigitorum,extensor digiti minimi and extensor carpi ulnaris. Themuscle belly ofbrachioradialisisprominentwhenworkingagainstresistance.Thedeepgroup contains: supinator, abductor pollicis longus, extensor pollicis

brevis,extensorpollicislongusandextensorindicis.

Bonesoftherightforearmandhand,posteriorview.

Jointsofthewristandhand,coronalview.

Rightforearm,wristandhand.

Cross-sectionofthewrist.

025:WRISTANDFOREARMFRACTURE

Shouldanathlete fallontoanoutstretchedwrist, abreakor fractureofthewristorbonesof the forearmmayresult.Sportsvulnerable tosuchinjury include running, cycling, skateboarding, rollerblading and otheractivitiesinwhichanoutstretchedhandmaybeusedtobreakafall.

ThetwomostcommonwristfracturesareColles’fractures,whichoccuratthedistalendoftheradius,andscaphoidfractures,whichinvolvethescaphoid,a smallbone thatarticulateswith the radiusnear thebaseofthethumb.

CauseofInjuryAfallontoanoutstretchedwrist.Ablowtothewrist.Extremetwistingofthewrist.

SignsandSymptomsDeformityofthewrist.Painandswelling.Limitedmotioninthethumborwrist.

ComplicationsifLeftUnattendedWrist fractures often fusenaturally, though complicationsmay arise inthe untreated fracture leading to limitations of wrist movement andforearm pronation and supination. Osteoarthritis may also result fromuntreated fractures. Untreated ormisdiagnosed scaphoid fractures runtheriskofnon-unionormalunionoffracturedbonefragments.

ImmediateTreatmentApplyanicepackoverthewristtoreduceswelling.Elevatethefracturedwristorforearmandplaceitinasling.

RehabilitationandPreventionImmobilizationwitharigidcast isgenerallyrequiredforsuchfracturestoproperlyheal,withX-rayfollow-upstoanalyzeimprovement.Wheresurgeryisrequired,wiresorscrewsmaybeemployedtofusefracturedsegments.

Long-termPrognosisPrognosis in the caseof radialorulnar fracturesvaries.Open fractures(where the skin is broken) tend to have less favorable outcomes.Mostscaphoidfracturesofthewristhealthoroughlyifimmobilizedearlyafterinjuryandallowedtohealfor8–12weeks.

026:WRISTSPRAIN

Wrist sprains involve injury to the ligamentsof thewrist. Such sprainsare a common occurrence when the hand is extended to break a fall.Ligaments are necessary for stabilization of the hand and control ofmotion. Wrist sprains vary from moderate to severe, with the latterinvolving complete tearing of the ligaments and instability of theassociated joint. The injury is common in athletes engaged in football,basketball, skiing, snowboarding, rollerblading and a variety of othersportsinwhichthehandsarevulnerable.

Theeightcarpalbonesofthewristareconnectedviacomplexligaments–fibrousbandsofconnectivetissue.Ligamentsalsoconnectthebonesofthewristwiththeradiusandulnaandthemetacarpalbonesofthehand.The smooth coordination of these bones required for fine handmovementisimpairedwhenoneormoreligamentsareinjured.

CauseofInjuryEngaging in sports where falls are common: e.g. in-line skating,

snowboarding,cycling, soccer, football,baseballandvolleyball.Lackofprotective equipment, including wrist guards. Muscle weakness oratrophy.

SignsandSymptomsPainwithmovementofthewrist.Burningortinglingfeelingatthewrist.Bruisingordiscolorationoftheskin.

ComplicationsifLeftUnattendedModerate to severe wrist sprains left untreated can lead to ongoingdeficit of movement and strength in the wrist as well as developingarthritisattheregionoftheinjury.

ImmediateTreatmentRICERregimenimmediatelyfollowinginjury.Immobilizationofinjuredwristtorestrictmovement.

RehabilitationandPreventionFlexibility and range of motion exercises may be encouraged by aphysicaltherapist,followinginitialrecoveryoftheligament.Shouldtheligament be torn completely, or if fracture accompanies the sprain,surgery may be required. Use of protective guards for wrists andconcentrationonbalanceduringsportmayhelptoavoidthisinjury.

Long-termPrognosisMostwrist sprains undergo full recovery given proper initial care andnecessaryhealingtime.

027:WRISTDISLOCATION

Most dislocations of the wrist involve the lunate bone, though otherbones may also be involved. When a bone is dislocated, it no longerarticulates properly with adjacent bones. The injury affects the softtissuessurroundingtheregionofdislocation,includingmuscles,nerves,tendons, ligamentsandbloodvessels.Dorsal ligamentsof thewristareweakerandmorelikelytobeinvolvedindislocations.

CauseofInjuryComplication of a severe wrist sprain. Hard fall onto an outstretchedhand.Congenitalabnormality,includingmalformedjointsurfaces.

SignsandSymptomsLossofhandandwristmovement.Severepaininthewrist.Numbnessorparalysisbelowthedislocationduetoseveredbloodvesselsornerves.

ComplicationsifLeftUnattendedOutcomes foruntreatedwristdislocationareunpredictable.Casesexistof full recoveryand restorationofmovement.Complications,however,may restrict motion of the wrist and produce ongoing pain, jointstiffness, discomfort and impaired flexibility and movement. Arthritismayalsodevelopintheinjuredregion.

ImmediateTreatmentImmobilizethewristanduseRICER.

RehabilitationandPreventionExercisesdesigned to strengthenwristmusclesand ligamentswillhelpprevent re-injury. Protection of thewrist during athletics, with gloves,wrist guards or taping may also offer some protection against wristdislocations.

Long-termPrognosisPrognosisdependson theseverityof thedislocationandanyattendantcomplications, including fracture. Proper early treatment andappropriaterehabilitationleadstofullrecoveryinmostcases.

028:CARPALTUNNELSYNDROME

Carpal tunnel syndrome (CTS) isaprogressiveafflictionwhichmaybecausedbydirecttraumaorrepetitiveoveruseresultingincompressionofthemediannerveatthewrist.Theconditionisthreetimesmorelikelytoaffectwomen,largelyduetooccupationaltaskssuchaskeyboardwork.Pregnancyanddiabetesarealsoriskfactors.

Thecarpaltunnelsurroundsthemediannerveandflexormuscletendonsintheirtendonsheathsastheypassfromtheforearmtothehand.Raisedpressure in the tunnel may occur as a result of irritated or inflamedtendons, leadingtocompressionofthemediannerveandcausingpain,weaknessornumbnessinthehandwhichmayradiateupthearm.Thecondition is one of a variety of entrapment neuropathies involvingcompressionortraumatoperipheralnerves.

CauseofInjurySporting activities that involve repetitive flexion and extension of thewrist, e.g. cycling, throwing events, racket sports and gymnastics.Congenitalpredisposition.Traumaorinjuryincludingfractureorsprain.

Occupationaltasks.

SignsandSymptomsBurning, numbness or itching in the palm of the hand and fingers.Sensationoffingerandwristswelling.Weaknessofgrip.Painthatmaywaketheindividualduringthenight.

ComplicationsifLeftUnattendedLeft untreated, CTS can cause loss of sensation in some fingers andpermanentweaknessofthethumbasthemusclesofthethumbatrophy.HeatandcoldperceptionmayalsobeaffectedinuntreatedCTScases.

ImmediateTreatmentCease repetitive stressactivitycausing thecondition. Immobilizationofthewristwithbandageorsplinttopreventfurtherirritation.

RehabilitationandPreventionHalting the repetitive sport or activity and allowing for rest andrehabilitation time following diagnosis of carpal tunnel syndrome isessential.Abandageorsplintmaybeusedtostabilizetheinjuredhand.Releasing the tension in thewristandhandduringsportsandperiodicexercises to retainmobility and retard stiffness in the handsmay helppreventtheonsetofCTS.

Long-termPrognosisRecurrenceofcarpaltunnelsyndromefollowingtreatmentisrare(exceptincasesofunderlyingdiseasesuchasdiabetes).Corticosteroidinjectionsand surgery in persistent cases. The majority of patients properly

attendingtotheinjuryrecovercompletely.

029:ULNARTUNNELSYNDROME

Oneofthreemajornervesresponsibleformotorfunctionandsensationinthehand,theulnarnerverunsalongtheinsideoftheforearmdowntotheheelofthehand.Inthehand,theulnarnerveradiatesacrossthepalmandintothelittlefingerandringfinger.Pressureontheulnarnervecanresultinpain,lossofsensationandmuscleweaknessinthehand.

CauseofInjuryOveruse ofmuscles and tendons of the forearm, especially in golf andsportsinvolvingthrowing.Abnormalgrowthinthewrist,suchasacyst.Suddentraumatotheulnarnervewithintheulnartunnel.

SignsandSymptomsWeaknessand increasingnumbnesson the little finger (medial) sideofthe hand. Difficulty grasping and holding objects. Tingling along theinnerforearm,especiallywhentheelbowisbent.

ComplicationsifLeftUnattendedWithoutpropertreatment,ulnartunnelsyndromecanleadtopermanentnerve damage and chronic weakening and numbness due to reducedbloodsupplytotheulnarnerve.

ImmediateTreatmentCease the activity which is causing pressure on the ulnar nerve, andavoidkeeping theelbow inabentposition.Splintorpad, especiallyatnighttokeepthearmstraight.

RehabilitationandPreventionInthecaseofulnartunnelsyndromeduetoanabnormalgrowthsuchasacyst,surgerymayberequired.Whererepetitivestressorexercisehaveledtoulnarnerveinflammation,non-surgicalphysicaltherapyincludingstrengthening exercises will often yield improvement in 4–6 weeks. Apadorsplintmaybeusedtoreducesymptomsatnight.

Long-termPrognosisIncaseswhereulnartunnelsyndromereceivespromptandappropriateattention, the prognosis for full recovery is good. Nerve damage anddeficit can result, however, should the condition be allowed to persistwithoutcare.

030:WRISTGANGLIONCYST

Ganglion cysts are thin, fibrous capsules containing a clear, mucinousfluid. They feel soft and mobile. Ganglion cysts are connected to anunderlying joint capsule or ligament via a thin stalk. They can involveany joint in thehandorwristbutoccurmainlyon tendonattachmentsandarepalpablebetweentheextensortendonsoftheforearmmuscles.Aganglioncystformswhentissuearoundthejointbecomesinflamedandswellswithfluid.Asthishappens,theballoon-likegangliongrowsintheconnective tissue of the joint or even in themembrane that covers thenearby tendon. Often, cysts are associated with the scapholunateligamentandscaphotrapezial jointof thewrist.Most cystsoccurat thedorsalwrist, volarwrist andvolar retinacular ordistal interphalangealareas.

Mostoften,ganglioncystsoccurinthe25–45year-oldagegroup,andaremore common in women than in men. Ganglion cysts are benigntumours (so do not spread to other body areas), and their cause isunknown. Sometimes they are also called synovial hernias or synovialcysts because of their relationship to the synovial cavities in the joint.Alsoknownassubchondralcysts.

CauseofInjuryFlawinthejointcapsule.Flawinthetendonsheath.Tissuetrauma.

SignsandSymptomsSwollen,sac-likeareawhichchangessize.Mayormaynotproducepain.Wristweakness.

ComplicationsifLeftUnattendedMostganglioncystsdisappearwithouttreatment,thoughinsomecasesthey recurover time.Suchcystsgenerallydonotposea serioushealthrisk,even if leftuntreated, thoughpainandweaknessof thewristmaypersistwithoutmedicalcare.

ImmediateTreatmentIcethreetimesadayifthecystispainful.Aspirinoranti-inflammatorymedication.

RehabilitationandPreventionCystsmay be drained of fluid by a physician. The patient should notattempt this.Often, cystswill gradually disappearwithout draining orsurgical intervention though they may recur. If the ganglion cyst ispainful,sports involvingintensiveuseofthewristshouldbelimitedoravoideduntilshrinkageordisappearanceofthecyst.

Long-termPrognosisCystsmaybeasymptomaticandself-limiting.Shouldmedicalattentionberequiredtheprognosisforfullrecoveryisexcellent.

031:WRISTTENDINITIS

Wristtendinitisiscausedbyirritationandinflammationofoneormoretendons around thewrist joint.Wrist tendinitis tends to occur in areaswhere the tendons cross each other or pass over an underlying bonystructure, and affects individuals involved in strenuous and repetitivetraining.

The tendons of thewrist are encased in tendon sheaths known as thetenosynovium.Suchsheathsprovideforthesmooth,friction-freeslidingof tendons in the wrist. Swelling, irritation and inflammation of thetenosynoviumcausesathickeningofthesheath,whichconstrictspropermovement of the tendons resulting in pain and a related affliction,tenosynovitis. Most wrist tendinitis occurs where a tendon passesthroughconstrictedtunnelsoffascia.

Four common sites of tendinitis are: the first dorsal compartmentaffectingtheabductorpollicislongusandextensorpollicisbrevismusclesof the thumb (De Quervain’s tenosynovitis); the digital flexormuscles(trigger finger); flexor carpi radialis tendinitis; and lateral epicondylitis(‘tenniselbow’).

CauseofInjurySports involvingwristoveruse, includingallballsports, racquetsports,rowing, weightlifting and gymnastics. Repetitive stress from typing orlifting.

SignsandSymptomsPaininthewrist,particularlyatthejoint.Inflammationintheregionoftheaffectedtendon(s).Limitedmobilityintheaffectedwrist.

ComplicationsifLeftUnattendedIf the activity causing tendinitis is continued and the condition leftuntreated, the inflammation and associated pain can worsen. Theconditioncanalsoleadtopermanentweakeningofthetendon(s).

ImmediateTreatmentImmobilizethewristanduseRICER.Anti-inflammatorymedication.

RehabilitationandPrevention

Often,aphysicianwilluseasplintorbracetopreventmovementoftheinjured wrist. In athletic events tendinitis sometimes results fromimproper technique. The best therapy for tendinitis is to restrict ortemporarilydiscontinuetheactivitycausingtendoninflammation.

Long-termPrognosisMostenjoyafullrecoveryfromtendinitis,providingtheafflictedwristispermittedproperrecuperationfrominflammation.


WristCurls

Asyousitonaweightbench,bendoverslightlyatthewaistwithyourelbows restingonyourknees.Gripabenchpressbarwithyourpalmsfacingupward.Relax your arms and let the bar inch toward the floor.Flexyourwristsupward,withoutmovingyourelbowsfromyourknees,thenlowerthebar.

ReverseWristCurls

Asyousitonaweightbench,bendoverslightlyatthewaistwithyourelbows restingonyourknees.Gripabenchpressbarwithyourpalms

facingdownward.Relaxyourarmsandletthebarinchtowardthefloor.Extend your wrists upward, without moving your elbows from yourknees,thenlowerthebar.

PlatePinch

Gripat least twoplates inonehandwithyour thumbonone sideandyourotherfingersontheother.Pinchyourthumbandfingerstogetherastightlyasyoucan.

WristStretch

Holdontoyourfingerswhileyoustraightenyourarm.Pullyourfingerstowardyourbody.

RopeWinding

Startwith theweight fully unravelled from the bar.Grip the barwithbothofyourpalms facing the floor.Roll theweightupby twisting thebar, then roll the weight down by twisting the bar in the oppositedirection.

Palms-outForearmStretch

Interlock your fingers in front of your chest and then straighten yourarmsandturnthepalmsofyourhandsoutward.

RotatingWristStretch

Place one arm straight out in front and parallel to the ground. Rotateyourwristdownandoutwardandthenuseyourotherhandtofurtherrotateyourhandupward.

CHAPTER8SportsInjuriesoftheElbow


Theelbowisahingejointcomprisedofthreebones:thehumerusoftheupperarmandthetwobonesoftheforearm–theulnaandtheradius.The elbow encompasses three articulations – the humeroulnar,humeroradialandproximal radioulnar joints.Of the forearmbones theulna is themostmedial, being on the little finger side, and is also thelargest. At the distal end of the humerus are the trochlea and thecapitulum,bonyfeaturesthatarticulatewiththeradiusandulna.

The elbow is reinforced by several important ligaments, the twomostimportant being the ulnar (medial) collateral ligament and the radial(lateral) collateral ligament.Themedialcollateral ligament iscomposedofthreestrongbandsthatreinforcethemedialsideofthe jointcapsule.The lateral collateral ligament is a strong triangular ligament thatreinforces the lateral side of the capsule. These ligaments connect thehumerustotheulnaandacttogethertostabilizetheelbow.Additionally,theannularligamentenvelopestheheadoftheradiusandholdsitfirmlyagainsttheulnatoformtheproximalradioulnarjoint.

Theelbowallowsflexionandextensioncapacityaswellastheabilitytopronate and supinate, affording a great range ofmotion. Considerableforceisrequiredtodislocatetheelbowjoint.

Thebonyprominenceatthetipoftheelbowisknownastheolecranonprocessoftheulna.Thefluid-filledsaclocatedattheolecranonprocessisthe olecranon bursa. It is the largest bursa in the elbow region andprovidescushioningprotectiontotheunderlyingbone.

(a)Elbowdislocation.(b)Elbowsubluxation.

The lateral epicondyle of the humerus is an important bony featurelocated just proximal to the outside of the elbow joint. Manymusclesattach to the lateral epicondyle, including the common tendon of theforearmextensormuscles,anconeusandthesupinatormuscle,whichisinvolvedinsupination(rotatingtheforearmtothepalmupposition).

Themedialepicondyleisabonyprominenceontheinsideoftheelbow.Itistheinsertionpointforthemusclesusedtoflexthewristandfingersandforpronation(rotatingtheforearmtothepalmdownposition).

Theelbowjoint:(a)rightarm,lateralview;(b)rightarm,medialview;(c)rightarm,mid-sagittalview.

Themusclesofthearmoriginatefromthescapulaand/orthehumerusandinsertontotheradiusand/orulnatoactupontheelbowjoint.Theyare: biceps brachii; brachialis; triceps brachii and anconeus.(Coracobrachialis, although acting upon the shoulder joint, is alsoincluded because of its proximity to the other muscles of this group.)Biceps brachii is the main supinator of the forearm and has twotendinous heads at its origin and two tendinous insertions. The shorthead of biceps forms part of the lateral wall of the axilla along withcoracobrachialis and the humerus. Brachialis lies posterior to bicepsbrachii and is the main flexor of the elbow joint. Triceps brachiioriginates from three heads and is the onlymuscle on the back of the

arm. The triceps brachii tendon permits the elbow to straighten withforceduringcertainactivities,e.g.push-ups.Thetendonoftricepsbeginsaround the middle of the muscle and consists of two segments, onecoveringthebackofthelowerhalfofthemuscle,theothermoredeeplysituatedwithinthemuscle.Thetwosegmentsorlamellæjoineachotherabovetheelbowandinsertontotheolecranonprocess.

Elbowjointmuscles;a)anteriorview,b)posteriorview.

032:ELBOWFRACTURE

Anelbowfracture isabreak involvinganyof the threearmbones thatwork together to form theelbow joint.Such fracturesmayoccuras theresultof ablunt force striking theelbowduringathleticsor froma fallonto the elbow. The injury is common to many sports, particularlycontact sports such as football. Fractures may be classified as distalhumeral fractures, radial fractures andulnar fractures. Fractures of theradialheadarethemostcommon.

CauseofInjuryFalling directly onto the elbow. Direct trauma to the elbow. Severetorsionoftheelbowbeyonditsnormalrangeofmotion.

SignsandSymptomsSwellingandpainintheregionoftheelbow.Deformityoftheelbowduetobonefracture.Lossofarmmobility.

ComplicationsifLeftUnattendedWithouttreatment,fracturedbonesoftheelbowcanfailtohealproperly,andat times fuse inmisalignment.Thiscan lead to long-termdeficit inrange of motion and strength, increased vulnerability to re-injury anddeformityofthejoint.

ImmediateTreatmentApply ice immediately to the swollen area. Immobilize the arm in a

splintorslingbeforeseekingemergencyhelp.

RehabilitationandPreventionElbow fractures occur from sudden, accidental trauma and are oftendifficulttoprevent.Avoidingathleticsatperiodsofextremefatigueandprotectionoftheelbowwithpaddingduringathleticsarebothprudent.Additionally, consuming calcium and performing bone strengtheningexercisesmayhelpavoidfractures.

Long-termPrognosisLong-termprospects for elbow fracturesvarydependingon thenatureandseverityofthefractureaswellastheageandmedicalhistoryoftheinjured athlete. Infections, stiffening of the elbow joint, arthritis, non-unionormalunionofbonearepossible.Inthecaseoflesssevereelbowfractures, full recovery may be expected, though the healing processoftenrequiresseveralmonths.

033:ELBOWSPRAIN

Ligaments are strong bands of tissue connecting bones and act tostabilizetheelbow.Aspraininvolvesthestretchingortearingofelbowligaments.Many sports are prone to elbow sprains, particularly sportsinvolving throwing, and often involve the medial collateral ligament.Elbowsprainsarealsocommoningymnastics.

CauseofInjurySudden,abnormaltwistingofthearm.Fallingontoanoutstretchedarm.Deficientstrengthinarmligamentsandmuscles.

SignsandSymptomsPain, tenderness and swelling in the area of the elbow joint. Bruisingaroundtheelbow.Limitedrangeofmotioninthearm.

ComplicationsifLeftUnattendedSprains,particularlywhentheyaresevere,canleadtofuturepainfulordisabling symptoms, including instability and weakness in the elbow,limitedrangeofmotionandosteoarthritis.

ImmediateTreatmentRICERregimentoreduceinflammationandtreatpain.Immobilizationofinjuredelbowwithaslingorsplint.


Proper athletic technique, avoiding exercise during periods of fatigueandprotective sportswear includingpadding can all reduce the risk ofelbow sprains. Following initial healing, range ofmotion exercises andgradualreturntoathleticactivitywillhelprestoreflexibility.Foratimeasupportivebracemaybeusedtopreventsuddenre-injury.

Long-termPrognosisDependingontheseverityofthesprainandgeneralhealthofthepatient,minor sprains heal thoroughly without future complication. Olderathletes or those who have suffered severe sprain (including sprainsoccurringinconjunctionwithfracturesordislocations)maysuffersomeimpairmentofmovementandpainassociatedwitharthritis.

034:ELBOWDISLOCATION

Dislocationoftheelbowoccurswhenthehumerusisseparatedbyforcefrom where it articulates with the ulna and/or radius. The injurytypicallyproducesconsiderablepain,swellingsandlossofmovementintheinjuredarm.Contactsportsaremorepronetosuchinjuries.Fracturesas well as injuries to arteries and nerves sometimes accompanydislocation.Apartialdislocationisknownasasubluxation.

(a)Elbowdislocation.(b)Elbowsubluxation.

CauseofInjuryBloworothertraumatotheelbow.Fallontoanoutstretchedarm.Violentcontactbetweentheelbowandanotherathleteorobject.

SignsandSymptomsSeverepainintheelbow,swellingandbruising.Lossofrangeofmotion.Lossoffeelinginthehandfollowingsharpinjurytotheelbow.

ComplicationsifLeftUnattendedImproper healing can follow if a dislocation is left untreated, causingnerve and arterial damage, osteoarthritis, ongoing pain in the injuredarm,lossoffullmovementanddistortionoftheelbowjoint.Infectionof

the dislocated region is also possible, particularly if a fracture isinvolved.

ImmediateTreatmentCheck for possible damage to an artery by taking the pulse. Treat theinjurywithiceandimmobilizetheelbowinasplintorsling.

RehabilitationandPreventionIce should be used to reduce initial pain and swelling, while propermedical attention is sought. The elbow should be moved as little aspossible and elevated frequently. Proper attention to athletic techniqueandpaddingoftheelbowregion,especiallyinthecaseofcontactsportssuchasfootball,mayhelppreventsuchinjuries.

Long-termPrognosisGenerally,dislocationswithoutfurthercomplicationsofnerveorarterialdamagehealthoroughlygivenproperinitialcareandsomerehabilitativeexercises.

035:TRICEPSBRACHIITENDONRUPTURE

The triceps brachii tendon is located at the back of the upper arm,insertingonto thebackof the elbow.Adirect fall ontoanoutstretchedhand can rupture this tendon (tendon avulsion) though the injury isfairly uncommon. Weightlifters and football linemen are among theathleteswhorunariskoftricepsbrachiitendonruptureduetoexcessiveweightonthetendon.

CauseofInjuryFallontoanoutstretchedhand,withtheelbowinmid-flexion.Excessiveweightlifting. Underlying health issues such as diabetes mellitus. It isbelievedtheuseofanabolicsteroidsincreasestheriskoftendonrupture.

SignsandSymptomsPain and swelling at the back of the elbow. Inability to straighten theelbow.Musclespasm.

ComplicationsifLeftUnattendedThe injury generally requires surgery to repair. Failure to repair arupturedtricepsbrachiitendoncancausepermanenttendondeficiency,leadingtomuscleweakness,continuedpain lossofelbowmobilityandweightbearingcapacity.

ImmediateTreatmentRICER regimen to reduce inflammation and treat pain. Preventmovementbyimmobilizingtheinjurywithasplintorsling.

RehabilitationandPreventionFollowingsurgery torepaira ruptured tricepsbrachii tendon,exercisesmay be used to gradually increase the range ofmotion, flexibility andstrength of the injured arm. Proper technique, particularly ifweightliftingorbodybuildingiscriticaltopreventsuchinjuries.

Long-termPrognosisWith surgery soon after the time of injury and proper rehabilitation,rupturesofthetricepsbrachiitendongenerallyhealcompletely,thoughcomplications such as accompanying fractures will affect long-termprognosis.

036:TENNISELBOW

Tennis elbow, alsoknownas lateral epicondylitis, is themost commonoveruse injury in the adult elbow, and causes thebonyprominenceontheoutsideof theelbowtobecomepainfulandtender.Theaffliction isusuallyrelatedtostrainoroveruseofthemusclesattachingtothelateralepicondyleofthehumerusor,lessfrequently,directtraumatotheelbow.

Theextensormusclesoftheforearm,whichextend(straighten)thewrist,become strained from overuse, causing inflammation and pain wheretheyattachtothebone.Thesupinatormusclewhichallowstheforearmto be twisted to the palm up position also attaches to the lateralepicondyleandcancausetenniselbow.Tendonsattachedtothebonesoftheelbowcanbecomerestrictedortaut,causingirritation.

CauseofInjuryOveruseofthemusclesattachedtotheelbow.Directinjurytotheelbow.Arthritis,rheumatismorgout.

SignsandSymptomsOuter part of the elbow is painful and tender to touch. Movement ispainful.Elbowisinflamed.

ComplicationsifLeftUnattendedTennis elbow is generally treated without surgery, though discomfortwill often worsen, with the potential for tendon or muscle damageshouldtheconditionbeignored.

ImmediateTreatmentAvoidanceoftheactivitiescausingrepetitivestresstotheelbow.RICERregimen for 48–72 hours following injury. Use of anti-inflammatorydrugsandanalgesics.

RehabilitationandPreventionOftenasplintorbandagewillbeusedto immobilize the injuredelbowand prevent excess movement. Activities involving repetitive stress totheelboworextensormusclesof thewrist shouldbeavoideduntil thecondition improves. Should surgery be required a rest period of sixweeksisadvisedbeforestrengtheningexercisesbegin.

Long-termPrognosisFewpatients suffering from tennis elbow require surgery.Of the smallpercentagethatdo,80–90%findtheconditionmarkedlyimproved.

037:GOLFER’SELBOW

Golfer’selbow,alsoknownasmedialepicondylitis,isaformoftendinitissimilartotenniselbow.Golfingisoneofmanysourcesoftheaffliction,whichcanresultfromanyactivityleadingtooveruseofthemusclesandtendons of the forearm. While the painful sensation at the elbow issimilar to tennis elbow, in the case of golfer’s elbow the pain andinflammationoccurattheinside(ormedialside)ofthejoint.

Themedialepicondyleisabonyprominenceontheinsideoftheelbow.It is the insertionpoint formusclesused tobend thewristdownward.Forceful, repetitive bending of the fingers andwrist can lead to smallruptures of muscle and tendon in this area. While the golfing swingproducesatighteningintheflexormusclesandtendonsthatcanleadtomedialepicondylitis,otheractivitiescanproducethesameinjury.

CauseofInjurySudden trauma or blow to the elbow. Repetitive stress to the flexormusclesandtendonsof theforearm.Repeatedstressplacedonthearm

duringtheaccelerationphaseofthethrowingmotion.Underlyinghealthissuesincludingneckproblems,rheumatism,arthritisorgout.

SignsandsymptomsTendernessandpainatthemedialepicondyle,whichworsenswhenthewrist isflexed.Painresultingfromliftingorgraspingobjects.Difficultyextendingtheforearm.

ComplicationsifLeftUnattendedGolfer’s elbow, while generally alleviated by proper rest, can causeincreasingpainandunpleasantnessifthestressfulactivitycontinues.Thecondition rarely requires surgery and responds well to properrehabilitation. Should surgerybe required, scar tissue is removed fromtheelbowwherethetendonsattach.

ImmediateTreatmentAvoidanceoftheactivitiescausingrepetitivestresstotheelbow.RICERregimenfor48–72hours following the injury.Useofanti-inflammatorydrugsandanalgesics.

RehabilitationandPreventionIn the case of golfing, the affliction can be reduced in severity orpreventedaltogetherthroughattentiontopropertechniqueandattentionto overuse. Golfer’s elbow is more prevalent early in the golf season,when muscles and tendons are not yet sufficiently conditioned.Rehabilitation generally involves avoiding the painful activity for aperiod. Use of analgesics for pain and anti-inflammatory drugs helpreduce symptoms.Afterhealing, resistive exercisesmaybeundertaken

toimprovestrength.

Long-termPrognosisThose suffering from golfer’s elbow generally make a full recoverywithoutsurgeryoradvancedmedicalcare,providedtheinjuredelbowisaffordedproperrestfromthestressfulactivity.

038:THROWER’SELBOW

Athletes involved in throwing sports are vulnerable to this condition,which is a result of severe stress to the elbow. The baseball pitch is acommonsourceofthrower’selbow,aswellastennis,volleyball, javelinthrowingandcricket.Forceful throwingmotionscandamagethebonesaswell as the associatedmuscles, tendons and ligaments of the elbow.Throwingactivityresultsinacompressionofstructuresonthelateraloroutsideof the elbow,while simultaneously stretching structureson themedial or inside of the elbow. Lateral compression can cause tinyfractures in the bones of the elbow leading to bone spurs and chips.Medialstretchingcancauseapainfulanddebilitatingstraintoligaments.

CauseofInjuryRepetitive strain from throwing activity. Direct injury to the elbow.Improperathletictechnique.

SignsandSymptomsPainoverbothsidesoftheelbow.Weakness,stiffnessornumbnessoftheelbow.Restrictedmobilityoftheforearmduetoelbowinjury.

ComplicationsifLeftUnattendedThrower’s elbow eventually restrictsmovement in the arm and causesongoing pain and inflammation. Bone spurs and chips, calciumformationand theproductionof scar tissueare all symptomaticof thisinjury over time if left unattended. Without proper treatment and

rehabilitation,pressureonnervesandmusclesduetoinflammationcanrestrictbloodflowandcompressnervesusedtocontrolforearmmuscles.

ImmediateTreatmentAvoidanceoftheactivitiescausingrepetitivestresstotheelbow.RICERregimen for 48–72 hours following injury. Use of anti-inflammatorydrugsandanalgesics.

RehabilitationandPreventionProperwarm-upinorder topreparemusclesandtendonsfor throwingactivities is an essential preventive measure. Stretching exercises tomaintainsupplenessandflexibilityoftendonsshouldbeanongoingpartofathleticpreparation.Bracingandstrappingthearmpriortothrowingactivitymay alsohelp toprevent thrower’s elbow.Attention toproperequipmentandtechniqueiscritical.Followingaperiodofrecoveryfrominjury, exercises directed at regaining flexibility, endurance and powershouldbeundertaken.

Long-termPrognosisWith proper rehabilitation, those suffering from thrower’s elbow cangenerallyexpectafullrecovery,thoughallowingtheproblemtoworsencan lead to permanent, potentially career-ending restrictions ofmovementforathletes.

039:ELBOWBURSITIS

Elbowbursitis,alsoknownasolecranonbursitis,referstoinflammationand swelling of the olecranonbursa. Bursae are small, fluid-filled sacs.They provide gliding or cushioning surfaces that lubricate and reducefriction. Bursae tend to be located adjacent to tendons of major joints,including the shoulders, hips, knees and elbows.Elbowbursitis occurswhen the bursa below the tip of the elbow becomes inflamed fromleaningonittoomuchorisinjuredthroughdirecttrauma.

Bursaearetypicallynotvisibleunlessbursitishascausedthemtoswelland become apparent. Non-inflammatory bursitis usually results fromrepeated trauma, such as leaning on the elbows, while inflammatorybursitisistheresultofinfectionoranunderlyinginflammatorymedicalconditionsuchasrheumatoidarthritis.

CauseofInjuryA hard blow to the tip of the elbow, causing the bursa to swell withexcess fluid. Leaning on the elbow tip for extendedperiods.An injury

thatbreakstheskin,causinginfectionofthebursa.

SignsandSymptomsPainintheelbowregionatrestandduringexercise.Arapidandpainfulswellingon thebackof theelbow (redandwarm if infected). Swellingmaystemfrombleedingorseepageoffluidintothebursalsac.Reducedmobilityoftheelbow.

ComplicationsifLeftUnattendedIn addition to continued pain, discomfort and loss of elbowmobility,untreated bursitis can lead to more serious complications, especiallywheninfectionispresent.Insuchcasesthefluidofthebursacanturntopusandthe infectioncanintensifyandspreadinaconditionknownasseptic bursitis, requiring aggressive medical treatment (includingantibioticsandoccasionallysurgicalremovaloftheinfectedbursa).

ImmediateTreatmentRest the afflicted elbow, avoiding all unnecessary pressure. Icecompresses,anti-inflammatorymedicationandanalgesics.

RehabilitationandPreventionAspirationbyneedletodrainfluidandreduceswellingmaybeneeded.Cortisone injections may also be given, which can help prevent re-accumulationoffluid.Barringseriousinfection,thesestepsaregenerallysufficient to treat elbow bursitis. Protecting the elbow during athleticswithbracingorpadding,andavoidingexcessiveleaningonthepointoftheelbowcanhelppreventtheinjury.

Long-termPrognosisThe long-term outlook for elbowbursitis is generally good, dependingontheseverityandnatureof the injury.Mostpatientscanexpecta fullrecovery, though complications can arise if infection is present,particularlyiftheconditionisnotgivenpromptmedicalattention.


DumbbellCurls

Standwithyourfeetshoulderwidthapartandadumbbellineachhand.Begin by letting the dumbbells rest naturally at your sides. Turn thedumbbellssoyourpalmsarefacingtheceilingasyoubendyourelbowsandliftthedumbbellsuptoyourchest.

CloseGripBenchPress

Lieonaweightbenchandletthebarrelaxagainstyourchestwithyourelbowsatyourside.Moveyourhandsasclosetogetheraspossibleandliftthebardirectlyupwards.

RopePressDown

Withyourfeetfirmlyontheground,griparopewithyourelbowsbentat a 90-degree angle.Pull the ropedownby straighteningyour elbowsandbringingyourhandstowardthefloor.

DumbbellKickbacks

Restonehandandthesamekneeonaweightbench.Beginbyholdinga

dumbbell with your elbow at a 90-degree angle in the other hand.Straightenyourelbowandpushthedumbbellasfarbehindyouasyoucan.Returntothestartingpositionslowlywithoutlettingthedumbbellfall.

DumbbellOverheadExtension

Holdadumbbellinonehandandputitbehindyourheadlettingitfalltowardthefloor.Withyourelbowpointingtowardtheceiling,raisethedumbbell ashighasyoucanuntilyourelbow is straight.Slowlybringthedumbbellbacktothestartingpositionandrepeat.

BroomstickRotatorStretch

Stand with your arm out and your forearm pointing upwards at 90degrees.Placeabroomstickinyourhandandbehindyourelbow.Withyourotherhandpullthebottomofthebroomstickforward.

OverheadTricepsStretch

Stand with your hand behind your neck and your elbow pointingupwards.Thenuseyourotherhandtopullyourelbowdown.

CHAPTER9SportsInjuriesoftheShoulderandUpperArm


The shoulder region is actually composed of three articulations: thesternoclavicular (SC) joint, the acromioclavicular (AC) joint and theglenohumeral (GH) joint.The scapulothoracic articulationdescribes themovement of the shoulder blade on the chest wall. The articulationreferredtospecificallyastheshoulderjointistheGHjoint:theothersarejointsof theshoulder (orpectoral)girdle.Thestructureof theshoulderpermits awide arrange ofmotion, allowing thepositioning of the armandhand.

TheGHjointconsistsofaball(formedbythehumeralhead)andsocket(theglenoidcavity).WhiletheGHjointisoneofthebody’smostmobilejoints, it is inherently unstable due to the glenoid cavity being onlyapproximately one-third the size of the humeral head (although it isslightlydeepenedbya rimof fibrocartilage called theglenoid labrum).The GH joint is stabilized by the joint capsule, the glenohumeral,coracohumeralandtransverseligaments,theglenoidlabrumandbytherotatorcuffmuscles.

Theshoulderregion.

The clavicle (collarbone) is a slender, curved bone. It acts as a strutattaching the shoulder to the body and works with the scapula toincrease range of motion at the shoulder. The clavicle attaches to thesternum medially (the SC joint) and to the acromion process of thescapula laterally (the AC joint). The AC joint is a plane joint. Afibrocartilage articular disc partially divides the articular cavity andabsorbsforcesandcompression.TheACjointisstabilizedbytheanteriordeltoidmuscle,thetrapeziusmuscleandbystrongstabilizingligaments.

The SC joint is functionally a ball-and-socket joint but, unlike mostarticular surfaces, the articular cartilage is fibrocartilage rather thanhyalinecartilage.TheSCjointissurroundedbyajointcapsule,thickenedanteriorly and posteriorly by strong stabilizing ligaments. Thesternoclavicular joint is strong and generally resistant to dislocation. Ithasawiderangeofmovement.

The biceps brachiimuscle is located on the front of the upper arm. Its

main function is to allowelbow flexion and supination and to supportloadsplacedon the arm.The longand shortheadsof themusclehaveseparatepoints of originon the scapula andattachvia a tendon to theradiusandviaanaponeurosistothefasciaoftheforearm.ThetendonofthelongheadofbicepsiscloselyassociatedwithmovementsoftheGHjoint.

The rotator cuff of the shoulder is composed of four muscles:subscapularis,supraspinatus,infraspinatusandteresminor.Theyhelptostabilize the GH joint during movement by keeping the head of thehumerusintheglenoidfossa.Thesubacromialbursa(afluid-filledsac)isthe largestandmostcommonly injuredbursa in theshoulderregion. Itprotects the supraspinatus tendon in the subacromial spacewhere it ispronetoimpingement.

Alongwiththepectoralisminor,thelargepectoralismajormuscleformstheanteriorwalloftheaxilla.Ithasawideoriginintheclavicle,sternumand first six costal cartilages and inserts on the bicipital groove of thehumerus. Pectoralismajor adducts andmedially rotates the arm at theshoulder.Theclavicularportionallowsthehumerustobebroughtuptothehorizontalandthedirectionofthesternocostalfibersallowsthearmtobeextendedagainstresistance,forexample,whendoingpress-ups.Itisanimportantmuscleinclimbing,throwingandpunching.

Shouldergirdlemuscles.

040:FRACTURE(COLLARBONE,HUMERUS)

Fractures of the shoulderusually involve a break in either the clavicle,the neck of the humerus or both. Impact injuries involving a suddenblow to the shoulder or a fall are usually responsible. Contact sportsincludingfootballandrugbycanresultinshoulderfracturesfollowingaviolentcollisionoftwoplayers.

Clavicular fractures are common, often resulting from a fall onto thelateral shoulder or an outstretched arm. Fractures of the humerus aregenerallytheresultofafallonanoutstretchedarm.

CauseofInjuryFallonanoutstretchedarm.Suddenblowtotheclavicle.Collisionoftwoathletesinsports.

SignsandSymptomsSeverepain.Rednessandbruisingaroundthesiteof injury.Inabilitytoraisethearm.

ComplicationsifLeftUnattendedComplicationsareuncommon.Duetotheproximityoftheclavicletothepleurae of the lungs and underlying nerve and blood vessels,pneumothorax, haemothorax and injury to the brachial plexus orsubclavianvesselsarepossible, requiringmedical intervention.Chronicpain,decreasedrangeofmotionandstiffnessdue toosteoarthritismayresultshouldtheinjurybegiveninsufficienttimetoheal.

ImmediateTreatmentIce and analgesics for pain. Immobilization of the injured arm with asling.

RehabilitationandPreventionBonesoftheclavicleandhumerusmustberealignedfollowingfracturesothatproperhealingmayensue.Healingoccurswhiletheclavicleandarmbonesareheldinplacewithastraporsling.Afterhealing,physicaltherapyincludingrangeofmotionandstrengtheningexercisesshouldbeundertakentorestorefullmovementandflexibility.

Long-termPrognosisMost shoulder fractures are successfully treated without resort tosurgery, although this is occasionally required for fractures of theclavicle. For less severe fractures, full recovery and restoration ofmobility may be expected. In the case of more severe fractures andparticularlyinolderpatients,somelossofmotionandthepossibilityofosteoarthritisexist.

041:DISLOCATIONOFTHESHOULDER

Dislocationof the shoulder at theGH jointmayoccurwhenan athletefallsonanoutstretchedhandorduringabductionandexternalrotationof the shoulder. Significant force is required to dislocate a shoulderunlesstheathleteisexperiencingre-injury.Ashoulderdislocationoccurswhen the head of the humerus pulls free of the glenoid fossa of thescapula.

While several types of shoulder dislocation exist, themost common isanteriordislocationwhichrepresents95%ofallcases.Inthisdislocationinjury, the structures responsible for stabilizing the anterior shoulder,including the capsule and the inferior glenohumeral ligament, are tornfreefromthebone.Compressionfracturesoftheposteromedialhumeralhead known as Hill-Sachs lesions are associated with anteriordislocations.More commonly, avulsion of the anterior glenoid labrumcanoccur,whichisknownasaBankartlesion.

CauseofInjuryViolent contact with another athlete or solid object. A fall onto an

outstretchedhand.Sudden,violenttorsionoftheshoulder.

SignsandSymptomsSeverepain in theshoulder.Armheldawayfromthebodyat theside,with the forearm turned outward. Irregular contour of the deltoidmuscles.

ComplicationsifLeftUnattendedDislocation of the GH joint causes damage to the joint ligaments,resultinginthe jointbecominglessstableandconsiderablymoreproneto successive dislocations during athletics. Immobilization of theshoulderduringthehealingphasedoesnotfullypreventsuchre-injury,which may require surgical intervention, since the immobilizedligamentsoftenfailtohealintheproperposition.Damagetotheaxillaryarteryandnervecanalsooccur,causingweaknessinthedeltoidmuscle.

ImmediateTreatmentRealignment or reduction of the dislocated joint. Immobilization andanalgesicsforpain.

RehabilitationandPreventionMost initial shoulderdislocationsare treatedwithout resort to surgery,although subsequent dislocations may require surgical care. Manyathletessufferarangeofdisabilitiesfollowingdislocation.Analternativetosurgicaltreatment–prolotherapy–involvesinjectionsdirectedattheanterior shoulder capsule and the insertionsof themiddle and inferiorglenohumeral ligaments. This may offer better relief from pain,restorationofmobilityandaspeedierreturntoathleticactivity.Further,

thetechniqueavoidstheformationofscartissuecommonaftersurgery.

Long-termPrognosisA large percentage of athletes may be unable to continue sportsfollowingashoulderdislocationwithoutsubsequentinjuriesortheneedfor surgical treatment. Furthermore, athletes who undergo surgeryfollowing shoulder dislocation are often unable to perform at theirformerlevel.Thealternativemethodofprolotherapymayofferreliefandmoreeffectivehealing.

042:SHOULDERSUBLUXATION

The shoulder complex enables extreme mobility due to its anatomicalstructure but provides little stability. Glenohumeral subluxation is apartialdislocationoftheball-and-socketjointoftheshoulder.Instabilityin the shoulder joint complex, particularly following dislocation, canresultinsubluxation.

CauseofInjuryA direct blow to the shoulder. A fall onto an outstretched arm.Strenuouslyforcingthearmintoanawkwardposition.

SignsandSymptomsSensationoftheshouldergoinginandoutofthejoint.Loosenessoftheshoulderjoint.Pain,weaknessornumbnessintheshoulderorarm.

ComplicationsifLeftUnattendedUntreated subluxation can cause wear and ultimately damage to theinternalstructuresoftheshoulder,sometimesrequiringsurgery.Lossof

mobility,ongoingpainandosteoarthriticcomplicationsmayresultfromuntreatedsubluxation.

ImmediateTreatmentRICER regimen to reduce inflammation and treat pain. Anti-inflammatorymedicinesandanalgesicsforpain.

RehabilitationandPreventionFollowingimmobilizationandhealing,strengtheningexercisesshouldbeundertaken. Recovery depends on factors including the athlete’s age,health, history of previous injury and severity of subluxation. If theshoulder subluxates frequently during activity, significant physicalrehabilitationwillbeneededandpossiblysurgery.

Long-termPrognosisNormal sports activity may be resumed once a full range of motionwithout subluxation has been achieved. Prognosis is dependent on theseverity of the subluxation and the athlete’s particular history.Subluxation is often due to previous shoulder injury and returning toathletics before full recovery can lead to further and worseninginstability.

043:ACROMIOCLAVICULARSEPARATION

Acromioclavicular separation isa ruptureof the ligaments that connectthe clavicle to the tip of the scapula known as the acromion process.Acromioclavicular (AC) joint injuries generally occur in the course ofupper-extremitystrengthtraining,variousthrowingsportsandcollisionsports (particularly football andhockey).The injury is commonamongathletesintheir30sand40s.

CauseofInjuryFallontothepointoftheshoulder.Fallontoanoutstretchedhand.Directblowtotheshoulder.

SignsandSymptomsPain, tendernessandswellingat theAC joint.Deformityof the injuredjoint. Pain or discomfort during cross-body adduction (turning theinjuredarminwardtowardtheoppositeshoulder).

ComplicationsifLeftUnattendedDegenerative joint abnormalities, chronic pain and stiffness andlimitations in mobility requiring surgery are possible should thecondition not be given prompt medical attention and allowed properhealingtime.

ImmediateTreatmentImmobilizationoftheinjuredarmwithasling.Icepacks,restandtheuseofanti-inflammatorymedicationandanalgesicsforpain.

RehabilitationandPreventionAC separations of a less severe nature are successfully treatedwithoutsurgery, though a thorough healing period of 6–8 weeks is generallyrequired. Following this, range-of-motion exercises should be used toavoidstiffness.Exercisesdirectedatmaintainingstrengthandstabilityoftheshoulderandupperbackmusclesmayhelpprevent the injury,anduseofpaddingaround theAC joint,particularlyduringcontact sports,mayhelpavoidre-injury.

Long-termPrognosisGivenadequatehealingtimeandrehabilitation,mostACseparationsareresolvedwithoutsurgery.Shouldsurgeryberequired,risksofinfectionandcontinuedpainexist,andrecoverytimefortheathleteislengthened.

044:STERNOCLAVICULARSEPARATION

Sternoclavicular separation occurs when a ligament connecting theclavicle to the sternum is torn. Rotation at the joint is affected by thisinjury, which may occur during contact sports when the shoulderforcefully strikes the ground or is landed on by another player. Theseparationmayoccuranteriorlyorposteriorly(infrontoforbehindthesternum).

CauseofInjuryDirectblowtothesternum.Fallontotheshoulderoroutstretchedhands.Shoulder striking the ground, or another athlete landing on top of theshoulder.

SignsandSymptomsPain, swelling and tenderness over the SC joint. Abnormal movementbetween the sternumandclavicle.Possibledisplacementof the clavicleinfrontoforbehindthesternum.

ComplicationsifLeftUnattendedUntreated sternoclavicular separation can lead to loss of motion andongoing pain, stiffness and weakness around the shoulder. In caseswhere the clavicle is forced behind the breastbone the risk exists fordamage to important underlying blood vessels requiring surgicalintervention.

ImmediateTreatmentReduction of the joint where needed and immobilizationwith a sling.RICERtoreduceswelling,traumaandpain.

RehabilitationandPreventionAs the injury is generally caused in sports accidents, prevention isusually not possible. In the case of anterior injury to the SC joint (themost common), the condition is generally resolvedwithout permanentcomplicationsgivenadequatehealingtime.Inmoreseverecases,surgerymay be required. Range of motion exercises should help restoremovementandrotationalability.

Long-termPrognosisWithadequatetimeforhealing,theinjuredathletetypicallymakesafullrecovery. If the injury is serious (particularly in the case of posteriordislocation) instability of the jointmaypersist, in some cases requiringsurgery.

045:BICEPSBRACHIITENDONRUPTURE

Repetitive strain, particularly due to over-lifting, can lead to irritationandmicroscopic tears in the biceps brachii tendon,which connects thebicepsbrachiimuscletothescapulaattheproximalendandtheradiusand fascia of the forearm at the distal end. A biceps brachii tendonruptureresultsfromsuddentraumatothebicepsbrachiitendon.Injuryat the proximal end of the tendon of the long head of biceps is mostcommon.Bicepsbrachiitendonrupturescanoccurfromweightliftingorthrowing sports but are generally uncommon, particularly in youngathletes.Inolderindividualsitisoftentheresultofdegenerativechangeorpreviousinjurytothetendon.

CauseofInjuryWeakness due to tears in the rotator cuff. Throwing activities.Weightlifting.

SignsandSymptomsBulge in the upper arm. Inability to turn the palm upward. Sudden,sharppainattheshoulder.

ComplicationsifLeftUnattendedGenerally,littlefunctionallossaccompaniesruptureofaproximalbicepsbrachiitendon,astwotendinousattachmentsoccurattheshoulder,onecompensating theother inmostcases.For this reason,surgery is rarely

requiredandcomplicationsarerare,thoughwithoutproperhealing,re-tearinganddegenerationofthetendonaremorelikely.

ImmediateTreatmentAnti-inflammatory and analgesic medications to reduce pain. RICERregimenimmediatelyfollowinginjury.Laterheattopromotebloodflowandhealing.

RehabilitationandPreventionFollowingrestandrecoveryofthetendon,flexibilityandstrengtheningexercises shouldbeundertaken to restore fullmobility in the shoulder.Avoidanceofsuddenliftingbeyondnormalcapacityandviolentloadingtothebicepsbrachiitendonasduringthrowingsportsmayhelppreventtheinjury.

Long-termPrognosisMost biceps brachii tendon ruptures resolve without medicalintervention if given proper time for healing. In younger athleteswithdemanding training schedules, surgerymay be contemplated to repairthe rupture. Tears and ruptures to the distal end of the biceps brachiitendon at the elbow are more rare but can be more severe, requiringsurgery.Inbothcasestheprospectsforfullrecoveryareexcellent.

046:BICEPSBRACHIIBRUISE

Bruisingtothebicepsbrachiicanoccurfollowingtearingand/orruptureof thetendonortraumatothemuscle.Overstrainfromweighttrainingcancausetearsandbruisingwhichmayalsoresultfromthrowingsportsorfollowingdirecttraumatotheshoulderduringafallorcollisionwithanotherathlete.

CauseofInjuryDirectblowtothebicepsbrachiiregionoftheupperarm.Bicepsbrachiitendonrupture.Repetitivestraintothebicepsbrachiimuscleortendon.

SignsandSymptomsDiscoloration of the biceps brachii area. Aching or tenderness in themuscle. Stiffness and limitation of movement in the affected arm andshoulder.

ComplicationsifLeftUnattendedBruising of the biceps brachii generally resolves without treatment.

Sportsinvolvingheavyuseofthebicepsbrachiimuscleincludingweighttrainingandthrowingsportsandcontactactivitieswithhighrisktothebicepsbrachiishouldbeavoidedtogiveadequatetimeforhealing.

ImmediateTreatmentRICER regimen and analgesics to reduce inflammation and pain.Immobilizationwithaslingtopreventexcessmovement.

RehabilitationandPreventionRest and avoidance of activities involving stress to the biceps brachiimuscle and tendons during the healing phase are generally sufficient.Range of motion exercises and graded strength training should beundertakentorestorefullpowerandresiliencetothemuscle.Stretchingexercisesperformedbeforeathleticactivitymayhelppreventinjuryandassociatedbruising.

Long-termPrognosisBruising to biceps brachii is generally a minor condition that is self-correctingwithoutresorttosurgery,givenadequatetimeforhealing.Nolong-termdeficitinstrengthormobilityisexpected.

047:MUSCLESTRAIN(BICEPSBRACHII,CHEST)

Muscle strains are among the most common sports injuries and oftenresultfromthesuddenextensionofajointbeyonditsnormalrange.Thiscauses damage to muscle and other soft tissue. The chest muscles(pectoralis major and minor) join the biceps brachii muscle at theshoulder.Weighttraining,sudden,violenttorsionoftheshoulderduringthrowingsportsorsuddenforceappliedtothenexusofthepectoralsandbiceps brachii (as when warding off a check in hockey with the armextended)canproducesuchinjuries.

CauseofInjurySudden movement leading to a muscle tear. Large physical demandplacedonthemuscle.Wardingoffacheckinhockeyortackleinfootball.

SignsandSymptomsTenderness and pain over the affected muscle. Stiffness. Pain duringmuscleuse.

ComplicationsifLeftUnattendedMuscle strains are usually self-limiting and repair themselves givenpropertimeofffromexertionforhealing.Insufficientrecoverytimecanlead to further tearing, increasing the risk of re-injury and causedegenerativechangesinthemusclesovertime.

ImmediateTreatmentRICER regimen and analgesics to reduce inflammation andpain. Thenheattopromotebloodflowandhealing.

RehabilitationandPreventionStretchingexercisesfollowinghealingcanhelprestorefullmobilitytotheaffected area while strengthening exercises can help prevent re-injury.Stretchingandwarm-up,aswellasattentiontoproperathletictechnique(particularlyinweighttraining)mayhelppreventthistypeofinjury.

Long-termPrognosisMusclestrains involvingthepectoralmusclesand/orbicepsbrachiiarecommonand–givenadequatetimeforproperhealing–generallynotaserious threat to theathlete,althoughsevereorrepeatedmusclestrainscancausechronicpainandleadtoimpairmentofmusclefunction.

048:SUBACROMIALIMPINGEMENT

Subacromial impingement problems in the athlete are associated withrepetitive overhead activity and throwing events. Compression of thenarrowsubacromialspaceonthetopoftheshoulderbetweentheheadofthehumerus and the acromionof the scapula results in local pain andloss of coordination in the rotator cuffmuscles of the shoulder. Tissuetrauma associated with it includes damage to the glenoid labrum, thetendon of the long head of biceps brachii and the subacromial bursa.Dysfunctionanddamageinthemusclesoftherotatorcuffcancausethehumeralheadtodisplaceupwardduringelevationofthearm,leadingtoirritationofstructuresinthesubacromialspacesuchasthesupraspinatustendonandsubacromialbursa.

CauseofInjuryRepeated overhead movements as in tennis, swimming, golf andweightlifting. Irritation of the rotator cuff due to throwing sportsincluding baseball. Underlying predisposition, including rheumatoidarthritis.

SignsandSymptomsShoulderpainanddifficultyraisingthearmintheair.Painduringsleepwhen the injured arm is rolled on. Pain during rotational movementssuchasreachingintoabackpocket.

ComplicationsifLeftUnattendedIncreasing stiffness of the joint and further loss of motion may resultshould impingement be ignored. Rotator cuff tendons may be tornshould athletic activity be undertakenprior to full recovery. Tendinitisandbursitisfrequentlydevelopwithimpingementasapre-condition.

ImmediateTreatmentRest, ice packs and anti-inflammatory medication. Corticosteroidinjectionsmaybeusedundertheacromiontoreduceinflammation.

RehabilitationandPreventionFollowing a period of healing, physical therapy will often be used torestore strength and range of motion in the affected rotator cuff.Avoidingor limitingrepetitivemotionsthatcauserotatorcuff irritationmay help prevent the injury. Strengthening exercises and light-weighttraining to strengthen the muscles of the rotator cuff are also usefulpreventivemeasures.

Long-termPrognosisTypically,theconditionshowsmarkedimprovementwithin6–12weeks.Incaseswhererecoveryhasnotbeenachievedin6–12months,surgerymay be recommended to release the ligaments. Surgery is usuallyfollowedbyphysicaltherapy,andsomemodificationofathleticactivity

maybenecessarytoreducethechancesofrelapse.

049:ROTATORCUFFTENDINITIS

Rotatorcufftendinitisresultsfromtheirritationandinflammationofthetendonsoftherotatorcuffmusclesintheareaunderlyingtheacromion.The condition is sometimes known as pitcher’s shoulder though it is acommon injury in all sports requiring overhead arm movements,includingtennis,volleyball,swimmingandweightlifting.

CauseofInjuryInflammation of the rotator cuff tendons from tennis, baseball,swimming, etc. Irritation of the subacromial bursa of the rotator cuffcausinginflammationandswellinginthesubacromialspace.Pre-existingdispositionincludinganatomicalirregularity.

SignsandSymptomsWeakness or pain with overhead activities, such as brushing hair,reachingup,etc.Poppingorcrackingsensationintheshoulder.Painin

theinjuredshoulder,particularlywhenlyingonit.

ComplicationsifLeftUnattendedRotatorcufftendinitiscanworsenwithoutattentionasthetendonsandbursabecomeincreasingly inflamed.Motionbecomesmore limitedandtendontearscancausefurtherandinsomecaseschronicpain.Prolongedirritationmayresultintheproductionofbonespurswhichcontributetofurtherirritation.

ImmediateTreatmentApplicationoficeanduseofanti-inflammatorymedication.Discontinueall athletic and other activity causing rotator cuff pain. Then heat topromotebloodflowandhealing.

RehabilitationandPreventionFollowing rest and healing of the injured shoulder, physical therapyshould be undertaken to strengthen the muscles of the rotator cuff.Occasionally steroid injections are required to reduce pain andinflammation. Moderation of rotator cuff use, adequate recovery timebetween athletic activities and strength training can all help avoid theinjury.

Long-termPrognosisGiven proper rest as well as physical therapy and (where needed)steroidal injections,mostathletesenjoya full recovery fromthis injury.Should a serious tear of the rotator cuff tissue occur, surgery may berequired although recovery to pre-injury levels of activity is usuallyexpected.

050:SHOULDERBURSITIS

Shoulder bursitis is not generally an isolated condition but is usuallyassociated with a rotator cuff tear or impingement syndrome. Thesubacromialbursaisthelargestandmostcommonlyinjuredbursaintheshoulderregion.

Bursitismaybecausedbyacombinationoffactorsincludingrotatorcuffdysfunction,instabilityinthejointsofthepectoralgirdle,osteoarthritis,posturalmisalignments,bonespursandanythingthatdecreasesspaceinthelimitedsubacromialspace.

CauseofInjuryOverusefromthrowingactivities, tennis,swimmingorbaseball.Fallingontoanoutstretchedarm.Localinfection.

SignsandSymptomsPainintheshoulder,particularlywhenraisingthearm.Painonlyingonorcompressingtheinjuredshoulder.Lossofstrengthandlimitedmotionoftheshoulder.

ComplicationsifLeftUnattendedFailuretoattendtoshoulderbursitisgenerallyresultsinaworseningofthe condition, a further thickening of tendons and bursa(e) leading toincreasedinflammationandpain.Theathleterunstheriskofdevelopinga chronic condition, as well as a danger that the fluid in the bursa(e)becomesinfected,apotentiallyserioussituationsometimesnecessitatingsurgery.

ImmediateTreatmentDiscontinue all activity causing inflammation of the shoulder. RICERregimenandanalgesics to reduce inflammation andpain.Thenheat topromotebloodflowandhealing.

RehabilitationandPreventionTheathleteshouldavoidpressuretotheinjuredshoulderandinflamedbursa(e) during recovery as well as any activities likely to irritate thecondition. Begin exercising the shoulderwhen instructed by amedicalprofessional in order to restore strength and shoulder mobility.Warming-up and cooling-down exercises, with an emphasis onstretching, strength training andmaintaining looseness in the shouldercanhelppreventbursitisfromdeveloping.

Long-termPrognosisShoulder bursitis tends to ease with proper healing and minorrehabilitation, and a full recovery to athletic activity can usually beexpected, particularly if no infection of the bursa is present. In somecases, aspiration of bursal fluid by needle is recommended to reduceinflammationandensurenoinfectionispresent.

051:BICIPITALTENDINITIS

Bicipitaltendinitisresultsfromirritationandinflammationtothebicepsbrachiitendon,whichliesonthefrontoftheshoulderandallowselbowflexionandsupinationoftheforearm.Overusecanleadtoinflammationand is a common affliction in golfers, weightlifters, rowers and thoseengagedinthrowingsports.

Irritationofthetendonofthelongheadofbicepsoccursasitmovesupand down in the intertubercular (bicipital) groove of the humerus.Inflammation can be to the tendon itself or to the tendon sheath orparatenons. Themusculo-tendinous junction of biceps brachii is highlysusceptible to injuries brought on by overuse, particularly followingrepetitiveliftingactivities.

CauseofInjuryPoortechnique,particularlyinweightlifting.Suddenincreaseindurationorintensityoftraining.Shoulderimpingementsyndrome.

SignsandSymptomsPainoverthebicipitalgroovewhenthetendonispassivelystretchedandduringresistedsupinationandelbowflexion.Painandtendernessalongthetendonlength.Stiffnessfollowingexercise.

ComplicationsifLeftUnattendedBicipitaltendinitis,leftwithoutcareandtreatment,generallyworsensasthe biceps brachii tendon becomes increasingly irritated and inflamed.Movement and the ability to perform athleticallywithout painwill befurther hampered. Exercising without adequate healing andrehabilitationcanleadtotearingofthetendonandtendondegenerationovertime.

ImmediateTreatmentRICERregimentorelievepainful inflammation.Anti-inflammatoryandanalgesicmedication.Thenheattopromotebloodflowandhealing.

RehabilitationandPreventionThecondition is self-limitinggivenrestandminimalmedicalattention.Following full recovery, exercises directed at improving flexibility,proprioception and strength may be undertaken. Thorough warm-upand stretching exercises and a steady athletic regimen that avoidssudden, unprepared increases in activity can help avoid this injury, ascanattentiontopropersportstechnique.

Long-termPrognosisA full return to athletic activity may generally be expected givenadequate time for tendon recovery and reduction of inflammation.

However,theinjuryfrequentlyrecurs.Surgeryisgenerallynotrequired.Corticosteroidinjectionsaresometimesusedtoreducepain,thoughtheymustbeappliedcautiouslyastheyincreasetheriskoftendonrupture.

052:PECTORALMUSCLEINSERTIONINFLAMMATION

Thepectoralismajororpectoralmuscleisusedinmanysportswhenthearms act to push away a weight (as during weightlifting) or anotherathlete (during various contact sports). Repetitive activity, particularlybench-pressing,cancauseirritationtothemuscleand/ortendonleadingtodiscomfortandlossofmobility.

CauseofInjuryExcessive load on the pectoralismajormuscle, especiallywhen bench-pressing. Excessive force against themuscle from pushing activities incontactsports.Afallontooneorbothoutstretchedarms.

SignsandSymptomsPain andweakness in the shoulder.Difficulty raising the arm. Pain orstiffnessduringlifting.

ComplicationsifLeftUnattendedIrritationofthepectoralmuscleinsertionwillbecomefurtheraggravatedif it isneglected.Tears in themuscleor tendoncandevelop, leading toincreasedpainandweaknessandthedangeroflong-termdegenerationof muscle and tendon. Should tearing at the insertion point becomeserious,surgerymayberequiredtorepairit.

ImmediateTreatmentImmediatecessationtoathleticactivitycausingirritation.RICERregimen

toreduceinflammationandtreatpain.Thenheattopromotebloodflowandhealing.

RehabilitationandPreventionThorough healing time must be allowed for the pectoral muscle andassociated tendons. Strength training of the pectorals through weightsand graded calisthenicswill generally help restore the athlete to priorcondition, provided no serious tearing of the muscle has resulted.Attentiontoproperweighttrainingtechniqueandagradualratherthansudden increase in stresson thepectoralmuscles canhelpprevent thisinjury.

Long-termPrognosisGiven proper care and healing time, combined with gradual strengthtraining of the pectoral and shouldermuscle complex, the athletemaygenerallyexpectafullreturntonormalactivity.

053:FROZENSHOULDER(ADHESIVECAPSULITIS)

Frozen shoulder or adhesive capsulitis causes severe restriction ofshouldermovement due to pain. The condition results from abnormalbandsoftissuethatformonthejointcapsule,therebyrestrictingmotionandproducingpainonmovement.Synovial fluidwhichusually servesto lubricate the joint space allowing smoothmotion is often lacking inthiscondition.Idiopathicadhesivecapsulitisismorecommoninfemalesanddiabetics.Onsetintheathletemayfollowtraumatotheshoulder.

CauseofInjuryScartissueformationfollowingshoulderinjury.Formationofadhesionsfollowingshouldersurgery.Repeatedtearingofsofttissuesurroundingtheglenohumeraljoint.

SignsandSymptomsDull,achingpainintheshoulderregion,oftenworseatnight.Restrictedmovementoftheshoulder.Painwhenmovingtheaffectedarm.

ComplicationsifLeftUnattendedFrozen shoulderhas a tendency toworsenover timewithout adequatetreatment and proper recovery period. Attempted athletic activityinvolving the affected shoulderwill likely lead to further adhesions of

the joint,withfurtherpainandrestrictionsofmovement.Productionofscartissuemayeventuallyrequiresurgicalremoval.

ImmediateTreatmentApplication of moist heat to the shoulder to loosen the affected joint.Musclerelaxantstorelaxshouldermusclesandarm.

RehabilitationandPreventionMoist heat shouldbe accompaniedby stretching exercises to graduallyrestore mobility. Heat therapy should be combined with doctor-supervisedphysicaltherapy.Movingtheshoulderthroughthefullrangeofmotionseveraltimesdaily,aswellasstrengthtrainingexercises,mayhelp avoid frozen shoulder. Injuries to the shoulder should be givenprompt medical attention to avoid formation of scar tissue wherepossible.

Long-termPrognosisThelengthofrecoverytimefollowingfrozenshouldervariesdependingontheunderlyingcauseaswellastheageandhealthoftheathleteandthehistoryofshoulderinjury.Iftheconditionfailstoimproveafter4–6months surgery may be required. Some lasting discomfort andimpairmentofmovementiscommonwiththisinjury.


StandingDumbbellPress

Gripdumbbellswithyourpalmsfacingforwardandthedumbbellslevelwithyour ears.Press themupwards toward the ceiling and thenbringthedumbbellsdownslowlywithoutlettingthemfallpastyourearsandrepeat.

AlternateFrontRaise

Grip a dumbbell in each hand letting them rest on the tops of yourthighs. Raise one dumbbell while keeping your palm facing the floor.Lowerthedumbbelltothestartpositionandrepeatwiththeotherarm.

LateralRaise

Grip a dumbbell in each hand with your palms facing each other.Simultaneously raiseyourarmsout to thesideso thatyourpalms face

theground.Lowerthedumbbellstothestartpositionandrepeat.

AlternateDumbbellCurl

Gripadumbbell ineachhandandlet themfallnaturallyatyoursides.Lift one at a time by bending your elbow and raising the dumbbelltowardyourchest.Slowly lower thedumbbell to thestartpositionandrepeatwiththeotherarm.

Press-Ups

Liefacedownwithyourpalmsonthefloorpositionedslightlytothesideofyourshoulders.Raiseyourbodyupbypressingagainsttheflooruntil

yourelbowsarestraight.Slowlyloweryourbodyuntilyourchestgrazesthefloorandrepeat.

ReachBackShoulderStretch

Standuprightandclaspyourhands togetherbehindyourback.Slowlyliftyourhandsupward.

Wall-assistedChestStretch

Standwith your arm extended to the rear and parallel to the ground.Holdontoanimmovableobjectandthenturnyourshouldersandbodyawayfromyouroutstretchedarm.

CHAPTER10SportsInjuriesoftheBackandSpine


The spine (vertebral column) ismadeupofbonesknownasvertebrae,separatedby fibrocartilage intervertebraldiscs.Thespineconsistsof33vertebrae in total: 7 cervical, 12 thoracic, 5 lumbar (the largestweightbearingvertebrae),5 (fused)sacraland3–4 (fused) in thecoccyx(tailbone). There is only slight movement between any two successivevertebrae, but there is considerable movement throughout the spinalcolumnasawhole.Theintervertebraldiscsarecomposedofathickringof fibrous cartilage known as the annulus fibrosis which surrounds ajelly-like material known as the nucleus pulposus. Intervertebral discsprovide flexibility, cushioning and protection to the spine. The spinalcanalrunsthroughthecenterofthevertebraeposteriortothediscsandcontainsthespinalcordrunningfromthebrainstemtothe levelof thefirstorsecondlumbarvertebrae.

Thevertebralcolumn,lateralview.

Transversesectionofalumbarintervertebraldisc.

Sagittalsectionofvertebrae.

Ligaments are resilient bandsmade up of fibrous tissue. They providestrong,flexiblelinkagesbetweenbones.Anumberofligamentssupportthespine.Theanteriorandposteriorlongitudinalligamentsconnectthevertebral bodies in the cervical, thoracic and lumbar regions. Thesupraspinousligamentattachestothespinousprocessesofthevertebrae.Itisenlargedinthecervicalregionwhereitisknownastheligamentumnuchae.The ligamenta flavaattach to, andextendbetween, theventral

portionsofthelaminaeoftwoadjacentvertebrae,fromC2/C3toL5/S1.The ligaments,muscles and tendonswork together tomanage externalforcestothespineduringmovement,particularlybendingandlifting.

Ligamentumnuchae.

Themuscles around the spine are primarily responsible for stabilizingthe spinal column and keeping the back in an upright position. Themusclesofthebackandsidesallowtheupperbodyandspinetomoveinflexion,lateralflexion,extension,hyperextensionandrotation.

Latissimus dorsi, the broadest muscle of the back, is one of the chiefclimbing muscles, since it pulls the shoulders downwards andbackwards, and pulls the trunk up to the fixed arms. It is thereforeheavilyused insports suchasclimbing,gymnastics (inparticular ringsand parallel bars), swimming and rowing. The rhomboid muscles aresituated between the scapula and vertebral column, and are so namedbecauseoftheirshape(rhombus).Quadratuslumborumrunsacrossthewaist from the iliac crest and iliolumbar ligament up to the lowest riband the transverse processes of L1 to L4. Its action is to side-bend thetrunkandalsotoresistthetrunkbeingpulledsidewaysintheoppositedirection.

The intercostal muscles are thin, layered sheets of muscle runningbetweenadjacentribs.Theexternalintercostalmusclesofthelowerribs

mayblendwith the fibersof externalobliquemusclesof theabdomen,which overlap them, thus effectively forming one continuous sheet ofmuscle. Internal intercostal fibers liedeep to, and runobliquely across,theexternalintercostals.

The erector spinae muscles of the back , also called sacrospinalis,comprise three sets of muscles organised in parallel columns. From

lateral to medial, they are: iliocostalis, longissimus and spinalis.Longissimus is the intermediate part of the erector spinae. It may besubdividedintothoracis,cervicisandcapitisportions.Thespinalisisthemost medial part of the erector spinae. It may be subdivided intothoracis,cervicisandcapitisportions.

The transversospinalis muscles are a composite of three small musclegroups situated deep to the erector spinae. Unlike the erector spinae,eachgroupliessuccessivelydeeperratherthansidebyside.Themusclegroups are, from superficial to deep: semispinalis, multifidus androtatores. Their fibers generally extend upward and medially fromtransverseprocessestohigherspinousprocesses.Multifidusisthepartofthetransversospinalisgroupthatliesinthefurrowbetweenthespinesofthevertebraeandtheirtransverseprocesses. It liesdeeptosemispinalisand the erector spinae. Rotatores are the deepest layer of thetransversospinalisgroup.

Interspinalesareshortmusclespositionedeithersideoftheinterspinousligament. Like the interspinales, the intertransversarii are also shortmuscles.Thecervical and thoracic regionsencompass intertransversariianteriores and intertransversarii posteriores, and the lumbar regionencompassesintertransversariilateralesandintertrans-versariimediales.

Musclesoftheback.

054:MUSCLESTRAINOFTHEBACK

Back strain frequently involves the lower back (lumbar spine andsacrum). Back strain occurs from a stretching injury to themuscles ortendons of the back. It is a common sports injury that can result fromlifting,suddenmovement,orafall,collisionwithanotherathlete,oranyactivityinwhichthemusclesofthebackareengaged.Backstrainoftenaffectsthelowerbackorlumbarregionandthepainassociatedwiththisinjuryrangesfrommoderatetosevere.

CauseofInjurySudden strain on the back muscles from lifting. Abrupt movementinvolvingmusclesoftheback.Repetitivestresstothebackmuscles.Poortechniqueorposturalweakness.

SignsandSymptomsPain,stiffnessandlossofmovementintheback.

ComplicationsifLeftUnattendedMuscle strains in the back usually resolve with proper rest. Ignoringmuscle strain, however, can lead to chronic back pain, stiffness anddiscomfort, with degeneration of the muscles and tendons. Musclespasms accompanying inflammation can cause further pain, in somecasessevere.

ImmediateTreatmentRestonafirmsurface,lyingonthebackwithkneesraisedratherthanonthestomach.Icepack,analgesicandanti-inflammatorymedication.

RehabilitationandPreventionAfteruseoficetoreduceinflammation,heattherapyinmodestamountsmayhelpeasediscomfort.Recoverytimesformusclestrain in thebackvarywidelydependingontheseverityofthestrain,locationandoverallhealth of the athlete. When the muscles have begun to heal, it isimportantthattheyreceivemoderateusetoavoidwastingandatrophy.Later, exercises to strengthen the back and restore mobility can helpavoidrecurrenceofthisinjury.

Long-termPrognosisMusclestrainsintheback,thoughsometimesquitepainful,usuallyhealthoroughlywithnoresiduallossofmovementorpain,thoughsomeriskof re-injury exists, particularly if the strain was severe. Surgery is notrequiredincasesofmusclestrain,providednoseveretearingoftissueortendonisinvolved.

055:LIGAMENTSPRAINOFTHEBACK

Sudden, irregular motion, repetitive stress or excessive load on theligamentsassociatedwiththespinecancauseasprainor tearingof theligaments.Theresultinginjury,whichaffectsathletesinabroadvarietyofsports,producespainandvaryingdegreesofimmobility.

CauseofInjuryLiftingbeyondnormalcapacity.Suddentorsionofthespine,includingafall during skiing or other sport. Unpreparedmovement involving theback.

SignsandSymptomsPainandstiffness.Difficultybendingoverandpainwhenstraighteningtheback.Tendernessandinflammation.

ComplicationsifLeftUnattendedAspraintotheligamentswillgenerallyforcetheathletetoresttheinjury

and allow healing time due to pain and stiffness precluding normalactivity. Should activity be continued before adequate healing, furthertearingof the ligamentsand lasting ligament injurymayresult.Amildligamentspraincanbecomeacutelypainfulandincapacitatingifignored.

ImmediateTreatmentRICER regimen immediately following injury. Non-steroidal anti-inflammatorydrugs(NSAIDs).

RehabilitationandPreventionInthecaseofmildtomoderateligamentsprain,afewdays’restshouldallow a return to most non-athletic daily activity. This should beundertaken to re-establish flexibility in the spine and avoid atrophy.Strengtheningexercisesforthebackshouldnotbeundertakenuntilfullrecovery. Warm-ups and stretching prior to sports, good posture andattentiontopropertechniquecanhelpavoidthisinjury.

Long-termPrognosisLess than 5% of back injuries require surgery, and surgery is rarelywarrantedforligamentsprain,although6–8weeksofrecoveryareoftenrequired,sometimeslonger,shouldthesprainbeserious.Failuretoallowcompletehealingwillincreasetheriskofre-injury.

056:THORACICCONTUSION

Acontusionisaclosedwoundtothebody’ssofttissue,resultingfromablow tomuscle, tendon or ligament. Contusion injuries cause bruisingandoftendiscolorationduetobloodpoolingaroundthesiteoftrauma.Contusionsofthebackarepossibleinavarietyofcontactsportssuchasfootballandhockeyduetoviolentforceappliedtothesofttissuesorastheresultofafallontotheback.

Contusions involve trauma to the subcutaneous tissue. Because themusculature iswellvascularizedandtheregionalbloodflowisusuallyhighat themomentof impact,bleedingoccurs from tornbloodvesselsinto theskinandsubcutaneous tissues, formingabruiseorecchymosis(discoloration of an area of the skin). Capillaries are damaged due tobluntforce,resultinginbloodseepingintothesurroundingtissue.Whilemostcontusionsacquiredinthecourseofsportsactivityareminor,someare symptomatic of serious injuries including fractures or internalbleeding.

CauseofInjuryOverloadingorover-stretchingmusclesthroughablowtothebackfromanother athlete during contact sports. Blow from sports equipment,especiallyhockeyandlacrosse.Hardfallontotheback.

SignsandSymptomsPain at injury site. Tenderness to the touch. Blue, purple, orange oryellow discoloration of the skin. Painful spasms and knot-likecontractions(whichactasaprotectivemechanism).

ComplicationsifLeftUnattendedContusionsmay indicatemore seriousunderlying conditions includingfracture,haematoma(bloodinthemuscle)orotherinternalbleeding,allof which should receive prompt medical attention. Minor contusionsgenerallyclearupinamatterofdayswithoutcomplication.Moreseverecases,however,mayrequire3–4weekstoheal.

ImmediateTreatmentDiscontinueactivityandapplyicetoreduceswelling.Anti-inflammatorymedicationandanalgesicsforpain,ifneeded.Activitymodification.

RehabilitationandPreventionAvoiding pressure or further trauma to the contusion site andapplicationoficeareusuallysufficienttospeedrecovery.Ascontusionsresult from blunt force accidents, they are generally not preventable,thoughproperconditioninganddiet(includinganabundanceofvitaminC) may lessen the severity of contusion. Follow-up management mayinclude application of superficial heat, ultrasound, massage and

appropriatestretchingandresistanceexercise.

Long-termPrognosisWhilecontusionsinthebackcanproducesignificantacutepain,theyarefastertohealthanmusclestrainsorligamentsprains.Severityofbruisingdependsonmany factors, includingmuscle tensionor relaxationat thetime of injury. Pain will generally subside in hours or days and skindiscolorationwillabateaswell.Theathleteshouldenjoyafullreturntoactivity,inmoreseverecasesafterabout4weeks,withoutlastingdeficit.

057:DISCPROLAPSE

Discsaresegmentsofconnectivetissuethatseparatethevertebraeofthespine, providing absorption from shock and allowing for the smoothflexingoftheneckandbackwithoutthevertebralbonesrubbingagainsteachother.

Aslippeddisc (alsoknownasaherniated, rupturedorprolapseddisc)results when the shock-absorbing pads or intervertebral discs split orrupture.Thediscscontainajelly-likesubstancewhichseepsoutintothesurrounding tissue, causing local inflammation and pressure on thespinal nerves (and occasionally the spinal cord) where they exit thespinal canal. Slipped discs most frequently occur in the lower backalthoughanydiscofthespineisvulnerabletorupture.

CauseofInjuryImproper weightlifting technique. Excessive strain. Forceful trauma tothevertebraldisc.

SignsandSymptomsPain in the back or neck. Numbness, tingling or pain in the buttocks,back,upperorlowerlimb.Changesinbowelorbladderfunction(thisisrarebutshouldbetreatedasamedicalemergency).

ComplicationsifLeftUnattendedSlipped or herniated discs require medical attention and evaluation.Symptoms of slipped disc may indicate other underlying ailmentsincludingfracture,tumours,infectionornervedamage,withserious–incertaincases,life-threatening–implications.

ImmediateTreatmentBedrest,applicationofalternatingiceandheat.Useofanti-inflammatoryandanalgesicmedication.

RehabilitationandPreventionRest and limited activity for several days is usually indicated, thoughnormal,non-athleticdailyactivityshouldberesumedsoonthereaftertopreventatrophyandrestoremobilityinthespine.Physicaltherapymaybecombinedwithmassageandgraduallyincreasingexerciseofthebackafter the pain has subsided. Strengthening and flexibility exercises,proper warm-up, avoidance of excessive or suddenweight lifting andattentiontogoodsportstechniquemayhelpavoidtheinjury.

Long-termPrognosisMostdisc injuries are resolvedwithout surgery, givenproper recoverytime.Thoughfullrestorationofstrengthandmobilitymaygenerallybeexpected,discsarevulnerable to re-injury,particularly forweightliftersand athletesplacing significantdemandson the backmuscles, tendonsandligamentsandonthespineitself.

058:DISCBULGE

A bulging disc is one that has extended outward beyond its normalboundaryduetovariousformsofdegeneration.Shouldthediscimpingeontheligamentsconnectingthevertebraeoronnervesofthespine,painresults. A bulging disc may also result when the nucleus pulposuspushesoutward.Discbulgesmaybeasymptomatic,onlyappearingonamagneticresonanceimaging(MRI)scan.

CauseofInjuryAge-relatedwear anddegeneration. Stretching of ligaments connectingvertebrae.Successivestrainsfromimproperweighttraining.

SignsandSymptomsBackpainradiatingtothelegs(lumbardiscs).Backpainradiatingtotheshoulders (cervical discs). Numbness, tingling or pain in the buttocks,back,upperorlowerlimb.

ComplicationsifLeftUnattended

A bulging disc may not cause symptoms and may not be diagnosedwithout amedical scan. As a disc bulgesmore over time, however, itmay begin to impinge on nerves and cause pain. Sudden stress to thediscs,asduringabruptmovementsorweightlifting,cancauseruptureorherniation of the disc, a more painful condition requiring rest andrehabilitation.

ImmediateTreatmentCessation of activity stressing the spinal discs. Rest and alternating iceandheattoreduceinflammationandpain.

RehabilitationandPreventionBulgingdiscsoftenoccurasanaturalconsequenceoftheagingprocess,thoughinsomecasestheyareaprecursortodischerniationorrupture.Bulgingdiscs are an exampleof contained injurywhileherniateddiscsare considereduncontained.Minimizingundue stresson thebackmayhelpavoidthisinjury.

Long-termPrognosisMore severely bulging discs may in time rupture, causing the innermaterialtoextrudeintothespinalcanal.Inlessseverecases,restandicearegenerallysufficienttorestorepain-freemobilitytotheathlete.

059:STRESSFRACTUREOFTHEVERTEBRA

Theupper and lower joints of the lumbar spine are joinedby theparsinterarticularis, the weakest bony portion of the vertebral neural arch,andtheregionbetweenthesuperiorandinferiorarticularfacets.Overuseinjuries can result in cracks or fractures in the pars interarticularis,sometimes to the point where the vertebrae shift out of place; thiscondition is known as spondylolisthesis. The lowest lumbar vertebra(L5), where the spine meets the pelvis, is the most common site forvertebralfractures.

Stress fractures of the vertebrae (spondylolysis) are a common athleticinjury caused by overuse or hyperextension of the spine. Gymnastics,weightliftingandfootballareamongthesportspronetothisinjury,andit is a particularly common occurrence in adolescent athletes duringsuddengrowthspurts.

CauseofInjuryGenetic predisposition. Mechanical stress caused by overuse, flexion,

twisting or hyperextension of the lumbar spine. Growth spurts,especiallyinadolescents.

SignsandSymptomsPain spreading across the lower back. Spasms causing stiffening in theback.Tighteningofhamstringmuscles,causingchangesinposture.

ComplicationsifLeftUnattendedIf slippage due to vertebral fracture is ignored, itwillworsen and canbecomeincapacitating.Bonethathasdevelopedcracksrequiressufficienttimetorebuild,aprocessknownasremodeling.Surgerymayultimatelyberequiredshouldfracturesfurtherdevelopandbecomesevere.

ImmediateTreatmentRestandavoidanceofoveruseorstresstothelumbarvertebrae.Icepack,analgesicandanti-inflammatorydrugstoreduceinflammationandpain.Thenheattopromotebloodflowandhealing.

RehabilitationandPreventionFollowingathoroughhealingperiod(whichmaylast6weeksorlongerdepending on the severity of injury), flexibility and strength trainingexercises should be undertaken, avoiding overuse. Exercising on hard,inflexiblesurfaceslikeconcreteincreasestheforcescausingstresstothelumbarspineandshouldlikewisebeavoided.

Long-termPrognosisUnlike most stress fractures, spondylolysis (and spondylolisthesis) donottypicallyhealwithtime,althoughgivenadequatehealingtime,bone

remodeling tends to repair lumbar fractures, particularly in less severecases.Shouldrestandnormalrehabilitation fail to restoremobilityandshould long-term pain persist, spinal surgery (in which the lumbarvertebraearefusedwiththesacrum)maybenecessary.


BarbellRow

Standwithyourkneesslightlybentandleanforwardatyourwaist.Holdon to a barbell with your hands placed slightly wider than yourshoulders.Liftthebarbybringingituptowardsyourchest,thenlowerslowlyandrepeat.

SingleArmDumbbellRow

Placeonekneeandhandonaweightbenchandgripadumbbellwithyour other hand. Begin holding the dumbbell off the floor with yourelbow bent at a 90-degree angle and your back almost parallel to theground.Letthedumbbellslowlyfalltothefloorandliftitbackup.

Pull-Ups

Withboth feeton the floor, reachupandgripapull-upbarwithyourhandspositionedslightlywiderthanyourshoulders.Pullyourselfupsothat your chin rises above the bar. Slowly lower yourself to the start

positionwithoutlettingyourfeettouchtheground.Repeat.

GoodMornings

With your feet shoulder width apart and your knees slightly bent,positionabarbellsoitsitsbehindyourneck.Slowlyleanforwardatyourwaist, keeping your back straight and your head up until your upperbodyisparalleltotheground.Thenslowlyraisethebarbellbacktoyouroriginalposition.

AlternateArm/LegRaise

Kneelonthegroundwithyourpalmsonthefloorinfrontofyou.Reachforwardwithonearmandbackwardwiththeoppositeleg.Loweryour

armandlegtothekneelingpositionandrepeatwithyourotherarmandleg.

LyingKneeRollStretch

Whilelyingonyourback,bendyourkneesandletthemfalltooneside.Keepyourarmsout to the sideand letyourbackandhips rotatewithyourknees.

KneelingReachStretch

Kneelonthegroundandreachforwardwithyourhands.Letyourheadfallforwardandpushyourbuttockstowardsyourfeet.

CHAPTER11SportsInjuriesoftheChestandAbdomen


Theribcageprotects theorgans inside thechest (thoracic) cavityand isessential to the breathing mechanism. The muscles responsible foropeningupthechestcavity,toallowairtoenterthelungs,attachtotheribs. The ribs are more flexible than many other bones due to theircartilaginous attachments. Ribs attach to the sternum and/or costalmarginatthefrontandarticulatewiththethoracicvertebraeattheback.

Theribsandsternum.

There are twelve pairs of ribs, comprising true, false and floating ribs.The first seven pairs (ribs 1–7) are known as true ribs, and attach viacostal cartilagedirectly to the sternum.Thenext threepairs (ribs 8–10)areknownasthefalseribs,andattachtocostalcartilagebutnotdirectlytothesternum.Thefinaltwopairsofribs(ribs11and12)areknownasfloating ribs, and lack attachment either to costal cartilage or to thesternum.

Breathingisavitalpartoflifeandsport,anditisworthnotingthemainskeletalmusclesinvolved.

Thediaphragmisthemaininspiratorymuscle.Contractionofthemusclecauses the dome of the diaphragm to descend, so enlarging thedimensionof the thorax inalldirections.Thediaphragmcontributes tospinal stability via an increase in intra-abdominal pressure, and withtransversus abdominis, continually works to control trunk movementand enhance the breathing pattern during movement, particularlyinvolvingtheextremities.

The outermost layer of the intercostal muscles is responsible for the

lateral expansion of the chest and stabilization of the ribs duringinspiration. Deep to them, the internal intercostals have an oppositeactioninforcedexpirationduringexercise.Theintercostalshaveacloseanatomicalconnectionwiththeinternalandexternalobliquemuscles.

The abdominalmuscles are themainmuscle group involved in forcedexpiration.Thesemusclesaltertheintra-abdominalpressuretoassisttheemptying of the lungs and transmit the pressure generated by thediaphragm. Intra-abdominalpressure is thepressurecreatedwithin thetrunk, in the closed cylinder of the diaphragm, pelvic floor andabdominalwall.Greaterpressureaddsstabilitytothetrunkandpelvis.

Themechanicsofrespiration.

Intra-abdominalpressure(IAP).

Thepelvicfloormusclesareacollectivegroupofmusclesandsofttissuethatmakesupthebaseoftheabdomino-pelviccavity.Thesehavearolein themaintenanceof the intra-abdominalpressureand transferenceofthe stability created by the respiratory process. Their main functionshoweverare tosupport the internalpelvicorgansandhelptomaintaincontinence.

Othermusclegroupsactivatedworkwith themainrespiratorymusclesbut become activated when exercise becomes demanding. They areneeded to stabilizeparts of thebody to enhance the respiratory action.Thescalenemusclesaidindeepinspirationbyfixingthefirstandsecondribs,andmaintainthemduringexpirationagainstthecontractionoftheabdominalmuscles.

Thesternocleidomastoidelevatesthesternumandincreasestheforwardand backward dimension of the chest during moderate to deepinspirationifthecervicalspineisheldstable.Serratusanteriorassistsininspirationtolaterallyexpandtheribcage,ifthescapulaearestabilized.

The pectorals act in forced inspiration to raise the ribs, although the

scapulae need to be stabilized by trapezius and serratus anterior toprevent scapular winging. Latissimus dorsi is involved in forcedinspiration and expiration. Erector spinae helps in respiration byextending the thoracic spine and raising the rib cage. Quadratuslumborum stabilizes the twelfth rib to prevent elevation during

respiration.

The anterior abdominalwallmuscles run between the ribcage and thepelvis. They act to support the trunk, permit movement, hold theabdominalorgans inplaceandsupport the lowerback.Thereare threelayers of muscle, with fibers running in the same direction as thecorresponding three layers ofmuscle in the thoracicwall. The deepestlayer consists of the transversus abdominis, whose fibers runapproximately horizontally. The middle layer comprises the internaloblique,whose fibers are crossedby theoutermost layer knownas theexternaloblique,formingapatternoffibersresemblingan‘X’.Overlyingthese three layers is the rectus abdominis,which runs vertically, eithersideofthemidlineoftheabdomen,andisassociatedwiththe‘six-pack’musclesseeninconditionedathletes.

Musclesofthethoracicandabdominalregion,anteriorview.

060:BROKEN(FRACTURED)RIBS

Contactsportssuchasfootballandhockey,orsportsthatmayresult infallsorblunttraumatothechest,haveahigherincidenceofribfracturesthanothersports.Extremesports,horsebackriding,andmartialartsareother examples of activities that may result in this injury. Pain andtendernessover the ribcageafterblunt traumaora fall, especiallywithdifficultybreathing,shouldalwaysbetreatedaspotentiallybrokenribsandmedical help sought.When the ribs or their cartilage componentsfracture or break, theyweaken the support andprotection of the chestcavity. This may interfere with the muscles’ ability to open the chestcavityeffectivelytoallowforadequateventilation,whichresultsinpoorairintakeandoxygenexchange.Anyoftheribsmayfracture,andoftenmorethanoneribisinvolvedintheinjury.

Broken(fractured)ribs.

CauseofInjuryHardblowtothechest,sideorback.Fall, landingonthechest,backorside. Forceful coughing –most common in peoplewith impaired bonehealth,e.g.osteoporosis.

SignsandSymptomsPain and tenderness over the fracture site, which may be noted alsowhen pressing on the sternum or compressing the ribcage. Pain anddifficultybreathing,especiallyoninhalation.Dependingonthenumberofribsinvolved,irregularmovementofthechestduringbreathingmaybenoted,aswellassomeswelling.

ComplicationsifLeftUnattendedFracturedribsthatareleftunattendedwillbepainfulandcouldleadtoinfectionsinthelungsduetoshallowbreathing.Reducedoxygenlevelsmay result from the lower volumeof air taken in. The bone endsmayseparate and cause damage to the delicate lung tissue underneath,causing apunctured lungor otherdamage; possibly even to theheart.Overallstabilityofthechestcavitywillbeaffectedalso.

ImmediateTreatmentIf a rib fracture is suspected, seek medical attention. Ice and anti-inflammatorymedicationmaybeusedforpainrelief.Compressionmaybeused to stabilize the areauntilmedical help is obtained, but shouldnot be used long-term due to the limiting of deep, cleansing breathsneededforlungtissuehealth.

RehabilitationandPreventionRestisessentialforrecoveryandrepairoffracturedribs.Itisimportantto take at least one deep, lung expanding breath each hour to ensureadequate lung tissue involvement and avoid infections in the lungs.Protectingtheinjuredareauntilitiscompletelyhealedisimportant.Duetotheinabilitytototallyrestthisareabecauseofitsconstantmovement

during breathing, it takes longer to heal, usually 6–8 weeks. Whenreturning to activity, this area should be padded and protected for anadditionalweekortwo.

Buildingmusclemass in the chest and back will help protect the ribsfrominjury.Usingproperlyfittingandappropriateprotectiveequipmentwillhelp toprotect the ribsalso.Avoiding trauma to the ribcage is themostimportantstepinpreventingribfractures.

Long-termPrognosisRibs usually heal completely if given adequate rest. The chances ofbreakingaribarenogreaterafteraninitialbreak,ifitisallowedtohealcompletely.Thenumberofribsinvolvedintheinjurymayimpactoverallrecoverytime.Ifunderlyingtissue,suchastheheartorlungs,isinvolvedin the injury itmay takemuch longer toheal completelyand thereforemayresultinsignificantrecoverytime.

061:FLAILCHEST

The ribs form a cage that protects the vital organs in thoracic cavity.Whenribsarefracturedinmultipleplacesallowingportionstofloatfree,flail chest may result. The chest wall is no longer one unit and thedetachedareamaymoveseparatelyfromtherestofthechestwall.Thisisaseriousconditionduetothedelicatenatureoftheunderlyingorgansandtheroleoftheribs,andchestwall,intheprocessofbreathing.Thisisamedicalemergencyandshouldbetreatedimmediately.Whenarib isbrokenintwoormoreplacestheintegrityoftheribcageiscompromisedand the chestwall loses its support. This is especially truewhenmorethan one rib is involved in the injury. This may also occur when thecostalcartilageisbrokenalongwithafractureintheribitself.Theabilityof the chest to expand and draw air into the lungs is affected andrespirations become irregular and shallow. Paradoxical chest rise orunevenriseacrosstheentirechestcavityoftenaccompaniesthis injury,resultinginthechestcollapsingduringinhalationandexpandingduringexhalation.

Flailchest.

CauseofInjuryBlunttraumatotheribcage.Fallorotherdirectblowtothechest,backorside. Crush injury to the thoracic area. Untreated rib fracture withadditionaltrauma.

SignsandSymptomsUnequalorunevenchestrise.Oneareamayseemtomoveindependentoftherestofthechestandinoppositiontonormalrespiratoryrise.Painandtenderness.Difficultybreathing.Bruisingandpossibleswellingovertheinjuredarea.Instabilityinthechestwalloverthefracturedribs.

ComplicationsifLeftUnattendedInflailchest,thebrokenribsarefloatingfreeandmaycauseinjurytothedelicate lung andheart tissue immediately below.This could lead to apneumothorax(airinthechestcavitycausingpartialortotalcollapseofthe lung) or haemothorax (loss of blood into thepleural cavity aroundthe lungs). Lung capacity and breathing are affected by the pain andinstabilityassociatedwith flail chest.The inability toproperlyventilatethe lungs could lead to hypoxia (a reduced concentration of oxygen inbloodand tissues).The inability to fully inflate the lungs could lead topneumoniaandotherrespiratorycomplications.

ImmediateTreatmentThis injury is a medical emergency due to the possible complications,and immediate medical help should be sought. Ice and anti-inflammatory or pain medication may be used for pain management.Compression of the injured area for stabilization may be used untilmedical help is obtained, but shouldnot beused long-termdue to the

compromisingofproperventilationofthelungs.

RehabilitationandPreventionRest is the most important step in the recovery phase of this injury.Protectingtheinjuredareaisimportantaswell.Returntoactivityshouldbe slow and the injured area padded for additional protection. Themusclessurroundingtheinjurysitewillrequirerehabilitationwhenthefractures have healed. This should be approached cautiously andgradually. Strengtheningandbuildingmusclemassaround the ribcagewillhelpprotectitfrominjury.Thethickmusclesofthechestandbackprovide good protection. The side of the ribcage should be protectedwithprotectivegear.Avoidingtraumatotheribcagewillalsoreducethechancesofthisinjury.

Long-termPrognosisFlailchestshouldrecoverfullywithadequaterestandrehabilitation.Insome cases surgical intervention may be required to stabilize thefractured ribs.Whenmany ribs are involved, ormultiple fractures arefound in each rib, the recovery timewill be increased. Damage to theunderlying tissue, or to supportive tissues, may increase the overallhealingtimeaswell.

062:ABDOMINALMUSCLESTRAIN

Strain to the abdominal muscles (also known as a pulled abdominalmuscle) occurs from over-stretching and/or tearing ofmuscle fibers, acommon injury in many sports. Such tearing tends to be mild but inseverecasesthemusclecanrupture.

CauseofInjuryMuscle stretched too far. Muscle stretched while contracting. Sudden,violentmovementofthetrunk.Directtrauma.

SignsandSymptomsAbdominalpainattheinjuredmuscle.Lowerbackpain.Musclespasms,occasionallybruising.

ComplicationsifLeftUnattendedMuscle strains of the abdomen are common and usually resolve withrest,althoughcontinuedvigorousexerciseand inadequatehealing timecanleadtomoreseriousdamagetomuscleandtendon,prolongedpainandinterferencewithnormalactivity.

ImmediateTreatmentRICERregimen.Anti-inflammatorymed-icationandanalgesics.

RehabilitationandPreventionRestandadequatehealingtimearegenerallysufficienttorelievemuscle

strainsof theabdomenandreturn theathlete to full capacity.Targetedexercisestostrengthentheabdominalmuscles,includingslowrepetitionexercisesforabdomenandspine,maythenbeundertaken.Attentiontoproper technique is critical in avoiding muscle strain injuries, as isthoroughstretchingpriortosportsactivity.

Long-termPrognosisAbdominalmuscle strainsbroadly fall into three categories of severity,each requiring similar care but varying lengths of time for properhealing. Generally, a full recovery to normal sports activity can beexpected.Theconditionoccurringwithoutseriouscomplicationdoesnotrequiresurgery.


GymBallDumbbellPress

Withbothfeetonthefloorsupportyourbackwithagymball.Startwithyour elbows bent and your hands holding a pair of dumbbells.Straighten your elbows by pushing the dumbbells directly upward.Lowerthedumbbellstothestartingpositionandrepeat.

FlatDumbbellFly

Whilelyingonaweightbenchgripadumbbellineachhand.Startwithyourelbowsslightlybentandyourarmsouttotheside.Keepingaslightbendinyourelbowsraisethedumbbellsupuntiltheymeetaboveyourchest.Slowlylowerthedumbbellstothestartpositionandrepeat.

GymBallCrunch

Situprightonagymballwithbothfeetontheground.Restyourhandsgentlyagainstthesideofyourheadandslowlyloweryourupperbodydown towards the gym ball. Raise your upper body back to the startpositionandrepeat.

WeightedSeatedTwist

Sitonthegroundwithyourfeetinfrontofyouandletyourupperbody

leanbackslightlyuntilyourbodypositionresemblesa‘V’.Gripaplateoutinfrontofyourchestwhilekeepingyourelbowsslightlybent.Rotateyourupperbodymovingtheplatefromsidetoside.

HangingLegRaise

Withyourarmssupportingyou,letyourlegsfallwithyourtoeshangingofftheground.Raiseyourlegsuntiltheyareparalleltotheground.Letthemfallslowlybacktothestartpositionandrepeat.

DoorFrameChestStretch

Standinadoorwaywithyourhandsrestingonbothsidesoftheframeataboutheadlevel.Keepingyourhandsandfeetoutsidethedoor,letyourupperbody’sweightslowlyfallforwardthroughthedoorway.

BackArchStomachStretch

Withboth feeton theground,pushbackagainstagymballuntilyourshouldersandneckarenotsupportedbyit.Raiseyourarmsaboveyourheadandreachasfarbacktowardthegroundasyoucan.

LateralSideStretch

Standwithyourfeetaboutshoulderwidthapartandlookforward.Keepyourbodyuprightandslowlybendtotheleftorright.Reachdownyourlegwithyourhandanddonotbendforward.

CHAPTER12SportsInjuriesoftheHips,PelvisandGroin


Thepelvicgirdle(orhipgirdle)consistsoftwopelvicorcoxalbones.Itprovidesastrongandstablesupportforthevertebralcolumnandpelvicorgans, and connects the vertebral column with the lower limbs. Thepelvicbonesunitewithoneanotherinthefront(anteriorly)atthepubicsymphysis, a stable joint reinforced by strong ligaments and afibrocartilage disc. With the sacrum and coccyx, the two pelvic bonesform a basin-like structure called the pelvis. At birth, each coxal boneconsists of three separate bones: the ilium, the ischium and the pubis.These bones eventually fuse and the area where they join is a deephemispherical socket called the acetabulumwhich articulates with theheadofthefemur.Althoughthepelvicboneisoneboneitiscommonlydiscussedintermsofitsthreeportions.

Theiliumisalarge,flaringbonethatformsthelargestandmostsuperiorportion of the pelvic bone. The iliac crests are feltwhen you rest yourhands on your hips. Each crest terminates in the front at the anteriorsuperioriliacspine(ASIS)andatthebackastheposteriorsuperioriliacspine(PSIS)ThePSISisdifficulttopalpatebutitspositionisrevealedbya skin dimple in the sacral region, level approximately to the secondsacralforamen.

Theischiumistheinferior,posteriorpartofthepelvicbone.Itisroughly

arch-shaped. At the bottom of the ischium are the roughened and

thickened ischial tuberosities (sometimes called the ‘sit-bones’ becausewhenwesitourweightisborneentirelybytheischialtuberosities).Thepubisistheanteriorandinferiorpartofthepelvicboneandismadeupoftwobonyprocessesorrami.

Bonesofthepelvicgirdle,anteriorview.

Thehipjoint,rightleg,lateralview.

Themost important hip flexormuscles are iliopsoas (iliacus andpsoasmajor)andrectusfemoris.Theirfunctionistopullthefemuruptowardtheabdomen,orconverselytopulltheabdomendowntowardthelegs,as in a sit-up. Runners, cyclists, soccer players, hikers, and peopleinvolved in jumpingactivitieswhere the legsare lifted raisedareallatriskofhipflexorstrains.

Thegroinareacoverstheinnerthighandthejunctionbetweenthetorsoandlegs.Themusclesofthegroinincludethepectineus,adductorbrevis,adductor longus, gracilis and adductor magnus. These muscles areresponsible for pulling the leg in toward themidline of the body andattachatthepelvisandthefemur,someuphighandothersclosertotheknee.

Thepiriformismuscleisasmall,triangularmusclethatoriginatesattheinternalsurfaceofthesacrumandinsertsontothegreatertrochanterof

the femur. Piriformis leaves the pelvis by passing through the greatersciatic foramen. The muscle assists in laterally rotating the hip joint,abductingthethighwhenthehipisflexed,andhelpstoholdtheheadofthefemurintheacetabulum.

Iliopsoasisactuallymadeoftwomuscles:theiliacus,whichoriginatesatthehipbone,andpsoasmajorwhichoriginatesatthelumbarspine.Bothmuscles share their insertion via a common tendon at the top of thefemur.Theiliopsoasmuscleisthemainflexorofthehipjoint.

Theiliopsoas,adductorsandpelvicregion,anteriorview.

063:HIPFLEXORSTRAIN

Hip flexors are located on the front of the hip and lift the thigh up orbendthewaistforwardordownwhenthelimbsarefixed.Thesemusclesareusedalotincycling,running,kickingandjumpingactivities.Whenanewload isplacedon themuscleorrepetitivestressesareencounteredwithoutrest,themusclemaystretchortear.

Deephipflexorsandquadratuslumborum.

CauseofInjuryRepetitive stress on the hip flexor muscles without adequate time forrecovery. Excessive stress placed on the muscles without appropriatestrengthening andwarm-up. Improper formwhen running, cycling orotheractivities.Forcefulhyperextensionofthelegatthehip.

SignsandSymptomsPain in the upper groin area over the anterior portion of the hip. Painwithmovementofthelegatthehip.Inflammationandtendernessover

thehipflexor.

ComplicationsifLeftUnattendedHipflexorstrainsleftuntreatedcanbecomechronicandleadtoinflexiblemusclesthatcouldleadtootherinjuries.Themusclecouldalsocontinuetotear,eventuallyleadingtoacompleterupturefromtheattachment.

ImmediateTreatmentCessationofactivitiesthataggravatethehipflexors.Iceforthefirst48–72hours. Anti-inflammatory medication. Then heat and massage topromotebloodflowandhealing.

RehabilitationandPreventionConditioning is the key to rehabilitation and prevention of hip flexorstrains. Muscles that are strong and flexible are much more resilient.Stretching the hip flexors, abdominals, lower back, quadriceps andhamstrings helps to lower the stress load placed on the hip flexors.Strengtheningofiliopsoasandtheothermusclesofthehip,quadriceps,lower back and abdomen will help to prepare the hip flexors forunexpectedstresses.

Long-termPrognosisAlthoughthepotentialforchronicpainandinflexibilityexists,hipflexorstrains usually recover fully when given adequate rest and activerecoveryusingstretchingandstrengtheningexercises.

064:HIPPOINTER

Hip pointer usually refers to a deep bruise of the iliac crest and themusclesthatcoverit.Itisoftencausedbyadirectblow.Hippointersaremostcommonlyassociatedwithfootballbutmaybeseeninanycontactsport.

A hip pointer is usually a bruise of themuscle or bone but can be assevereasachiporfracture.Theiliaccrest(feltwhenyourestyourhandsonyourhips)istheareaofboneinvolvedandthemusclesthatattachtoit include the hip flexors, the abdominals and the gluteal musclesresponsiblefortherotationofthehips.Becausethesemusclesareinjuredat their attachments any movement involving these muscles will bepainful.

CauseofInjuryDirectimpacttothehip.

SignsandSymptomsPainandtendernessovertheiliaccrest.Painwithmovementofthehipand sometimes with weightbearing (due to the muscle involvement).Localinflammation,bruisingandswelling.


Left unattended, the pain and inflammation can lead to improper gaitandbecomechronic. If thebone ischippedor fractured, failure to treatcanleadtoimproperhealingandfutureinjuriestothesite.

ImmediateTreatmentCessation of the activity. Ice the area immediately. X-ray for possiblefractureorbonechips.

RehabilitationandPreventionUseofproperprotectiveequipmentduringactivitiesandstrengtheningthe supporting muscles around the hip for added padding andprotection.Unfortunately there isnot a lot that canbedone topreventfallingorcontactwiththehiparea.

Rehabilitation includes rest until the pain subsides, then gradualreintroduction to the activity. Any activities causing pain should bediscontinueduntiltheareaispainfree.

Long-termPrognosisHip pointers seldom cause long-term disability and most athletes canreturn to full function after treatment and a rehabilitation period.Surgeryisseldomrequiredexceptinseverefracturecases.

065:AVULSIONFRACTURE

Anavulsionfractureoccurswhenatendonorligamentpullsawayfromtheboneatitsattachment,pullingapieceoftheboneawaywithit.Thisusually results from a forceful twisting muscular contraction, orpowerfulhyperextensionorhyperflexion.This injury ismoreprevalentinchildrenthaninadults.Thetendonorligamenttendstotearbeforetheboneisinvolvedinadults,butthesofterbonestendtobecomeinvolvedinchildren.Avulsionfracturesarecommonlyseeninboysagedbetween13and17,althoughtheligament-bonejunctionisacommonsiteofinjuryinmiddle-agedpeople.

Although any tendon or ligament in the body can be involved in anavulsion fracture, it is more common in those around the pelvis.Avulsion fractures most commonly occur at apophyses, sites where amajortendonattachesontoagrowingbonyprominence.Inchildren,thegrowthplate isaweakersitewhere thebone is still forming,and isanarea where avulsion fractures often occur. The anterior superior iliacspine(ASIS),anteriorinferioriliacspine(AIIS)andtheischialtuberosityarethebonyprominencesmostcommonlyinvolved.Thecorrespondingmusclesaffectedaresartorius,rectusfemorisandthehamstrings(pages161and176)respectively.

CauseofInjuryForceful twisting, extending or flexing causing extra stress on theligamentsortendons.Directimpactonajointcausingforcefulstretchingoftheligaments.

SignsandSymptomsPain, swelling and tenderness at the injury site. Sudden localized painthatmayradiatedownthemuscle.

ComplicationsifLeftUnattendedLeftuntreatedanavulsionfracturewillleadtolong-termdisabilityinthemusclesandjointsinvolved.Incompleteorincorrecthealingmayleadtoinjuriestoothermuscles.

ImmediateTreatmentRICERregimen.Immobilizationofthejointinvolved.Anti-inflammatorymedication.Seekimmediatemedicalhelp.


Initial rest for the injuredmusclesand joints followedbystrengtheningof the muscles and supporting ligaments will help rehabilitate andprevent future fractures.Gradual re-entry into fullactivity is importanttopreventre-injuringtheweakenedarea.

Long-termPrognosisWith proper treatment most simple avulsion fractures will healcompletelywithno limitations. In rarecasessurgerymaybeneeded torepair the avulsed bone, especially in children when the avulsioninvolvesagrowthplate.

066:GROINSTRAIN

Aswithanystrain,groinstrain(alsoknownasrider’sstrain)isastretchor tearofanyorallof theadductormusclesof the inner thighor theirtendons.Soccer,hockeyandothersportsthatrequirepivotingandquickdirectionchangesare themostcommonactivities forgroinpulls.Theseinjuries range from simple stretching of the muscles to more severetearingofthefibers.Aswithotherstrainsitisgraded1throughto3with3beingthemostseveretear.

Dueto this locationandfunction,athletes involved insportswhere theleg ismoved forcefully inwardoroutwardaremoresusceptible to thisinjury.Damageisusuallytothemusculo-tendinousjunction,about5cmfromthepubis.

CauseofInjuryForceful stretching of the adductor muscles of the hip. Forcefulcontractionoftheadductormuscles.

SignsandSymptomsGrade1:Mildpain.Stiffnessintheadductormusclesbutlittleornoeffectonathleticperformance.

Grade 2: More painful. Some swelling, tenderness, limited range ofmotion,painwhenwalkingorjogging.

Grade 3: Very painful. Significant swelling, pain with weight bearing,sometimespainatrestoratnight.

ComplicationsifLeftUnattendedUntreated groin strains can lead to an awkward gait and chronic painthat could lead to injuries in other areas. A minor muscle tear couldbecomemoresevereandeventuallytearcompletely.

ImmediateTreatmentRICER. Anti-inflammatorymedication. For a Grade 3 strain it may benecessarytoseekamedicalevaluation.

RehabilitationandPreventionAfterinitialtreatment,minorstrainswillrespondtoagradualstretchingand strengthening programme. More serious strains will requireadditionalrestandaslowentrybackintoactivitieswithextrawarm-upactivitiesbeforeeachsession.

Prevention of groin strains requires warming-up properly beforeactivities, stretching for good flexibility in the adductors andstrengthening of the abductor muscles, adductor muscles, abdominalsandhipflexorsforgoodmuscularbalance.

Long-termPrognosisMostgroinstrainswillhealwithnolastingeffects.Onlythemostseverestrains,withcompletetears,requiresurgicalcorrection.

067:OSTEITISPUBIS

Osteitis pubis is an inflammation of the pubic symphysis and thesurroundingmuscles.Thisisachronicproblemthatoftenresultsfromamuscleimbalance,repetitivestressesoranuntreatedinjurytothebonesormusculatureofthearea.Soccerplayers,hockeyplayers,sprintersandother athletes who are involved in running, kicking or rapid lateralmovementsaremoresusceptibletothistypeofinjury.

Thepubicsymphysiswithitsfibrocartilagediscisinvolvedinthisinjury.Noinstabilityofthepubicsymphysisoccurs,butthereistendernessoverthe area. The adductor muscles and hip flexors are also involved.Repetitivestressesonthisareaorachangeintheangleofstress,fromamajor trauma, can lead to a change in the structure of the pubicsymphysis.Thiscausesashiftinthepullofthemusclesattachedthere.

CauseofInjuryRepetitive stresses on the pubic symphysis from running, kicking, etc.Unresolvedtraumatothisarearesultinginabnormalforcesonthepubic

symphysis.

SignsandSymptomsAdductororlowerabdominalpainthatlocalizestothepubicarea.Painincreaseswithrunning,kickingorpushingofftochangedirection.

ComplicationsifLeftUnattendedUntreated osteitis pubiswill lead to increased pain and disability. Theincreasedpainmayleadtoawkwardformduringcertainactivitieswhichcouldleadtootherinjuries.

ImmediateTreatmentIceandrestfromaggravatingactivities.Anti-inflammatorymedication.

RehabilitationandPreventionRestoring flexibility to the entire hip girdle when the pain subsides.Gradual re-introduction to athletic activity. Stop an activity if it causespain. Strengthening the adductor muscles and the hip flexors helpspreparethisareatohandlethestressesmoreefficiently.Properwarm-uptechniques before running, kicking or other direct impact activities arealsoimportant.

Long-termPrognosisWhentreatedproperlythereareseldomanylong-termeffects.Fullrangeofmotionandstrengthshouldreturn.Ifpainandlimitedmobilitylingertheinjuryshouldbere-evaluated.

068:STRESSFRACTURE

Repetitivestressorunnaturalstressplacedonthesurfaceofbone,oftenfrommusclefatigue,canleadtostressfractures.Running, jumpingandother high-impact activities can cause small cracks or fractures along abone.Stressfracturesmayoccurinanybonesubjectedtorepetitivestressorimpact.

Stressfracturesaremostcommonlyfoundinthebonesofthefoot,lowerlegandhip.Whenamusclebecomesfatiguedandcannolongerabsorbthe shockof impact, that stressgets transferred to thebone.Over timethatstresswillcausesmallcracksinthebone.Fatigueincertainmusclesmayalsocreatestrengthimbalancesthatputanunnaturalstressonthebonecausingsmallfractures.Stressfracturestothepubis, femoralneckand proximal third of the femur are seen in individuals who performaerobicdanceactivitiesorextensivejogging.

CauseofInjuryRepetitivestressfromimpactactivities.Unnaturalstressonabonefrom

differentrunningsurfaces.Strengthimbalancescausingunusualstress.

SignsandSymptomsGeneralizedareaofpain.Painonweightbearing.Whenrunning,thepainissevereinthebeginning,withnoormoderatepaininthemiddle,andseverepainreturningattheendoforaftertherun.

ComplicationsifLeftUnattendedWhenleftunattendedastressfracturemaydevelopintoamoreseriouscompletefracture.Thepainandnaturalguardingoftheinjuredareacanleadtoinjuryinotherareas.

ImmediateTreatmentRestisthemostimportanttreatment.Anti-inflammatorymedication.

RehabilitationandPreventionWhen recovering from a stress fracture it is important to start activityslowly. Itmaytake4–8weeks fora fracture tocompletelyheal.Duringthat time it is important to identify training problems that may havecausedthestressfractureoriginally.Itisalsoimportantduringthistimeto keep up general conditioning using activities that do not requireexcessiveimpactontheaffectedarea.

Topreventstressfractures,itisimportanttowarm-upproperlyanduseproper equipment (avoidusingworn out running shoes, etc.). Increaseexerciseintensityslowlyandeatplentyofcalcium-richfoodstosupportbonerepairandgrowth.

Long-termPrognosisWith proper treatment and rehabilitation most stress fractures healcompletely with no future concerns. A rare few may require surgicalpinningtostrengthenthefracturearea.

069:PIRIFORMISSYNDROME

Piriformissyndromeisaresultofimpingementofthesciaticnervebythepiriformis muscle. Incorrect form or improper gait often leads totightness and inflexibility in piriformis. The condition occurs morefrequently inwomen thanmen (6:1).Whenpiriformis becomes tight itputspressureon theunderlyingnerve, causingpain similar to sciatica.Thepainusuallystartsinthemid-glutealregionandradiatesdownthebackofthethigh.

CauseofInjuryIncorrect form or gaitwhilewalking or jogging.Weak glutealmusclesand/ortightadductormuscles.

SignsandSymptomsPainalongthesciaticnerve.Painwhenclimbingstairsorwalkingupanincline.Increasedpainafterprolongedsitting.


Chronic pain will result if left untreated. The tight muscle could alsobecomeirritatedcausingstressonthetendonsandpointsofattachment.

ImmediateTreatmentRICER. Anti-inflammatory medication. Then heat and massage topromotebloodflowandhealing.

RehabilitationandPreventionDuring rehabilitation a gradual return to activity and continuedstretching of the hip muscles is essential. Start with lower exerciseintensityorduration. Identifying the factors thatcaused theproblem isalso important. Strengthening the gluteal muscles and increasing theflexibilityof the adductorswillhelp to alleviate someof the stress andprevent the piriformis from becoming tight. Maintaining a goodstretchingregimentokeepthepiriformismuscleflexiblewillhelp,whiledealingwiththeotherissues.

Long-termPrognosisPiriformissyndromeseldomresultsinlong-termproblemswhentreatedproperly.Rarely,acorticosteroidinjectionorotherinvasivemethodmayberequiredtoalleviatesymptoms.

070:ILIOPSOASTENDINITIS

Inflammationoftheiliopsoastendonandisusuallycausedbyoveruseorincorrectuseofequipment.Theiliopsoasmuscleandtendoncanbecomeinflamedthroughrepetitivehip flexion,suchas is involved inrunning,jumping and even weight training that involves a lot of bending andsquatting.Occasionallytheunderlyingbursawillalsobecomeinflamed.

CauseofInjuryRepetitivehipflexionsuchasrunning, jumpingandkicking.Untreatedtraumatotheiliopsoasmuscle.

SignsandSymptomsPain with hip movement. Tenderness over the upper groin. Onset isgradualandpainworsenswithactivity.

ComplicationsifLeftUnattendedTendinitiscaneventually lead toamuscle tear if leftuntreatedandtheactivity that caused it continues. Bursitis is also another problem thatmaydevelopfromunattendedtendinitis.



Oncemostofthepainhasbeenmanageditisimportanttostartworkingon the strength and flexibility in the affected muscle. Increasing theflexibilityinthemusclesresponsibleforhipextension(gluteusmaximusand the hamstrings) will speed recovery and reduce the chance ofrecurrence. Proper warm-up before activity and developing a strengthbalance between hip flexors and extensors will also help prevent thisinjury.

Long-termPrognosisIliopsoas tendinitis seldom needs more than the initial treatment andrehabilitationtorecoverfully.Ifpainpersistsorbecomesmoresevereitmaybenecessarytoconsultaphysician.

071:TENDINITISOFTHEADDUCTORMUSCLES

Inflammation in theadductormuscle tendonsor tendonsheathsduetooveruse can cause pain in the groin area. Sprinting, football, hurdlingand horse riding can all cause overuse in these muscles. Unresolvedinjuriessuchasgroinstraincanalsoleadtotendinitis.

Theadductormusclesincludethepectineus,adductorlongus,adductorbrevis,gracilisandadductormagnusandthetendonsanyofthesemaybecome inflamed. The pain is similar to a groin strain but onset isgradualandchronicinnature.

CauseofInjuryRepetitivestress totheadductormuscles.Previous injurysuchasgroinstrain.Tightglutealmuscles.

SignsandSymptomsPain in the groin area. Pain when bringing the legs together againstresistance.Painwhenrunning,especiallysprinting.

ComplicationsifLeftUnattendedIf left unattended, tendinitis of the adductor muscles can lead toimbalance and injury to the othermuscles of the hip joint. It can alsoresultinatearofoneormoreoftheadductormuscles.

ImmediateTreatmentIce and rest from activities that cause pain. Anti-inflammatory

medication.Thenheatandmassagetopromotebloodflowandhealing.

RehabilitationandPreventionRehabilitation for tendinitis of the adductors starts with gradualreintroduction into activitywith stretching and strengthening exercisesfor the affected muscles. Use heat packs on the affected area beforeexerciseatfirst,thencontinuewithgoodwarm-upactivitiestomakesurethe muscles are ready for activity. Strengthening the adductors andstretching the opposing abductors will help prevent this injury fromrecurring.Rehabilitatingallgroinpullsandotherhipinjuriescompletelywillalsopreventproblemswiththeadductors.

Long-termPrognosisLong-term problems are seldom seen with tendinitis of the adductormusclesaftertreatment.Ifpainandlimitedmobilityinthehippersists,additionalhelpmayberequiredfromasportsmedicinespecialist.

072:SNAPPINGHIPSYNDROME

Snapping hip syndrome is a condition where a snapping or poppingsensation is felt in the hip with hip flexion and extension. It is mostcommonlycausedbya tendonsnappingoverabonyprominence.Thissyndromemaypresentwithorwithoutpainandisparticularlyprevalentindancers.

External snapping hip syndrome can be the result of a tight ‘Iliotibialband’ (ITB) or gluteus maximus tendon snapping over the greatertrochanterofthefemur.Whenlandingfromajump,running,climbingorsquatting these tendons are forced over the bony prominence of thegreater trochanter. This can cause inflammation of the muscle andtendon.

Internal snapping syndrome may be caused by the iliopsoas tendonsnappingoverthe iliopectinealeminenceof thehip. Inmorerarecases,tearingofthecartilage(labraltears)ofthehipjointmaycausesnappingaswell.

CauseofInjuryTightITBorglutealmuscles.Tightiliopsoasmuscle.Labraltear.

SignsandSymptomsSnappingsensationinthehip.Mayormaynotpresentwithpain(morecommonlyreportedasdiscomfort).

ComplicationsifLeftUnattendedSnappinghipsyndromecanleadtoirritationandpossiblebursitisifleftuntreated. The inflamedmuscle becomes tight and can cause stress onothermusclesaswell.

ImmediateTreatmentRICERprogramme.Anti-inflammatorymedication.

RehabilitationandPreventionRehabilitationstartswithstretchingandstrengtheningthemusclesofthehip. A balance in strength and flexibility of all the muscles will helppreventsnappinghipsyndrome.Properwarm-upof thehipmuscles isimportant before beginning any activity that involves flexion orextension tomake sure themuscles are adequately prepared. It is alsoimportanttomaintainfitnesslevelswhileresting,usingactivitiesthatdonotaggravatetheaffectedarea.

Long-termPrognosisSnappinghipsyndromeseldomrequiresmorethantheinitialtreatmentand rehabilitation to recover fully. In very rare cases surgicalinterventionmayberequiredtocorrecttheproblem.

073:TROCHANTERICBURSITIS

Trochantericbursitiscommonlyresultswhenthebursaoverthegreatertrochanter of the femur is irritated by repetitive stresses encounteredduringrunningactivities.Thegreatertrochanteristhebonyprominenceontheupperlateralportionofthefemurtowhichmanymusclesofthehip and thigh attach. The trochanteric bursa lies between gluteusmaximusandtheposterolateralsurfaceofthegreatertrochanter.Severalothermuscles cross this regionandbecause theyaregenerally rubbingacrossthebonethebursacanbecomeinflamed.Thegreatertrochanterisnear the surface and is susceptible to impact injuries. Trochantericbursitismayalsobecausedbytensionintheiliotibialband(ITB).

CauseofInjuryRepetitiveactivities involving thehip suchas running. Impactorothertraumatothebursaoverthegreatertrochanter.LimitedITBmovement.

SignsandSymptoms

Tendernessoverthebonyprominenceoftheupperthigh/hip.Swellingoverthebursa.Painwhenflexingorextendingthehip.

ComplicationsifLeftUnattendedIf left unattended this injury can cause chronic pain. The bursa mayrupturewithcontinuedirritationofanalreadyinflamedarea.

ImmediateTreatmentRestfromaggravatingactivities.Ice.Anti-inflammatorymedication.

RehabilitationandPreventionRestfromactivitiesthataggravatethebursaisthefirststeptoreducingpain and inflammation.After rest a gradual return to sport is advised.Stopanyactivitiesthatcausearecurrenceofthepain.Creatingabalanceofstrengthandflexibilityinallthemusclesofthehipwillhelppreventtrochantericbursitis.Warmingupthemusclesofthehipproperlybeforeactivityisalsoimportant.

Long-termPrognosisBursitis generally does not cause any long-term disability whentreatment and rehabilitationprogrammes are followed. Surgery is onlyindicatedinveryextremecases.


Lunge

Withadumbbell ineachhand restingatyour sides, step forwardwithonefootwhilelettingyouroppositekneefallalmosttotheground.Pushupward, returning to the start position, then step forward with yourotherfootlettingyourotherkneedothesame.

BodyWeightSquat

With your feet shoulderwidth apart, reach your hands out in front ofyou and bend your knees like you are about to sit in a chair. Slowlyreturntostandingandrepeat.

Single-leggedGlutealRaiseHold

Lieonyourbackwithyourarmsatyoursides.Keeponelegstraightandbring theother footup towardsyourbackside.Raiseyourbacksideofftheground,hold for a secondand then lower again.Repeatwithyour

otherleg.

SideStepLunge

With one foot elevated on a support, bring your arms out from yoursidesandliftyourotherlegupandawayfromyourbodytotheside.

HangingKneeRaise

Whilehangingonabarwithyourfeetofftheground,liftandbendyourknees while keeping your arms straight. Bring them as close to yourchestaspossible.Slowlylowertothestartpositionandrepeat.

LegOutAdductorStretch

Standwithyour feetwide apart.Keepone leg straight and toes facingforwardwhile bending the other leg and turning your toes out to the

side.Loweryourgroin toward thegroundand rest yourhandson thebentkneeortheground.

KneeUpRotationStretch

Sitwithonelegstraightandtheotherlegcrossedoveryourknee.Turnyour shoulders andput your armontoyour raisedknee tohelp rotateyourshouldersandback.

LyingFootOverKnee

Lieonyourbackandslightlybendoneleg.Raiseyourotherfootupontoyourbentlegandrestitonyourthigh.Thenreachforwardholdingontoyourkneeandpullyourbentlegtowardyou.

CHAPTER13SportsInjuriesoftheHamstringsandQuadriceps


Thefemur,or thighbone, is theheaviest, longestandstrongestboneinthebody. Itsproximalendhasaball-likeheadthatarticulateswith thepelvicboneintheacetabulumandformsthehipjoint.Distallythelateralandmedialcondylesarticulatewiththetibiatoformthekneejoint.Thequadriceps, hamstrings, adductor and abductor muscles all haveattachmentsonthefemur.

Thehamstringsareagroupofthreemusclesthatworktogethertoextend(straighten) the hip and flex (bend) the knee. During running thehamstrings slow down the leg at the end of its forward swing andprevent the trunk from flexing at the hip joint. The threemuscles are:bicepsfemoris,semitendinosusandsemimembranosus.

The quadriceps group is composed of four muscles: vastus lateralis,vastusmedialis,vastus intermediusandrectus femoris.Thequadricepstendon attaches to and surrounds the patella (kneecap), becoming thepatellar (tendon) ligament below this and inserting on the anteriorsurfaceofthetibia.Thepatellamovesupanddowninthegrooveatthefront of the femur as the knee flexes and extendswhich results in thetendonpassingoverthisboneaswell.

Thehipjoint;a)rightleg,lateralview,b)pelvicgirdletoleg,posteriorview.

Theiliotibialband(ITB)isanon-elasticcollagencordstretchingfromthelateralpelvistobelowtheknee.Itisattachedtotheiliaccrestatthetop,blendswiththetensorfasciaelatae(TFL)andgluteusmaximusmuscles,anddescendstoattachtoGerdy’stubercleonthelateralproximaltibia.The deep fibers attach to the linea aspera of the femur on theposterolateral thigh. TFL flexes, abducts and medially rotates the hipjoint,andstabilizestheknee.

Thequadriceps.

Thehamstrings.

074:FEMORALFRACTURE

Ittakestremendousforcetofracturethefemurduetoitsstrengthandthesupportingmusculature. Football,hockeyandotherhigh-impact sportsareoftenassociatedwith femoral fractures.The femur ismore likely tofractureatthefemoralneck,asitissmallerindiameterandiscomposedof cancellous bone which has a relatively low density. Femoral neckfracturesusuallyinvolveahardimpactorexcessivelandingforcefromahighfall.The femurmayalso fracturealong theshaft,which isusuallycaused by tremendous impact from a road traffic accident or shearingforceacrossthebone.

Femurfracture:a)closed,b)open,c)complicated,d)pathological,e)stress.

CauseofInjuryHigh-impactforceacrossthefemur,suchasacaraccidentoraggressivetackleinfootball.High-impactforcedirectedthroughthefemursuchasfromlandingfromahighfall.Directimpacttotheupperportionofthehip.

SignsandSymptomsSevere pain.Deformity andpossible shortening of leg length. Swellinganddiscoloration.Inabilitytomovethelegorbearweight.

ComplicationsifLeftUnattendedPermanentdisabilitywillresultifthisinjuryisleftuntreated.Bloodlossdue to internal injuries to themuscles andarteries could lead to shock

anddeath.

ImmediateTreatmentIceandimmobilization.Seekimmediatemedicalhelp.

RehabilitationandPreventionFemoralfracturesrequireextensiverehabilitationduetothetimeneededforhealingandthemusculatureinvolved.Thebonemayrequiresurgicalrepairwithaplate, rodorpins,which increases therehabilitationtime.Rehabilitationwillusuallyinvolveaphysicaltherapistworkingonrangeofmotionandstrengtheningthemuscles.

Preventionoffemoralfracturerequirescommonsensesafetyprecautionsand/oravoidanceofactivitiesthatmightresultinhigh-impactblowstothe femur. Strengthening the muscles of the quadriceps, hamstrings,adductorsandabductorswillalsoprovideextraprotectionforthefemur.

Long-termPrognosisWith immediate treatment and repair of the femur along withrehabilitation to strengthen the supportingmuscles, there shouldbenolong-termlimitations.Fullrecoverymaytakeuptoninemonths.

075:QUADRICEPSSTRAIN

A forceful stretch or tear of the muscle or tendon in a weightbearingmuscle such as the quadriceps is painful and difficult to rest. Thequadriceps are involved in supporting the hip and knee to hold theweightofthe.Aquadricepsstraincanresultfromaforcefulcontractionofthequadricepsorunusualstressplacedonthemuscles.Aswithotherstrainsitisgraded1through3,with3beingthemostseveretear.

A strain may occur in any of the quadriceps muscles but the rectusfemorisismostcommonlyinjured.Theforcegeneratedinactivitiessuchas sprinting, jumping andweight trainingmay causemicrotears in themuscle.Whenthemuscleisstretchedforcefullyunderaloadasinhigh-impact sports like football and hockey itmay also pull away from themuscle–tendonjunctionorbonyattachmentortearcompletely.

CauseofInjuryForcefulcontractionorstretchofthequadriceps.

SignsandSymptomsGrade1:Mildly tenderandpainful.Littleornoswelling.Fullmuscularstrength.

Grade 2: More marked pain and tenderness. Moderate swelling andpossiblebruising.Noticeablelossofstrength.

Grade 3 (full tear): Extreme pain. Deformity, swelling and bruising.Inabilitytocontractthemuscle.

ComplicationsifLeftUnattendedA grade 1 or 2 tear left unattended can continue to tear and become

worse.Agrade3tear leftuntreatedcanresult in lossofmobilityandaseverelossofflexibilityinthemuscle.

ImmediateTreatmentRICERregimen.Anti-inflammatorymedication.Immobilizationinseverecases.Thenheatandmassagetopromotebloodflowandhealing.

RehabilitationandPreventionAfter the required restperiod, activities shouldbe resumed cautiously.Avoid activities that cause pain. Stretching and strengthening of thequadricepswillbenecessary.Ensuringabalanceofstrengthbetweenthequadriceps and hamstrings is important to prevent a strain. Properwarm-uptechniquesmustbeobservedtopreventstrainsandgraduallyincreasingintensitywillhelpaswell.

Long-termPrognosisQuadricepsstrainsseldomresultinlong-termpainordisability.Surgeryisonlyneededinrarecaseswhereacomplete teardoesnotrespondtoimmobilizationandrest.

076:HAMSTRINGSTRAIN

Ahamstringstrainor‘pull’isastretchortearofthehamstringmusclesor tendons. This is a very common injury, especially in activities thatinvolve sprinting or explosive accelerations. A common cause of ahamstring strain is muscle imbalance between the hamstring andquadriceps,withthequadricepsbeingmuchstronger.

Any of the hamstringmuscles can be strained.Commonlyminor tearshappen in the belly of the biceps femoris muscle closest to the knee.Complete tears or ruptures usually pull away from this attachment aswell. Excessive force against the muscles, especially during eccentriccontraction (when the muscle is contracting and lengthening againstforce)cancausestretching,minortearsorevencompleterupture.

Rightleg(posteriorview).

CauseofInjuryStrength imbalance between the hamstrings and quadriceps. Forceful

stretching of the muscle, especially during contraction. Excessiveoverloadonthemuscle.

SignsandSymptomsGrade1:Mildly tenderandpainful.Littleornoswelling.Fullmuscularstrength.

Grade 2: More marked pain and tenderness. Moderate swelling andpossiblebruising.Gaitaffected–limping.

Grade3(fulltear):Extremepain.Markedswellingandbruising.Inabilitytobearweight.

ComplicationsifLeftUnattendedPain and tightness in the hamstring muscles will get worse withouttreatment. Tightness in the hamstrings can lead to lower back and hipproblems.Untreatedstrainscanprogresstoafullrupture.

ImmediateTreatmentGrade1:Ice.Anti-inflammatorymedication.

Grades2and3:RICER.Anti-inflammatorymedication.Seekmedicalhelpif a complete rupture is suspected or if the patient is unable to walkunaided.Thenheatandmassagetopromotebloodflowandhealing.

RehabilitationandPreventionStretching after the initial pain subsides will help speed recovery andprevent future recurrences. Strengthening the hamstrings to balancethemwith the quadriceps is also important.When re-entering activity,properwarm-upmustbestressedandagradual increaseinintensityis

important.

Long-termPrognosisHamstringstrainsthatarerehabilitatedfullyseldomleaveanylingeringeffects.Completerupturesmayrequiresurgerytorepairandlong-termrehabilitation.

077:THIGHBRUISE(CONTUSION)

A thigh contusion is adeepbruise to themuscles of thequadricepsorhamstrings near the femur. The bruising causes pain and limitedflexibilityinthemuscle.Animpacttoanyofthehamstringorquadricepsmuscles squeezes the muscle between the impacting force and theunderlyingbone.Thiscausesbleeding in themuscle, inflammationandeventually the formation of scar tissuewhich reducesmuscle function.Swellingandbruisingfrominflammationandbleedingputspressureonthesurroundingmusclefibers,reducingflexibility.

High-impactsportssuchasfootballandhockeyarecommonlyassociatedwith thigh contusions, but any direct trauma to the thigh can cause acontusion.

CauseofInjuryImpacttothemusclefromabluntsurfacesuchastheground,ahelmet,

foot,etc.

SignsandSymptomsPainandtendernessovertheinjuredarea.Swellingandbruisingmaybepresent.Painonweightbearingandstretchingofthemuscle.

ComplicationsifLeftUnattendedMyositisossificans,theformationofbonyorcalcifieddepositsinmuscletissue, candevelop fromunattended thigh contusions.Muscle rupturescan also occur when a contusion is left untreated and activity iscontinued.

ImmediateTreatmentRestand ice.Anti-inflammatorymedication.Thenheatandmassage topromotebloodflowandhealing.

RehabilitationandPreventionAfterthepainsubsidesitisimportanttoregainflexibilityandstrengthintheinjuredmuscle.Gentlestretchingwillimproveflexibilityandhelptoavoid scar tissue formation. While the muscle is healing, working thesurrounding muscles as tolerable may help to speed recovery byincreasing blood flow and limit scarring. Use of proper protectiveequipmentduringactivities andavoiding impact to the thighwillhelppreventthighcontusions.

Long-termPrognosisPropertreatmentofathighcontusionwillensurethattherearenofuturecomplications. Flexibility and strength should return to normal after

rehabilitationoftheinjuredmuscle.

078:ILIOTIBIALBANDSYNDROME

Iliotibialband(ITB)syndromereferstoexcessivepullingorfrictionoftheITB over the greater trochanter of the femur near the hip and/or thelateralcondyleat theknee.This frictionor tensioncauses inflammationandsignificantpainwhenthekneesandhipsflexorextend.Bursitiscanalsoensue.

CauseofInjuryTension or friction of the ITB. Repetitive hip and knee flexion andextensionwhilethetensorfasciaelatae(TFL)iscontracted,suchaswithrunning.TightTFLandITB.Muscleimbalances.

SignsandSymptomsKneepainoverthelateralcondyle.Painwithflexionandextensionoftheknee.

ComplicationsifLeftUnattendedThe ITB and accompanying TFL become tight due to the pain andinflammation.Ifleftunattendedthiscanleadtochronicpainandfurtherinjurytothekneeandhip.


RehabilitationandPreventionIncreasing flexibility aspain allowswill help speed recovery.After thepainhassubsided,increasingstrengthandflexibilityofallthemusclesofthe thighs andhips todevelopbalancewill helpprevent future issues.Identifying and fixing any errors in running form will also help topreventrecurrenceoftheinjury.

Long-termPrognosisITB syndrome can be treated successfully with no lingering effects.Inflammation and pain may return when the activity is resumed andformcorrectionsmustbemadetopreventfutureproblems.

079:QUADRICEPSTENDINITIS182

Inflammationofthequadricepstendoncanbearesultofrepetitivestressto the quadriceps or excessive stress before themuscle is conditioned.Minortearsmayoccurinthetendonwhenitisstretchedwhilesubjectedto loading. Pain just above the patella (kneecap), especially whenextending(straightening)theknee,usuallyaccompaniesthisinjury.

Rightleg(anteriorview).

CauseofInjuryRepetitive stress to the tendon, e.g. running or jumping. Repetitiveaccelerationanddeceleration,e.g.hurdlingorfootball.Untreatedinjurytothequadriceps.

SignsandSymptomsPainjustabovethepatella.Jumping,running,kneelingorwalkingdownstairsmayaggravatethepain.


Thequadricepsmusclesmaybecomestiffandshortenedandthetendonwill becomeweak if left untreated. This could lead to a rupture of thetendon.Achangeingaitorlandingforminthecaseofhurdlerscanleadtootherinjuriesaswell.

ImmediateTreatmentRestandice.Anti-inflammatorymedication.Trainingmodification.

RehabilitationandPreventionRehabilitationshouldincludestretchingandstrengtheningexercisesforthequadriceps.Activitiessuchasswimmingcanbehelpfultoreducethestress on the tendon during rehabilitation. Return to a normal activityscheduleshouldbedelayeduntilpainsubsidescompletelyandstrengthisrestored.Keepingthequadricepsflexibleandstrongwillhelppreventthiscondition.

Long-termPrognosisA full recoverywithno long-termdisability or lingering effects can beexpected in most cases of tendinitis, and surgery is only necessary inextremelyrarecases.


BarbellSquat

Standwithyourfeetshoulderwidthapartandabarrestingatthebaseofyourneck.Withoutmovingyourfeet,bendyourkneesasthoughyouareabouttositinachair,andslowlycomebacktoastandingposition.

BarbellLunge

Standwithyourfeetshoulderwidthapartandabarrestingatthebaseofyourneck.Stepforwardwithonefootandletyouroppositekneefalltothe groundwithout letting it touch. Push yourself backup to the start

position and then step forwardwith your other foot, letting the otherkneedothesame.

BarbellStep-Up

Standinfrontofanelevatedsupportorstepwithabarbellrestingatthebaseofyourneck.Stepupontothesupportwithonefootandletyour

other foot follow. Step back down and do the same, but with your

oppositefoot.

NordicCurl

Lie on your stomach and have a friend hold your ankles. Withoutpressingagainstthefloorwithyourhands,liftyourbodyuptoasclosetoakneelingpositionasyoucan.Releaseandrepeat.

LegPress

Sitonalegpressmachinewithyourfeetshoulderwidthapartinfrontofyou.Pressagainsttheplatewithyourlegsuntiltheyarenearlystraight.Slowlylowertothestartpositionandrepeat.

LyingHamstringCurl

Lieonyourstomachandplaceyourfeetunderneaththecylinder-shapedpad. Bend your knees and lift the pad as close to your backside aspossible.Slowlylowertothestartpositionandrepeat.

LyingHamstringStretch

Lie onyour back andbendone leg.Raise your straight leg andpull ittowardyourchest.

KneelingQuadStretch

Kneelononefootandtheoppositeknee.Ifneeded,holdontosomethingtokeepyourbalance.Pushyourhipsforward.

CHAPTER14SportsInjuriesoftheKnee


Thekneejointconnectsthebonesoftheupperandlowerleg.Thekneecan be considered as two articulations: the patellofemoral andtibiofemoral joints. In the tibiofemoral joint the medial and lateralcondylesofthefemurformthetopofthejoint,articulatingwiththeheadofthetibiabelow.Thepatella,orkneecap,isasesamoidbonethatrestsover the anterior surface of the knee joint in the groove between thefemoral condyles. Just below and lateral to the knee, the head of thefibulaarticulateswiththetibiatoformthesuperiortibiofibularjoint.

Note: There is often confusion about whether to refer to the

patellartendwwonorthepatellarligament.Thepatellarligament

(ligamentumpatellae)extendsfromthepatelladowntothetibial

tuberosity.Ifonethinksofthepatellaasaboneinitsownright,

then it shouldnaturally be called the patellar ligament, since it

connects two bones (the patella to the tibia). However, if you

consider the patella to be a sesamoid bone living within the

quadricepstendon,thencallingit thepatellartendonalsoseems

correctas itconnectsmuscletobone.Anothersuggestionmight

bethatasatendonagesitbecomesmoreligamentous.Forclarity,

itisreferredtoasthepatellar(tendon)ligamentthroughout.

Thekneeisstabilizedbytough,fibrousbandsofligaments.Thecollateralligamentspreventexcessiveside-to-sidemotionof theknee.The lateralcollateralligament(LCL)ontheoutsideofthekneeconnectsthefemurtotheheadofthefibula.Themedialcollateralligament(MCL)ontheinsideofthekneeconnectsthefemurtothetibia.

Theposterior cruciate ligament (PCL) is located in the rearof thekneeinside the fibrous joint capsuleandconnects the femurand the tibia. Itcontrols backward displacement of the tibia. The anterior cruciateligament (ACL) also lies inside the joint capsule and connects the tibiaand femur in the centre of the knee. It controls rotation and forwarddisplacement of the tibia. The LCL, MCL, PCL and ACL are the fourmajorligamentsoftheknee.

Rightleg(anteriorview)withkneebentatninetydegrees.

Thecruciateswiththebonesseparated.

Other ligamentshelpadd stability to the joint.The transverse ligamentrunsinfrontofthelateralandmedialmenisci(seebelow)andconnectsthe two. The oblique and arcuate popliteal ligaments round out theligamentstructureandhelpstabilizetheposterolateralaspectofthejoint.

The knee joint also contains two specialist structures called menisci,crescent-shapedwedges of fibrocartilage attached to the flat surface ofthe top of the tibia. Their function is to improve the fit of the jointsurfaces; reduce friction between the tibia and the femur; disperse thebodyweightandactasshockabsorbers.Themeniscikeepthekneejointmovingsmoothlyandwithin theproperplane.Theyareprone towearandtearandareoftendamagedinsportsinjuries.

The fibrous capsuleof theknee joint is strengthenedby the tendonsofthemuscles that cross the joint. The quadriceps tendon runs from thequadriceps muscles to the patella. It continues over and around thepatellaandbecomesthepatellartendonbelowthebonetoitsattachmentonthetibia.Posteriorly,thetendonsofthehamstringcomplexrunoverthekneejointandconnecttothetibia.Thegastrocnemiustendonsrunupfrom the gastrocnemius muscle, in the posterior calf, to attach on thefemoralcondyles.Mediallythecapsuleisstrengthenedbythecombined

pes anserine (duck’s foot) tendon attachments of sartorius, gracilis and

semitendinosus.

Thekneejoint,anteriorview.

Thekneejoint,mid-sagittalview.

Thesynoviumisthemembranethatlinesthekneejointandsecretesfluidforlubrication.Theentirearticularcapsuleis linedwithsynovium.It isresponsibleforkeepingthejointlubricatedandprotectingthecartilage.

Bursaearesmallsacsfilledwithsynovialfluid.Theycushionandprotectthe bones, tendons and ligaments of the knee. There are numerous

bursae around the knee, some of which are directly connected to the

synovial membrane of the joint. The clinically important ones are thesuprapatellar, and infrapatellar bursae anteriorly; the popliteal bursaposteriorlyandthepesanserinebursamedially.

Thekneejoint,rightleg,anteriorview.

Themusclesaroundtheknee jointareresponsibleformovementof theupperandlowerlegandstabilityofthekneejoint.Themajormusclesatthefrontoftheupperleg(orthigh)aresartoriusandquadriceps,whichinclude rectus femoris, vastusmedialis, vastus intermedius and vastuslateralis. The major muscles at the back of the upper leg are thehamstrings, which include biceps femoris, semitendinosus andsemimembranosus.

Themajormusclesonthe insideof thethigharepectineus,gracilisandthe adductors, which include adductor brevis, adductor longus andadductor magnus. On the outside of the thigh are tensor fasciae latae(TFL)and,toalesserdegree,theglutealmuscles,whichincludegluteusmaximus, gluteusmedius and gluteusminimus. Themajormuscles ofthelowerlegincludetibialisanterioratthefrontandgastrocnemiusandsoleusattheback.

Theleg;a)anteriorview,b)posteriorview.

080:MEDIALCOLLATERALLIGAMENTSPRAIN

Medialcollateralligamentsprainsareusuallycausedbyforceappliedtotheoutsideofthekneejointasinatackleinfootball.Forceappliedtotheoutsideofthekneecausestheinsideofthekneetoopen,stretchingthemedialcollateralligament.Theextentofthestretchdetermineswhethertheligamentsimplystretches,tearspartiallyorcompletelytears.

CauseofInjuryForceappliedtotheoutsideofthekneejoint.

SignsandSymptomsPain over the medial portion of the knee. Swelling and tenderness.Instabilityinthekneeandpainonweightbearing.

ComplicationsifLeftUnattendedTheligament,inrarecases,mayrepairitselfbutifleftunattendedcouldleadtoamoreseveresprain.Thepainandinstabilityinthekneemaynot

resolve.Continuedactivityontheinjuredkneecouldleadtoinjuries intheotherligamentsduetotheinstability.

ImmediateTreatmentRICER.Immobilization.Anti-inflammatorymedication.

RehabilitationandPreventionDepending on the severity of the sprain, simple rest and gradualintroductionbackintoactivitymaybeenough.Formoreseveresprains,bracesmaybeneededduring the strengtheningphase of rehabilitationand the earlyportionof the return to activity.Themost severe sprainsmay require extended immobilization and rest from the activity. Asrangeofmotionandstrengthbegintoreturn,stationarybikesandotherequipment may be used. Ensuring adequate strength in the thighmusclesandconditioningbeforestartinganyactivitythat issusceptibletotraumatothekneewillhelppreventthesetypesofinjuries.

Long-termPrognosisThe ligament will usually heal with no limitations, although in somecases there is residual looseness in the medial part of the knee. Veryrarely,surgeryisrequiredtorepairtheligaments.Meniscaltearingmayalsoresultinaseveresprainthatmayrequiresurgicalrepair.

081:ANTERIORCRUCIATELIGAMENTSPRAIN

The anterior cruciate ligament (ACL) is commonly injured in sportswheretherearealotofdirectionchangesandpossibleimpacts.Football,lacrosseandotherfast-movinggamesoftenresultinACLsprains.

Themost commonmechanism for this injury iswhen the knee rotateswhile the foot isplanted.Thestresscancausea tear in theACLwhichcanrangefromminortearingofafewfiberstoacompleterupture.Itcanalso be torn as the result of a hard blow to the knee; usually otherligamentsand themeniscusare involved.Sharppainat the timeof theinjury accompanied by swelling in the knee jointmay be a sign of anACLtear.

CauseofInjuryForceful twisting of the knee when the foot is planted. Occasionally aforcefulblowtotheknee,especiallyifthefootisfixedaswell.

SignsandSymptoms

Pain immediately that may go away. Swelling in the knee joint.Instabilityintheknee,especiallywiththetibia.

ComplicationsifLeftUnattendedIf left unattended this injury may not heal properly. Instability in thejointcouldleadtoinjurytootherligaments.Chronicpainandinstabilitycouldleadtofuturelimitations.

ImmediateTreatmentRICER. Immobilization. Immediate referral to a sports medicineprofessional.

RehabilitationandPreventionOnce stability and strength return and pain subsides, gradualintroduction of activities such as stationary biking can be undertaken.Range ofmotion and strengthening exercises are an important part ofrehabilitation.Swimmingandothernon-weightbearingexercisemaybeuseduntil thestrengthreturns tonormal.Strengthening themusclesofthe quadriceps, hamstrings and calves will help to protect the ACL.Proper conditioning before beginning high-impact activities will alsoprovideprotection.

Long-termPrognosisACL sprains that involve a complete tear often require surgery toreattach the ligament. Minor sprains can often be healed completelywithoutsurgery.Returntofullactivitymaybeaprolongedprocessandsomeactivitiesmaybelimited.

082:MENISCUSTEAR

Tearing of themenisci can occurwith forceful twisting of the knee ormay accompany other injuries such as ligament sprains. An ‘unhappytriad’iswhenablowtothelateralsideofthekneecausestearingofthemedial collateral ligament, the anterior cruciate ligament and themenisci.Thisisoftenseeninsportsthatrequireaplantingofthefoottoquickly change direction. The medial meniscus is injured much morefrequently than the lateral meniscus, mainly due to it being moresecurelyattachedtothetibiaand,therefore,lessmobile.

CauseofInjuryForcefultwistingofthekneejoint,mostcommonlyseenwhenthekneeisalsobent.Mayaccompanyligamentstrainsaswell.

SignsandSymptomsPaininthekneejoint.Swelling.Catchingorlockinginthejoint.

ComplicationsifLeftUnattendedAmeniscaltearcancauseprematurewearonthecartilageattheendsofthebonesandunderthepatella.Thiscanleadtoarthriticconditionsanda fluid build-up in the knee joint. Loose pieces of cartilage and jaggededgesofadamagedmeniscusandcancausecatchingandlocking.

ImmediateTreatmentRICER.Anti-inflammatorymedication.

RehabilitationandPreventionWhenrecovering fromameniscal tear it is important to strengthen themuscles surrounding the knee to prevent the injury from happeningagain. Strong quadriceps and hamstrings help support the knee andprevent the twisting that might cause a tear. The muscles should bestretchedregularlyaswellsincetightmusclescanalsocauseproblemsintheknee.Aftersurgical repairofameniscus tearweightbearingshouldbeencouragedastolerable,butaswithanyrestartofactivityshouldbedonegradually.

Long-termPrognosisAteartoameniscususuallyrequiresarthroscopicsurgerytorepair.Thesurgeryrequiresremovalofthetornedgesofthemeniscusbutleavesthemain body of themeniscus intact. Therefore,mostmeniscus tears healfullywithnolong-termlimitations.

083:BURSITIS

Bursitiscanbeapainfulcondition,especiallyintheweightbearingkneejoint.Sincethejobofthebursaistocushionandlubricatethejointwherefriction is likely to occur, inflammation will result in pain in mostweightbearing, flexion or extension activities. The knee joint has onaveragefourteenbursae.

Theprepatellarbursaisthemostcommonlyinjuredduetoitssuperficiallocation. Repetitive kneeling or impact to the patella can damage thisbursa. The infrapatellar bursae are most commonly inflamed duringjumping and landing from repetitive friction of the patellar (tendon)ligament.Thepes anserinebursa is less commonly involved in injuriesbutcanresultfromloadbearingontheinsideoftheknee,asseenwithimpropergaitoruseofwornorimproperlysizedrunningshoes.Bursaecanswellasaresultoffluideffusionfromthekneejointitselfasmaybeseeninthecaseofpoplitealbursitis,alsoknownasaBaker’scyst.

CauseofInjury

Repetitive pressure or trauma to the bursa. Repetitive friction betweenthebursaandtendonorbone.

SignsandSymptomsPain and tenderness. Swelling. Pain and stiffness when kneeling orwalkingdownstairs.

ComplicationsifLeftUnattendedIf a bursa is allowed to rupture and release its fluid the naturalcushioningwillbelost.Thebuild-upoffluidwillcauselossofmobilityinthejointaswell.


RehabilitationandPreventionStrengtheningthemusclesaroundthekneewillhelptosupportthejoint,andincreasingflexibilityalsowillrelievesomeofthepressureexertedbythe tendons upon the bursa. Frequent rests when required to be in akneeling or crouching position also help to prevent this condition.Identifying any underlying problems such as improper equipment orform is important during rehabilitation to prevent bursitis fromrecurring.

Long-termPrognosisBursitis is seldoma long-termconcern if treatedproperly.Occasionallydrainingofthefluidfromthejointisnecessary.

084:INFLAMMATIONOFTHESYNOVIALPLICA

Thesynovialplicaisathinfibrousmembranethatisaremnantfromthefoetal knee development. The plica once divided the knee into threeseparate compartments during foetal development but then became apart of the knee structure as the compartments became one protectivecavity.

Plica seldom cause problems by themselves butmay become inflamedduetofrictionorpinchingbetweenthepatellaandthefemur,commonwhenthekneeisflexedandplacedunderstress.Thisinturncausesmorefrictioncreatingaviciouscycle.

CauseofInjuryTrauma to the flexed knee. Repetitive stress, especially with medialweightbearing,e.g.cycling.

SignsandSymptoms

Pain.Tendernessoverthesynovialplica.

ComplicationsifLeftUnattendedThe synovial plica will continue to become inflamed and limit flexionactivityinthekneeifleftunattended.Thepainmayalsocauseachangeingaitorrunningformthatcouldleadtootheroveruseinjuries.

ImmediateTreatmentReducingactivity.RICER.Anti-inflammatorymedication.

RehabilitationandPreventionStrengthening thequadricepsandhamstringswill takepressureoff thesynovial plica. Increasing flexibility in these muscles will also relievepressure thatmaybe irritatingthecondition.Useofproperequipment,especiallyrunningshoes,caneliminatethe irritationandforcethekneebackintoproperalignmentduringactivity.

Long-termPrognosisOnce pain subsides, a return to normal activity can be expected. Veryrarely isarthroscopic surgeryrequired to remove theplica.Noadverseeffects have been found from the removal of the synovial plica and acompletereturntoactivitycanbeexpected.

085:OSGOOD-SCHLATTERDISEASE

Osgood-Schlatterdiseaseisatraction-typeinjuryofthetibialapophysiswhere the patellar (tendon) ligament pulls on the tibial tuberosity justbelowtheknee.Itisaconditionthataffectsactiveyoungteens.Itismoreprevalentinmales(particularlyboysaged10–15)thanfemalesandhasaslightly higher prevalence in the left knee than the right. When thequadricepsistightorthereisrepetitiveflexionandextensionthisstressmaycauseinflammationandpain.Asimilarcondition,Larsen-Johanssonsyndrome, results in pain and tenderness over the inferior pole(extremity) of the patella but is treated in a similar way to Osgood-Schlatterdisease.

Thebonesofadevelopingskeletonarenotashardasmaturebones.Sotheforceoftheligamentpullinguponthetibiamaycausesmallavulsionfracturesleadingtoinflammationandpain.Thebodymaytrytorepairand protect this area by building more bone, resulting in a bonyprominence just under the knee which gives the characteristic tibialbump. This is exacerbated in adolescents by a growth spurt, since thelengtheningofbonesoften exceeds thegrowthof themuscles attachedcausingtightmuscles.Thisputsadditionalforceontheattachedtendons.During running, jumping and kicking activities, the quadriceps mustcontractandrelaxcontinuouslywhichalsostressestheattachmentatthetibia.

CauseofInjuryTight quadriceps due to growth spurt. Prior knee injury. Repetitivecontractionsofthequadricepsmuscles.

SignsandSymptomsPain,worse at full extension and during squatting, subsideswith rest.Swelling over the tibial tuberosity just below the knee. Redness andinflammationoftheskinjustbelowtheknee.

ComplicationsifLeftUnattendedIf left unattended the condition will continue to cause pain andinflammation and could lead tomuscle loss in the quadriceps. In rarecases, untreated Osgood-Schlatter disease could lead to a completeavulsionfractureofthetibia.


RehabilitationandPreventionMostcasesofOsgood-Schlatterdisease respondwell to restand thenaregimen of stretching and strengthening the quadriceps muscles.Limiting activities that cause pain and tend to aggravate the issue isimportant during recovery. Gradual increases in intensity and properwarm-uptechniqueswillhelppreventthiscondition.

Long-termPrognosisThis condition tends to correct itself as thebonebecomes stronger andmature. The pain and inflammation subside and there are seldom anylong-termeffects.Rarecasesmayrequirecorticosteroidinjectionstoaidrecovery.

086:OSTEOCHONDRITISDISSECANS

Osteochondritis dissecans occurswhen a fragment of bone adjacent tothearticularsurfaceofajointisdeprivedofitsbloodsupply,leadingtoavascularnecrosis.Thiscausesthecartilagetobecomebrittleandpieces,orloosebodies,maybreakoff.Loosecartilageinthejointcancausepainandinflammation.Afeelingofinstabilityanda“clicking”orlockinginthejointmaybenoticed.Althoughfoundinseveraljoints,thisconditionismostcommonlyassociatedwiththekneeandisparticularlyprevalentinmalesaged10–20years.

CauseofInjuryLoss of blood supply to the end of the bone and attached cartilage.Impact to the joint causing a tearingor breakingof the cartilage at theboneend.Repetitivefrictionleadingtothecartilagebecomingbrittleandbreakingaway.

SignsandSymptoms

Aching, diffuse pain and swelling, especially during activity. Stiffnesswith rest. Clicking or weakness in the joint.Momentary locking if thebonyfragmenthasdisplacedandisfreefloatingwithinthejoint.

ComplicationsifLeftUnattendedIf left unattended, loose bodies will continue to cause damage to theinner surface of the joint and could eventually lead to degenerativeosteoarthritis.Theloosebodiescouldalsoleadtotearingor“grooving”ofothercartilageinthejoint.

ImmediateTreatmentRestandreferraltoasportsmedicineprofessional.Immobilization.Anti-inflammatorymedication.Positivediagnosismadewitharadiograph.

RehabilitationandPreventionStrengthening the muscles surrounding the knee will help support itbetterduringactivity.Limitingtheamountoftimespentdoingrepetitivemovementsmayalsoberequired.Treatmentofminorinjuriestothejointmayalsohelp stop the chanceof theblood supplybeing cutoff.Limitactivitiesthatcausepainandgraduallyworkbackintoafullschedule.

Long-termPrognosisIfthebrokencartilagedoesnotreleasefromtheboneitmayrepairitself.However,ifitbecomeslodgedinthejointandthebodydoesnotdissolveitsurgerymayberequired.Inyoungerathletesacompleterecoveryandreturntoactivitymaybeexpected.Inolderathletesthedevelopmentofdegenerativeosteoarthritisisusuallyaby-productofthiscondition.

087:PATELLOFEMORALPAINSYNDROME

Pain in the patella (kneecap), especially after sitting for a long time orrunning downhill, may result from incorrect movement of the patellaoverthefemurortighttendons.Thearticularcartilageunderthepatellamay become inflamed as well, leading to another condition calledchondromalaciapatellaewhichisfoundmorecommonlyinwomen.

Theangleformedbetweenthetwolinesofpullofthequadricepsmuscleandthepatellar(tendon)ligamentisknownastheQ-angle.Ifthepatellamoves out of its normal path, even slightly, it can cause irritation andpain. Tight tendons also place pressure on the patella causinginflammation.

CauseofInjuryIncorrect running form or improper shoes. Weak or tight quadriceps.Chronicpatelladislocations.

SignsandSymptomsPainonandunder thepatellawhichworsensafter sitting forextendedperiodsorwalkingdownstairs.Clickingorgrindingmaybe feltwhenflexingtheknee.Dull,achingpaininthecentreoftheknee.

ComplicationsifLeftUnattendedTheinflammationfromthisconditionifleftunattendedcanworsenandcause more permanent damage to the surrounding structures. If thetendon becomes inflamed it could eventually rupture. The cartilageunderthepatellamayalsobecomeinflamed.

ImmediateTreatmentRest and reducing exercise intensity and duration. Ice and anti-inflammatorymedication.

RehabilitationandPreventionRehabilitation starts with restoring the strength and flexibility of thequadriceps.Whenreturningtoactivityafterpainhassubsided,gradualincreasesinintensity,limitingrepetitivestressesonthekneeandproperwarm-uptechniqueswillensurethatthepaindoesnotreturn.

Strong, flexible quadriceps and hamstrings and avoiding overuse willhelp prevent patellofemoral pain syndrome. A good warm-up beforetrainingwillalsohelp.

Long-termPrognosisWithcompletetreatmentthereareseldomanylong-lastingeffects.Ifthecondition does not respond to treatment surgical intervention may benecessary.

088:PATELLARTENDINITIS(JUMPER’SKNEE)

Activitiesthatrequirerepetitivejumpinglikebasketballorvolleyballcanlead to tendinitis in the patellar (tendon) ligament, also referred to asjumper’s knee. The force placed on the tendon over time can lead toinflammationandpain.Thepain isgenerally felt justbelowthepatella(kneecap).

Patellar tendinitis affects the teno-osseous junction of the quadricepstendonas itattaches to thesuperiorpoleof thepatellaandthepatellar(tendon)ligamentasitattachestotheinferiorpoleofthepatellaandthetibial tuberosity. Pain is concentratedon thepatellar (tendon) ligamentbutcanalsooccurattheinsertionofthepatellar(tendon)ligamentintothe tibial tuberosity. The patellar (tendon) ligament is involved instraighteningtheknee.It isalsothefirstareatoexperienceshockwhenlandingfromajump.Itisforcedtostretchasthequadricepscontractstoslow down the flexion of the knee. This repetitive stress can lead tominortraumatothetendonwhichwillleadtoinflammation.Repetitiveflexionandextensionof thekneealsoplacestresson this tendon if thetendondoesnottravelintherequiredpath.

CauseofInjuryRepetitive jumping and landing activities. Running and kickingactivities.Untreatedminorinjurytothepatellartendon.

SignsandSymptomsPainandinflammationofthepatellartendon,especiallyfromrepetitiveoreccentrickneeextensionactivityorkneeling.Swellingandtendernessaroundthetendon.

ComplicationsifLeftUnattendedAswithmost tendinitis, inflammation that is left untreatedwill causeadditional irritation,settingupaviciouscycle.Thiscaneventuallyleadtoaruptureofthetendon.Damagetosurroundingtissuemayalsooccur.


RehabilitationandPreventionStretching the quadriceps, hamstrings and calves will help relieve

pressureon thepatellar tendon.Duringrehabilitation it is important toidentifytheconditionsthatcausedtheinjuryinthefirstplace.Thoroughwarm-up and proper conditioning can help prevent the onset of thiscondition.Asupportstrapplacedbelowthekneemaybeneededatfirsttosupportthetendonduringtheinitialreturntoactivity.Preventionofthisconditionrequiresstrongquadricepsandagoodbalanceofstrengthbetweenthemusclesthatsurroundtheknee.

Long-termPrognosisComplete recovery without lingering effects can be expected withrehabilitation and treatment. Occasionally it may return due to aweakenedtendon,especiallyinolderathletes.

089:CHONDROMALACIAPATELLAE(RUNNER’SKNEE)

Softening and degeneration of the articular cartilage of the patella inathletesisusuallyaresultofoveruse,traumaorabnormalforcesontheknee.Inolderadultsitcanbearesultofarthritis.Painunderthepatellaandagrating sensationwhen theknee is straightenedare signsof thiscondition.

The underside of the patella is protected by thick articular (hyaline)cartilage,which ismadeup of collagen fibers andwater. The cartilagecan become damaged and softened by repetitive micro-trauma due tooveruseorabnormalloadbearingontheknee.Thisdegenerationmakesthe surface roughwhich causes additional inflammationandpain. It isdescribedinfourprogressivestages,fromsofteningandblistering,tofullcartilagedefectsandexposureofthesubchondralbone.

CauseofInjuryRepetitivemicro-traumatothecartilagethroughoveruse.Misalignmentofthepatella.Previousfractureordislocationofthepatella.

SignsandSymptomsPainthatworsensaftersittingforprolongedperiodsorwhenusingstairsorrisingfromaseatedposition.Tendernessoverthepatella.Gratingorgrindingsensationwhenthekneeisextended.

ComplicationsifLeftUnattendedCartilagethatdegeneratesandbecomesroughcancausescarringonthebone surface it rubs against. This in turn causes more inflammation.Cartilagecanalsobetornwhenitisroughleadingtoloosebodiesinthejoint.

ImmediateTreatmentRestandice.Anti-inflammatorymedication.

RehabilitationandPreventionLimitingactivityuntilthepainsubsidesandgradualreturntoexerciseisadvised. Strengthening and stretching the quadriceps is important torelievepressureonthepatella.Activities that increasethepain,suchasdeepkneebending,shouldbeavoideduntilcompletelypainfree.Avoidabnormal stress on the knee and keep the hamstrings and quadricepsstrongandflexibletopreventthiscondition.

Long-termPrognosisChondromalaciapatellaecommonly respondswell to therapyandanti-inflammatory medication. In rare cases surgery may be required tocorrectamisalignmentofthepatella.

090:PATELLARDISLOCATION

A subluxation or dislocation of the patella (kneecap) commonly occursduringdeceleration,forexamplewhenslowingfromaruntoawalk.Thepatella slides partially out of the groove between the femoral condylesbut does not limit mobility. Pain and swelling may accompany thiscondition. Athletes who have a muscle imbalance or a structuraldeformity,suchasahighpatella,haveahigherchanceofsubluxation.

Iftheoutermuscleofthequadriceps,vastuslateralis,isstrongerthantheinner muscle, vastus medialis, the imbalance may cause an uneventensiononthepatella,pullingitoutofalignment.Inaddition,thelateralfemoralcondyleandpatellamaybebruised.Thishappenswithforcefulcontractionssuchasplanting,changingdirectionorlandingfromajump.

CauseofInjuryStrength imbalance between the outer and inner quadriceps. Impact tothesideofthepatella.Twistingoftheknee.

SignsandSymptomsFeeling of pressure under the patella. Pain and swelling behind thepatella.Painwhenbendingorstraighteningtheknee.

ComplicationsifLeftUnattendedContinuedsubluxationscancausesmallfracturesinthepatella,cartilagetearsandputstressonthetendons.Failuretotreatasubluxationcouldleadtochronicsubluxations.


RehabilitationandPreventionDuringrehabilitationactivitiesthatdonotaggravatetheinjuryshouldbesought,suchasswimmingorbikinginsteadofrunning.Strengtheningofvastus medialis and stretching vastus lateralis will help correct themuscle imbalance that may cause this condition. A brace to hold thepatella in placemay be neededwhen initially returning to activity. Topreventsubluxationsitisimportanttokeepthemusclessurroundingthekneestrongandflexibleandavoiddirectimpacttothepatella.

Long-termPrognosisSubluxations respondwell to rest, rehabilitation and anti-inflammatorymeasures. Rarely surgery may be required to prevent recurringsubluxationsduetomisalignmentorinstability.


LegExtension

Sitdownandputthetopsofyourfeetbehindthecylinder-shapedpad.Push against it until your legs are nearly straight. Slowly lower to thestartpositionandRepeat.

DumbbellWalkingLunge

Withadumbbellineachhand,lungeforwardwithonefootlettingyouropposite knee almost touch the ground. Instead of returning to youroriginalposition,stepforwardwithyourbacklegandlungelettingyourotherkneealmosttouchtheground.Continue.

DumbbellStepUp

Withadumbbellineachhand,stepupontoanelevatedsupportorstep.

Stepdownandstepbackupwithyourotherfoot.

WallSit

Stand straightupwith a gymball placedbetweenyour back andon awall.Slidedownwardwiththegymballrollingdownthewalluntilyouareinasittingposition.Holdthepositionforasecondandthenraiseupintothestandingposition.

StationaryBike

Sit comfortably on a stationary bike with your hands gripping thehandlebars.Placeyourfeetsecurelyonthepedalsandrotatethem.

StandingQuadStretch

Standuprightwhilebalancingononeleg.Pullyourotherfootupbehindyour buttocks and keep your knees together while pushing your hipsforward.Holdontosomethingforbalance.

LateralSideStretch

Standuprightandcrossonefootbehindtheother.Leantowardthefootthatisbehindtheother.

CHAPTER15SportsInjuriesoftheShinandCalf


The tibia (shinbone) is the larger andmoremedialof thebonesof thelowerleg.Atitsproximalend,themedialandlateralcondylesarticulatewith the distal end of the femur to form the knee joint. The tibialtuberosityisaroughenedareaontheanteriorsurfaceofthetibiaandthemedialmalleoluscanbefeltastheinnerbone(medialmalleolus)oftheankle.Thetibiaistheweightbearingboneofthelowerlegandthereforetakesalargeamountoftheforceofimpactduringrunningandjumpingactivities.

Tibiaandfibulaoftherightleg,anteriorview.

Thefibula lies lateralandparallel to the tibiaandis thinandstick-like.The fibula is not a weightbearing bone but is an important point formuscleattachment.Thedistalheadofthefibulacanbefeltasthelateralmalleolusoftheankle.

Musclesoftheposteriorcalfincludegastrocnemiusandsoleus,knownasthetricepssurae,andplantaris.ThesemusclesattachtothefootviatheAchillestendon.Thesemusclesareresponsibleforplantarflexingthefootattheanklejoint,enablingjumping,pushingofffromaplantedfootandrising up on tiptoes. The tibialis anterior muscle originates from thelateral condyle of the tibia and inserts into the medial and plantarsurfacesof thebonesof themedialarch.Tibialisanterior is responsiblefordorsiflexingthefootandisusedduringrunningandwalkingto‘toe

up’ with each step. Together with tibialis posterior, tibialis anteriorinverts the foot and ankle while laterally the peroneal muscles are

responsibleforeversion.

The Achilles tendon is the largest tendon in the body, beingapproximately 15 centimetres long and 2 centimetres thick. Taking itsname from themythical Greekwarrior Achilles, it originates from themusculo-tendinous junction of the calf muscles and inserts into theposterior aspect of the calcaneus (heel bone). The tendon is separatedfromthecalcaneusbytheretrocalcanealbursaandfromtheskinbythesubcutaneouscalcanealbursa.Itplantarflexesthefootattheanklewhenthe calf muscles contract. The Achilles tendon is well known for itsvulnerabilitytosportsinjury.

Thecalfmuscles.

TheAchillestendon(lateralview).

091:FRACTURES(TIBIA,FIBULA)

The tibia and fibula have outer shells of cortical bone with cancellousbone underneath. Cortical bone is stiffer and capable of withstandinggreat stress.When the outer shell is cracked it is called a fracture. Thebonemaybeeitherpartiallyfracturedorcompletelybroken.

Althougheither the tibiaor fibulacanbe fracturedalone theyaremostcommonlyfracturedtogether.Mostfracturesinvolvetheproximal(nearthe knee) or distal (near the ankle) ends of the bone. Due to the thincoveringofskinandothertissueoverthetibiathesefracturesareoftenopenfracturesmeaningthebrokenboneendsbreaktheskin.

CauseofInjuryDirect force (impact) to thebonesalongtheshaftorextremeloadingofthebone,suchaslandingfromahighfall.Rotationalorindirectforcesonthe bones, e.g. tackle in football. Twisting, especiallywhen the bone isunderloadorwhenthefootisfixed.

SignsandSymptomsPain,inabilitytowalkorbearweightandofteninabilitytomovetheleg.Deformitymaybepresentatthefracturesiteorthefracturemaybeopen(seeabove).Swellingandtenderness.

ComplicationsifLeftUnattendedInstabilityinthelowerlegisonelong-termcomplicationofanuntreatedfracture. Blood vessel damage from a fracture can lead to internal

bleedingandswellingaswellascirculationproblemsforthefoot.Nerveinvolvement can lead to serious problems such as drop foot or loss ofsensationinthelowerlegandfoot.

ImmediateTreatmentImmobilizetheleg.Controlanybleedingthatmightbepresentwithanopenfracture.Seekmedicalattentionimmediately.

RehabilitationandPreventionAfterthefracturehashealeditwillbenecessarytorebuildthestrengthandflexibilityofthemusclesofthelowerleg.Rangeofmotionactivitiesmaybeneededforthekneeandankledependingonthelocationofthefractureandtheextentofimmobilizationrequired.Whenthefracturehashealedagradual re-entry into activitymustbeobserved toprevent re-injury.Strongcalfandtibialisanteriormuscleswillhelpprotectthetibiaandfibula.

Long-termPrognosisIf set properly and allowed toheal fully, a fracture shouldnotpresentanyfutureproblems.Insomecasesarodorpinsmaybeneededtoholdthe bones in place during healing. Surgery may be required in a fewcaseswherebloodvesselornervedamageissevere.

092:CALFSTRAIN

Failuretowarm-upproperlycanleadtocalfstrains.Thecalfmusclesareusedwhen taking off during a sprint, jumping, changing directions orstandingupfromadeepsquat.Theseareusuallyexplosivemovementsrequiringforcefulcontractionsofthecalfmuscles.Strainscanresultfromincorrect foot positioning during activity or an eccentric contractionbeyondthestrengthlevelofthemuscle.

Whentakingoffandchangingdirectionthecalfmusclesareparticularlyvulnerable to tearing at their junction with the tendon. An eccentriccontraction, a contraction while the muscle stretches such as whenlandingfromajump,canalsocauseatearifthemuscleisfatiguedornotstrongenoughtobeartheloadplacedonit.

CauseofInjuryForceful contraction of gastrocnemius or soleus. Forceful eccentriccontraction.Improperfootpositionwhenpushingofforlanding.

SignsandSymptomsPaininthecalfmuscle,usuallymid-calf.Painwhenstandingontiptoesandsometimespainwhenbendingtheknee.Swellingorbruisinginthecalf.

ComplicationsifLeftUnattendedAny strain left unattended can lead to a complete rupture. The calfmuscles are used when standing and walking so pain can become

disabling.Alimporchangeingaitduetothisinjurycouldleadtoinjuryinotherareas.


RehabilitationandPreventionAsthepainsubsides,aprogrammeoflightstretchingmayhelpfacilitatehealing.When thepainhassubsided,strengtheningandstretchingwillhelptopreventfutureinjury.Properwarm-upbeforeactivitieswillhelpprotectthemusclefromtears.Strong,flexiblemusclesresiststrainsbetterandrecovermorequickly.

Long-termPrognosisMuscle strains, when treated properly with rest and therapy, seldomhave lingering effects. In very rare cases where the muscle detachescompletely,surgerymayberequiredtore-attachthemuscle.

093:ACHILLESTENDONSTRAIN

Achilles tendon strains can be very painful and require significanthealing time.An injury to this tendoncanbedebilitatingbecauseof itsinvolvement in walking and even balance during weightbearing.Explosive activities such as sprinting and jumping, and activities thatinvolve pushing against resistance such as rugby andweight training,contributegreatlytothisinjury.

Thestraincanbegradedonascalefrom1to3:

Grade1strain:Stretchingorminortearoflessthan25%ofthetendon.

Grade2strain:25–75%tearingofthetendonfibers.

Grade3strain:75–100%ruptureofthetendonfibers.

CauseofInjuryAbrupt, forceful contraction of the calf muscles, especially when themuscleandtendonareeithercoldorinflexible.Excessiveforceappliedtothefootforcingtheankleupwardintodorsiflexion.

SignsandSymptomsPain in theAchilles tendon, frommilddiscomfort ingrade1 strains tosevere,debilitatingpainingrade3strains.Swellingandtenderness.Painwhenrisingonthetoes. Inabilitytobendtheankle.Stiffness inthecalfandheelareaafterresting.


Aminortearmaybecomeacompleteruptureifleftunattended.Bursitisandtendinitismaydevelopfromthe inflamedtendonrubbingover theheel.

ImmediateTreatmentRICER. Anti-inflammatory medication. Then heat and massage topromote blood flow and healing. Immobilization andmedical help forgrade3strains.

RehabilitationandPreventionRest is important andagradual return to activitymustbeundertaken.Stretching and strengthening the calf muscles is important torehabilitation and to prevent recurrence.Warming-up the calfmusclesproperly before all activities, especially those involving forcefulcontractionssuchassprinting,isessentialtopreventstrains.

Long-termPrognosisDuetothelowerbloodsupplyintendons,theytakelongertohealthanthe muscle, but with rest and rehabilitation the Achilles tendon canreturn to normal function. Severe ruptures usually require surgicalrepair.

094:ACHILLESTENDINITIS

TheAchilles tendon crosses the back of the heel,whichmeans it ridesovertheboneasthemusclecontractsandstretches.InflammationoftheAchillestendoncanbeverypainful;allofthebody’sweightissupportedbythisstructureandfootwearoftenpressesagainstthisarea.Repetitivestress to the tendon can lead to inflammation that causes additionalirritationandfurtherinflammation.

Activitiessuchasbasketball,running,volleyballandotherrunningandjumpingsports can lead toAchilles tendinitis.Repetitive contractionofthemusclesinthecalfandimproperfootwearorexcessivepronationofthefeetcanleadtoinflammationinthetendon.

CauseofInjuryRepetitive stress from running and jumping activities. Improperfootwear or awkward landing pattern of the foot during running.UntreatedinjuriestothecalforAchillestendon.

SignsandSymptoms

Painandtendernessinthetendon.Swellingmaybepresent.Contractionofthecalfmusclecausespain;runningandjumpingmaybedifficult.

ComplicationsifLeftUnattendedInflammation in the tendoncan lead todeteriorationof the tendonandeventual rupture if leftuntreated. Inflammationmay lead to tighteningofthetendonandattachedmusclewhichcouldleadtotearing.

ImmediateTreatmentRest, reducing or discontinuing the offending activity. Ice. Anti-inflammatorymedication.Thenheatandmassagetopromotebloodflowandhealing.

RehabilitationandPreventionAfter a period of rest, usually lasting 5–10 days, gentle stretching andstrengtheningexercisescanbeinitiated.Heatmaybeusedonthetendonbeforeactivitytowarmthetendonproperly.Adequatewarm-up,alongwith strengthening and stretching exercises for the calves, will helppreventtendinitisoftheAchillestendon.

Long-termPrognosisTendinitis seldom has lingering effects if treated properly. Tendinitismay take from five days to several weeks to heal but rarely needssurgerytorepairit.

095:MEDIALTIBIALPAINSYNDROME(SHINSPLINTS)

Shinsplintsareacommoncomplaintofrunnersandotherathleteswhohavejusttakenuprunning.Shinsplintsisatermusedtocoverallpainintheanteriorshinareabutthereareseveralpossiblecauses.Medialtibialpainsyndrome,themostcommoncauseofshinpain,referstopainfeltovertheshinbonefromirritationofthetendonsthatcovertheshinandtheir attachment to the bones. Changes in duration, frequency orintensityofrunningcanleadtothiscondition.

When themuscle and tendon becomes inflamed and irritated throughoveruse or improper form, it will cause pain in the front of the shin.Repetitive pounding on the lower leg, such as with running, can alsoleadtopainintheshin.

CauseofInjuryRepetitivestressonthe tibialisanteriormuscle leadingto inflammationatitsbonyattachmenttothetibia.Repetitiveimpactforcesonthetibia,aswithrunningandjumping.

SignsandSymptomsDull,achingpainovertheinsideofthetibia.Painisworsewithactivity.Tendernessovertheinnersideofthetibiawithpossibleslightswelling.

ComplicationsifLeftUnattendedIf left unattended, shin splints can cause extreme pain and causecessation of running activities. The inflammation can lead to other

injuriesincludingcompartmentsyndrome.


RehabilitationandPreventionItisimportanttouselow-impactactivities,suchasswimmingorcycling,to maintain conditioning levels while recovering. Stretching tibialisanteriorwillaidrecovery.Topreventthisconditionfromdevelopingtryalternatinghigh-impact activitydayswith lower-impactdays. It is alsoimportant tostrengthenthemusclesof the lower legtohelpabsorbtheshockofimpactactivities.

Long-termPrognosisMedialtibialpainsyndromecanbeeffectivelytreatedwithnolong-termeffects.Onlyinrarecasesdoestheconditionfail torespondtorestandrehabilitation,leadingtochronicinflammationandpain.Surgerymayberequiredinthoserarecases.

096:STRESSFRACTURE

Repetitive impact activities, such as running and jumping, can causesmallcracksinthebonecalledstressfractures.Thesemostoftenoccurintheweightbearingbone,thetibia,ofthelowerleg.

Ground forces are transferred up the length of the tibia. Bones areconstantlyremodellingandrebuilding,leadingtotheremovalofcalciumfrom one area of the bone to build another, causing a relativelyweakarea.When impact is transferred up the shaft and encounters a weakarea,due toeitherboneremodellingorapriorstress fracture, thebonemaycrack slightly.Over time thismay lead toamore serious crackorfracture. Fatigued muscles also contribute to the possibility of stressfractures.Themuscles aremeant to take someof the shockaway fromthebonesbutafatiguedmuscleisapoorshockabsorber.

Athleteswithlowerbonedensity,duetodietaryinsufficiencyorgeneticpredisposition, aremore susceptible, as are athleteswho train on hardsurfacesatincreaseddistanceandduration.Womenaremoresusceptibletothisinjurythanmenduetobonedensitydeficiencyconditionssuchasirregularorabsentmenstrualcycles,eatingdisordersorosteoporosis.

CauseofInjuryRepetitivestressonthebonethroughimpactactivitiessuchasrunningorjumping. Low bone density. Muscle fatigue leading to lower shockabsorptionbythemuscles.

SignsandSymptoms

Pain onweightbearing thatworsenswith activity and diminisheswithrest. Pain ismost severe at the early stage of activity, subsiding in themiddle and returning at the end. Point tenderness and some swellingpossible.

ComplicationsifLeftUnattendedIf left unattendeda stress fracture canbecomea complete fracture andleadtocomplicationssuchasbleedingandnervecompromise.Thepainfrom an untreated stress fracture may require complete cessation ofactivityandcausefurtherinjurytosurroundingtissues.

ImmediateTreatmentRICER.Anti-inflammatorymedication. If any instability isnoted in thelower leg, or inability to bear weight, a sports medicine professionalshouldbeconsulted.

RehabilitationandPreventionDuring the recoveryphase it is important tomaintain fitness levels byusing low- or non-impact activities such as swimming or biking.Strengthening the muscles of the lower leg will aid shock absorption.Warming-up properly and using cross training techniques to limitimpactonthebonewillhelppreventstressfractures.

Long-termPrognosisStressfracturesgenerallyhealcompletelywithrest.Returningtoactivitytoosoonmaycausearecurrence.Veryrarely,surgicalinterventionmaybeneededtostrengthentheboneatthefracturesite.

097:ANTERIORCOMPARTMENTSYNDROME

Musclesare coveredbyan inflexible fibrous sleeve called fascia.Fasciacreatesa compartment for themuscle,withbone formingonesideandthe fascia covering the other sides. In the lower leg the twobones, thetibia and the fibula, create a more rigid compartment. The tibialisanterior muscle runs over the tibia and fibula and is enclosed by thefascia.Anteriorcompartmentsyndromeisusuallycausedbyswellingorenlargement of tibialis anterior in in the anterior compartment of thelower leg. Increased intramuscular swelling, as a result of trauma oroveruse,createspressure inside thecompartmentwhich impedesbloodflow and muscle function. The nerves in the compartment may becompressed causing numbness and weakness in the foot. Anteriorcompartment syndrome is more often a chronic rather than an acuteinjury.Runnersandotherathletesinvolvedinactivitiesthatrequirealotofrepetitiveflexionandextensionofthefootaremostsusceptible.

Pain, especially when dorsiflexing the ankle to lift the foot or whenraisingthetoes,anddecreasedsensationandweakness inthefootmaybeexperienced.Virtuallyanyinjuryinvolvingbleedingorlocalswellingmayleadtocompartmentsyndrome.

CauseofInjuryAcute: trauma to the tibialis anterior muscle causing bleeding and/orswelling.

Chronic: overuse of themuscle causing inflammation and swelling andincreased pressure in the compartment. Rapid growth of the musclebeforeitsfascialenvelopecanexpand(asseenwithanabolicsteroiduse).

SignsandSymptomsPainandtightnessintheshin(especiallythelateralside).Worsenswithexercise. Decreased sensation on top of the foot over the second toe.Weaknessandtinglinginthefoot.

ComplicationsifLeftUnattendedRaisedpressure in the compartmentmay lead topermanentnerve and

blood vessel damage if left unattended. The underlying cause of theconditionwillmostlikelycontinuetocauseirritationandswellingifnottreated.

ImmediateTreatmentRest,iceandelevation(nocompression).Anti-inflammatorymedication.Sportsmassagemaybeusedtostretchthefascia.

RehabilitationandPreventionStretchingthemusclesinthefrontoftheshinwillhelptoalleviatesomeof the pressure and elongate themuscle.Massage to stretch the fasciamay also help to speed recovery. Gradual strengthening and a goodflexibility program will help prevent this condition. Avoiding directtraumatotheshinareawillpreventacutecompartmentsyndrome.

Long-termPrognosisIf treated before damage to the nerves and blood vessels becomesserious,therecoveryrateisverygood.Acuteorseverechronicanteriorcompartmentsyndromemayrequiresurgical interventiontorelievethepressureinthecompartment.


StandingCalfRaise

Withadumbbell inonehandandyouroppositehandholdingon to asupport, place your toes on the edge of a step and let yourheel lowertowardtheground.Slowlyraiseupbystraighteningyourankle.Slowlyloweryourselftothestartposition,repeatandthenswitchsides.

SeatedCalfRaise

In a seated position place your toes on the edge of the step and yourkneessecurelyunderthepaddedweight.Slowlyraisetheweightupbystraighteningyourankles,thenlowertheweighttothestartpositionandrepeat.

SquatJump

Keepingyourfeetshoulderwidthapart,bringyourarmsbehindyouandbend your knees. Jump forward bringing your knees and feet up andontothebox.Carefullystepofftheboxandrepeat.

SingleLeggedDeadlift

Standuprightwithadumbbellineachhandrestingatyourside.Balanceononelegwithaslightlybentknee.Slowlyleanforwardatyourwaistmoving the dumbbells toward the ground and letting your other legmove backward behind you. Raise your body back up to the startpositionandrepeat.

HeelBackCalfStretch

Standuprightandleanagainstawall.Placeonefootasfarfromthewall

as is comfortable andmake sure that both toes are facing forward andyourheelisontheground.Keepyourbacklegstraightandleantoward

thewall.

AchillesStretch

Standuprightandtakeonebigstepbackward.Bendyourbacklegandpushyourheeltowardtheground.

CHAPTER16SportsInjuriesoftheAnkle


The talocrural or ankle joint is a hinge joint and comprises the tibia,fibulaandthetalusandcalcaneusbonesofthefoot.Itsmainfunctionistoallowflexionandextensionofthefoot.Thecalcaneusorheelbonesitsbeneath the talus. The talus articulates proximally with the tibia andfibulaatthetalocruraljointanddistallywiththecalcaneusatthesubtalarjoint.Thedome-likearticularsurfaceofthetalusiscoveredwithcartilagetocushionandprotectit.Thenavicular,medialcuneiform,intermediatecuneiform, lateral cuneiformand cuboid constitute theother five tarsalbones.

Theanklejointcomplex(posteriorview).

Thefoot(lateralview).

The ankle is stabilized by strong collateral ligaments. Medially thedeltoidligamentprotectsagainsteversionstrains.Thethreebandsofthelateral collateral ligament run between the fibula, talus and calcaneus.Posteriorandanteriorligamentsconnectthetibiaandfibula.

Thetibialisposteriortendonrunsbehindthemedialmalleolus(theinnerbonyprominence)oftheankleandhasmanypointsofattachmenttothebonesunder themedialarchof the foot.This tendonsupports thearchand aids in inversion of the foot. The tendons of peroneus longus and

peroneusbrevisrunfromtheperonealmusclestothefoot.Theypassinagroove behind the lateralmalleolus (the outer bony prominence of theankle) and attach beneath the medial arch and to the first and fifthmetatarsalbones.Theyareheldinplacebyasheaththatisreinforcedbyabandofligament.Thesetendons,alongwiththeperonealmuscles,helptostabilizetheankleandassistthecalfmusclesinplantarflexion.

Theelevenmusclesthataffecttheanklejointaredividedintofourcompartmentsbythefascialintermuscularsepta.

Theligamentsoftheankleaidstabilityandprovidesupport(lateralview).

Flexordigitorumlongus(FDL),flexorhallucislongus(FHL)andtibialisposteriorlieinthedeepposteriorcompartmentofthelowerleg.FDLandFHLflexthetoes.Tibialisposterioristhedeepestmuscleand,withFHL,helps maintain the medial arch of the foot. The peroneus longus andperoneusbrevismuscleslieinthelateralcompartmentofthelowerleg.

Both these muscles plantarflex and evert the foot and help preventinversion sprains. The course of the tendon of insertion of peroneuslongus helpsmaintain the transverse and lateral longitudinal arches ofthefoot.

Thelowercalfmuscles,posteriorview.

098:ANKLEFRACTURE

Duetotheankle’sinvolvementinallrunningandjumpingactivitiesitisvery susceptible to injury.Themajorityof athleteshave experiencedatleastaminorsprainoftheankle.Anklefracturesarelesscommonbutarenonethelessmorecommonthanotherfractures.Runningorjumpingonuneven or changing surfaces can lead to ankle fractures. High-impactsports such as football and rugby, where the possibility of forcefultwisting of the ankle may occur, also have a high incidence of anklefractures.

Inananklefracture,anyorallof thebonesandligamentsmaybecomeinvolved.Anklefracturesmostcommonlyinvolvetheendsofthetibiaorfibula, or both, with some ligament stretching and tearing present aswell.

CauseofInjuryForcefultwistingorrollingoftheanklecancausetheendsofthebonestofracture.Forcefulimpacttothemedialorlateralsideoftheanklewhilethefootisplanted.

SignsandSymptomsPainful to touch. Swelling and discoloration. Inability to weightbear.Deformitymaybepresentinthejoint.

ComplicationsifLeftUnattendedAn ankle fracture that is left unattended can result in incorrect or

incompletehealingof thebones.Continuedwalkingor runningon theinjured ankle could result in further damage to the ligaments, bloodvesselsandnervesthatpassthroughthejoint.

ImmediateTreatmentStop the activity. Immobilize the joint and apply ice. Seek medicalattention.

RehabilitationandPreventionWhiletheankleisimmobilizeditisimportanttokeepconditioninglevelsupbyusingupperbodyexercisesandweighttraining.Whenclearedforactivitywiththeankle,strengtheningandstretchingofthemusclesofthelower leg is essential for a speedy recovery. An ankle brace may beneededforsupportduringtheinitialreturntoactivity.Strongercalfandanterior compartment muscles help support the ankle and prevent orlessenthe incidenceof injuries.Avoidrunningand jumpingonunevensurfacesasmuchaspossible.

Long-termPrognosisAlthoughpeoplewhohavefracturedtheirankletendtohaveaslightlyhigherrateofre-injury,properstrengtheningandrehabilitationusuallyleadtoafullrecovery.Compoundfracturesorfracturesresultinginbonymisalignment may require surgical pinning to hold the bone in placewhileitheals.

099:ANKLESPRAIN

Anyone involved inathletics is susceptible toanankle sprain,anacuteinjury to any or all of the ligaments that support the ankle structure.Tearingorstretchingoftheligamentscanoccurwhenthefootisrolledortwisted forcefully. High-impact sports involving jumping, sprinting orrunning on changing or uneven surfaces often lead to ankle sprains.Basketball, football, cross country and hockey are a few of the sportscommonlyassociatedwithanklesprains.

Lateralankleorinversionsprainscommonlyoccurwhenstressisappliedto the ankle during plantarflexion. The anterior talofibular ligament ismost commonly injured.Themedialmalleolusmayactasa fulcrumtofurther injure the calcaneofibular ligament if the strain continues. Theperoneal tendonsmayabsorb someof this strain.Medial ankle sprainsare less common because of the strong deltoid ligament and bonystructureoftheankle.Whenligamentsarestretchedbeyondtheirnormalrangesometearingofthefibersmayoccur.

CauseofInjurySuddentwistingofthefoot.Rollingorforcetothefoot,mostcommonlylaterally.

SignsandSymptomsFirst-degree sprains: Little or no swelling;mild pain and stiffness in thejoint.

Second-degreesprains:Moderateswellingandstiffness;moderatetoseverepain;difficultyweightbearingandsomeinstabilityinthejoint.

Third-degree sprains: Severe swelling and pain; inability to weightbear;instabilityandlossoffunctioninthejoint.

ComplicationsifLeftUnattendedChronic pain and instability in the ankle joint may result if left

unattended.Lossofstrengthandflexibilityandpossiblelossoffunctionmayalsoresult.Increasedriskofre-injury.

ImmediateTreatmentRICER. Second- and third-degree sprains may require immobilizationandimmediatemedicalattentionshouldbesought.

RehabilitationandPreventionStrengtheningthemusclesofthelowerlegisimportanttopreventfuturesprains.Balancetrainingwillhelptoimproveproprioception(thebody’sawareness of movement and joint position sense) and strengthen theweakenedligaments.Flexibilityexercisestoreducestiffnessandimprovemobilityareneededalso.Bracingduringtheinitialreturntoactivitymaybe needed but should not replace strengthening and flexibilitydevelopment.

Long-termPrognosisWith proper rehabilitation and strengthening the athlete should notexperienceanylimitations.Aslightincreaseintheprobabilityofinjuringthatanklemayoccur.Athleteswhocontinuetoexperiencedifficultywiththe anklemayneed additionalmedical interventions including, in rarecases,possiblesurgerytotightentheligaments.

100:TIBIALISPOSTERIORTENDINITIS

Painalongthemedial(inner)sideofthelowerleg,ankleandfootmaybethe result of tibialis posterior tendinitis. The tibialis posterior tendonstabilizes the footagainst eversionandsupports themedial archof thefoot,whichputsfrictionandtensiononthetendon.Ifthearchfalls,stressonthetendonwillincrease.Thiscanoccurwithpoorrunningmechanics,improperfootwearoruntreatedinjuries.

CauseofInjuryImproper running mechanics. Improper footwear. Prior injury to themedialsideoftheankle.

SignsandSymptomsPainandtendernessovertheinnersideoftheshin,ankleandfoot.Painwhenwalkingorrunning.Someswellingmaybenotedoverthetendon.

ComplicationsifLeftUnattendedIf leftunattended, thisconditioncanleadtoafallenarchoracompleterupture of the tendon. Thepainmay cause a change in footfall duringrunningleadingtoinjuriesinotherstructuresofthefootandankle.


RehabilitationandPreventionAfter pain subsides it is important to stretch and strengthen the calfmuscles tosupport the tendonandspeedrecovery.Archsupportsmaybe required until the tendon heals and the muscles are strengthened.Gradual reintroduction intoactivity is importantandproperwarm-upswill help prevent a recurrence of the injury. Proper footwear andcorrections of any mechanical inefficiency will also help prevent thisinjury.

Long-termPrognosisProper treatment should lead to a complete recovery. The longer theconditionexistsbefore treatment the longerrecoverywill take. Insomecasesorthoticsmayberequiredtopreventarecurrence.

101:PERONEALTENDONSUBLUXATION

The tendons of peroneus longus and peroneus brevis run from theperoneal muscles in the lateral calf to the foot. They pass around thelateral malleolus through a groove in the bone. Peroneal tendonsubluxation (dislocation) is most commonly a chronic condition thatdevelopsafterasprainorfracture.Thetendonmovesoutofthegrooveinwhichitrunsduetodamagetotheligamentousstructuresdesignedtohold it in place. Pain on the lateral ankle and a popping sensation arepossiblesignsofthiscondition.

Runningandjumpingcancauserepetitivestresstothetendonespeciallywhen it is subluxating repeatedly.Somepeoplearepredisposed to thisinjury due to a shallow, or non-existent groovewhere the tendons lie.Peroneal tendon subluxation may also occur if the tip of the lateralmalleolusisfracturedbyforceddorsiflexionoradirectblow.

CauseofInjuryTearingorstretchingoftheligamentsthatsupportthetendons,usuallydue to an ankle sprain or fracture. Repetitive stress to the tendons,

causinginflammationandswelling,allowingthetendonstoslideoutofthegroove.

SignsandSymptomsPainand tenderness along the tendons.Poppingor snapping sensationonthelateralsideoftheankle.Swellingmaybenotedalongthebottomofthefibula.

ComplicationsifLeftUnattendedThe peroneal tendons become irritated when they dislocate, whichcausesinflammation.Thisinflammationcanleadtotearingorcompleteruptureofthetendonsifleftuntreated.

ImmediateTreatmentRICER. Anti-inflammatory medication. Possible immobilization,especiallywithacutedislocation.

RehabilitationandPreventionStrengthening of themuscles in the lower leg after pain subsides andnormal function returns will help support the tendons. Treating anklesprains properly will help prevent subluxation. Strong calf and shinmuscleswillhelpsupportthewholefootandanklestructure,preventingthisconditionaswell.

Long-termPrognosisWhen treated promptly, subluxation of the peroneal tendons usuallyrespondswelltonon-surgicaltechniques.Insomecases,surgerymayberequired to repair the sheath and ligaments that cover the tendon to

restorestability.

102:PERONEALTENDINITIS

The tendons of peroneus longus and peroneus brevis run from theperonealmusclesinthelateralcalftothefoot.Theperonealmusclesareinvolved in stabilizing the foot and providing support to the ankle topreventlateralrollingofthejoint.Peronealtendinitisismostcommonlyaresultofoveruseoftheperonealmusclesorofinversionsprainswhichstretchtheperonealtendons.Itcanbecausedbyexcessivepronationofthefootastheperonealmuscleshavetoworkhardertostabilizethefootwhenitispronated.

Running and jumping involve repeated contraction of the peronealmuscles and can lead to inflammation of their tendons. Runners whooftenrunonunevensurfacesorhaveexcessivepronationoftendevelopperonealtendinitis.

CauseofInjuryOver-pronationofthefootduringrunningorjumping.Priorankleinjuryleadingtoanincorrectpathoftravelforthetendons.

SignsandSymptomsPain and tenderness along the tendons. Pain is most severe at thebeginning of the activity and diminishes as the activity continues.Gradualincreaseinpainovertime.

ComplicationsifLeftUnattendedUnattended tendinitis can lead to a complete rupture of the tendons.Peroneal tendinitis can lead to subluxations. The chronic inflammationcanalsoleadtodamagetotheligamentssurroundingthetendons.

ImmediateTreatmentRest, especially from running or jumping activities. Ice. Anti-inflammatorymedication.

RehabilitationandPreventionStretchingofthecalfmusclesandagradualreintroductionintoactivityisimportantforrehabilitation.Duringtherecoveryperioditisimportanttoidentify and correct any foot or gait abnormalities that may becontributingtotheproblem.Preventionofthisconditionrequiresstrong,flexiblemusclesofthelowerlegtosupportthefootandankle.

Long-termPrognosisWithproper treatment,peroneal tendinitiswillusuallyheal completelywithnolingeringeffects.Inrarecasesthetendinitismaynotrespondtotraditionaltreatmentandmayrequiresurgicalinterventiontorelievethepressurecausingtheinflammation.Orthoticstosupportthemedialarchmayberequiredinsomecases.

103:OSTEOCHONDRITISDISSECANS

Osteochondritis dissecans occurswhen a fragment of bone adjacent tothearticularsurfaceofajointisdeprivedofitsbloodsupply,leadingtoavascularnecrosis.Fracturescanoccuronthesurfaceofthetalusorthecartilagemaybecomebruisedfromanytwistinginjurycausingthetalustocomeintohardcontactwiththetibiaorfibula.Thepoorbloodsupplyof articular cartilage means that repairing damage is difficult for thebody. Damaged cartilage becomes brittle and pieces, or loose bodies,may break off. Loose cartilage in the joint can cause pain andinflammation.

Thespace in theankle joint isverysmallandwhenaboneorcartilagefragmentfromthetalusgetslodgedinthejointcavityitcancausepain,swellingandlossofmovementintheankle.Thesesymptomsmaycomeandgoasthefree-floatingfragmentfloatsinandoutofthejointcavity.Priorankleinjuriesmakeapersonsusceptibletothiscondition,asdoesanycompromiseofthebloodsupplytothefeet.

CauseofInjuryLossofbloodflowtothearticularsurfaceofthetalusalongwithinjuryto the bone. Repetitive wear on the cartilage and bone surface of thetalus.Previousankleinjury.

SignsandSymptomsPainanddiscomfort in the joint. If the fragmentbecomesdetachedandlodgedinthejoint,swellingandlossofmovementmayoccur.Acatchingsensationintheanklemaybefelt.

ComplicationsifLeftUnattendedLoosebodiesinthejointcancausescarringandadditionaldamageifleftunattended. As the jointmoves and the loose body grinds against thecartilageandbone surfaces, itwillwearat these surfacesmaking themroughandeventuallyleadtoarthritis.

ImmediateTreatmentAnti-inflammatorymedication.Rest andpossible immobilizationof thejoint.Referraltoasportsmedicineprofessional.

RehabilitationandPreventionRehabilitating the ankle after this typeof injury includes strengtheningthe muscles of the lower leg to offer additional support to the joint.Stretching and range ofmotion activitiesmay be required if the anklewas immobilized for treatment. Gradual return to activitywill help toprevent it from recurring immediately. Treating all ankle injuriesproperly,nomatterhowminor,willhelpmaintainagoodbloodsupplytothejointandprotectthetalus.

Long-termPrognosisMany times the loose body does not completely detach from the boneallowingthebodytoreabsorbit.Ifaloosebodydoesbecomedetacheditmayrequiresurgicalremoval.Ifallowedtowearatthejointloosebodiescanleadtoosteoarthritisespeciallyintheolderathlete.

104:SUPINATION

Supination occurs at the subtalar joint between the talus and thecalcaneus(heelbone).Thedistal(lower)endsofthetibiaandfibularestonthetalusofthefootatthetalocruraljoint.Thisistraditionallyreferredto as a hinge joint because its main function is to allow flexion andextension of the ankle. The subtalar joint below allows pronation andsupinationofthefoot.Pronationandsupinationmovementsaidbalanceandimproveshockabsorption.

Supinationistheoutwardrollingofthefootattheankle.Thisisanormalmovement during the push-off phase of running,walking or jumping.Excessivesupinationcancausedamagetothelateralligaments,tendonsand muscles of the lower leg and ankle. Acute over-supination maycausestretchingortearingofthelateralligamentsofthefootandankle.Excessivesupinationcanleadtoaweakeningoftheanklestructureanddecreasedstability.

CauseofInjuryWeak or loose tendons and ligaments in the ankle. Weak or fatiguedmusclesofthelowerleg.Forcefuloutwardrollingoftheankle.Improperorwornfootwear.Unevenorslopedrunning(orlanding)surface.

SignsandSymptomsPaininthearch,heeland/orkneesandhips.Instabilityintheankle.Painover theoutsideof the ankle.Painmaybe immediatewithacuteover-supination(suchasananklesprain).

ComplicationsifLeftUnattendedMayleadtochronicweaknessandinstabilityintheankle.Thepainandimpropergaitmay lead to compensationand injury toother structuresand tissues. The ligaments may lose their elasticity from excessivestretchingandtearingmayoccur.

ImmediateTreatmentRest, ice and anti-inflammatory/analgesic medication. Acute over-supinationmay requiremedical attention and immobilization. Chronicsupination will require correction of the underlying problems whilstallowingadequaterestforthetissuestorecover.

RehabilitationandPreventionProperwarm-upisessential.Strengtheningandstretchingofthemusclesofthelowerlegmayhelpsupporttheankle,keepitmovinginthecorrectplaneandreduceexcessivesupination.Orthoticsandgaitanalysismaybe required. Gradual return to full activity is recommended andretrainingoftheathletetoimproveorcorrectrunningformisimportant.Ensureproperfootwearandasmooth,flatrunning(orlanding)surface.

Long-termPrognosisWill respondwell if treated earlywith a good rehabilitation plan. Thelength of time the condition is allowed to persist will also affect therecovery time. In rare cases, surgery may be required to tighten thetendonsorcorrectskeletalfactors.

105:PRONATION

Pronationoccursatthesubtalarjointbetweenthetalusandthecalcaneus(heel bone). The distal (lower) ends of the tibia and fibula rest on thetalusofthefootatthetalocruraljoint.Thisistraditionallyreferredtoasahingejointbecauseitsmainfunctionistoallowflexionandextensionofthe ankle. The subtalar joint below allowspronation and supination ofthefoot.Pronationandsupinationmovementsaidbalanceandimproveshockabsorption.

Pronationistheinwardrollingofthefootattheankleduringwalkingorrunning. While some pronation is natural and part of normal gait,excessivepronationcanleadtochronicinjuriesandacuteover-pronationcanleadtostrainsorsprains.

The strong medial ligaments of the ankle help provide support andpreventexcessivepronation.The tibialisanteriorandposteriormusclesof the lower leg also offer support. When ligaments are loose or themusclesfatiguethesupportislostwhichresultsinmorepronation.Thiscauses thearchof the foot to flattenoutwhich in turnfurtherstretchestheligaments.Duringweightbearinginthemid-stancephaseofthegaitcycle there is a tendency for the calcaneus to evert (roll in) and theforefoottoabduct(pointoutward)astheanklemovesintodorsiflexion.

CauseofInjuryLoose or torn tendons from previous ankle injuries.Weak or fatiguedmusclesof the lower leg. Improperorworn footwear.Uneven running(orlanding)surfaces.

SignsandSymptomsPain in the arch, heel and/or knees and hips. Pain during the landingphase of running or jumping. Visible inward rolling of the foot andankle. Instability in the ankle. Painmay be immediate for acute over-pronation, such as an ankle eversion sprain, or gradual for chronicpronationdisorders.

ComplicationsifLeftUnattendedPronation has been linked with shin splints, plantar fasciitis,chondromalaciapatellae,tendinitisandevenstressfractures.Thelongerpronationcontinuesthemorethemedialligamentsofthefootandanklewillbestretched,leadingtoankleinstability.Thearchesmayflattenoutand lead to other problems of the foot. Chronic pronation of the footbeyondnormalrangescanleadtooveruseandchronicinjuries.

ImmediateTreatmentRest,iceandanti-inflammatory/analgesicmedication.Foracuteinjuries,immobilization and reduction of weightbearing activities may berequired.Forchronicinjuriesseekthehelpofaqualifiedsportsmedicinespecialisttohelpidentifyandcorrecttheproblem.

RehabilitationandPreventionCorrecttheunderlyingproblem,e.g.ifduetotherunningsurfacechangethe surface toone that is flat or smooth. Ifdue to footwear trynewordifferent shoes. If necessary use orthotics and gait training. Warm-upproperly. Stretching and strengtheningwill offer support and keep themusclesofthelowerlegstrongandflexible.Completelyrehabilitateanyankleinjurybeforereturningtosporttopreventrecurrence.

Long-termPrognosisThe condition usually respondswell to treatment, although the longerpronation goes untreated and is allowed to cause damage to theligaments the longer the recovery time. In very rare cases, surgicalintervention may be required to correct any underlying orthopedicissues.


CalfRaise

Stand upright and place your toes on the edge of the step and yourshoulderssecurelyunderthepaddedweight.Slowlyraisetheweightupbystraighteningyourankles,thenlowertheweighttothestartpositionandrepeat.

Single-leggedCalfRaise

With a dumbbell in each hand raise one leg slightly off the ground.Slowlyraiseupbystraighteningyourankle, then loweryourself to thestartposition,repeat,andthenswitchsides.

AnkleJumps

With your arms at your sides, jump off the ground using only youranklesandcalves.

Goose-steps

With adumbbell in eachhand, take 10 steps forwardwalking only onyourtoes.

AchillesStretch

Standuprightandtakeonebigstepbackward.Bendyourbacklegandpushyourheeltowardtheground.

Cross-overShinStretch

Standuprightandplace the topofyour toeson theground in frontofyour other foot. Slowly bend your other leg to force your ankle to the

ground.

CHAPTER17SportsInjuriesoftheFoot


The foot consists of twenty-six small bones.The seven tarsals form theankle.Thetwolargesttarsalscarrythebodyweight:thecalcaneus,ortheheelbone,andthetalus.Thetalussitsbetweenthetibia, thefibulaandthecalcaneus.Thetibiaandfibularestontopofthetaluswhichrestsonthe calcaneus. The other tarsal bones are: the navicular, medialcuneiform, intermediate cuneiform, lateral cuneiform and the cuboid.Thefivemetatarsalsarelong,narrowbonesthatformtheinsteporsoleofthefootandthefourteenphalangesconsistofshort,narrowbonesthatformthetoes,withtwojointsinthebigtoeandthreeintheothers.

Thesesamoidbonesofthefootarelocatedontheplantarsurfaceofthefirstmetatarsalhead.Thesesamoidbonesaresphericalandembeddedinthe tendonof the flexorhallucisbrevis (FHB).Theyreduce frictionandguide the tendon to aid transmission of the force generated by FHBwhich is responsible for ‘toeing off’ in walking and running. Thesesamoidbones alsohelp elevate thebonesof thebig toe andassist inweightbearing.

Thebonesoftherightfoot,anteromedialview.

The sheer number of articulations between the bones of the footmeantheyareusuallydescribedingroups:thesubtalarjoint(betweenthetalusand calcaneus); transverse tarsal joints (the articulations between thetalus,navicular, cuboidand the cuneiforms); tarsometatarsal joints (thearticulations between the cuneiforms, the cuboid and the metatarsals);metatarsophalangealjointsandinterphalangealjoints.

Inadditiontotheligamentsstabilizingthemanyjointsbetweenadjacentbonesofthefoot,strongligamentscriss-crosstheplantarsurface(thesoleofthefoot).Bandsoffasciaknownasretinaculakeepthetendonsofthemusclesofthefeetandlowerleginplacearoundtheankle.

Themedialarchofthefoot.

Theplantarfasciaisathick,tough,collagenoussheetofligamentontheplantar surface which stretches from the calcaneus to the proximal

phalanges.Itprovidescushioningandstructuralsupporttothefootandthearches,andactsasapointofattachmentforthemanymusclesofthefoot.

The foot is not a rigid structure. The bones of the foot flatten onweightbearing and the foot pronates and supinates during gait. Thisdynamic flexibility is supported by medial and lateral longitudinalarchesandtwotransversearchesunderthetarsalandmetatarsalbones.Arches are formed by the shape of the bones of the foot and arestrengthenedbystrongligaments(thespringligamentofthemedialarchisoneofthemostclinicallyimportant)andbythemusclesofthefootandthelowerleg.

Amultitudeofmuscles control the foot. Someof theseoriginate in thelower leg.Others, the intrinsicmusclesof the foot,originate in the footitself.Alongwiththestructureofthejoints,thisallowsforawiderangeofmovementatthefootandankle.Theseincludeflexionandextension(plantarflexion) at the ankle and at the individual joints of the toes;

eversion and inversion occur at the subtalar articulation between thecalcaneusandtalus;thewholefootmaybeadductedandabductedawayfromthemidlineofthebodyandthetoesthemselvesmaybespreadorpulledtogether.Conjointmovementsoverseveraljointsallowrotationofthe foot on the ankle and pronation and supination.Extensor hallucislongus (EHL) and extensor digitorum longus (EDL) are the mainextensor muscles of the toes. Their tendons run over the front of theankle and foot and attach to the phalanxes of the toes. Thesemusclesdorsiflexthefootandworkinoppositiontotheflexormuscles.Theflexorgroup of muscles, flexor hallucis longus (FHL) and flexor digitorumlongus(FDL),havetendonsthatrunbehindthemedialmalleolusoftheankleandunderthefoot,attachingtothetoes.Thesemusclesplantarflex

thefootandtoes.

Outlineofthethreearchesofthefoot.

Themainextensormusclesofthetoes.

Therearefourlayersofmuscleinthesoleofthefoot.Thefirstlayeristhemost inferior (the most superficial and closest to the ground onweightbearing)andcomprisesabductorhallucis,flexordigitorumbrevisand abductor digiti minimi. Abductor digiti minimi forms the lateralmarginofthesoleofthefoot.Thesecondlayercontainsthelumbricalesand quadratus plantae, plus the tendons of flexor hallucis longus andflexordigitorum longus.The third layer contains flexorhallucis brevis,adductorhallucisandflexordigitiminimibrevis.Thefourthlayeristhedeepest and consists of the four dorsal interossei, the three plantarinterosseiandthetendonsoftibialisposteriorandperoneuslongus.

Thefourlayersofmusclesinthefoot:a)firstlayer,b)secondlayer,c)thirdlayer,andd)fourthlayer.

106:FRACTUREOFTHEFOOT

A foot fracturemay involve any of the 26 bones of the foot butmostcommonlyoccurs to themetatarsalswhendirect force isapplied to theshaft.Contactsportsandsportsthatcouldresultinhigh-impactlandingsor collisions have a higher rate of foot fractures. Those athletes withlowerbonedensityduetonutritionaldeficiency,osteoporosis(orabsentmenstrualcyclesinfemaleathletes)aremoresusceptibletofractures.

CauseofInjuryTrauma to the bones of the foot, e.g. fall, blow, collision or violenttwisting.

SignsandSymptomsPain,whichcanbesevere.Swellinganddiscoloration.Possibledeformityatthefracturesite.Painonweightbearingandpossibleinabilitytowalk.Numbnessofthefootortoes.

ComplicationsifLeftUnattendedAfracturethatisleftuntreatedcanleadtodamagetothebloodvesselsand nerves in and around the fracture site. The bones may healincorrectly or not heal at all.Weakness and instability in the footmayresult.

ImmediateTreatmentImmediate removal from activity. Ice, elevation and possible

immobilization.Seekimmediatemedicaltreatment.

RehabilitationandPreventionAfterpainsubsides,stretchingofthemusclesthatwerenotusedduringrecoveryisimportant.Strengtheningofmusclesthathaveatrophiedduetolackofuseduringimmobilizationisamust.Strongmusclestosupportthefootareessentialtopreventfootfractures.Avoidingdirecttraumatothefootisthebesttoolforprevention.Properfootweartooffersupportandprotectionwillalsohelppreventthisinjury.

Long-termPrognosisIf allowed to heal completely, a fracture will usually heal to becomestronger than before the injury. In fractures that are compound ormisaligned,surgicalpinningmayberequiredtostabilizetheboneuntilitheals. If the ligaments are stretched or torn the chance of re-injuryincreases.

107:RETROCALCANEALBURSITIS

Theretrocalcanealbursa liesbetween theAchilles tendon insertionandthecalcaneus(heelbone)andhelpstolubricateandcushionthetendonas it runs over the heel. This bursa is stressed during repetitivemovements of the ankle and foot such as during running, walking orjumping. The repetitive friction of the tendon running over the bursaduring forceful plantarflexion during push-off compresses the bursabetweenthetendonandboneandcancauseinflammation.

WornorincorrectlysizedfootwearorexcessivepronationofthefootcanleadtoproblemswiththisbursaandtheAchillestendon.Shoesthatfittootightly,especiallyaroundtheheel,mayputadditionalstressonthetendonandbursa.

CauseofInjuryRepetitivestresstothebursabythefrictionoftheAchillestendonduringwalking, running or jumping. Increasing duration or distance tooquickly. Improper footwear. Gait dysfunction such as over-pronation.InjurytotheAchillestendon.

SignsandSymptomsPain,especiallywithwalking,runningor jumping.Tendernessovertheheelarea.Rednessandslightswellingmaybenotedovertheheel.

ComplicationsifLeftUnattendedThe bursa can rupture completely if the injury is left unattended. ThiscompleterupturecouldleadtootherproblemswiththeAchillestendonduetoincreasedfriction.Thepainmaymakeitdifficulttoriseupontothetoesduringwalking,runningorjumping.

ImmediateTreatmentRestfromactivitiesthatcausepain.Ice.Anti-inflammatorymedication.

RehabilitationandPreventionStrengthening themusclesof the calf and stretching themusclesof thelower legwill facilitate healing.Using activities that donot irritate thearea tomaintain fitness levels is essential. Keeping themuscles strongand flexible and allowing adequate warm-up before all activities willhelppreventbursitis.

Long-termPrognosisProper treatment and rest should lead to a complete recovery. In rarecases the fluid that buildsupdue to the inflammationmayneed to bedrained to facilitatehealing.Surgery isonlynecessary inextremecasesthatdonotrespondtorestandrehabilitation.

108:STRESSFRACTURE

Stressfracturesinthefootareusuallyaresultofrepetitiveimpacttothebones of the feet. Running or jumping on hard surfaces, changing thedurationordistanceofworkoutstooquicklyorfatiguedmusclesthatcanno longerabsorbshockcan lead to the formationofsmallcracks in thebone.Thesmallcracksaccumulateandbecomeastressfracture.

A stress fracture can occur in any of the bones of the foot but aregenerally seen in the metatarsals. The calcaneus can also becomefracturedduetoimproperfootwearorasaresultofanoldinjurythathasgoneuntreated.Aweakpointinthebonefromapreviousinjuryordueto bone remodelling can develop stress fractures under normal stressconditions.

CauseofInjuryRepetitivetraumatothebonesofthefoot.Weakenedareaofboneduetoprevious injury or other condition.Muscle fatiguemaking themusclesineffectiveshockabsorbers.

SignsandSymptomsPainat the siteof the fracture.Painonweightbearing,with inability towalkinseverecases.Swellingmaybenotedoverthefracturesite.Somelossoffootfunctionmaybenoted.

ComplicationsifLeftUnattendedMoreseriousstressfractureincludingacompletebreakinthebonemay

occur if left unattended. Swelling and inflammation may causecirculatory and nerve problems in the foot. Pain may increase to thepointofdisabilityandinabilitytowalk.


RehabilitationandPreventionStrengthening themuscles that support the footwill help to lessen theimpactofbodyweightandgroundimpact forcesonthefoot.Agradualreturn to activity after the injury has healed is important to preventrecurrence.Properfootwear,correctwarm-uptechniques,avoidinghardrunning surfaces and a calcium-rich diet will help prevent stressfracturesinthefoot.

Long-termPrognosisStressfractureswillusuallyhealcompletelyandhavenolingeringeffectsifrestandrehabilitationareused.Thefracturesiteshouldhealtobecomestronger than it was originally. Only in severe cases where the bonefractures completely and does not respond to rest and immobilizationwillsurgeryberequired.

109:FLEXORANDEXTENSORTENDINITIS

Thetendonsofthemusclesresponsibleforflexingandextendingthetoesand foot can become inflamed and irritated. Overuse, tightness inopposing muscles and/or the calf muscles, joint dysfunction or gaitabnormalities can cause this condition. Extensor tendinitis is morecommonbutflexortendinitis tendstobemorepainfulanddebilitating.Dancersaremostcommonlyassociatedwithinjurytotheflexortendons.

CauseofInjuryExtensor tendinitis: Tight calf muscles, over-exertion of the extensormuscles,fallenarches.

Flexor tendinitis: Repetitive stress to the tendon from excessivedorsiflexion(extension)ofthefoot.

SignsandSymptomsExtensor tendinitis:Painon the topof the foot,painwhendorsiflexingthetoes,somestrengthlossmaybeexperienced.

Flexortendinitis:Painalongthecourseofthetendon,inthemedialarchof the foot and behind the medial malleolus of the ankle. Pain whenwalkingorflexingthetoesagainstresistance.

ComplicationsifLeftUnattendedTendinitis when left unattended can cause strains to the associatedmuscles and could lead to a complete rupture of the tendon. Thepainmaybecomesevereenoughtolimitallactivity.

ImmediateTreatmentRest from activities that cause pain. Ice the tendon.Anti-inflammatorymedication.

RehabilitationandPreventionWhile resting the foot it is important to identify the conditions thatcaused theproblem.Stretching the calfmusclesand tibialis anteriorontheshinwillhelprelievethepressureonthetendons.Warming-upandgradually increasing workload will help prevent tendinitis. Orthoticsmayberequiredwhenreturningtoactivitytocorrectanyarchproblems.

Long-termPrognosisMost people recover completely from tendinitis with simple rest andcorrectionofthecause(s).Insomerarecasessurgerymayberequiredtoreducethepressureonthetendonsandrelievetheinflammation.

110:MORTON’SNEUROMA

Branches of the plantar nerve supply the toes and run between themetatarsal heads where they can become compressed, which causesinflammationandswelling.Morton’sneuroma iscausedbyswellingofnerve and scar tissue causing compression of the plantar nerve. It ischaracterized by pain, burning sensations and/or numbness on theplantar surface of the foot, usually between the third and fourthmetatarsals.

Running(especiallysprinting),walkingandjumpingallplacerepetitivestress on the metatarsals and have the potential to cause Morton’sneuroma.Footdeformities,underlyinggait abnormalities suchasover-pronationortight-fittingshoeswhichcompressthefootcanalsoleadtothiscondition.

CauseofInjuryRepetitivestressortraumatotheballofthefoot,suchaswithrunning,walking or jumping. Pronation.Wearing footwear that compresses thefoot.Injuriestothemetatarsalsofthethirdandfourthtoes.

SignsandSymptomsPain and/or burning sensation in the affected area. Possible loss ofsensation in the third and fourth toes. Possible numbness, tingling orcramping in the forefoot.Whileweightbearing inshoes, severepainonthe lateral side of the footmay be present which is relieved by goingbarefoot.

ComplicationsifLeftUnattendedIf left unattended a neuroma may lead to permanent nerve damage.

Permanent loss of sensation to the toes may result. Pain will increase

withouttreatmenteventuallyleadingtodisability.

ImmediateTreatmentRestfromormodificationofactivity.Anti-inflammatorymedication.Ice.

RehabilitationandPreventionA gradual return to activity and avoiding repetitive trauma to theforefootwillhelpspeedrecovery.Paddingmaybeneededwhenactivityisresumed.Themostimportantstepinpreventionofthisconditionistouse footwear that allows plenty of room for the forefoot.Narrow-toedshoesandhighheelsshouldbeavoided.

Long-termPrognosisWhen treated properly a neuroma should recover completely withoutanylong-termeffects.Thelongertheinjurygoesuntreatedthehigherthepotential for lingering effects. Surgerymay be required if conservativetreatmentdoesnotleadtorecovery.

111:SESAMOIDITIS

Thesesamoidbonesinthetendonofflexorhallucisbrevisonthebaseoftheheadofthefirstmetatarsalcanbecomeinjuredandinflamedcausinga condition similar to tendinitis. Runners, dancers and catchers inbaseballareallsusceptible to this injury. Increasingactivity tooquicklycausesadditionaltraumatothesmallsesamoidbones.

CauseofInjuryIncreasedactivitywithoutproperconditioning.Littlenaturalpaddinginthe forefoot leaving the sesamoid bones unprotected. High archesleadingtorunningontheballsofthefeet.

SignsandSymptomsGradualonsetofpain.Painovertheboneandsurroundingtendon.Painincreaseswithactivity.

ComplicationsifLeftUnattendedIf left unattended this condition canworsen to the point that the painbecomesdebilitating.Inflammationinthetendoncancauseirritationtosurroundingtissue.Aswithtendinitis,acompleterupturemayoccur iftheconditionisallowedtogountreated.

ImmediateTreatmentRest.Ice.Anti-inflammatorymedication.

RehabilitationandPreventionFindingactivitiesthatdonotstressorirritatetheinjuredareawillhelptomaintain fitness levels while healing takes place. Strengthening themuscles of the lower legwill help support the foot.Wearing paddinginsidetheshoesmaybenecessarywhenreturningtoactivity.Graduallyincreasingdistanceordurationwillhelpprevent this condition,aswillwarming-upproperlybeforebeginningexercise.Orthoticsorimplantstocorrectarchproblemsmayalsohelppreventsesamoiditis.

Long-termPrognosisSesamoiditis responds well to rest and anti-inflammatory treatments.Complete recovery can be expected with no lingering effects. In rarecases where the condition does not respond to preliminary treatmentssurgicalinterventionmayberequired.

112:BUNIONS

Tightorill-fittingshoescanleadtoswellingandenlargementofthebaseofthebigtoeknownasabunion.Injurytothebigtoe,abnormalstressonthe outside of the toe and reduced force transference through the footduring gait due to medial arch problems can also lead to bunions.Women are much more likely to get bunions than men due to thewearingoftighter-fittingshoes.Abunion-likeconditionmaydeveloponthelateralaspectofthefifthtoecalledabunionette.

Bunions are typically found on the medial aspect of themetatarsophalangeal jointwhichconnects the toeandfoot.Whentight-fitting shoes, an injury or other condition causes pressure on the toe(forcing it inward) the joint becomes inflamed and enlarged. There isinflammation of the bursa overlying the medial aspect of the firstmetatarsalhead.Thefirstmetatarsalmovesmediallywhilethetoemoveslaterallytowardthesecondtoe,sometimesevenslidingunderit,formingahalluxvalgusdeformity.

CauseofInjuryTight-fittingshoes.Untreated injuryto thebig toe.Unusualpressure totheoutsideofthefirsttoe.Over-pronationofthefoot.

SignsandSymptomsBumpat thebaseof thebig toe.Halluxvalgusdeformity.Rednessandtendernessintheaffectedarea.Painonwalking.

ComplicationsifLeftUnattendedBunions left unattended may lead to further complications such asbursitis, difficulty walking, arthritis and chronic pain. Hallux valgusdeformitiesmaycausefurtherproblemsduetomisalignment.

ImmediateTreatmentRemove and discard tight-fitting shoes.Wear roomier shoes especiallywhenexercising.Paddingthebunionmayrelievesomeofthepain.Anti-inflammatorymedication.

RehabilitationandPreventionPrevention is essentialwhen assessing bunions. Footwearwith enoughroom for the feet will help prevent this condition. Avoiding unduepressureandtakingcaretotreatevenminortoeinjurieswillalsopreventbunions.Paddingtheareawhenexercisingwillhelpalleviatepain.

Long-termPrognosisBunionsrespondreasonablywelltotreatment.Incaseswherethebuniondoesnotrespondtotreatmentandfunctionissignificantlycompromised,surgery may be needed to correct the condition. Depending on the

surgicalprocedurerecoverymaybealmostimmediateorrequireseveralmonths.

113:HAMMERTOE

Hammertoegetsitsnamefromthehammer-orclaw-likeappearanceoftheaffectedtoe.Theproximalphalanx(mostoftenthatofthesecondtoe)ishyperextended(dorsiflexed)atthemetatarsophalangealjointwhilethemiddlephalanx is strongly flexedat theproximal interphalangeal joint.The distal phalanx may also be hyperextended. This puts increasedpressureontheballofthefootandcausesthetopofthemiddlephalanxto rubagainst theshoe.Cornsand/orcallusesmaydevelopdue to thepressureofthetoeagainsttheshoes.

Ill-fitting shoes may cause this condition. Weakness in the intrinsicmusclesof thefootornervedamagetothetoeflexormusclesmayalsoresultinthiscondition.Diabetes,stroke,arthritisorpriorinjurycanalsocauseadysfunctionalflexionofthetoes.

CauseofInjuryIll-fittingshoes.Muscleornervedamagetothetoeflexormuscles.

SignsandSymptomsHammer-likeappearanceofthetoe.Painanddifficultymovingthetoe.

Cornsandcallusesmaydevelopontheaffectedtoe.

ComplicationsifLeftUnattendedWhen left unattended hammer toe can lead to other problems such asarthritis,painfulcornsandcallusesandflexortendinitis.Itmayalsoleadtoacompleteinabilitytoextendorstraightenthetoe.

ImmediateTreatmentSwitchtoroomiershoes.Anti-inflammatorymedication.

RehabilitationandPreventionStretching and strengthening the toeswill aid recovery and correct thealignment of the toes if they are still flexible. Selecting properly fittedshoes and stretching the toes regularly will help prevent hammer toefromdeveloping.Strapsandpaddingmayberequiredtorelievesomeofthepain.

Long-termPrognosisSurgery may be required if the toe has become inflexible and othertreatmentsdonotwork.

114:TURFTOE

Painat thebaseofthebigtoemaybearesultof turf toe.Athleteswhojam their toe or repeatedly push off when running or jumping aresusceptible to this injury. Turf toe is often caused by forcedhyperextension of the metatarsophalangeal joint. The name turf toecomesfromthefactthatthisinjuryiscommonamongathleteswhoplayonartificialturf.

Turftoedevelopsatthemetatarsophalangealjointatthebaseofthegreattoe.Theplantarjointcapsuleorligamentistornleadingtoinstabilityandpain. This can lead to dislocations, cartilage wear and eventuallyarthritis. The tendons that cross the joint canbecome involved aswell.Jammingthetoe,orpushingoffwhenrunningorjumpingputsstressonthecapsuleandcanleadtotearing.

CauseofInjuryJammingthetoe.Repeatedpushingoffonthetoe,especiallyonahardersurfacesuchasartificialturf.

SignsandSymptomsPainatthebaseofthetoe.Someswellingmaybenotedinthejoint.Painincreaseswhenpushingoffwiththetoe.

ComplicationsifLeftUnattendedTurftoecanleadtochronicpainandtheinabilitytorunorjump.Whenleft unattended turf toe can lead to other conditions such as toedislocationsandarthritis.

ImmediateTreatmentRest.Ice.Anti-inflammatorymedication.

RehabilitationandPreventionAs the pain subsides it is important to work on the strength andflexibilityof the toes.Adjusting thewaypressure isapplied to the footwhenpushing offwill also help to correct the condition(s) that causedtheturftoe.Alternatingworkoutsbetweenhardandsoftersurfaceswillhelp prevent the development of this condition. Special inserts thatsupportthetoemaybeusedwhenreturningtoactivity.Agradualreturntofullactivityisimportant.

Long-termPrognosisTurftoedoeshaveatendencytoreturnwhenworkingoutonthesamesurface.Inmostcasespainwillsubsideandnormalfunctionwillreturn.Inveryrarecasessurgeryisrequiredtoalleviatethesymptoms.

115:FLATFEET(PESPLANUS)

Pes planus (flat feet or fallen arches) is a condition in which the footflattens and the medial longtitudinal arch falls toward the ground.Peoplewithflatfeetoftenhavedifficultyfindingshoesthatfitproperlywhich can lead to other foot problems or gait disturbances. Thiscondition is the opposite of claw foot (pes cavus) but is much morecommon.

Inpesplanus,theflatteningofthearchisassociatedwithover-pronation,theexcessive inwardrollingof the footandankle,whichoften leads tootherinjuriesofthefoot,ankle,knees,hipsandlowerback.Thelowarchputsadditionalstressonthecalfmusclesandthemedialankleandisapossible contributor to ankle sprain and shin splints.Athleteswithpesplanus must work to maximize strength in the arch and the affectedmuscles.

CauseofInjuryWeakness or instability in the muscles, tendons and ligaments in thelower leg and arch of the foot. May be hereditary or acquired due totraumaorillness.

SignsandSymptomsUnusuallylow,flattenedarchinwhichtheentiresoleofthefootmakescontactwiththeground.Paininthefoot,ankleandlowerleg,especiallywhenwalking,runningorwhenstandingforlongperiodsoftime.

ComplicationsifLeftUnattendedMostpeoplewith flat feetdon’texperiencepainoranyotherproblemsbut athletes or very active individualswith pes planus can experiencepainandpossibleinjurytootherstructuresinthefoot,ankleandlowerleg.Bunions.

ImmediateTreatmentIf pain is experienced, rest and limiting weightbearing activities willusually bring quick relief. If pain continues see a sports medicineprofessionalorpodiatristforacompletefootandgaitanalysis.

RehabilitationandPreventionStrength exercises for the ankle, feet and toes are the first and mostimportant step in rehabilitation. Foot gymnastics (games and exercisesfor the feet and toes) and barefoot walking on sand or other unevensurfaceswillhelptostrengthenallthesofttissuesofthefootandlowerleg. Finding properly fitting shoes, orthotics, arch supports or custommade shoes is important for comfort, to help support the arch andpreventinjuryduetoinstabilityofthefoot.

LongtermPrognosisWhentreatedproperly,muchofthepainassociatedwithpesplanuscanberelieved.Surgerymaybealastresort,especiallywhenpainissevere

andothertreatmentsdonothelp.

116:CLAWFOOT(PESCAVUS)

Pes cavus (claw foot) is a condition that gives the foot a claw-likeappearance. People with claw foot often have difficulty finding shoesthat fit properly which can lead to other foot problems or gaitdisturbances.Thisconditionistheoppositeofflatfeet(pesplanus)butismuchlesscommon.

Inpescavus,theexaggeratedheightandinflexibilityofthelongitudinalarchisassociatedwithtightcalfmuscles,increasedstressontheAchillestendonandpainintheforefootasfootpositioningputsadditionalstressonthemetatarsalheads.Thehigharchputsadditionalstressonthecalfmuscles and the lateral ankle. Athletes with pes cavus must work tomaximizeflexibilityinthearchandtheaffectedmusclesorworkarounditintheiractivities.

CauseofInjuryMay be inherited or acquired due to trauma or neurological disease.Possiblysecondarytocontracturesordisturbedbalanceofthemuscles.

SignsandSymptomsUnusuallyhigh,inflexiblearch.Paininthefoot,especiallywhenwalkingorrunning.Toesmaybebent.

ComplicationsifLeftUnattendedPescavuscancausechronicpainandpossibleinjurytootherstructuresinthefoot.Footandankleinstabilityiscommonandcouldleadtostrainsandsprains.

ImmediateTreatmentStretch the calf muscles and the foot. Contact a sports medicineprofessionalifpainfulandunresponsivetoself-management.

RehabilitationandPreventionStretching the calfmusclesand the foot is the first andmost importantstep in rehabilitation. Finding properly fitting shoes is important forcomfort,tohelpsupportthearchandpreventinjuryduetoinstabilityofthefoot.Strengtheningthemusclesofthelowerlegwillalsosupportthefoot. Ifsurgery isrequired itwillbe important to increasestrengthandflexibilityinthemusclesthatareimmobilized.

Long-termPrognosisWhentreatedproperly,muchof thepainassociatedwithclawfootcanberelieved.Surgerymaybeanoptionespeciallywhenpainissevereandothertreatmentsdonothelp.

117:PLANTARFASCIITIS

Plantar fasciitis is an overuse condition affecting the plantar fascia oraponeurosis at its insertion on the calcaneus. The plantar fascia is atough, fibroussheetwhichruns fromthe tuberosityof thecalcaneus tothemetatarsalheads.Itisimportantforsupportingthelongitudinalarchofthefoot,asapointofmuscleattachmentandforcushioningthebonesofthefoot.

Repetitive anklemovement, especially when restricted by tight calves,canirritatetheplantarfasciaat thecalcaneus.Painisusuallyfelt intheheelespeciallyuponrising fromanextendedrest.Walkingor running,especiallyonhardsurfacesandwithtightcalfmuscles,makesanathletemore susceptible to this injury. High or fallen arches and incorrectfootwearcanalsoleadtoplantarfasciitis.

CauseofInjuryRunning on hard surfaces. Improper or ill-fitting footwear. Archproblems. Training errors. Overuse. Over-pronation. Poor flexibility ofthe calf muscles (gastrocnemius, soleus and plantaris) and Achillestendon.

SignsandSymptomsPainundertheheelwhichisworseafterexerciseorwhenrisingfromanextended rest. Pain may diminish during exercise but return after theactivityisstopped.

ComplicationsifLeftUnattendedPlantarfasciitisthatisleftunattendedcanleadtochronicpainthatmaycauseachangeinwalkingorrunninggait.Thisinturncanleadtoknee,hipandlowerbackproblems.

ImmediateTreatmentRest. Ice. Ultrasound. Anti-inflammatory medication. Then heat andmassagetopromotebloodflowandhealing

RehabilitationandPreventionStretching the Achilles tendon and the plantar fascia will help speedrecoveryandpreventrecurrence.Aspecialorthoticorinsertfortheshoemayberequiredatthebeginningofthereturntoactivity.Strengtheningthe muscles of the lower leg will also serve to protect the fascia andpreventthiscondition.

Long-termPrognosisMostpeoplewithplantar fasciitisrecovercompletelyaftera fewweeksto a few months of treatment. Injections of corticosteroid may benecessaryincaseswherethefasciadoesn’trespondtoearlytreatment.

118:HEELSPUR

Aheelspurisahookorspikeofboneonthecalcaneus.Heelspursareoftenassociatedwithplantarfasciitis,althoughtheymaybeseenwithoutit.Spurscanoccuronotherbonesaswell.

Whenasectionofbonebecomesinjuredorirritateditwilladdcalciumtotheareatostrengthenit.Thesecalciumdepositsbecomebonespurs. Inthefoot,heelspurscanformonthelowersurfaceofthecalcaneus,andsiteswheretendonsorligamentsattachtobonearemorecommonlythesitesofthesespurs.Bonespursirritatethetendonsthatcrossoverthem,creatingmore inflammationwithin the tendonwhichmay increase thespur.

Athletes with previous injuries or irritations of the tendon to boneattachmentshaveahigherriskofbonespurs.

CauseofInjuryIrritation of the plantar fascia at its calcaneal attachment. Untreatedminorinjurytobones.Calciumdepositsontheoutsideofahealthybone.

SignsandSymptomsPainandtendernessattheheel.Possiblegrindingorclickingfeltasthetendoncrossesthespur.

ComplicationsifLeftUnattendedBone spurs can cause injury to the tendons that pass over themwhichcausesmoreinflammationandinturnmayworsenthebonespur.

ImmediateTreatmentRestfromactivitiesthatcausepain.Anti-inflammatorymedication.

RehabilitationandPreventionIdentifying and correcting the condition(s) that caused the irritation tothe plantar fascia around the heel spur will help with recovery andprevent a recurrenceof symptoms.Stretching themuscles and tendonsinvolvedwillalsospeedrecovery.Theuseofaheelcup,heelcradleorother orthotic device to reduce stress on the calcaneus may also helpwhenreturningtoactivity.Makingsuretotreatevenminorinjurieswillalsohelppreventbonespurs.

Long-termPrognosisHeel spurs should respond well to rest and rehabilitation. Some mayrequireorthoticstoalleviatethesymptomsandaidrecovery.Surgeryisoccasionallyrequiredinindividualswhosesymptomsdonotrespondtoconservativetreatment.

119:BLACKNAIL(SUBUNGUALHAEMATOMA)

A subungual haematoma is bleeding under the toenail caused by aninjuryor infectionto thenailbed.Crushing injury is themostcommonmechanismforthiscondition.Thepocketofbloodmaybesmallorcoverthewholeareaunderthenail.

The nail protects the area under the toenail, the nail bed, but whencrushingtrauma,anobjectunderthenailorinfectioncausesdamagetothis soft area bleedingmay occur. Because the nail is a hard surface itcontains thebleedingwhich causes raisedpressure in thenail bedandpain.Depending on the initial injury the underlying bonemay also beinvolved.

CauseofInjuryCrushing injury to the toe. Foreign object under the nail causing alacerationtothenailbed.Infectionunderthenailcausingbleeding.

SignsandSymptomsPainandpressureunderthenail.Red,maroonorotherdarkcolorunderthenail.

ComplicationsifLeftUnattendedThebleedingandresultingpressureunderthenailmaycausedamagetotheunderlying tissues causingnecrosisover time.Thenailmay falloffand this could lead to infection ifnot treatedproperly. If thebonewasfracturedduringtheinitialinjurychronicpainmayresult.

ImmediateTreatmentRest, iceandelevation.Ifthenail is lostit is importanttokeeptheareacovered and protected. If the possibility of a fracture exists, as with acrushinjury,seekmedicalattention.

RehabilitationandPreventionThenailmayneedtoberemovedduringtreatment,ormayfalloffonitsown, leaving the nail bed exposed. It is important to keep this areaprotectedtopreventinfection.Itisalsoimportanttoprotecttheaffectedtoewhile it ishealing.Paddingoverthetoesmaybeneeded.Avoidingimpacttothetoesandprotectingthemduringactivitieswillhelppreventthisinjury.

Long-termPrognosisA subungual haematoma will usually respond well to treatmentalthoughincasesinvolvingmorethan25%ofthenailbedandpressurethatisunrelievedbyinitialtreatmentsaphysicianmayneedtodraintheblood from the nail bed. If an infection is the cause, oral or topicalantibioticsmayberequired.

120:INGROWNTOENAIL

Ingrown(ingrowing)toenailscanbeverypainful.Theycanresult fromtrauma to the toe, tight-fitting shoes or improper grooming of thetoenails. The toenail is a horny cutaneous platewhich normally growsoutwardawayfromthebaseofthetoe.Itismadeupofepithelialscalesfromthestratumlucidumoftheskin.Ifthenailiscutorbrokentoocloseto thebase itmaygrowinto theskinonthesideof the toe,or theskinmaygrowoverthetoenail.

Injurytothetoe,suchasstubbingthetoeoratoefracture,cancausethetoenailtogrowintotheskin.Tight-fittingshoesmayalsoputpressureontheoutsideof thetoepressingskin intothenailandcausingit togrowover thenail.Painand infectionmayalsoresult fromtheskingrowingoverthenailorthenailgrowingintotheskinonthesides.Rednessandswellingontheoutsideofthetoemayalsobenoted.

CauseofInjuryTraumato the toe,suchasstubbingthe toe.Tightor improperly fittingshoes.Impropertoenailgrooming.

SignsandSymptoms

Pain. Redness and swelling in the affected area. Pus or other signs ofinfectionmaybepresent.

ComplicationsifLeftUnattendedIf left unattended an ingrown toenail may become infected and theinfectionmayeventuallyinvolvetheentiretoeoreventhefoot.Thepainmay become chronic and affect the ability to wear certain shoes. Theathletemaydevelopalimp.

ImmediateTreatmentSoak the foot in warm water. Get rid of tight-fitting shoes and selectroomierones.Keepthefeetdryduringtheday.Seektheassistanceofaqualifiedpodiatrist.

RehabilitationandPreventionWhen treating an ingrown nail it is important to protect it fromadditionaltraumaorinjury.Changesocksasneededtokeepthefeetdry.Wearing shoes with plenty of room for the toes will aid healing andprevent further ingrown toenails. Protecting the toes from traumawillalsohelppreventthiscondition.Aftertraumatothetoeitisimportanttocheckthetoenailsforbreakageandpressingofthenailintotheskin.

Long-termPrognosisIngrowntoenailscommonlyrespondtotreatmentandrepaircompletely.Ingrown toenails may become a recurring problem in some cases,especially if the underlying causes are not addressed. In cases whereinfectionhassetinanddoesnotrespondtoinitialtreatmentsurgerymayberequired.Removalofallorpartofthetoenailandtheinfectedtissue

mayberequired.


Bounding

In a running motion, raise one knee and jump upward and forwardpropelling off your back foot. Continue running forward with anexaggeratedhigharmaction.

ZigzagShuffle

Whilekeepingyourbodyfacing forward,pushoutwardwithyour feetasyourunsidewaysfromoneconetothenext.

CalfMuscleStretch–Soleus

Standuprightwhileleaningagainstawallandplaceonefootbehindtheother.Makesurethatbothtoesarefacingforwardandyourheelisontheground.Bendyourbacklegandleantowardthewall.

FootStretch

Kneel on one foot with your hands on the ground. Place your body

weightoveryourkneeandslowlymoveyourkneeforward.Keepyourtoesonthegroundandarchyourfoot.

GlossaryofTerms

Abrasion. Skin wound in which the external layers have beenrubbed/scrapedoff.

Achillestendinitis.InflammationoftheAchillestendon.Acuteinjury. Injury froma specificevent leading toa suddenonsetof

symptoms.Adhesive capsulitis. Adhesive inflammation between the joint capsule

andtheperipheralarticularcartilageoftheglenohumeral jointintheshoulder. Causes pain, stiffness and limitation of movement. Alsoknownasfrozenshoulder.

Anteriortibialcompartmentsyndrome.Swelling,tightnessandpainofthe anterior tibial compartment of the leg. Usually a history ofexcessiveexertion.

Arthropathy.Anyjointdisease.Atrophy. Wasting or deterioration of tissue due to disease, disuse or

malnutrition.Articular dysfunction. Disturbance, impairment or abnormality of a

joint.Avulsionfracture. Fracturewhere a bone fragment becomes separated

fromthemainboneatthesightoftendinousattachments,oftenduetoexcessivetensileforces.

Baker’s cyst. Swelling behind the knee, caused by leakage of synovialfluidintothepoplitealbursa.

Blister.Fluidaccumulationundertheskincausedbyfrictionoftheskinagainstahardorroughsurfacecausingtheepidermistoseparatefromthedermis.

Bunion.Swellingoverthemedialaspectofthefirstmetatarsophalangeal

jointresultingindisplacementofthegreattoe(halluxvalgus).Bursa.Protectivesaccontainingsynovialfluid,typicallyfoundbetween

tendonsandbones.Itactstoreducefrictionduringmovement.Bursitis.Inflammationofabursa,e.g.subacromialbursitis.

Calcifictendinitis.Inflammationandcalcificationofthemuscletendon.Mostcommonlyseenintherotatorcuffoftheshoulder.

Callus.Localizedthickeningofepidermisduetophysicaltrauma.Cancellous.Bonetissueofrelativelylowdensity.Capsulitis.Inflammationofajointcapsule.Carpaltunnelsyndrome.Compressionofthemediannerveasitpasses

throughthecarpaltunnel,leadingtopainandtinglinginthehand.Cauliflowerear.Haematomabetween theperichondriumandcartilage

oftheouterear.Chondralfracture.Fractureinvolvingthearticularcartilageofajoint.Chondromalacia patellae. Degenerative condition in the articular

cartilage of thepatella causedby abnormal compressionor shearingforces.

Chronicinjury. Injury characterizedby a slow, sustaineddevelopmentofsymptomsthatculminatesinapainfulinflammatorycondition.

Claw toe. Toe deformity, particularly in patients with rheumatoidarthritis,consistingofdorsalsubluxationoftoes2–5;painfulconditionduringwalking.Thepatientdevelopsashufflinggait.

Collateral ligaments.Major ligaments that cross themedial and lateralaspectsofajoint.

Colles’ fracture. Fracture of the radius and ulna, just proximal to thewrist, that results in the distal segment displacing in a dorsal andradialdirection.

Compressiveforce.Axial loadingthatproducesasqueezingeffectonastructure.

Compartment syndrome. Condition in which increased intramuscularpressureimpedesbloodflowandfunctionoftissueswithinthefascialcompartment.

Concussion. Violent shaking or jarring of the brain resulting inimmediateortransientimpairmentofneurologicalfunction.

Contracture.Adhesionformationinanimmobilizedmuscle,leadingtoashortenedcontractilestate.

Contraindication.Aconditionadverselyaffectedbyaspecificaction.Contusion. Compression injury involving accumulation of blood and

lymphwithinamuscle.Alsoknownasabruise.Cruciate ligaments. Major ligaments that criss-cross the knee in the

anteroposteriordirection.

Deepveinthrombosis(DVT).Theformationofastationarybloodclotinthewallofoneormoreofthedeepveinsofthelowerleg.

De Quervain’s tenosynovitis. Inflammatory tenosynovitis of theabductor pollicis longus and extensor pollicis brevis tendons in thethumb.

Diffuse injury. Injury over a large body area, usually due to low-velocity/high-massforces.

Discogenicpain.Paincausedbyderangementofanintervertebraldisc.Discopathy.Diseaseofanintervertebraldisc.

Efferent nerves. Nerves carrying stimuli from the central nervoussystem.

Epicondylitis.Inflammationandtractionapophysitisontheepicondylesofthedistalhumerus.

Epiphysealfracture.Injurytothegrowthplateofalongboneinchildrenandadolescents;mayleadtoarrestedbonegrowth.

Erythema.Rednessoftheskinproducedbycongestionofthecapillaries.

Fasciitis.Inflammationofthefascialenvelopessurroundingmuscles.Fracture.Adisruptioninthecontinuityofabone.Frozenshoulder.Seeadhesivecapsulitis.

Ganglioncyst.Benignmasscommonlyseenonthedorsalaspectof thewrist.

Golfer’selbow.Inflammationofperiosteumatthemedialepicondyleofthe humerus caused by activities (e.g. golf) that involve gripping,flexionandpronationoftheforearm.

Haematoma.Localizedmassofbloodandlymphconfinedwithinaspaceortissue.

Hallux.Thefirst,orgreat,toe.Halluxrigidus.Painfulflexiondeformityofthegreattoeinwhichthere

islimitationofmotionatthemetatarsophalangealjoint.Halluxvalgus.Angulationofthegreattoetowardthesecondtoe.Hammertoe.Hyperextension/flexiondeformityofthetoes.Heelspur.Bonyspurformationonthecalcaneus.Hernia.Protrusionofabdominalviscerathroughaweakenedportionof

theabdominalwall.Herniated disc. Rupture of an intervertebral disc causing the inner

contenttopushout.Hippointer.Contusionscausedbydirectcompressiontoanunprotected

iliaccrestthatcrushessofttissueand,sometimes,theboneitself.

Iliotibial band syndrome. Pain/inflammation at the iliotibial band, atough, fibrous thickening of the fascia of the lower limb stretchingfrom the iliac crest of the hip to below the knee. There are variousbiomechanicalcauses.

Impingement syndrome. Chronic shoulder condition caused byrepetitive overhead activity that damages the glenoid labrum, longheadofbicepsbrachiiandthesubacromialbursa.

Inflammation. Protective response to tissue damage characterized bypain,swelling,redness,heatandlossoffunction.

Innervation.Nervesupplyofatissue.Ischaemia.Localoxygendeficiencyduetodecreasedbloodsupply.

Laceration.Woundthatmayleaveasmoothorjaggededgethroughtheskin, subcutaneous tissues,musclesandassociatednervesandbloodvessels.

Larson-Johansson syndrome. Inflammation or partial avulsion of theapexofthepatelladuetotractionforces.

Lesion.Anypathological or traumaticdiscontinuityof tissueor lossoffunctionofapart.

Lordosis.Theconcavecurveinthelumbarregionofthespine.

Mallet finger. Rupture of the extensor tendon from the distal phalanxduetoforcefulflexionofthephalanx.

Menisci.Fibrocartilagediscswithinthekneethatreducejointstress.Meralgia paraesthetica. Entrapment of the lateral femoral cutaneous

nerve at the inguinal ligament, causing pain and numbness of theoutersurfaceofthethighintheregionsuppliedbythenerve.

Metatarsalgia.Painaroundthemetatarsalheadsinthefoot.Microtrauma. Small-scale injury to the tissues of the musculoskeletal

system.Morton’sneuralgia.Painaroundthemetatarsalscausedbycompression

ofabranchoftheplantarnervebythemetatarsalheads.Morton’sneuroma.Thickeningandfibrosiscausingcompressionof the

plantarnerveinthefoot,resultinginMorton’sneuralgia.Muscle spindle. Encapsulated receptor sensitive to stretch found in

muscletissue.Myositis.Inflammationofconnectivetissueswithinamuscle.Myositisossificans.Accumulationofcalciumdepositsinmuscletissue.

Neuritis.Inflammationofanerve.Neuropathy.Functionaldisturbanceorpathologicalchangeinanerve.Non-union fracture. A fracture inwhich healing is delayed or fails to

unite.NSAID.Non-steroidalanti-inflammatorydrug.

Oedema. Accumulation of lymphatic fluid in the tissues caused byfailureofthelymphaticsystemtodrainproperly.

Osgood-Schlatter disease. Inflammation or partial avulsion of thepatellarligamentatthetibialapophysisduetotractionforces.

Osteitis. Inflammation of a bone, causing enlargement of the bone,tendernessanddull,achingpain.

Osteoarthritis. Non-inflammatory degenerative joint diseasecharacterized bydegeneration of the articular cartilage, hypertrophyofboneat themarginsandchanges in the synovialmembrane.Seenparticularlyinolderpersons.

Osteochondritisdissecans.Localizedareaofavascularnecrosisresultingfrom complete or incomplete separation of joint cartilage andsubchondralbone.

Overuseinjury.Anyinjurycausedbyexcessive,repetitivemovementofthebodypart.

Painfularcsyndrome.Shoulderpainonabduction(elevation)ofthearmfrom60–120degrees.

Paralysis.Partialorcompletelossoftheabilitytomoveabodypart.Passive stretching. Stretching of muscles, tendons and ligaments

produced by a stretching force other than tension in the antagonistmuscles.

Patellofemoral stress syndrome. A painful conditionwhere the lateralpatella retinaculum is tight or the vastus medialis muscle is weak,leading to lateral excursion and pressure on the lateral facet of thepatella.

Pescavus.Abnormallyhighmedialarchofthefoot.Pesplanus.Flatfeetorfallenarches(maybeflexibleorrigid).Plantarfascia.Specializedbandoffasciathatcoverstheplantarsurface

ofthefootandhelpssupportthelongitudinalarch.Plyometric training. Exercises that employ explosive movements to

developmuscularpower.Posterior compartment syndrome. Pain and reduced function due to

raisedpressurecausingcompressionofvesselsintheposteriorfascialcompartmentsofthelowerleg.

Prognosis.Predictionofthelikelyprogressoroutcomeofaninjury.Proprioceptors.Specializeddeepsensorynervecellsinjoints,ligaments,

musclesandtendonssensitivetostretch,tensionandpressurewhichareresponsibleforjointandlimbpositionsense.

Q-angle. Angle between the line of quadriceps force and the patellar(tendon)ligament.

Radiculopathy.Diseaseofspinalnerveroots.Referredpain. Pain felt in a region of the body other thanwhere the

sourceorcauseofthepainislocated.Repetitivestrain injury (RSI).Refers toanyoveruse condition suchas

strainortendonitisinanypartofthebody.Rheumatoid arthritis. Autoimmune disease in which the immune

systemattacksthebody’sowntissues.Causesinflammationofmanypartsofthebodyanddamagetosynovialjoints.

Rotator cuff. The SITS (supraspinatus, infraspinatus, teres minor, andsubscapularis) muscles that hold the head of the humerus in theglenoidfossaandproducehumeralrotation.

Sacroiliitis.Inflammationofthesacroiliacjoint.Scapulocostalsyndrome.Pain inthesuperiororposterioraspectof the

shoulder girdle as a result of long-standing alteration of therelationshipbetweenthescapulaandtheposteriorthoracicwall.

Sciatica.Pain in thedistributionof the sciaticnervedue toaherniateddisc, a muscle-related or facet joint disease or compression bypiriformis.

Scoliosis.Lateralrotationalspinalcurvature.Seronegativespondyloarthropathy.Agroupofinflammatoryrheumatic

diseasescausingsynovitisofperipheraljoints.

Sesamoidbones.Smallbonesembeddedin tendons– the largest is thepatella.

Sesamoiditis.Inflammationofthesesamoidbonesofthefirstmetatarsal.Sever’s disease. A traction-type injury or osteochondrosis of the

calcanealapophysisseeninyoungadolescents.Shearforce.Aforcethatactsparallelor tangentiallytoaplanepassing

throughanobject.Snapping hip syndrome. A snapping sensation either heard or felt

duringmotionatthehip.Somaticpain.Painoriginatingintheskin,ligaments,muscles,bonesor

joints.Spasm.Transitorymusclecontractions.Spondyloarthropathy.Diseaseofthejointsofthespine.Spondylolisthesis.Forwarddisplacementofonevertebraoveranother.Spondylolysis.Fractureofavertebra(usuallyatthevertebralarch).Spondylosis.Degenerativespinalchangesduetoosteoarthritis.Sprain.Injurytoligamentoustissue.Static stretch. Slow, sustained muscle stretching used to increase

flexibility.Stenosis.Abnormalnarrowingofaductorcanal,e.g.spinalstenosis,a

narrowingofthevertebralcanal,causedbyencroachmentoftheboneuponthespace.

Strain.Injurytomuscleorligamentoustissue.Stress.Thedistributionofforcewithinabody.Stress (march) fracture. Hairline crack of a bone caused by excessive

repetitivestress.Subungualhaematoma.Collectionofbloodunderthenail.Synovitis.Inflammationofasynovialmembrane,particularlyofajoint.

Tendinopathy.Diseaseofatendon.Tendinitis.Inflammationofatendon.Alsoknownastendonitis.

Tenniselbow.Tendinitisoftheextensormusclesoftheforearmattheirinsertion on the lateral epicondyle of the humerus. Also known aslateralepicondylitis.

Tenosynovitis.Inflammationofatendonsheath.

Resources

Anderson,D.M. (chief lexicographer): 2003.Dorland’s IllustratedMedical

Dictionary,30thedition.Saunders,animprintofElsevier,Philadelphia.

Anderson, M.K. & Hall, S.J.: 1997. Fundamentals of Sports Injury

Management.Williams&Wilkins,Baltimore.

Arnheim,D.D.:1989.ModernPrinciplesofAthleticTraining.TimesMirror,MO.

Bahr, R. & Maehlum, S.: 2004.Clinical Guide to Sports Injuries. HumanKinetics,Champaign.

Cramer,J.T.,Housh,T.J.,Weir,J.P.,Johnson,G.O.,Coburn,J.W.&Beck,T.W.: 2005.The acute effects of static stretching on peak torque,mean power

output, electromyography, and mechanomyography. European Journal ofAppliedPsychology.Vol.93:5–6,530–539.

Delavier, F.: 2001. Strength Training Anatomy. Human Kinetics,Champaign.

Dornan,P.&Dunn,R.:1988.SportingInjuries.UniversityofQueenslandPress,Queensland.

Jarmey, C.: 2008. The Concise Book of Muscles, 2nd edition. LotusPublishing,Chichester.

Jarmey,C.:2006.TheConciseBookof theMovingBody.LotusPublishing,Chichester.

Klossner, D.: 2006. NCAA Sports Medicine Handbook. The National

CollegiateAthleticAssociation,IN.

Lamb,D.R.:1984.PhysiologyofExercise.MacmillanPublishingCo.,NewYork.

Levy,A.M.& Fuerst,M.L.: 1993.Sports InjuryHandbook. JohnWiley&Sons,Inc.,NewYork.

Micheli, L.J.: 1995.SportsMedicine Bible. HarperCollins Publishers, Inc.,NewYork.

Norris,C.M.:1998.SportsInjuries:DiagnosisandManagement.ButterworthHeinemann,Oxford.

Reid, M.G.: 1994. Sports Medicine Awareness Course. Sports MedicineFederation,ACT,Australia.

Rushall,B.S.&Pyke,F.S.:1990.TrainingforSportsandFitness.MacmillanEducationAustralia,NewSouthWales.

Sports Medicine Australia: 1986. The Sports Trainer. Jacaranda Press,Queensland.

Tortora, G.J. & Anagnostakos, N.P.: 1990. Principles of Anatomy and

Physiology.Harper&Row,NewYork.

United States Consumer Product Safety Commission: 2000. Consumer

ProductSafetyReview.Spring,Vol.4:4.

Walker,B.E.:1998.TheStretchingHandbook.WalkerboutHealth,Robina.

Walker, B.E.: 2006. The Sports Injury Handbook. Walkerbout Health,Robina.

Walker, B.E.: 2011. The Anatomy of Stretching, 2nd edition. LotusPublishing,Chichester.

Index

abdominalmuscle,149seealso:chestandabdomen

strain,155

abrasion,55,247seealso:skin

Achillestendinitis,206,247seealso:shinandcalf

Achillestendon,201,202

strain,205

ACjoint.Seeacromioclavicularjoint

ACL.Seeanteriorcruciateligament

acromioclavicularjoint(ACjoint),117,123seealso:shoulderandupperarm

separation,123

acutecervicaldiscdisease.Seecervicaldiscinjury

adhesivecapsulitis,247.Seefrozenshoulder

anatomicaldirections,9

ankle,213

fracture,216

jumps,224

osteochondritisdissecans,221

peronealtendinitis,220

peronealtendonsubluxation,219

pronation,223

rehabilitationexercises,224–225

sportsassociatedwithanklesprains,217

sprain,217

supination,222

tibialisposteriortendinitis,218

annulusfibrosis,137

anteriorcompartmentsyndrome,209seealso:shinandcalf

anteriorcruciateligament(ACL),185,189

anteriortibialcompartmentsyndrome,247

arthropathy,247

articularcapsule,17

articularcartilage,15,197

articulardysfunction,247

athlete’sfoot,58seealso:skin

avulsionfracture,164,247seealso:pelvisandgroin

backandspine,137

discbulge,144

discprolapse,143

ligamentsprainofback,141

musclestrainofback,140


stressfractureofvertebra,145

thoraciccontusion,142

Baker’scyst,191,247

Bankartlesion,121

bicepsbrachii,105seealso:shoulderandupperarm

bruise,126

tendonrupture,125

bicipitaltendinitis,131seealso:shoulderandupperarm

bodyweightexercises,30,31

bones,12

metacarpalbones,81

ofpelvicgirdle,159

ofrightfoot,227

ofrightforearmandhand,92

ofrightwristandhand,81

sesamoidbones,14,250

sit-bones,159

spongybone,14,247

spurs,73

tarsalbones,227

boxer’sfracture.Seemetacarpalfractures

brachialplexus,64

brokenribs,152seealso:chestandabdomen

bulgingdisc,144

bunions,237,247seealso:foot

burnersyndrome.Seecervicalnervestretchsyndrome

bursa,17,113,247

bursitis,130,191,247seealso:knee

calcifictendinitis,247

calfseealso:shinandcalf

lowercalfmuscles,215

musclestretch–soleus,246

strain,204

calluses,60,247seealso:skin

cancellousbone.Seespongybone

capsulitis,247

carpaltunnel,91

carpaltunnelsyndrome(CTS),97,247seealso:forearm;wrist

carpometacarpaljoint(CMCjoint),81

cartilage,12,16–17

cauliflowerear,247

cervicaldiscinjury,71seealso:neck

cervicalnervestretchsyndrome,68seealso:neck

cervicalradiculitis.Seepinchednerve

cervicalspine.Seeneck

cervicalspondylosis.Seespurformation

chafing,55seealso:skin

chestandabdomen,149

abdominalmusclestrain,155

brokenribs,152

flailchest,153–154


chondralfracture,247

chondromalaciapatellae,195,197,247seealso:knee

chronicinjuries,19,247

clavicularfractures,120

clawfoot,241seealso:foot

clawtoe,247

collateralligaments,247

Colles’fractures,94,247

compartmentsyndrome,247

compressiveforce,247

concussion,247

contracture,247

contusion,66,67,142,247seealso:head

corns,60seealso:skin

cranium,61

cruciateligaments,247

cuts,55seealso:skin

deepveinthrombosis(DVT),248

DeQuervain’stenosynovitis,248

dermatophytes,58seealso:skin

diaphragm,149seealso:chestandabdomen

DIP.Seedistalinterphalangealjoints

disc,143seealso:backandspine

bulge,144

prolapse,143

discogenicpain,248

dislocation

elbow,108

finger,87

ofpatella,198

ofshoulder,121

wrist,96

distalinterphalangealjoints(DIP),81

DVT.Seedeepveinthrombosis

ears,63,76seealso:head

EDL.Seeextensordigitorumlongus

EHL.Seeextensorhallucislongus

elbow,103

bursitis,113

dislocation,108

fracture,106

golfer’selbow,111


sprain,107

subluxation,108

tenniselbow,110

thrower’selbow,112

tricepsbrachiitendonrupture,109

epicondylitis,248

epiduralhaematoma,66

epiphysealfracture,248

epiphysis,15

epistaxis,77

erythema,248

extensordigitorumlongus(EDL),229

extensorhallucislongus(EHL),229

eyes,63,75seealso:head

facialbones,61,62seealso:head

fallenarches.Seeflat—feet

fasciitis,248

FDL.Seeflexordigitorumlongus

femoralfracture,177seealso:hamstrings;quadriceps

femur,175

FHB.Seeflexorhallucisbrevis

FHL.Seeflexorhallucislongus

fingerseealso:handandfingers

dislocation,87

sprain,86

fitnessandskilldevelopment,28seealso:sportsinjuryprevention

fitnesscomponents,regaining,49seealso:sportsinjurymanagement

FITTprinciple,25seealso:sportsinjuryprevention

flailchest,153–154seealso:chestandabdomen

flat

bones,14

feet,240

flexorandextensortendinitis,234seealso:foot

flexordigitorumlongus(FDL),215,229

flexorhallucisbrevis(FHB),227

flexorhallucislongus(FHL),215,229

foot,213,227

blacknail,244

bunions,237

clawfoot,241

flatfeet,240

flexorandextensortendinitis,234

fractureoffoot,231

hammertoe,238

heelspur,243

ingrowntoenail,245

morton’sneuroma,235

rehabilitationexercises,246

retrocalcanealbursitis,232

sesamoiditis,236

stressfracture,233

turftoe,239

forearm,91seealso:wrist

carpaltunnelsyndrome,97

Colles’fractures,94

fracture,94


scaphoidfractures,94

ulnartunnelsyndrome,98

fracturedribs,152seealso:chestandabdomen

frostbite,57seealso:skin

frozenshoulder,133,248seealso:shoulderandupperarm

ganglioncyst,248

GHjoint.Seeglenohumeraljoint

glenohumeraljoint(GHjoint),117

glenohumeralsubluxation,122

glenoidlabrum,117

golfer’selbow,111,248seealso:elbow

greatertrochanter,172

groinseealso:pelvisandgroin

strain,165

haematoma,248

haemorrhage,66seealso:head

hallux,248

rigidus,248

valgus,237,248

hammertoe,238,248seealso:foot

hamstrings,175,176seealso:quadriceps

femoralfracture,177

hamstringstrain,179

iliotibialbandsyndrome,181

quadricepsstrain,178

quadricepstendinitis,182


strain,179

tears,40

thighbruise,180

handandfingers,81

fingerdislocation,87

fingersprain,86

hand/fingertendinitis,88

malletfinger,85

metacarpalfractures,83


thumbsprain,84

head,61seealso:neck

concussion,66

contusion,66

ears,63,76

epiduralhaematoma,66

eyes,63,75

fracture,66

haemorrhage,66

nose,63,77

subduralhaematoma,66

teeth,63,74

traumas,66

heelseealso:foot

spur,243,248

hernia,248

herniateddisc,248

Hill-Sachslesions,121

hinge,17

joint,223

hipseealso:pelvisandgroin

flexorstrain,162

pointer,163,248

HPV.Seehumanpapillomavirus

humanpapillomavirus(HPV),60

hyalinearticularcartilage,17

hyalinecartilage.Seearticularcartilage

IAP.Seeintra-abdominalpressure

iliaccrest,163

iliopsoas,160seealso:pelvisandgroin

tendinitis,169

iliotibialband(ITB),171,176seealso:hamstrings;quadriceps

syndrome,181,248

IMjoints.Seeintermetacarpaljoints

impingementsyndrome,248

inflammation,248

ofsynovialplica,192

inflammatorybursitis,113

ingrowntoenail,245seealso:foot

intermetacarpaljoints(IMjoints),81

interphalangealjoints(IPjoints),81

intra-abdominalpressure(IAP),150

IPjoints.Seeinterphalangealjoints

ischaemia,248

ischium,159

ITB.Seeiliotibialband

joint,17

ACjoint,117,123

ankle,213

CMCjoint,81

distalinterphalangealjoints,81

elbow,103,104

glenohumeraljoint,117

hinge,223

hipjoint,160,175

intermetacarpaljoints,81

interphalangealjoints,81

knee,185,186

metacarpophalangealjoint,81

proximalinterphalangealjoints,81

sternoclavicularjoint,117

talocruraljoint,213

ofwristandhand,92

jumper’sknee.Seepatella—tendinitis

knee,185

anteriorcruciateligamentsprain,189

bursitis,191

chondromalaciapatellae,197

inflammationofsynovialplica,192

medialcollateralligamentsprain,188

meniscustear,190

Osgood-Schlatterdisease,193

osteochondritisdissecans,194

patellardislocation,198

patellartendinitis,196

patellofemoralpainsyndrome,195


kneecap.Seepatella

knucklejoints.Seemetacarpophalangealjoint

laceration,248

Larsen-Johanssonsyndrome,193,248

lateralepicondylitis.Seetenniselbow

lateralcollateralligament(LCL),185

LCL.Seelateralcollateralligament

lesion,248

ligament,17

sprainofback,141

sprains,190

ligamentumnuchae,138

longextensortendon.Seemalletfinger

lordosis,248

lowercalfmuscles,215

magneticresonanceimaging(MRI),144

malletfinger,85,248seealso:handandfingers

MCL.Seemedialcollateralligament

MCPjoint.Seemetacarpophalangealjoint

medialcollateralligament(MCL),185

sprain,188

medialepicondylitis.Seegolfer’selbow

medialtibialpainsyndrome,207seealso:shinandcalf

melanocytes,56seealso:skin

melanoma,56seealso:skin

menisci,248

meniscustear,190seealso:knee

meralgiaparaesthetica,248

metacarpalfractures,83seealso:handandfingers

metacarpophalangealjoint(MCPjoint),81

metatarsalgia,248

microtears,24,38

microtrauma,248

Morton’sneuralgia,248

Morton’sneuroma,235,249seealso:foot

MRI.Seemagneticresonanceimaging

multifidus,139

muscle,11

musclestrainseealso:strain

ofback,140

bicepsbrachii,127

chest,127

musculo-tendinousunit,12

myositis,249

ossificans,180,249

nasalbone,61

neck,64–65seealso:head

cervicaldiscinjury,71

cervicalnervestretchsyndrome,68

contusion,67

extensionstretch,78

fracture,67

muscles,65

neckstrain,67

pinchednerve,72


spurformation,73

strain,67

whiplash,69

wryneck,70

neuritis,249

neuropathy,249

non-steroidalanti-inflammatorydrugs(NSAIDs),72,249

non-unionfracture,249

nose,63,77seealso:head

NSAIDs.Seenon-steroidalanti-inflammatorydrugs

nucleuspulposus,137

oedema,249

olecranonbursitis.Seeelbow—bursitis

olecranonprocess,103

opposition,9

Osgood-Schlatterdisease,193,249seealso:knee

osteitis,249

pubis,166seealso:pelvisandgroin

osteoarthritis,249

osteochondritisdissecans,194,221,249seealso:ankle;knee

osteoporosis,231

overload,52

overtraining,27seealso:sportsinjuryprevention

overuseinjury,249

painfularcsyndrome,249

paralysis,249

patella,185seealso:knee

dislocation,198

tendinitis,196

patellofemoralpainsyndrome,195,249seealso:knee

patellofemoralstresssyndrome.Seepatellofemoralpainsyndrome

PCL.Seeposteriorcruciateligament

pectoralismajor,132

pectoralmuscleinsertioninflammation,132seealso:shoulderandupperarm

pelvisandgroin,159

avulsionfracture,164

groinstrain,165

hipflexorstrain,162

hippointer,163

iliopsoastendinitis,169

osteitispubis,166

piriformissyndrome,168


snappinghipsyndrome,171

stressfracture,167

tendinitisofadductormuscles,170

trochantericbursitis,172

perimysium,12

periosteum,15

peronealtendinitis,220seealso:ankle

peronealtendonsubluxation,219seealso:ankle

pescavus,249.Seeclawfoot

pesplanus,249.Seeflat—feet

physicalinjury,11seealso:sportsinjury

pinchednerve,72seealso:neck

PIP.Seeproximalinterphalangealjoints

piriformis

muscle,160

syndrome,168

pitcher’sshoulder.Seerotatorcuff—tendinitis

pivot,18

planeorgliding,17

plantar,9seealso:foot;skin

fascia,242,249

warts,60

plantaris,201

platepinch,101

plyometrictraining,35,249seealso:fitnessandskilldevelopment

PNF.Seeproprioceptiveneuromuscularfacilitation

posteriorcompartmentsyndrome,249

posteriorcruciateligament(PCL),185

posteriorsuperioriliacspine(PSIS),159

post-exercisemusclesoreness,24,38

pronation,10,223seealso:ankle

proprioceptiveneuromuscularfacilitation(PNF),24

proprioceptors,249

proximalinterphalangealjoints(PIP),81

PSIS.Seeposteriorsuperioriliacspine

pulledabdominalmuscle.Seeabdominalmuscle—strain

Q-angle,195,249

quadriceps,175seealso:hamstrings

femoralfracture,177

hamstringstrain,179

iliotibialbandsyndrome,181


strain,178

tendinitis,182

thighbruise,180

radiculopathy,249

referredpain,249


repetitioncircuit,33seealso:circuittraining

repetitiveimpactactivities,208

repetitivestrain,125

repetitivestraininjury(RSI),249

repetitivestress,167

respirationmechanics,150seealso:chestandabdomen

retinacula,228

retraction,10

retrocalcanealbursitis,232seealso:foot

rheumatoidarthritis,249

ribcage,149seealso:chestandabdomen

ribsandsternum,149seealso:chestandabdomen

RICERregimen,46

rider’sstrain.Seegroin—strain

rotation,10

rotatorcuff,118,249seealso:shoulderandupperarm

tendinitis,129

RSI.Seerepetitivestraininjury

runner’sknee.Seechondromalaciapatellae

sacroiliitis,249

sacrospinalis,139

saddle,18

sarcoplasm,12


scapulocostalsyndrome,249

scartissue,47,48

sciatica,249

SCjoint.Seesternoclavicularjoint

scoliosis,249

septalhaematoma,77

seronegativespondyloarthropathy,249

sesamoidbones,14,250

sesamoiditis,236,250seealso:foot

Sever’sdisease,250

shearforce,250

shinandcalf,201

Achillestendinitis,206

Achillestendonstrain,205

anteriorcompartmentsyndrome,209

calfstrain,204

fractures,203

medialtibialpainsyndrome,207


stressfracture,208

shinbone.Seetibia

shinsplints.Seemedialtibialpainsyndrome

shortbones,14

shoulderandupperarm,117

acromioclavicularseparation,123

bicepsbrachiibruise,126

bicepsbrachiitendonrupture,125

bicipitaltendinitis,131

dislocationofshoulder,121

fracture,120

frozenshoulder,133

musclestrain,127

pectoralmuscleinsertioninflammation,132


rotatorcufftendinitis,129

shoulderbursitis,130

shouldersubluxation,122

sternoclavicularseparation,124

subacromialimpingement,128

shoulderbursitis,130

shoulderdislocation,121

shouldersubluxation,122

sit-bones,159

skier’sthumb.Seethumb—sprain

skin,53

abrasions,55

athlete’sfoot,58

blisters,59

calluses,60

chafing,55

corns,60

cuts,55

dermatophytes,58

frostbite,57

melanocytes,56

melanoma,56

plantarwarts,60

sunburn,56

skull,62

slippeddisc,143

snappinghipsyndrome,171,250seealso:pelvisandgroin

softtissueinjuries,45seealso:sportsinjurymanagement

spasm,250

spheroidalorball-and-socket,18

spine,137seealso:backandspine

spondyloarthropathy,250

spondylolisthesis,145,250

spondylolysis,250

spondylosis,250

spongybone,14,247

sportsinjurymanagement,45seealso:fitnesscomponents,regaining

sportsinjuryprevention,21

sprain,19,250

ankle,217

anteriorcruciateligament,189

elbow,107

finger,86

ligament,190

ligamentsprainofback,141

medialcollateralligament,188

andstraininjuries,19

thumb,84

wrist,95

spurformation,73seealso:neck

stenosis,250

sternoclavicularjoint(SCjoint),117

sternoclavicularseparation,124seealso:shoulderandupperarm

strain,19,250seealso:musclestrain

abdominalmuscle,155

Achillestendon,205

back,140

calf,204

groin,165

hamstrings,179

hipflexorstrain,162

muscle,127

neckstrain,67

quadriceps,178

repetitive,125

strengthtraining,29seealso:fitnessandskilldevelopment

stress,250

fracture,167,208,233,250

fractureofvertebra,145

stretchingandflexibility,37seealso:sportsinjuryprevention

subacromialbursa,118,130

subacromialimpingement,128seealso:shoulderandupperarm

subchondralcysts.Seewrist—ganglioncyst

subduralhaematoma,66

subluxation,108,198

subungualhaematoma,250.Seeblacknail

sunburn,56seealso:skin

supination,10,222seealso:ankle

synovialcysts.Seewrist—ganglioncyst

synovialhernias.Seewrist—ganglioncyst

synovialjoint,17

synovialplica,192seealso:knee

synovitis,250

talocruraljoint,213

tarsalbones,227

teeth,63,74seealso:head

tendinitis,88,250

Achilles,206,247

ofadductormuscles,170

bicipitaltendinitis,131

calcifictendinitis,247

flexorandextensortendinitis,234

hand/fingertendinitis,88

iliopsoas,169

patellartendinitis,196

peronealtendinitis,220

quadricepstendinitis,182

rotatorcuff,129

tibialisposteriortendinitis,218

wristtendinitis,100

tendinopathy,250

tendons,17

tenniselbow,110,250seealso:elbow

tenosynovitis,250

tenosynovium,91

tensorfasciaelatae(TFL),176,181,187

TFL.Seetensorfasciaelatae

thighbone.Seefemur

thighbruise,180seealso:hamstrings;quadriceps

thighcontusion,180

thoraciccontusion,142seealso:backandspine

thrower’selbow,112seealso:elbow

thumbseealso:handandfingers

sprain,84

stretch,89

tibia,201

tibialisposteriortendinitis,218seealso:ankle

timedcircuit,33seealso:circuittraining

tineapedis.Seeathlete’sfoot

torticollis.Seewryneck

TranscutaneousElectricalNerveStimulation.SeeTENS

transversospinalismuscles,139

transversusabdominis,151seealso:chestandabdomen

triceps

brachiitendonrupture,109

surae,201

trochantericbursitis,172seealso:pelvisandgroin

turftoe,239seealso:foot

ulnarcollateralligament.Seethumb—sprain

ulnartunnel,91

syndrome,91,98seealso:forearm;wrist

ultrasound,48

ultraviolet(UV),56

unresolvedinjuries,170

UV.Seeultraviolet

ventral,10

verrucae.Seeplantar—warts

vertebralcolumn.Seespine

warm-up,21seealso:sportsinjuryprevention

dynamicstretching,42,23

whiplash,69seealso:neck

wrist,91seealso:forearm

carpaltunnelsyndrome,97

Colles’fractures,94

dislocation,96

fracture,94

ganglioncyst,99



sprain,95

tendinitis,100

tenosynovium,91

ulnartunnelsyndrome,98

wryneck,70seealso:neck

The Anatomy of Sports Injuries, Your Illustrated Guide to Prevention, Diagnosis, and Treatment

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Transcript of The Anatomy of Sports Injuries, Your Illustrated Guide to Prevention, Diagnosis, and Treatment