Sports Medicine

Achilles Tendon Injuries

The achilles tendon is the largest tendon in the body. It connects the muscles in the back of the lower leg to the heel bone (the calcaneus) and must withstand large forces during sporting exercises and pivoting. There are two main types of injuries that affect the achilles tendon: 1) overuse and inflammation, called achilles tendonitis, and 2) a tear of the tendon.

Achilles Tendonitis

Achilles tendonitis often occurs when an individual rapidly increases the intensity of training or starts new types of training when the body is not fully conditioned. The patient may experience mild pain after exercise that gradually worsens. Mild swelling, morning tenderness, and stiffness may also occur, but may improve with use. Severe episodes of pain along the length of the tendon several hours after exercise may also be experienced.

Because other symptoms may be present, it is best to see a doctor for full evaluation of an achilles injury. Treatment depends on severity and typically involves rest and non-steroidal anti-inflammatory medications (NSAIDs) to relieve pain and inflammation. A brace may be needed to relieve the stress on the tendon and to support the ankle, and bandages may be applied to restrict joint movement.

Surgery is sometimes an option to repair any tears and remove any inflamed or fibrous tissues. Recovery generally includes rehabilitation to avoid future weakness in the ankle.

Achilles Tear

The achilles tendon may tear if it is overstretched, usually while playing sports. The tear may be partial or complete and most commonly occurs just above the heel bone. A snap or crack sound may be heard at the time of injury. Pain and swelling near the heel and an inability to bend the foot downward or walk normally are signs that the tendon may be ruptured.

Surgery is typically needed for a complete rupture. After surgery, the ankle will be kept stable in a cast or walking boot for up to 12 weeks. A torn ligament may also be managed non-surgically with a below-knee cast, which allows the ends of the torn tendon to heal on their own. This nonsurgical approach may take longer to heal, and there is a higher chance that the tendon could re-rupture. Surgery offers a better chance of full recovery and is often the treatment of choice for active people who wish to resume sports.

If you suspect that you have signs or symptoms of an achilles tendon injury, please see your doctor for further evaluation and discussion of treatment options.

Ligaments are tough, non-stretchable fibers that hold bones together. A tear to the anterior cruciate ligament (ACL) of your knee joint is among the most common sport-related injuries. The ACL connects the thighbone to the shinbone and prevents the thighbone from moving too far forward over the knee joint. This ligament also helps stabilize the shinbone from rotating out of the knee joint.

The ACL can tear when it’s stretched beyond its normal range. This typically happens by sudden twisting movements, slowing down from running, or landing from a jump. The patient may hear a popping sound at the time of injury and the knee may give way and begin to swell and hurt.

Because the ACL is not capable of healing itself (ligaments, unlike muscles, do not have their own blood supply), it can only be reconstructed surgically — it cannot simply be repaired. Less active people may choose to treat a torn ligament non-surgically with a rehabilitation program focusing on muscle strengthening and lifestyle changes. Surgical reconstruction, however, helps many people recover full function after an ACL tear.

After ACL reconstruction, performing rehabilitative exercises may gradually return full flexibility and stability to the knee. Building strength in the thigh and calf muscles to support the reconstructed knee is a primary goal of rehabilitation. The patient may need to use a knee brace for a short time, and it is important not to return to full activity too soon to prevent re-injury.

A bursa is a fluid-filled space that acts as a cushion between tendons, bone, and skin and helps joints move with ease. There are over 150 bursae in your body, and several are found around the outer area of the hip, near the portion of the thighbone called the greater trochanter. Bursitis occurs when a bursa becomes inflamed, and when the bursae around the hip joint are inflamed it is common to feel pain in the hip.

Inflammation of a bursa is caused by repetitive-use injuries, prolonged pressure, lumbar spine diseases, rheumatoid arthritis, or infection. It can affect anyone at any age, but is most common in women and the middle-aged. The main symptom is aching pain over the part of the outer hip. The pain worsens with movement or pressure and may travel down the outside of the thigh toward the knee. Pain caused by pressure at night can make sleeping very difficult.

Your doctor will be able to diagnose bursitis after physically examining the specific area causing pain and tenderness. An X-ray may be taken to rule out other causes.

Initial treatment of bursitis involves resting, immobilizing the area, and non-steroidal anti-inflammatory medications (NSAIDs) to reduce inflammation and relieve pain. Exercise and physical therapy, especially for the hip and lower back, can be helpful to strengthen the surrounding muscles and help prevent further episodes. If these measures don’t relieve the pain, a doctor may recommend an injection of corticosteroids around the bursa, which usually brings rapid pain relief. Surgery to remove the damaged bursa may be an option in severe cases.

To help prevent bursitis, try:

• Stretching the hip muscles before activity
• Practicing good posture
• Avoiding repetitive hip movements that cause the pain
• Cushioning joints (cushion chairs when sitting, and use extra hip support when sleeping)

The lower back is made up of five lumbar bones (vertebrae), all of which are separated by spinal discs composed of a gel-like substance and covered with cartilage. These discs act as shock absorbers and help your entire spinal column move. The vertebrae themselves can be felt when you touch your back, and all the muscles that stabilize the spine attach to these bony points. The spinal canal, which holds the spinal cord and the nerves that branch off, runs the length of the spinal column. Because the lower back supports the majority of the body’s weight, it is very common to experience pain that comes from the muscles, the nerves, or the spine itself.

In fact, low back pain is the second most common reason people visit their doctor. There are many causes of back pain. The most common causes of back pain include:

• Injury to a muscle (strain) or ligament (sprain)
• Disc herniation
• Degenerative disc disease
• A pinched nerve (sciatica)
• Hip joint inflammation (sacroiliitis)

Strains and sprains can occur for many reasons, and may not be caused by any single event. Using improper lifting techniques, being overweight, and having poor posture can cause enough strain on the structures of the lower back to cause injury. Individuals are particularly at risk if they have a job that requires heavy lifting, they don’t exercise, or if they have a history of osteoporosis or arthritis.

Most people find that low back pain improves with simple, at-home measures that include rest and non-steroidal anti-inflammatory medications (NSAIDs) or acetaminophen to relieve pain. Sometimes, stronger muscle relaxants and narcotics are used for a short period. Prolonged bed rest (longer than two or three days) is not recommended and may actually worsen the problem.

It is important to gradually resume activity after the first couple of days of rest. Other methods of care include applying heat or cold packs, massage therapy, ultrasound, electrical stimulation, and traction and reduction (physically maneuvering the bones). Injection with local anesthetics or corticosteroids is also an option for short-term pain relief. With all causes of low back pain, one of the most important ways to improve the condition is through strengthening and conditioning.

Surgery for low back pain is an option when nonsurgical options have been unsuccessful. The most commonly performed back operation is spinal fusion, which limits movement of the most painful part of the back. Surgery is considered successful when pain is reduced; however, recovery can take longer than a year. Furthermore, it is rare for people to have complete recovery from pain. Surgery is not the right answer for everyone, and a doctor can best discuss the benefits and limitations of surgery for with patients.

How to prevent low back pain:

• Use correct lifting techniques
• Exercise regularly to strengthen back muscles
• Maintain good posture
• Maintain a healthy body weight

Home care for low back pain:

• Stop normal activity and apply ice for first few days
• Apply heat to lower back.
• Gradually increase activity to normal
• Take over-the-counter pain relief (ibuprofen or acetaminophen)

Back pain with a loss of bowel or bladder control, leg weakness, weight loss, or fever may suggest a more serious condition. If you experience these symptoms, please seek emergency care for further evaluation.

What is the meniscus and how can it be injured?

The knee joint is buffered by a layer of articular cartilage that caps the ends of the femur (thigh bone) and tibia (shin bone). Another cartilage component, called the meniscus, forms an extra cushion where the leg bones meet to form the knee joint — like a wedged shock absorber that helps distribute weight evenly in the knee.

The meniscus can be injured by trauma or through a degenerative process. Sports injury accounts for most trauma-induced meniscal tears, usually from a bend-and-twist motion. Other injuries may be due to wear-and-tear of more brittle cartilage, a byproduct of the aging process. Often meniscal tears occur at the same time other components of the knee are injured. A common injury among athletes involves simultaneously the anterior cruciate ligament (ACL), the medial collateral ligament (MCL) and the meniscus.

In part due to the “C” shape of the meniscus, tears occur in a number of different locations. Flap, transverse, torn horn, and bucket handle rank among the most common tears.

What are the symptoms of a meniscal tear?

You may have heard a popping sound when your injury first occurred. After that, pain and swelling or tenderness may set in. Other symptoms include an inability to move your knee normally, or walk without pain or a clicking, uncomfortable feeling. For some, an injured knee may occasionally get stuck, or lock, at a 45° angle temporarily.

In order to diagnose you properly, your doctor will consider your symptoms, ask you about your activity leading up to the injury, and examine your knee carefully. Because meniscus injuries can also be accompanied by injuries to the other soft tissue in the knee, your doctor will want to look at the big picture. In addition to examining your knee in specific positions and manipulating its movement, your doctor will likely want you to have X-rays (to check for fractures) or an MRI.

A muscle cramp — the sudden involuntary contraction of one or more muscle groups — usually results in intense pain. The exact cause of muscle cramps is unknown. However, overuse, heat, dehydration, and salt and mineral depletion are considered triggers. In general, overuse, injury, and exercise in hot weather often lead to cramps. Occasionally, muscle cramps can signal other serious medical conditions, such as narrowing of the arteries to the legs (atherosclerosis), nerve compression because of lumbar spine narrowing (spinal stenosis), or potassium depletion.

Just about everyone experiences muscle cramps in their lifetime. They often occur when you’re exercising, although they can happen while sitting or sleeping, as well. They are very common in endurance athletes and other people who perform strenuous activities. Athletes most often experience muscle cramps in the preseason of their sport, when their bodies are not yet conditioned. The most commonly affected muscles are the calf, the hamstring, and quadriceps.

Muscle cramps usually go away on their own and don’t require medical treatment. There are a few things you can do to help relieve the pain and even prevent cramps. The most important home-care management technique is to stay hydrated with salt-replenishing fluids. Other methods you can use to get rid of cramps include:

• Gentle stretching and massaging of the cramping muscle
• Holding the muscle in a stretched position until the cramp stops
• Applying heat to tense or tight muscles or cold to sore or tender muscles

Regular flexibility exercises can also help prevent cramps from starting. Flexibility exercises are best done before and after you work out to stretch muscle groups that are prone to cramping.

Please see your doctor if your muscle cramps are severe, occur often, respond poorly to treatment, or have no obvious cause. Your doctor may choose to evaluate for possible problems with circulation, nerves, medications, or nutrition.

“Runner’s knee” is a blanket term to describe a number of conditions that cause pain at the front of the knee (patellofemoral pain). A common complaint of athletes, it is often the result of irritation in the soft tissues around the front of the knee. For some people, it is the result of their kneecap being out of alignment, which results in the wear and tear of the kneecap cartilage. This chronic wear and tear can eventually cause the cartilage to soften and break down, a condition identified as chondromalacia. As a result, the underlying bone and knee joint become irritated.

You may experience dull, aching pain around the front of the kneecap where it connects to the lower end of the thighbone. The pain may worsen when going up or down stairs, squatting, or kneeling.

Treatment of patellofemoral pain depends on the underlying cause. The most important way to improve your condition is rest and rehabilitation. In some cases, surgery can correct the underlying condition and improve support to the knee. Arthroscopy can be performed to remove small fragments of kneecap cartilage. Realigning the kneecap is also an alternative, done by opening the knee and reducing the abnormal pressures on the cartilage.

What causes “runner’s knee”?

• The kneecap being out of alignment
• Overuse
• Previous injury
• Weak thigh muscles

At home, general care involves RICE:

• Rest
• Ice
• Compression
• Elevation

The term shin splints refers to the pain that develops along the inside of your shin (the tibia bone). Also known as medial tibial stress syndrome (MTSS), it commonly affects runners, aerobic dancers, and people in military boot camp because it is an exercise-related overuse injury. In such injuries, your repeated movements during exercise cause muscle fatigue. This fatigue leads to additional forces applied to the tissue (called the fascia) that attaches muscles to the bone. The muscles that attach to the tibia, which include the soleus muscle (ankle flexor) and the flexor digitorum longus (toe flexors), are what actually hurt during MTSS. Injury to the bone itself does not cause pain.

Early in the condition, pain is experienced at the beginning of a training session and disappears as the exercising continues. As your injury progresses, the episodes of pain lengthen.

With repeated stress-related injuries, the bone itself can be affected and may eventually develop multiple microfractures — what is referred to as a stress fracture. The pain associated with a stress fracture will be sharp and focused on a very small area of your bone. Stress fractures are more serious and typically require you to restrict your activities to ensure proper healing.

Treatment of MTSS involves rest and often requires you to completely stop training for a period of time. It’s important to follow your doctor’s guidance and begin with lengthened rest time scheduled between training sessions. Your doctor may recommend that you take anti-inflammatory medications or use cold packs and mild compression to relieve the pain. For severe conditions that do not respond to the usual treatment, surgery may be an option. However, a full return to sports is not always achieved following surgery.

You may be more likely to develop MTSS if you:

• Have flat feet or abnormally rigid arches
• Have “knock-knees” or “bow legs”
• Are a frequent runner
• Are an aerobic dancer

If you suspect that you have signs or symptoms of MTSS, the pain is prolonged, or if there is no improvement with rest, see your doctor for further evaluation and treatment.

Stress fractures are tiny cracks in a bone caused by the overuse and the repetition of movements during exercise. When your muscles are fatigued, they become unable to absorb additional shock during exercise and transfer the overload of stress to the bone. This constant process causes tiny “micro cracks” in the bone.

Stress fractures are most common in the weight-bearing bones of the lower legs. They result from increasing the amount and intensity of activity or from an impact on unfamiliar surfaces. For example, a tennis player who changes from a soft to hard court may experience a stress fracture. Athletes participating in tennis, basketball, track and field, and gymnastics are most susceptible to stress fractures, especially if they are not resting enough between training sessions.

Studies have shown that women are more at risk for stress fractures than are men. This appears to be related to nutritional deficiencies and a woman’s propensity for decreased bone mass density.

The most common signs and symptoms include swelling and pain that decreases with rest and increases with activity. Also, there may be a spot that feels tender or painful when pressure is applied. A stress fracture is sometimes mistaken for a shin splint. However, stress fractures are more serious.

The most important factor in managing your pain and healing the fracture is rest, which may be needed for 4 to 12 weeks. You may also have to modify other daily activities during these weeks. The next step, rehabilitation, includes a program of muscle strengthening and generalized conditioning. If pain persists, careful use of non-steroidal anti-inflammatory medications (NSAIDs) may be helpful. However, these medications may limit bone repair and therefore should be used cautiously. In most cases, stress fractures can be managed with these conservative measures. However, more severe fractures may require surgery to fix and prevent further injury to the bone, as well as to ensure proper healing. Recovery from this kind of surgery is approximately six months.

You may be at risk for a stress fracture if you:

• Participate in high-impact sports
• Have been told you have low bone density
• Suddenly begin an intense training schedule
• You are an adolescent (bones are not fully mature)

If you suspect that you have signs or symptoms of a stress fracture, if the pain is prolonged, or if there is no improvement with rest, please see your doctor for further evaluation and treatment.

What is a rotator cuff and how can it be injured?

The rotator cuff is a combination of muscles and tendons at the top of the upper arm that helps stabilize the shoulder joint and move the arm (both lift and rotation). The “cuff” of muscles attaches to the scapula (shoulder blade) with a tendon connected to the front and side of the humerus bone (upper arm). This network of muscles and tendons gives the shoulder more mobility than any other joint in the body.

Although injury to the rotator cuff can be the result of trauma, such as a dislocation or fracture, tears in any component of the rotator cuff are most often caused by overuse, called wear-and-tear injuries. Any sport or activity that requires repetitive arm movement, like tennis, weight lifting or painting, can lead to a rotator cuff injury. Those who develop tears through overuse may also have experienced several months of pain associated with inflammation, either bursitis, which is inflammation of the joint bursa (fluid), or tendonitis, which is inflammation of one or more tendons.

What are the symptoms of a rotator cuff tear?

The symptoms of a rotator cuff tear depend on the cause. Tears caused by trauma may create an immediate and sharp pain in the shoulder and weakness in the arm. Tears caused by overuse may create pain that begins as a minor twinge when lifting the arm. With overuse injuries, pain may develop into chronic distress in the shoulder that radiates and limits your arm and shoulder movements. Pain may even interrupt your sleep.

In order to diagnose you properly, your doctor will consider your symptoms and examine your shoulder and neck to ensure that your pain isn’t caused by a pinched nerve, arthritis, or another condition. You will be asked to perform a few simple movements so that your doctor can measure your range of motion. Your doctor may also require you to have X-rays, an MRI, or an ultrasound.