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Concussions

Head trauma is one of the most potentially dangerous injuries in sports. The medical community continues to consider what long-term health problems can be linked to concussion. A crucial aspect in the future evaluation and treatment of head injury is in training sports medicine physicians, managers and others involved in athletic care to understand the impact of the injury and an athlete's ability to return to action. Literally, a concussion is the agitation of the brain by either a direct or indirect blow. This impairment of neural function can alter consciousness, vision and equilibrium, and can also cause many other mental malfunctions. Common symptoms include headache, dizziness, blurred vision and nausea. Rather than testing a potential concussion victim by asking familiar questions such as name and date of birth, it is more useful to question them about what field they are playing on, team they are facing, who scored last, and similar aspects of the current contest. There are two commonly used classifications of concussion severity: the Cantu and Colorado guidelines. The Cantu scale ranks as "mild" any concussion during which there is no loss of consciousness, and posttraumatic amnesia lasts less than 30 minutes. A moderate concussion under the scale is one where the loss of consciousness is less than five minutes and the posttraumatic amnesia more than 30 minutes. A severe concussion is considered one where the unconscious state is longer than five minutes and amnesia continues for more than 24 hours. Deciding when a concussion victim returns to play is a potential matter of life and death. Evidence suggests that once an athlete has had one concussion, his or her chance of incurring a second is four times greater than for someone who has never had a concussion. The player should never return to action during the same game, and it is always wise to keep a player out of practice or another game until there is certainty the trauma has subsided. A second blow, even a minor one to chest, side or back, can cause rapid cerebral swelling in a concussion sufferer, which can lead to death. It is always preferred that the victim of even the mildest concussion stay out of competition for at least a week, or until all symptoms have diminished. However, some athletes may require weeks or months of recovery. In the case of a second or third concussion, the timetable shifts significantly, with doctors frequently recommending that an athlete stop playing for the rest of the season. Any athlete suffering any head injury should be closely monitored for the first 24 hours, being awakened every two hours in the evening to establish alertness. The concussion victim should be taken to an emergency room if he complains of double or blurred vision, severe headache, increased weakness, loss of coordination or memory, vomiting, slurred speech, or inability to concentrate. The following signs also mandate emergency evaluation:

• Blood or watery fluid coming out of the ears or nose.
• Unequal or dilated pupils
• Asymmetry of the face
• Increased swelling along the scalp.

Temporomandibular Joint Syndrome (TMJ)

Alternative Names:

Temporomandibular Dysfunction syndrome, Myofascial Pain Dysfunction syndrome

Definition:

Temporomandibular joint syndrome affects the joint where the jawbone (mandible) connects to the skull (specifically the temporal bone).

The Temporomandibular joint (TMJ) is formed by two bones called the mandible (jaw bone) and the temporal bone (bone of the skull located on the side of the head). There is a disc or meniscus between the two bones acting as a cushion and guide to help the joint function properly. There is one TMJ on each side of the head connecting in the region just in front of the ears.

Cervical spondylosis

Alternative Names:

Cervical Osteoarthritis

Definition:

Cervical spondylosis refers to common age-related changes in the area of the spine at the back of the neck. With age, the vertebrae (the component bones of the spine) gradually form bone spurs, and their shock-absorbing disks slowly shrink. These changes can alter the alignment and stability of the spine. They may go unnoticed, or they may produce problems related to pressure on the spine and associated nerves and blood vessels. This pressure can cause weakness, numbness, and pain in various areas of the body. In severe cases, walking and other activities may be compromised.

Causes, incidence, and risk factors:

Cervical spondylosis results from chronic degeneration of the cushions between the neck vertebrae (cervical disks) and mineral deposits (calcification) in the disks. There may be abnormal growths or "spurs" on the vertebrae (the bones of the spine).

Risks include old neck injury (which may have occurred several years previously). However, the disorder also occurs commonly in older people who have no history of neck injury . It is thought to result from normal changes of aging.

Torticollis

Alternative Names:

loxia; wryneck

Definition:

A form of dystonia (prolonged muscle contractions) in which the neck muscles contract involuntarily causing the head to turn.

Causes, incidence, and risk factors:

The condition may occur without known cause (idiopathic), be genetic (inherited), or be acquired secondary to damage to the nervous system or muscles. It may develop in childhood or adulthood. Congenital torticollis (present at birth) may be caused by malpositioning of the head in the uterus or by prenatal injury of the muscles or blood supply in the neck.

Whiplash

Definition:

An injury to the cervical vertebrae and adjacent soft tissues that occurs from a sudden jerking, or backward or forward acceleration, of the head. One source of this injury is a vehicle that is suddenly and forcibly struck from the rear.

Back Spasms

Back spasms are a contraction of the back muscles in response to a stress on the spine. Usually, one of the structures of the spine such as a joint or one of the ligaments of the spine is injured. The nerves that supply the sensory information to the injured area - the nerves that pick up the sensation of pain - are also connected to the nerves that control the muscles of the back. So the stimulus from an actual spine injury will cause the surrounding muscle of the back to contract - that is the spasm.

Back spasms are usually are the result of a sudden or extended trauma upon the spine or the muscles supporting the spine. For example, an athlete could change his training regimen or overextend himself, which could lead to a muscle or ligament strain and subsequent spasm. At the other end of the spectrum, you may be on a long airplane flight in a cramped, uncomfortable seat, and your muscles could be forced into an unfamiliar position. Once you stand up, those strained muscles could trigger a spasm.

Stress can also be a contributing factor. When you are stressed, you're often unconsciously clenching your shoulders or teeth. This is counterproductive to the normal motion of the joint. The joint is in a position like that of the airline seat and the results, unfortunately, can be similar.

Most spasms affect the paraspinal musculature - the muscles running from the base of the skull to the pelvis on either side of the backbone. They are the muscles most commonly "thrown out" - and often the mere act of sitting up or turning to the side can be excruciatingly painful.

In order to treat back spasms, you must address the inflammation of the spine. We treat back spasms with rest, ice, anti-inflammatory medications and specifically designed exercises that can help strengthen the support of the injured joint. There are a whole group of muscle relaxants that are used, but we really de-emphasize those kinds of medications in favor of anti-inflammatories to eliminate the underlying cause.

When some people talk about a "crick in their neck," there may be some role for spinal correction where a skilled, licensed health care provider can free up the motion in a joint that is having residual spasms.

We also stress the importance of a preventative exercise program specifically designed to restore normal health and motion to the joints. This helps to provide coordinated muscle strength to ensure the joint works properly at all times, even when you're not thinking about it. And just as the treatment for an inflamed back would be the same as the treatment for an inflamed knee, you would want to build up coordinated muscle strength in your spine just as you would your injured knee.

Many times, back spasms occur after an activity. You play a sport, sit down for a while, stand up and stretch - and it hits you. This is why one of the most important post-exercise things you can do is to maintain proper posture. When you come in from a golf game, you need to sit properly in a chair in the clubhouse if you don't want to experience stiffness or worse when you stand.

Proper posture involves a chest-out, head-up alignment. As far as stretching is concerned, it is important to emphasize stretching in the initial treatment program because too often it involves taking the joints of the spine through a range of motion that it is not prepared to handle. This can cause further injury not only in the spasming muscles but also to the underlying structure. Once you've established muscle control of the spine through a conditioning and strengthening program, you can and should stretch your back and its extremities including the hamstrings and hip flexors and abdominals. This is especially important when warming up for activities.

Ankylosing Spondylitis

Alternative Names:

Marie-Strumpell disease; rheumatoid spondylitis; spondylitis

Definition:

Spondylitis involves inflammation of one or more vertebrae. Ankylosing spondylitis is a chronic inflammatory disease that affects the joints between the vertebrae of the spine, and the joints between the spine and the pelvis. It eventually causes the affected vertebrae to fuse or grow together. (See also tuberculosis and arthritis).

Causes, incidence, and risk factors:

The specific cause for this disease is unknown, but genetic factors seem to play a role. The disease starts with intermittent hip and/or lower back pain that is worse at night or after inactivity. Back pain begins in the sacroiliac joint (joint between the pelvis and the spine) and may progress to include the lumbosacral spine and the thoracic spine (chest portion of the spine). Pain may be eased by assuming a bent posture. Limited expansion of the chest occurs because of the involvement of the joints between the ribs. The symptoms may worsen, go into remission, or stop at any stage.

With progressive disease, deterioration of bone and cartilage can lead to fusion in the spine or peripheral joints affecting mobility. It can be extremely painful and crippling. The heart, the lungs, and the eyes may also become affected. The disease most frequently begins between the ages of 20 and 40 but may begin before 10 years of age. It affects more males than female

Back Spasms

Herniated Disc

The disc is a round, multi-layered ligament that connects two vertebral bodies together. The fibers of each of the layers are crossed like a basket weave and are at different angles to provide strength and support. Additionally, it has a jelly-like substance in the center that serves as a shock absorber.

The function of a vertebral disc is:

• To serve as a shock absorber in and help diffuse the pressure that goes through our back with different tasks that we demand of it.

• To help bind the two vertebrae together so together they can form a great support for us to move around.

• Provide space between our vertebrae so as to allow adequate space for the spinal nerves to exit the spinal chord and travel to the area of the body that they need to innervate properly.

The most common cause of a herniated disc is a twisting type of injury. It can be caused by a fall or lifting something heavy. Compression injuries can cause disc herniations as well. Abnormal wear and tear over a period of several years can also lead to a gradual deterioration of the disc and a resultant disc herniation.

You tear the annulus - the basket-type, supporting structure of the disc - by twisting. This weakens the structure and makes it work abnormally. A herniation is when you have a "blowout" of the annulus. The inner layers of the annulus will break off and come out through the tear. A piece of the annulus of the disc itself ends up in the spinal canal.

Most herniated discs start with this tear in the annulus of the disc, so a patient will experience severe back pain and spasm. Then as the tear increases in size or as the piece on the inside of the disc extrudes out of the disc into the spinal canal, the back pain will decrease. The person then can start experiencing leg pain, weakness, numbness and sciatica depending upon which nerve the fragment is pressing.Every strength and conditioning coach who works with athletes has some sort of trunk or core strengthening type of program that varies according to the sport. Research with baseball pitchers and hitters and PGA golfers, many different types of athletes, that shows that the role of coordinated trunk strength is a vital part of athletic performance and prevention of back injuries.

Herniated Nucleus Pulposus

Alternative names:

cervical radiculopathy; herniated intervertebral disk; lumbar radiculopathy; prolapsed intervertebral disk; radiculopathy; ruptured disk; slipped disk

Definition:

A condition in which part or all of the soft, gelatinous central portion of an intervertebral disk (the nucleus pulposus) is forced through a weakened part of the disk, resulting in back pain and nerve root irritation.

Causes, incidence, and risk factors:

The spinal vertebrae are separated by cartilage disks, filled with a gelatinous substance, that provide cushioning to the spinal column. These disks may herniate or rupture from trauma or strain, especially if degenerative changes have occurred in the disk.

Radiculopathy refers to any disease condition of the spinal nerve roots. The term "lumbar radiculopathy" means that the lower back nerves are involved; "cervical radiculopathy" means that the neck nerves are involved. Herniated disk is one cause (but not the only cause) of radiculopathy.

Most herniation takes place in the lumbar area of the spine. Lumbar disk herniation occurs 15 times more often than cervical (neck) disk herniation, and it is one of the most common causes of lower back pain. The cervical disks are affected 8% of the time and the upper-to-mid-back (thoracic) disks only 1 to 2% of the time.

Nerve roots (large nerves that branch out from the spinal cord) may become compressed resulting in neurological symptoms such as sensory or motor changes.

Disk herniation occur more frequently in middle aged and older men, especially those involved in strenuous physical activity. Other risk factors include any congenital conditions that affect the size of the lumbar spinal canal.

Low Back Pain

Low back pain can be caused by a wide variety of different structures. The lumbar spine (the region that makes up the lower part of the vertebral column) is comprised of five vertebrae with a spongy type of disc between them that allow for shock absorption. All this is held together by ligaments that are like little pieces of plastic that provide stability to the lumbar spine. On top of all of this are layers of muscle which act to both protect the spine and provide the strength to allow us to do the movements that are required in everyday life.

Low back pain (LBP) can be a result of damage to any of these structures. Sometimes LBP is a result of a simple strain to one of the muscles. In a more serious case overuse in the lower back may result in a sprain to one of the ligaments. In either of these two cases the pain usually stays local. If damage occurs in one of the discs, the result may be pain that travels into the buttock and/or down the leg. If the jelly part of the disc (the center part called the nucleus) starts to leak out, it will put pressure on one of the nerves which can send pain down the leg.

In longer-term (chronic) cases, degenerative changes may occur to the discs or the vertebrae. If the discs start to degenerate, they become narrower. The result is the vertebra come close together, and the result is a compression of the nerves and the vertebrae start rubbing together. This chronic type of pain is more difficult to alleviate because there are a number of factors to deal with. The answer is good prevention!

Comon causes of Low Back pain:

• muscle strain, pulled muscle in the back, or similar injury (the most common cause)

• mechanical breakdown in the lumbar vertebrae

• menstruation or premenstrual syndrome (PMS)

• prolonged sitting in a poor postural position

• arthritis

• in children: scoliosis, Scheuermann's kyphosis, or pondylolysis

• bladder infection

• endometriosis

• ovarian cancer/cysts

• pressure on a nerve root (for example, spinal tenosis or herniated disc)

Sciatica

The nerve most likely to cause trouble in the lower back is the sciatic nerve, which branches from the nerve roots that descend off the spinal cord in the lumbar and sacral areas and threads through the pelvis and deep into the buttocks, then down the hip and along the back of the thigh to the foot. Sciatica usually occurs on one side when a sciatic nerve has been compressed by a herniated disc, by spinal stenosis (a narrowing of the gap that the nerves pass through) or mechanical vertebral abnormalities. The sensation of sciatica can vary widely -- from mild tingling to pain severe enough to cause immobility.

Some people experience sharp pain in one part of the leg or hip and numbness in other parts. The pain increases after prolonged standing or sitting and is aggravated by sneezing, coughing, or laughing. If spinal stenosis is causing sciatica, patients may also experience it after bending backwards or walking more than 50 to 100 yards. It is important to get a full clinical evaluation for the true cause of the sciatica, only then can your therapist help reduce the pain and disability that results. Sometimes objective diagnostic tools such as X-rays, CT scans, or and MRI is necessary to determine the cause of the problem. These tests would be down in consultation with your physician.

Lumbar Traction

Suggestions for Treatment Parameters Traction has many uses in the athletic training and physiotherapy settings for treating patients suffering from low-back pain. Traction is the application of a pulling force, used especially as a means of counteracting the natural tension within tissues. Traction can be any treatment, including manual distraction of a joint, passive distraction from hanging upright or inverted to utilize the effects of gravity, positioning the patient to accentuate separation and the application of force through a specifically designed machine. Traction can be used as part of joint mobilization or as an individual treatment plan, as with spinal traction.

Lumbar traction is a frequently used form of traction due to the immense number of patients suffering from low-back pain. Each year, 5 percent of the population experiences some event of low-back pain. Sixty percent of all patients will experience a recurrence of this pain, which underlies importance of getting an accurate diagnosis and appropriate treatment.

Traction encourages a stretching out of the spine, both overall and between each individual spinal segment. This stretching causes a temporary change of the overall spinal length, as well as changes in pressure in the discs and ligaments, and muscle length. There are many factors involved in the success of this kind of treatment. Some of these factors include patient positioning, devices used, weight used, treatment time and, most importantly, patient cooperation. With each factor affecting success, they must be individually assessed and altered to achieve optimal success for each patient.

Once traction is applied, there is a separation of the vertebra and a decrease in spinal pressure. If the patient experiences a decrease in pain levels or paresthesia while in traction, the assessment is good and traction should be continued in the rehabilitation program.6 Soft tissue is greatly affected by spinal traction. Chronic shortening of muscles and ligaments due to faulty posture and/or injury can be counteracted with traction. The force of the traction will promote lengthening of the tissue. However, the clinician must be careful, applying a force heavy enough to stress the tissue but not so significant to cause damage. The decrease in pain will be temporary unless the patient complies with an appropriate treatment and exercise program to compliment this approach.

The indications for traction are almost as numerous as the methods. These indications can be very helpful and also quite confusing. The use of traction in rehabilitation and pain control often has a period of trial and error.

Each condition requires different treatment parameters and often different methods are used to be completely effective. The intent of traction is to apply a distraction of the lumbar spinal segments, which can decrease pressure within a joint space or on a nerve, and to apply a stretch to the inert and dynamic structures about those joints. Conversely, there are several contraindications that must be observed to prevent a worsening of conditions or other injury to the patient. These contraindications can have serious effects and should be closely evaluated before beginning treatment with the use of traction. These contraindications are included because of the effects traction has on the spine and related structures, as well as on internal components. Traction applies a significant amount of pressure on the abdomen and internal structures, including the arteries and veins. Consequently, this treatment must be avoided with patients who have some internal conditions that could be worsened by an increase

Preventing Back Injury

Many of us have experienced the pain of a back injury. We lift a box incorrectly or try to move one that is a little too heavy - and the pain hits us right in the middle of action. The injury is not only bothersome, but can lead to a recurring, life-altering condition. More than 100 million work days are lost each year because of back injuries. Taking a few simple precautions can guard against hurting your back:

• Bend at your hips and knees to lower yourself for lifting or putting down an object.

• Stand directly in front of and face the object you lift. Pivot with your feet rather than your back if you must twist or change directions.

• Anytime you reach above shoulder level, use a stool or step-ladder.

• Pushing is better for your back than pulling.

• Keep the object you're lifting close to your body.

• Spread your feet apart, with one foot slightly ahead of the other, to establish a wide base of support when lifting.

A regular exercise program with workouts three to five times a week can help keep your back strong and injury-free. Focus on improving strength, flexibility and aerobic conditioning. When working out, include exercises to strengthen the abdominal muscles, the muscles in the lumbar spine and those that stabilize the pelvic girdle. These exercises will not eliminate injuring your back, but it will decrease the chance of that occurring. Even if you don't have time to hit the gym, you can work out while doing housework or watching TV. It's also important to frequently stand and stretch if you have a desk job, making sure your workstation and chair are adjusted to give your back a break.

Sciatic Nerve Dysfunction

Alternative names:

neuropathy - sciatic nerve

Definition:

A condition involving impaired movement and/or sensation in the leg, caused by damage to the sciatic nerve Causes, incidence, and risk factors: Sciatic nerve dysfunction is a form of peripheral neuropathy. It occurs when there is damage to the sciatic nerve, which is located in the leg and supplies the muscles of the back of the knee and lower leg. It supplies sensation to the back of the thigh, part of the lower leg, and the sole of the foot. Incomplete damage to the sciatic nerve may appear identical to damage to one of the branches of the sciatic nerve (tibial nerve dysfunction or common peroneal nerve dysfunction).

Dysfunction of a single nerve group, such as the sciatic nerve, is classed as mononeuropathy. Mononeuropathy implies a local cause of the nerve damage, although systemic disorders may occasionally cause isolated nerve damage (such as occurs with mononeuritis multiplex). The usual causes are direct trauma (often from an injection into the buttocks), prolonged external pressure on the nerve, and pressure on the nerve from nearby body structures. Entrapment involves pressure on the nerve where it passes through a narrow structure. The damage includes destruction of the myelin sheath of the nerve or destruction of part of the nerve cell (the axon). This damage slows or prevents conduction of impulses through the nerve.

The sciatic nerve is commonly compressed as a result of pressure from a lumbar disc. It may also be injured by prolonged sitting or lying with pressure on the buttocks. It is commonly affected by systemic diseases causing polyneuropathy (damage to multiple nerves) such as diabetes mellitus or polyarteritis nodosa. It may be damaged by pressure from lesions such as a tumor, abscess, or bleeding in the pelvis. In many cases, no cause can be identified. These mechanical factors may be complicated by ischemia (lack of oxygen from decreased blood flow) in the area. A ruptured lumbar disk may cause symptoms that simulate the symptoms of sciatic nerve dysfunction.

Scoliosis

Scoliosis or is a lateral (away from the middle) curvature of the spine that may occur in the thoracic or lumbar segment of the spine. Scoliosis may occur by itself, or in combination with kyphosis ( a rounding of the spine) Scoliosis may occur in 4 ways:

• As a congenital condition noticed at birth usually related to a defect in the vertebrae or fused ribs.

• As a paralytic or musculoskeletal disorder resulting from paralysis of the muscles due to polio, cerebral palsy, or muscular dystrophy.

• Idiopathic (of unknown cause) that appears in a previously straight spine.

• As a compensation for a leg length discrepancy

An idiopathic disorder is the most common form and may have a genetic cause. Most cases occur in girls and become apparent during the rapid growth phase of puberty (there are infantile and juvenile forms). Scoliosis may be suspected when one shoulder appears to be higher than the other, or parents and friends may notice nothing. Routine scoliosis screening is now done in junior high school/middle school and many very early cases are detected that previously would have gone unnoticed until they were more advanced.

There may be fatigue in the spine after prolonged sitting or standing. Pain will become persistent if irritation of ligaments results. As the spine curves laterally, a compensatory curve may develop to maintain balance. The greater the initial curve of the spine, the greater the chance for progression of the condition after growth is complete. Severe scoliosis (curves in the spine greater than 60 degrees) may cause respiratory problems.

Evaluating the cause of the problem will help in determining how much the patient can be helped.

Spinal

Alternative Names:

Neck/Spinal Injury

Definition:

Injury to the neck or spinal cord. Considerations: When someone has a spinal injury, additional movement may cause further damage to the spine. The purpose of first aid is to prevent further harm to the victim until you can obtain medical help.

If in doubt about whether a person has received a spinal injury, assume he or she has.

A spinal cord injury is very serious because it can mean the loss of sensation and function in the parts of the body below the site of the injury.

Causes:

• awkward positioning of the body

• bullet or stab wound

• direct trauma to the face, neck, head or back

• diving accident

• electric shock

• exertion

• twisting of the trunk

Spondylolisthesis

Definition:

Forward slippage of a lumbar vertebra on the vertebra below it.

Causes, incidence, and risk factors:

The spine is commonly spoken of by anatomical sections: cervical (neck), thoracic (rib cage), lumbar (from bottom of the thoracic spine to the top of pelvis), sacral (pelvis) and coccygeal (tail). Spondylolisthesis is a condition in which a vertebra slips forward on the vertebra below it. It normally occurs in the lumbar vertebra, most often at the level between the fifth lumbar vertebra and the first sacral vertebra. Spondylolisthesis may occur as the result of a congenital defect in the fifth lumbar vertebra, stress fractures, and traumatic fractures. Spondylolisthesis may occasionally be associated with bone diseases.

Spondylolisthesis may vary from mild to severe. It is associated with and can produce increased lordosis (abnormal anterior convexity of the spine). Symptoms may include lower back pain and pain in the thighs and buttocks, stiffness, muscle tightness, and tenderness in the slipped area. Neurologic damage may result from pressure on nerve roots and may cause sciatic (pertaining to the hip or ischium) pain.

Tailbone Trauma

Alternative names:

coccyx injury

Definition:

An injury to the small bone at the lower tip of the spine.

Considerations:

Actual fractures to the tailbone are infrequent. Tailbone trauma usually causes bruising to the bone or pulling of the ligaments.

Causes:

Backward falls onto a hard surface such as a slippery floor or ice are the most common cause of this injury.

Axillary Nerve Dysfunction

Alternative names:

neuropathy - axillary nerve

Definition:

A condition involving impaired movement or sensation of the shoulder because of damage to the axillary nerve. Causes, incidence, and risk factors: Axillary nerve dysfunction is a form of peripheral neuropathy. It occurs when there is damage to the axillary nerve, which supplies the deltoid muscles of the shoulder. It is not a specific, separate disease but is a manifestation of many conditions that can cause damage to the axillary nerve.

Dysfunction of a single nerve group, such as the axillary nerve, is classed as mononeuropathy. Mononeuropathy implies a local cause of the nerve damage, although systemic disorders may occasionally cause isolated nerve damage (such as occurs with mononeuritis multiplex). The usual causes are direct trauma, prolonged external pressure on the nerve, and pressure on the nerve from nearby body structures.

Conditions associated with axillary nerve dysfunction include fracture of the humerus (upper arm bone), pressure from casts or splints, and improper use of crutches. Other causes include systemic disorders that cause neuritis (inflammation of nerves). In some cases, no detectable cause can be identified. Mechanical factors may be complicated by ischemia (a lack of oxygen from decreased blood flow) in the area.

Brachial Plexopathy

Alternative names:

brachial plexus dysfunction; neuropathy - brachial plexus

Definition:

A condition involving decreased movement or sensation in the arm and shoulder caused by impaired function of the brachial plexus, a nerve area that affects the arm.

Causes, incidence, and risk factors:

Brachial plexus dysfunction (brachial plexopathy) is a form of peripheral neuropathy. It occurs when there is damage to the brachial plexus, an area where the nerve from the spinal cord splits into the individual arm nerves.

Damage to the brachial plexus is usually related to direct trauma to the nerve, stretch injury (such as jerking of the arm), pressure caused by tumors in the area of the brachial plexus, and damage that results from radiation therapy (such as for lung cancer). It may be related to pressure caused by congenital abnormalities that affect the cervical ribs, tumors, or injury by toxins, chemicals, or drugs. In some cases, no cause can be identified (neuralgic amyotrophy). The mechanical factors (pressure) may be complicated by ischemia (lack of oxygen because of decreased blood flow) in the area.

Collarbone Injuries

The collarbone, or clavicle, is the connection between your axial skeleton, or your trunk, and your upper extremity. It runs from the middle of your chest to your shoulder and connects your shoulder blade and your shoulder to the anterior chest wall.

The most common collarbone injuries are fractures to the clavicle or injuries to the joints at each end of the clavicle, the acromio-claviclar (AC) and the sternoclavicular (SC) joint, which is on the side closest to the chest, and the other is the acromioclavicular joint, which is on the shoulder end. An injury to this joint is commonly referred to as a shoulder separation.Shoulder separations are very common in sports like football and hockey. If you look around an NHL locker room, every other player will have had a shoulder separation.

The two mechanisms for injury are direct and indirect injuries. Direct injuries, as their name suggests, are caused by direct blows to the shoulder, particularly from the top of the shoulder. Indirect injuries are caused by falling on an outstretched hand or a blow to the outside of the shoulder, which pushes the shoulder into the chest and compresses the clavicle, causing it to be injured.

With fractures or separations, significant pain and swelling will be present, often with an initial inability to lift the arm over the head. A deformity is often present, since the bone is immediately under the skin. There is also a general feeling of "looseness," that things are moving around in the shoulder, and the shoulder or arm can feel heavy. The clavicle and its joints support the arm, and the loss of integrity of the collarbone makes it more difficult to use the arm.

Additionally, in the sternoclavicular joint there can be a popping or clicking where the patient can actually feel the shoulder popping out of place. In the acromioclavicular joint, the patient frequently reports some fatigue with repetitive exertion, especially overhead. The injuries caused by direct blows can partially be offset by wearing good, well-fitted pads that provide more cushioning (i.e., shoulder pads). The indirect injuries, such as falling on your hand to break a fall, are obviously more difficult to prevent.

Rotator Cuff Tendonitis

Alternative names:

pitcher's shoulder; shoulder impingement syndrome; swimmer's shoulder; tennis shoulder

Definition:

An inflammation of the tendons of the shoulder.

Causes, incidence, and risk factors:

The rotator cuff holds the head of the humerus into the fossa of the scapula. Tearing and inflammation of the tendons of the shoulder muscles can occur in sports requiring the arm to be moved over the head repeatedly as in tennis, pitching, swimming, and lifting weights over the head. Chronic inflammation or injury can cause tearing of the rotator cuff. The risk factors are an age of over 40 years and participation in sports or exercise that involves repetitive arm motion over the head (such as baseball).

Shoulder Problems Put the Pinch on Athletes

The shoulder is one of the regions of the body that is frequently injured in competitive and recreational sports.

The shoulder is perhaps man's most vulnerable major joint and statistical studies have shown that between eight and 13 percent of injuries in athletics involve the shoulder. The shoulder can be injured by trauma, direct or indirect, or by over usage and these injuries can occur from the age of Little Leaguers to professional baseball and football players.

Throwing maneuvers and racquet sport activities are by far the most common activities which can lead to trauma and over-use in the shoulder. Such activities as baseball, softball, swimming, football, wrestling, tennis, racquetball, volleyball, and gymnastics all have a significant chance of causing shoulder problems, both traumatic injuries and over-use syndromes.

A typical example of a traumatic injury is a football player that has been tackled and goes down on the direct point of his shoulder and sustains acromioclavicular separation in which the collarbone is separated from the shoulder blade when ligaments are torn. This often times will require surgical intervention but certain types of AC joint injuries can be treated with rest, ice and rehabilitation.

The over-use type syndrome that occurs can be seen in a swimmer in which a competitive free-styler training at 1200 meters daily with an average of 15 strokes per length will take the shoulder through a range of motion 7200 times during that activity.

This will undoubtedly lead to the micro trauma to the soft tissue of the shoulder, leading to an over-use type syndrome in which he may have pain and impingement of the shoulder. The shoulder is one of the regions of the body that is extremely complicated in regards to function and abnormalities. The shoulder involves four separate joints, the acromioclavicular, the glenohumeral, the scapulothoracic and the sternoclavicular joints. The shoulder, like the knee, can have abnormalities in which you get a tear of tissues including the rotator cuff, the glenoid labrum, which is a cartilage lip around the socket of the shoulder.

Over-use can lead to inflammation of the tendons or the bursas about the shoulder and ultimately degenerative changes about the joints of the shoulder. The symptoms that you may encounter with shoulder abnormalities are pain with certain motions, a popping or grinding, and inability to perform certain motions of the shoulder.

Thoracic Outlet Syndrome

Definition:

An abnormal condition characterized by numbness/tingling of the fingers and weakening of the grip. Usual causes include a compression of the vascular and or neurological structures around the neck and shoulder.

Common Elbow Injuries

The grip size of tennis rackets and other sports equipment tends to add abnormal stresses to the elbow. Tennis elbow, or inflammation and pain in the outer side of the elbow involving the lateral epicondyle of the humerus, usually results from excessive hand twisting.

Injuries to the elbow joints are not as common as injuries to other joints; however, these injuries can hinder athletic performance when they occur. Common elbow injuries often result from the overhead throwing motion in sports such as baseball, volleyball and tennis. They are usually related to stresses placed on the ligamentous structures by overloaded torque factors and to strains of the muscle and tendon groups. Other debilitating elbow injuries can result from external factors that cause contusions, bursal ruptures and possibly fractures.The elbow consists of three bones: the humerus, or upper arm, the ulna and radius, or forearm. These bony structures consist of two joints that allow the elbow to flex and extend and the forearm to rotate, or pronate/supinate. The joint capsule encompasses the joint, and thickened portions of the capsule make up the ligament structures.

The most common ligament structure associated with elbow injury is the ulnar collateral ligament (UCL), located on the inside part of the elbow. The largest and strongest muscles of the joint are the biceps, which cause flexion, and the triceps, which produce extension. The forearm muscles allow flexion and extension of the wrist and rotation of the elbow.

The overhead throwing motion in sports such as volleyball, baseball and tennis often cause common elbow injuries.

Tendinitis of the elbow joint commonly occurs at the epicondyle attachments of the flexor and extensor muscle groups. The extensor musculature attaches at the lateral, or outside, epicondyle - the area where the common tennis elbow occurs. This type of tendinitis usually results from repetitiously overloading eccentric contractions. The grip size of certain tennis rackets and other sports equipment also tends to add abnormal stresses. Medial, or inside, epicondylitis is often referred to as golfer's elbow. This occurrence is similar to tennis elbow; the golf club places an eccentric stress to the flexor mass during contact, causing microtrauma to the musculotendinous junction. The missed golf shot usually adds to these stresses.

Thrower's elbow is another common elbow injury seen in sports medicine.6 During throwing, the overloading force on the UCL can cause microtrauma to the ligament, and tearing can result if healing does not supersede the repetitive trauma. In order to counteract the stresses placed on the ligament, the athlete must strengthen the flexor/pronator mass to create a strong medial muscle complex.

Contusions, or bruises, posterior to the elbow joint can often rupture the olecranon bursa. This occasionally occurs when a basketball player blocks a fall with their elbows. Ruptures of the olecranon bursa can result in a buildup of fluid in the back of the elbow that can swell to the size of a golf ball. A physician may choose to drain the bursa if it inhibits performance and apply compression to force out the fluid and prevent further swelling. Padding should be used to protect the affected area from additional trauma.

The ulnar nerve is another common structure that is suspect to sports-related injuries. The ulnar nerve is the large nerve that runs behind and medial to the elbow joint. When substantial external force is applied to the elbow area, paresthesia, or a "zing," can run down the forearm and into the fingers, often referred to as hitting the funny bone. If enough trauma is applied over a period of time, the body responds to protect the nerve by building up scar tissue around it. The pressure of this scar tissue can compress the nerve to the point of consistent pain or numbness. If this occurs, surgery is usually considered to release the scar tissue and possibly re-route the nerve.

The ulnar nerve is another common structure that is suspect to sports-related injuries. The ulnar nerve is the large nerve that runs behind and medial to the elbow joint. When substantial external force is applied to the elbow area, paresthesia, or a "zing," can run down the forearm and into the fingers, often referred to as hitting the funny bone. If enough trauma is applied over a period of time, the body responds to protect the nerve by building up scar tissue around it. The pressure of this scar tissue can compress the nerve to the point of consistent pain or numbness. If this occurs, surgery is usually considered to release the scar tissue and possibly re-route the nerve.

Although injuries to the elbow joint may not be as common as injuries to other joints, coaches must be aware of the causes and characteristics of these setbacks. If a coach is unsure about their assessment of an athlete's injury, they should consult their certified athletic trainer and/or team physician. Excluding an open fracture, the ICE principle should be used in the application of first aid to an elbow joint injury - ice, compression and elevation. A rehabilitation program designed by a sports medicine team is advised for many elbow injuries. Progressive, hands-on treatment with modalities such as electrical stimulation can enhance an athlete's return to play. Proper-fitting equipment and correct technique play key roles in the prevention of elbow injuries.

Elbow Room

Lateral Epicondylitis/tennis elbow

Alternative names:

epicondylitis; epitrochlear bursitis; tennis elbow

Definition:

The inflammation of the muscles of the forearm, or their tendons near their origin on the humerus (the bone of the upper arm).

Causes, incidence, and risk factors:

The injury may be caused by the repetitive motion of twisting the wrist against resistance or frequent rotation of the forearm. There may be a partial tear of the tendon fibers at or near their point of insertion on the humerus. Risk factors are forceful repetitive wrist or forearm movement. The injury is associated with tennis playing. The incidence is 9 out of 10,000 people.

Radial Head Dislocation

Alternative names:

dislocation - elbow - partial; elbow subluxation (partial dislocation)

Definition:

A dislocation means the displacement of a body part (usually a joint) from its normal location. In a radial head dislocation, the forearm slips out of position at the elbow joint.

Considerations:

This is a common but easily preventable injury in 1 to 3 year old children.

Once the elbow dislocates it is likely to do so again, especially in the 3 or 4 weeks following the injury.

Causes:

This injury occurs frequently among toddlers. It is caused by a sudden pull on the child's arm or hand. It typically occurs when an adult pulls the child up from the arm, often to prevent a fall, to assist the child up a curb, or to hurry the child along. Swinging toddlers from the arms while playing can also cause this injury.

"Nursemaid's elbow " does not usually occur after 4 years of age. By this time the child's joints and ligaments are stronger and they are less likely to be in a situation where this injury might occur.

Radial Nerve Dysfunction

Alternative names:

neuropathy - radial nerve

Definition:

A condition involving impaired movement and/or sensation of the back of the arm (triceps), the forearm, or the hand, caused by damage to the radial nerve.

Causes, incidence, and risk factors:

Radial nerve dysfunction is a form of peripheral neuropathy. It occurs when there is damage to the radial nerve, which travels down the arm and supplies movement to the triceps muscle at the back of the upper arm, extension to the wrist, and helps in movement and sensation of the wrist and hand.

Dysfunction of a single nerve group such as the radial nerve is classed as mononeuropathy. Mononeuropathy implies a local cause of the nerve damage, although systemic disorders may occasionally cause isolated nerve damage (such as that which occurs with mononeuritis multiplex). The usual causes are direct trauma, prolonged pressure on the nerve, and compression of the nerve from nearby body structures. Entrapment involves pressure on the nerve where it passes through a narrow structure.

The radial nerve may be injured at the axilla (underarm) by direct pressure (for example, "crutch palsy" caused by improper use of crutches or pressure caused by hanging the arm over the back of a chair). A more common cause of radial nerve dysfunction is trauma that occurs in the upper arm, such as a fracture of the humerus (upper arm bone) or pressure to the upper arm from arm positions during sleep or coma. "Saturday-night palsy" is a term for an injury that occurs to the radial nerve during deep sleep, such as that which may occur when a person is intoxicated. Prolonged or repeated constriction of the wrist (such as that which may occur with a tight watch strap) may cause an injury to terminal portions of the radial nerve. In some cases, no detectable cause can be identified. These mechanical factors may be complicated by ischemia (lack of oxygen from decreased blood flow) in the area.

Carpal Tunnel Syndrome

Alternative names:

median nerve dysfunction

Definition:

A condition that results from compression of the median nerve at the wrist.

Causes, incidence, and risk factors:

Carpal tunnel syndrome is caused by pressure exerted on the median nerve at the wrist. The median nerve supplies sensation to the thumb-side of the palm, and to the thumb, index finger, middle finger, and the thumb-side of the ring finger. It also supplies movement to part of the hand. The nerve enters the hand through a gap formed by the wrist bones (called the carpal bones) and the tough membrane that holds the bones together (the transverse carpal ligament). This gap is called the carpal tunnel. The passageway is rigid, so swelling of any of the tissues in this area can cause compression of the nerve (this is also called entrapment of the nerve).

The condition occurs most often in women 30 to 60 years old, but it also occurs in men and in all age groups. Some of the conditions associated with carpal tunnel syndrome include pregnancy, premenstrual syndrome (PMS), and menopause; this is probably because of hormone changes that cause fluid retention and swelling of the tissues. Other conditions associated with carpal tunnel syndrome include rheumatoid arthritis, renal failure, diabetes mellitus, acromegaly, hypothyroidism, multiple myeloma, obesity, recent tuberculosis, fungal infection, and high blood pressure. Injury or trauma to the area, including (but not limited to) repetitive movement of the wrists, can cause swelling of the tissues and carpal tunnel syndrome. This injury may be from sports such as racquetball and handball, or from sewing, typing, driving, assembly-line work, painting, writing, use of tools (especially hand tools or tools that vibrate), or similar activities.

Colles' Fracture

Alternative names:

buckle fracture; fracture - Colles' (wrist); wrist fracture - transverse

Definition:

A break across the end of both of the lower arm bones. A Colles' fracture results in a backward and outward position of the hand in relation to the wrist.

Considerations:

The Colles' fracture is a common fracture in children and the elderly. It occurs when a person falls foreword and then attempts to break the fall by throwing the hands forward. The impact of the hand on the ground and the sudden uptake of body weight by the wrist causes the ends of the radius and ulna (the two bones in the forearm) to buckle just above the wrist.

The fracture may appear on X-ray as a mild increase in density on the top side of bone with a slight irregularity in the surface rather than a nice smooth line. Severe injuries will show evidence of a fracture through the entire bone.

Treatment may range from simple immobilization with a splint and sling to a lightweight fiberglass cast. If immobilization is insufficient to repair the fracture, surgical intervention with internal fixation may be necessary.

Older people with colles fractures often fail to regain full mobility of the wrist joint. Carpal tunnel syndrome may occur as a late complication of the injury. Chronic pain may result from injury to the ligaments.

Causes:

This injury is usually the result of trauma from a fall in which the person attempts to break the fall using the hands and arms. It is frequently associated with such sports as rollerblading, skateboarding, running or any other activity in which the hands may be called upon to prevent a foreword fall occurring at relatively high speed.

Distal Median Nerve Dysfunction

Alternative names:

neuropathy - distal median nerve

Definition:

A form of peripheral neuropathy (disease of the nerves) involving impaired movement and/or sensation of the thumb caused by damage to the distal median nerve.

Causes, incidence, and risk factors:

Distal median nerve dysfunction occurs when there is damage to the distal portion of the median nerve, which travels down the arm and provides movement and sensation to the thumb. (The distal portion is the part closest to the hand.) Carpal tunnel syndrome, another form of median nerve dysfunction, is one of the more common peripheral neuropathies.

Dysfunction of a single nerve group, such as the distal median nerve, is classed as mononeuropathy. Mononeuropathy implies a local cause of the nerve damage, although occasionally systemic disorders may cause isolated nerve damage (such as occurs with mononeuritis multiplex). The usual causes are direct trauma, prolonged pressure on the nerve, and compression of the nerve by nearby body structures. Entrapment involves pressure on the nerve where it passes through a narrow structure.

Wrist fractures may injure the median nerve. The nerve may be compressed at the wrist because of tendonitis, arthritis, or conditions that affect connective tissue or cause deposits in the tissues (such as multiple myeloma, pregnancy, acromegaly, and hypothyroidism). In some cases, no detectable cause can be identified. These mechanical factors may be complicated by lack of oxygen from decreased blood flow (ischemia) in the area.

Carpal tunnel syndrome may be associated with entrapment of the nerve following prolonged or repeated pressure on the wrist area (such as may occur with repetitive wrist movements). This is a fairly common occupational or recreational injury.

Common Peroneal Nerve Dysfunction

Alternative names:

neuropathy - common peroneal nerve; peroneal nerve injury

Definition:

A disorder characterized by progressive loss of movement or sensation of the feet and legs caused by damage to the peroneal nerve.

Causes, incidence, and risk factors:

Common peroneal nerve dysfunction is a peripheral neuropathy (damage to nerves not including the brain or spinal cord). It may occur in a person of any age. The peroneal nerve is a branching of the sciatic nerve. It supplies movement and sensation to the lower leg, foot, and toes.

Involvement of a single nerve, such as the common peroneal nerve, is classed as mononeuropathy. Mononeuropathy implies a local cause of the nerve damage, although systemic conditions may cause isolated nerve injuries (such as occurs with mononeuritis multiplex). Damage to the nerve causes destruction (degeneration) of the covering of the nerve cells (myelin sheath), or degeneration of the entire nerve cell. There is a loss of muscle control, loss of muscle tone, and eventual loss of muscle mass because of lack of nervous stimulation to the muscles.

Common causes of damage to the peroneal nerve include trauma or injury to the knee, fracture of the fibula bone of the lower leg, tight plaster cast (or other long-term constriction) of the lower leg, habitual leg crossing, chronic wearing of high boots, pressure to the knee from positions during deep sleep or coma, and other conditions that place pressure on the back of the knee. The common peroneal nerve may also be injured during knee surgery. Another risk is a very thin or emaciated body build. Systemic conditions such as diabetic neuropathy or polyarteritis nodosa may cause damage to the common peroneal nerve. Charcot-Marie-Tooth disease is an inherited disorder that affects all nerves, with peroneal nerve dysfunction apparent early in the disorder.

Deep Venous Thrombosis

Alternative names:

clot in the legs; DVT; peripheral thrombosis

Definition:

A condition where there is a blood clot in a deep vein (a vein that accompanies an artery).

Causes, incidence, and risk factors:

Deep venous thrombosis (DVT) affects mainly the veins in the lower leg and the thigh. It involves the formation of a clot (thrombus) in the larger veins of the area. This thrombus may interfere with circulation of the area, and it may break off and travel through the blood stream (embolize). The embolus thus created can lodge in the brain, lungs, heart, or other area, causing severe damage to that organ.

Risks include prolonged sitting, bedrest, or immobilization; recent surgery or trauma, especially hip surgery, gynecological surgery, heart surgery, or fractures; childbirth within the last 6 months; obesity; and the use of medications such as estrogen and birth control pills. Risks also include a history of polycythemia vera, malignant tumor, hypercoagulability (changes in the levels of blood clotting factors making the blood more likely to clot), disseminated intravascular coagulation (DIC), and dysfibrinogenia. DVT may be associated with, or may cause, pulmonary embolus.

Deep venous thrombosis occurs in approximately 2 out of 1,000 people. The condition is most commonly seen in adults over age 60.

Tibial Nerve Dysfunction

Alternative names:

neuropathy - tibial nerve

Definition:

A condition involving impaired movement or sensation in the leg, caused by damage to the tibial nerve.

Causes, incidence, and risk factors:

Tibial nerve dysfunction is a form of peripheral neuropathy. It occurs when there is damage to the tibial nerve, one of the branches of the sciatic nerve of the leg. It innervates (stimulates) the calf muscles ("hamstrings") and muscles that allow the foot to bend (foot flexors). It supplies sensation to the bottom of the foot.

Dysfunction of a single nerve group, such as the tibial nerve is classified as mononeuropathy. Mononeuropathy implies a local cause of the nerve damage, although occasionally systemic disorders may cause isolated nerve damage (such as occurs with mononeuritis multiplex). The usual causes are direct trauma (for example, after an intramuscular injection), prolonged pressure on the nerve, and compression of the nerve from nearby body structures. Entrapment involves pressure on the nerve where it passes through a narrow structure. The damage includes destruction of the myelin sheath of the nerve or destruction of part of the nerve cell (the axon). Damage to the axon slows or prevents conduction of impulses through the nerve.

The tibial nerve is commonly injured by fractures or other injury to the back of the knee or the lower leg. It may be affected by systemic diseases causing polyneuropathy (damage to multiple nerves) such as diabetes mellitus or polyarteritis nodosa. It may be damaged by pressure from lesions such as tumor, abscess, or bleeding into the knee. In some cases, no detectable cause can be identified. The mechanical factors may be complicated by ischemia (lack of oxygen from decreased blood flow) in the area.

Femoral Nerve Dysfunction

Alternative names:

neuropathy - femoral nerve

Definition:

A condition involving impaired movement and/or sensation in the leg (a form of peripheral neuropathy), caused by damage to the femoral nerve.

Causes, incidence, and risk factors:

The femoral nerve is located in the leg and supplies the muscles that assist the knee with bending. It supplies sensation to the front of the thigh and part of the lower leg. Femoral nerve dysfunction affects approximately 2 out of 10,000 people. Dysfunction of a single nerve group such as the femoral nerve is classed as mononeuropathy. Mononeuropathy implies a local cause of the nerve damage, although systemic disorders may occasionally cause isolated nerve damage (such as occurs with mononeuritis multiplex). The usual causes are direct trauma, prolonged pressure on the nerve, and compression of the nerve by nearby body structures or pathologic structures (such as a tumor). Entrapment involves pressure on the nerve where it passes through a narrow structure. The damage includes destruction of the myelin sheath of the nerve or destruction of part of the nerve cell (the axon). This damage slows or prevents conduction of impulses through the nerve. The femoral nerve can be injured as a result of pelvic fractures. It may be injured during procedures involving catheterization of the femoral artery. It can be affected by systemic diseases causing polyneuropathy (damage to multiple nerves) such as diabetes mellitus or polyarteritis nodosa. It can be damaged by pressure from lesions such as tumor, abscess, or internal bleeding into the pelvis or abdomen. One relatively common risk factor is a prolonged "lithotomy" position, where the patient lays on his back with his thighs and legs flexed, during surgery or diagnostic procedures. In some cases, no detectable cause can be identified. Mechanical factors, such as pressure, may be complicated by ischemia (lack of oxygen from decreased blood flow) in the area.

Legg-Calve-Perthes Disease

Alternative names:

coxa plana; Legg-Perthes disease; Perthes disease

Definition:

A deterioration of the head of the thighbone (femur) due to insufficient blood supply to the area.

Causes, incidence, and risk factors:

The disorder causes a flattening of the top of the femur (the ball of the head of the femur). Usually just 1 leg is affected. The blood flow to the femur is interrupted, and the tip of the bone dies over a period of 1 to 3 weeks. A new blood supply causes new bone cells to appear in the region over the next 6 to 12 months. New bone then replaces the old bone within 2 to 3 years. It occurs most frequently in boys 4 to 10 years old and tends to occur in families.

Myositis

Sciatic Nerve Dysfunction

Alternative names:

neuropathy - sciatic nerve

Definition:

A condition involving impaired movement and/or sensation in the leg, caused by damage to the sciatic nerve Causes, incidence, and risk factors: Sciatic nerve dysfunction is a form of peripheral neuropathy. It occurs when there is damage to the sciatic nerve, which is located in the leg and supplies the muscles of the back of the knee and lower leg. It supplies sensation to the back of the thigh, part of the lower leg, and the sole of the foot. Incomplete damage to the sciatic nerve may appear identical to damage to one of the branches of the sciatic nerve (tibial nerve dysfunction or common peroneal nerve dysfunction).

Dysfunction of a single nerve group, such as the sciatic nerve, is classed as mononeuropathy. Mononeuropathy implies a local cause of the nerve damage, although systemic disorders may occasionally cause isolated nerve damage (such as occurs with mononeuritis multiplex). The usual causes are direct trauma (often from an injection into the buttocks), prolonged external pressure on the nerve, and pressure on the nerve from nearby body structures. Entrapment involves pressure on the nerve where it passes through a narrow structure. The damage includes destruction of the myelin sheath of the nerve or destruction of part of the nerve cell (the axon). This damage slows or prevents conduction of impulses through the nerve.

The sciatic nerve is commonly compressed as a result of pressure from a lumbar disc. It may also be injured by prolonged sitting or lying with pressure on the buttocks. It is commonly affected by systemic diseases causing polyneuropathy (damage to multiple nerves) such as diabetes mellitus or polyarteritis nodosa. It may be damaged by pressure from lesions such as a tumor, abscess, or bleeding in the pelvis. In many cases, no cause can be identified. These mechanical factors may be complicated by ischemia (lack of oxygen from decreased blood flow) in the area. A ruptured lumbar disk may cause symptoms that simulate the symptoms of sciatic nerve dysfunction.

Anterior Cruciate Ligament

Alternative names:

• ACL injury

• cruciate ligament injury - anterior

• injury - ACL

• injury - anterior cruciate ligament

• injury - knee - ACL

• knee injury - anterior cruciate ligament

Definition:

An injury to the knee described as a partial or complete tear, dislocation, or stretch of the anterior cruciate ligament (ACL) from the bone attachments that form the knee, or anywhere else along the length of the ligament.

Causes, incidence, and risk factors:

The anterior cruciate ligament (ACL) is a powerful ligament extending from the top-front surface of the tibia to the bottom-rear surface of the femur. The ligament prevents the knee joint from anterior instability, that is, instability in the front of the joint.

A sudden deceleration (coming to a quick stop), combined with a direction change while running, pivoting, landing from a jump, or overextending the knee joint in either direction can cause injury to the ACL. This injury occurs in 4 out of 1,000 people.

Baker

Alternative names:

popliteal cyst

Definition:

An accumulation of joint fluid (synovial fluid) that forms in the tendon sheaths behind the knee.

Causes, incidence, and risk factors:

In children, the Baker's cyst appears as a painless swelling behind the knee that is more obvious with the knee fully extended. A large cyst may cause some discomfort or stiffness but generally is asymptomatic. Baker's cysts usually disappear spontaneously after several years.

Dislocation

Patellar dislocation Alternative names: dislocation of the knee cap; injury - knee - patellar; injury - patella; knee cap dislocation; knee injury - patellar Definition: A dislocation (subluxation) of the knee cap which usually occurs to the outside of the leg (laterally). Causes, incidence, and risk factors: Dislocation usually occurs as a result of sudden direction changes while running and the knee is under stress or it may occur as a direct result of injury. During this maneuver the knee cap may slip sideways and around to the outside of the knee. The first episode (first several episodes) are accompanied by pain and inability to walk. If the condition causing dislocation is left uncorrected repeat dislocations tend to cause less pain and immediate disability. However, the remain just as damaging to the patellar/femoral joint.

Meniscus Tears

Alternative names:

• injury - knee - meniscus

• knee injury - meniscus

• tear - meniscus

Definition:

A tear of the meniscus that can result in a leakage of fluid within the knee (synovial fluid) into surrounding tissue.

Causes, incidence, and risk factors:

The meniscus is a C-shaped fibrous cartilage that is found in certain joints forming a buffer between the bones. The meniscus also serves as a shock-absorption system, assists in lubricating the joint, and limits the joint flexion and extension. Meniscal tears are most commonly caused by twisting or hyperflexion of the joint.

Osgood-Schlatter Disease

Alternative names:

osteochondrosis

Definition:

A painful swelling of the bump on the front of the tibia (anterior tibial tubercle).

Causes, incidence, and risk factors:

The disease probably results from microtrauma (small, usually unnoticed injuries caused by repetitive overuse) before the complete maturity of the anterior tibial tubercle attachment. The disorder is typified by a painful swelling just below the knee on the front (anterior) surface of the lower leg bone (tibia). The area is tender to pressure and swelling may be minimal to very marked. Running, jumping, and climbing stairs cause discomfort. Symptoms occur on one or both legs. The disorder is seen most often in active, athletic adolescents, boys being more often affected than girls.

Patellar

Alternative names:

patellae - femoral grinding

Definition:

Softening of the knee cartilage.

Causes, incidence, and risk factors:

Chondromalacia patella occurs in adolescents and young adults, more frequently in women. The cause is thought to be related to overuse trauma and/or abnormal forces on the knee. Many affected adolescents have a mildly abnormal alignment of the patella (knee cap) and femur. Affected people of all ages have knee pain and a grating or grinding sensation when they extend their knee.

Posterior Cruciate Ligament (PCL) Injury

Alternative names:

cruciate ligament injury - posterior; injury - knee - PCL; injury - PCL; injury - posterior cruciate ligament; knee injury - posterior cruciate ligament; PCL injury

Definition:

An injury to the knee described as a partial or complete tear, dislocation, or stretch of the posterior cruciate ligament (PCL) from the bone attachment that form the knee, or anywhere else along the length of the ligament.

Causes, incidence, and risk factors:

The posterior cruciate ligament (PCL) is a powerful ligament extending from the top-rear surface of the tibia to the bottom-front surface of the femur. The ligament prevents the knee joint from posterior instability, that is, instability in the back of the joint. The PCL is usually injured by hyperextension (overextending the knee), or a direct blow to the flexed knee (the position of the knee when you bend the leg).

Runner's Knee

Alternative names:

knee pain - runner's condition; patellofemoral stress syndrome

Definition:

A condition of strain on the knee caused when the patella (knee cap) rubs against the femur instead of following its normal tracking

Causes, incidence, and risk factors:

The most common cause of runner's knee is pronation and lateral (away from the middle) pulling of the patella. This causes misalignment with the connective tissues and muscles involved with knee movement.

Achilles Tendon Injuries

Achilles Tendon Injuries The Achilles tendon is a thick band of tissue that attaches the muscles of the calf to the heel bone and is the key to the foot's ability to flex. The Achilles tendon enables the athlete to push off of the foot when walking or running. There are many factors that can cause a tendon to tear. Patients with certain systemic diseases can have a predisposition to tendon ruptures in all areas of the body. These include people who have taken steroids for a long time, as immuno-suppression tends to weaken connective tissue.

Pathologic ruptures are when there is a pre-existing problem with the stability of the tendon. The most common cause of Achilles tendon tears is related to a problem called tendinosis - a painless degenerative condition with the tendon due to old age or overuse. With this condition, the tendon is not as strong as it should be, and some traumas cause it to rupture. There is a lot of tendonitis in the Achilles region in younger athletes as a result of uveruse but probably the most common group affected by Achilles tendon ruptures is the older athletes who do a lot of exercise at once.

Characteristically, the tendon tears a certain distance from its insertion in the heel bone, where it has the least amount of blood supply. There seems to be direct correlation to aging where the older athlete, in general, has less blood flow to the heel region. The best advice to lessen injuries in the Achilles area is to:

• Practice proper stretching before beginning an activity

• Loosen up by breaking a light sweat and then doing gentle calf stretches. (This is especially true if you are older or not well conditioned.)

• Be aware of any pain in the Achilles tendon and make sure to treat any sign of tendonitis with RICE - rest, ice, compression and elevation.

Achilles Tendonitis

Alternative names:

tendonitis of the heel

Definition:

An inflammation of the Achilles tendon (the large thick tendon that connects the gastrocnemius and soleus muscles of the calf to the heel). The inflammation may be associated with overuse syndrome, trauma, infectious process or an arthritic process.

Metatarsus Adductus

Alternative names:

forefoot varus; metatarsus varus

Definition:

A foot deformity characterized by a sharp inward angle of the front half of the foot.

Causes, incidence, and risk factors:

Metatarsus adductus is thought to occur as a result of the infant's position inside the uterus where the feet are bent inward at the instep. Metatarsus adductus is a flexible deformity and the foot can be straightened with little effort. The appearance may be of great concern to the parent but poses little risk for the infant. Nine out of ten cases resolve voluntarily and the majority of the remainder can be corrected with simple exercises.

Pes Cavus

Alternative names:

high arch; high foot arch

Definition:

Excessive elevation of the longitudinal (toe to heel) arch of the foot.

Causes, incidence, and risk factors:

Pes cavus or high arch is the opposite of flat feet. Highly arched feet are much less common than flat feet and more likely to be associated with an abnormal orthopedic or neurological condition. Neuromuscular diseases that cause changes in muscle tone may be associated with the development of high arches.

Unlike flat feet, highly arched feet tend to be painful because more stress is placed on the section of the foot between the ankle and the toes (metatarsals). Highly arched feet may make it difficult to fit shoes, generally require a foot support, and can cause significant disability.

Plantar Fascitis

The plantar fascia is a dense multi-layered fibrous connective tissue with a broad aponeurosis just dorsal to subcutaneous fibrous septae of the calcaneal fat pad. It originates at the medial calcaneal tuberosity and spans the plantar aspect of the foot inserting into the plantar plates of the MTP joints and bases of the proximal phalanges. The medial band is the thickest and most commonly involved portion of the plantar fascia.

The plantar fascia functions to provide passive support of the medial longitudinal arch, absorb forces in the early stance phase of gait, and stabilize the foot during propulsion through the windlass mechanism. Repetitive tensile forces overload the soft tissue attachments to the plantar aspect of the heel causing tendinitis (inflammation) and/or tendinosis with collagen degeneration and subsequent angiofibroblastic hyperplasia. These forces often cause a spur to develop, however, the spur is not the problem- it's the reaction to the problem."

Etiological predisposing factors include obesity, tight gastroc-soleus, structural pes cavus, compensatory excessive subtalar joint pronation, and 1st MTP joint hypomobility. These objective findings are exacerbated by training errors in which the patient signficantly increases the frequency, duration, or intenstiy of forces on the lower extremity. In other words, training errors in the presence of biomechanical and/or anatomical factors is the recipe for the onset of symptoms.

The typical clinical presentation is that of a gradual or insidious onset with sharp, burning pain localized to the plantar fascia origin. A common chief complaint is "that the "first steps" of the morning are the "worst steps" of the day. Objective findings often include varus deformities or malalignments, tenderness at the medial calcaneal tuberosity and medial arch, decreased ankle joint dorsiflexion range of motion, and a painful supinated gait to avoid stress on the plantar fascia. Differential diagnosis needs to rule out tarsal tunnel syndrome, medial calcaneal nerve entrapment, calcaneal stress fractures, and S1 radiculopathies.

80-90% of patients respond well to conservative care, however, resolution of symptoms often takes 6-10 months. Acute phase goals include decreasing pain and inflammation, minimizing strain on the plantar fascia, and identifying and addressing any predisposing factors. This is accomplished through avoidance of any activities that aggravate the symptoms and a reduction in the intensity, duration, and frequency of weight bearing activites. The inflammation can be treated with ice massage at home and dexamethasone iontophoresis in the clinic. Also, at home, the patient should place a rolling pin at the foot of their bed and easy chair for gentle arch stretching if sitting or non-weight bearing for more than 15-30 minutes. Massaging the arch over the rolling pin will offset the physiological creep that occurs in the fascia and minimizes the acute pain and inflammatory reaction from initial weight bearing after prolonged sitting.

For the patient with a cavus foot, rehabilitation emphasis should focus on stretching and mobility. Gastroc-soleus stretching, talocrural and 1st MTP joint mobilizations, and soft tissue techniques to the plantar fascia will address common contributing factors. In the hypermobile planus foot, treatment should be aimed at strengthening the muscles that control and reverse pronation and support the medial longitudinal arch. Orthotic inserts can also be used to control or normalize abnormal compensatory motions. Many patients also benefit from modified Low-Dye taping techniques to take strain off the plantar fascia.

For the patient who doesn't respond well to these initial interventions, consideration should be given to using a night splint. These devices will maintain ankle and toe dorsiflexion during the night and allow the plantar fascia to heal at a functional length. The referring physician may also try corticosteroid injections in there has been no change in symptoms after compliant conservative management that include non-steroid anti-inflammatory medication.

Finally, review appropriate shoe wear with the patient. The best type of shoe for this condition has a stiff, firm heel counter with a beveled and flared heel for increased stability. An athletic shoe with an elevated heel, good midsole cushioning (for the cavus foot), and adequate forefoot flexbility is often the most comfortable shoe for the patient.

Running Shoes

The First Step in Avoiding Running Injuries

Running injuries, like most injuries, are avoidable. Often, a runner's training is halted by injuries that are non-traumatic in origin. Non-traumatic running injuries usually result from the body being unable to handle the stresses placed upon it. Runners and other athletes training seriously for competition are notorious for training too much, too quickly. They also may train too fast, too soon. Training errors can be avoided simply by stressing basic training principles and common sense. Sometimes athletes forget that their hard work is valuable only if they listen to their body and provide it with enough rest and recovery.

Finding the right running shoe is a step in the right direction toward avoiding injury. In fact, a proper shoe is the most valuable piece of equipment in which a runner can invest. Not only will the correct shoe type fit an individual's foot shape, but it will also ensure control over any abnormal motion that the foot goes through during the running cycle. The correct shoe type also may help control faulty running mechanics. When anatomical and biomechanical deviations are controlled, the chance of non-traumatic overuse injuries is greatly diminished.

I. Determine Foot Type

The first step is to examine the athlete's weight-bearing feet. The arch height often indicates how the feet will function during the gait cycle and can give clues about the type of shoe the athlete needs. In general, flat feet can cause many problems for people who spend a great amount of time on their feet. A well-constructed shoe with a solid arch may be a simple answer. A high-arched foot also can cause problems, especially for a runner who logs many miles. This type of foot usually needs a shoe that provides extra cushioning. A simple test can help athletes determine their foot type. Get a bare foot thoroughly wet and then step on any surface that will leave a footprint (a piece of cardboard or a brown paper bag works best). The outline of the foot will tell the story. If the complete imprint of the foot can be seen, the athlete has a flat foot. An imprint that shows the heel and forefoot connected by about half of the arch is a normal foot. A high-arched foot leaves an

II. Determine Biomechanical Needs

Pronation is not evil. The mild, rolling-inward motion of the foot as it flattens to the ground is normal and necessary. But when the foot rolls in too much (hyperpronation) or too little (underpronation), the results can be biomechanically disastrous. When pronation is not controlled by the muscle function, it becomes evil. The right shoe can be very helpful in restoring the normal amount of pronation needed during the running cycle.A useful method to determine if an athlete pronates abnormally is to closely inspect him or her during walking or running (the extra load tends to exaggerate things). A few signs to look for in a hyperpronator are a heel that tilts inward as the foot flattens and an arch that seems to flatten farther than when at rest. Hyperpronators usually have low arches, large bunions and abnormally large calluses under their first, second and third toes. Underpronators will exhibit heels that tilt outward throughout the gait cycle, have high, rigid

III. Buying a Shoe

If an athlete is serious about preventing injuries, he or she needs to find a specialty running - and training - shoe store. Not only will these stores stock a wide variety of brands and styles, but they will also know a good deal about the shoes, foot mechanics and, most importantly, how to find the right shoe for the athlete's individual needs. A good salesperson will inquire about the type of training (road, track or trail), how often and how far the athlete runs and if he or she plans on racing in the future. The salesperson also should look at the foot and watch the athlete walk to quickly screen for arch-height deviations and abnormal amounts of pronation. Finally, the salesperson should inquire about recent injuries and ask why the athlete needs to change the type of shoe with which he or she currently trains. After all, why change something that already works? There are five basic running shoe categories: motion control, stability, cushioned, lightweight training and t

Motion-Control Shoes

Motion-control shoes are designed to check hyperpronation and the rate at which a foot pronates. This type of shoe best provides the stability that a low-arched, hyperpronating foot lacks. It features a durable carbon outsole that provides a solid, stable base; a firm midsole that prevents the shoe from breaking down; medial posting (to control pronation) and a firm heel seat to prevent the rearfoot from excessively pronating. These shoes also may provide variable lacing systems and medial leather reinforcements for even more midfoot control.

Stability Shoes

A biomechanically efficient runner with a normal arch and no major motion-control problems should look for a stability shoe. Named for its firm midsole and tendency for medial posting, the stability shoe also features shock-absorption characteristics that result in a mixture of control and cushioning.

Cushioned Shoes

A cushioned shoe is built with softer midsoles on a more curved base to encourage foot motion. It is the "shoe-of-choice" for faster, lighter runners who may have higher, more rigid arches. The reduced medial support results in a more flexible, shock-absorbing shoe.

Lightweight Training Shoes

Lightweight trainers are for faster-paced training and racing. They are generally the second pair of shoes for racers who want more support and cushioning than a super-lightweight racer.

Trail Shoes

Athletes should look for a trail shoe if they spend a lot of time off-road. What makes these shoes different is better traction on the soles and a more durable material (mesh lace or leather) that encases the upper foot. The stability and cushioning varies, so close inspection is needed. Some newer models are geared for winter weather with GoreTex lining; others have traction that is applicable for high school cross-country running.

Conclusion

Running shoe companies know that no two feet are exactly the same. As a result, there is a wide range of shoes on the market. They also know that the consumer expects the best and will constantly seek it. That is why companies seem to be constantly producing new styles. If athletes are serious about preventing injuries, it is important to find the right shoe to fit their individual needs. It also is important to remember that shoes have lifespans of 300 to 500 miles. That means if an athlete is running 30 miles per week, he or she may need a new pair of running shoes every two-and-a-half to three months. Telltale signs that a shoe's time has come include significant wear on the soles, tears or an obvious stretched-out appearance of the upper material (especially at the midfoot), and a heel counter that lists to one side when viewed on a flat surface. A shoe doesn't have to look worn out to have less support. When the shoe starts to break down, so will the athlete.

If an athlete is still having a problem finding the right shoe, or if he or she has a specific injury that needs attention, a sports medicine professional is invaluable. These individuals can help assess an injury and prescribe treatments and exercises that can treat the problem. Sports medicine professionals also can help an athlete find the right shoe or fit him or her with custom orthotics to control problems with mechanics that a running shoe cannot. Ultimately, it is up to the athlete to listen to the body for any warning signs of potential injury and take the necessary steps to avoid further problems.

Femoral Nerve Dysfunction

Alternative names:

neuropathy - femoral nerve

Definition:

A condition involving impaired movement and/or sensation in the leg (a form of peripheral neuropathy), caused by damage to the femoral nerve.

Causes, incidence, and risk factors:

The femoral nerve is located in the leg and supplies the muscles that assist the knee with bending. It supplies sensation to the front of the thigh and part of the lower leg. Femoral nerve dysfunction affects approximately 2 out of 10,000 people. Dysfunction of a single nerve group such as the femoral nerve is classed as mononeuropathy. Mononeuropathy implies a local cause of the nerve damage, although systemic disorders may occasionally cause isolated nerve damage (such as occurs with mononeuritis multiplex). The usual causes are direct trauma, prolonged pressure on the nerve, and compression of the nerve by nearby body structures or pathologic structures (such as a tumor). Entrapment involves pressure on the nerve where it passes through a narrow structure. The damage includes destruction of the myelin sheath of the nerve or destruction of part of the nerve cell (the axon). This damage slows or prevents conduction of impulses through the nerve. The femoral nerve can be injured as a result of pelvic fractures. It may be injured during procedures involving catheterization of the femoral artery. It can be affected by systemic diseases causing polyneuropathy (damage to multiple nerves) such as diabetes mellitus or polyarteritis nodosa. It can be damaged by pressure from lesions such as tumor, abscess, or internal bleeding into the pelvis or abdomen. One relatively common risk factor is a prolonged "lithotomy" position, where the patient lays on his back with his thighs and legs flexed, during surgery or diagnostic procedures. In some cases, no detectable cause can be identified. Mechanical factors, such as pressure, may be complicated by ischemia (lack of oxygen from decreased blood flow) in the area.

Myositis

Sciatic Nerve Dysfunction

Alternative names:

neuropathy - sciatic nerve

Definition:

A condition involving impaired movement and/or sensation in the leg, caused by damage to the sciatic nerve Causes, incidence, and risk factors: Sciatic nerve dysfunction is a form of peripheral neuropathy. It occurs when there is damage to the sciatic nerve, which is located in the leg and supplies the muscles of the back of the knee and lower leg. It supplies sensation to the back of the thigh, part of the lower leg, and the sole of the foot. Incomplete damage to the sciatic nerve may appear identical to damage to one of the branches of the sciatic nerve (tibial nerve dysfunction or common peroneal nerve dysfunction).

Dysfunction of a single nerve group, such as the sciatic nerve, is classed as mononeuropathy. Mononeuropathy implies a local cause of the nerve damage, although systemic disorders may occasionally cause isolated nerve damage (such as occurs with mononeuritis multiplex). The usual causes are direct trauma (often from an injection into the buttocks), prolonged external pressure on the nerve, and pressure on the nerve from nearby body structures. Entrapment involves pressure on the nerve where it passes through a narrow structure. The damage includes destruction of the myelin sheath of the nerve or destruction of part of the nerve cell (the axon). This damage slows or prevents conduction of impulses through the nerve.

The sciatic nerve is commonly compressed as a result of pressure from a lumbar disc. It may also be injured by prolonged sitting or lying with pressure on the buttocks. It is commonly affected by systemic diseases causing polyneuropathy (damage to multiple nerves) such as diabetes mellitus or polyarteritis nodosa. It may be damaged by pressure from lesions such as a tumor, abscess, or bleeding in the pelvis. In many cases, no cause can be identified. These mechanical factors may be complicated by ischemia (lack of oxygen from decreased blood flow) in the area. A ruptured lumbar disk may cause symptoms that simulate the symptoms of sciatic nerve dysfunction.