Generelt om skader

[AMB]

Hej. Døjer pt med skulderskade og har søgt gennem nettet utallige timer, for at finde gode råd. Dem er der mange af, men specielt den her tråd på bodybuilding.net virker som guld.

http://www.bodybuilding.net/training/muscl...uries-1978.html

Desværre er der begrænsning på hvor mange gange, man kan se siden uden at oprette sig som bruger så her paster jeg alle de artikler som ligger i tråden. Den er bestemt værd at læse igennem og folk har lagt videoer og links ud, som jeg ikke paster her. Der tales bl. a. om diesel crew på youtube.

Selvfølgelig står jeg ikke til ansvar for noget af det her, og vil som alle andre råde dig til at søge professionel hjælp, hvis du ingen fremgang føler med din skade. Meget af det her er også PREHAB hvilket betyder forebyggende behandling dvs hvis du allerede ER skadet er det ikke sikkert de her øvelser gør meget for dig, men hvad ved jeg. Tjek det ud under alle omstændigheder.

Søg ved at trykke ctrl+f og skriv fx "shoulder", "shoulders".

[AMB]

*Muscle and Joint Injuries (Care and Management)

*Should you Use Anti-Inflammatories (Article)

*Wrapping and Ankle Sprain

*Trigger Points

*Shoulder Problems Overview

*Shoulder Injury Rehab

Muscle and Joint Injuries

This article will focus on the soft tissue injuries that a bodybuilder or strength athlete may incur and the important first steps one should take to ensure a speedy recovery. It will not go into specific injuries and is not meant as a comprehensive guide or a replacement for professional medical advice.

Please keep in mind that asking “some dudes I know at the gym” does not constitute medical advice!

Also, it is important to note that injuries to the head, neck, face, or spinal cord; bone fractures, breaks, or injuries with excessive bleeding, are beyond the scope of this article and may require immediate medical attention.

First, some definitions:

Muscle: OK, so you know what a muscle is.

Tendon: Fibrous connective tissue serving for the attachment of muscles to bones and other parts.

Ligament: (Joint Ligament) A band or sheet of strong fibrous connective tissue connecting the articular ends of bones, binding them together and facilitating or limiting motion. It is important to note that ligaments have little if any flexibility. There are other parts of a joint that can be injured, such as the meniscus, but you don’t really want this article to be that long…

The two basic soft tissue injuries are strains and sprains.

Strain: A trauma, tear, or rupture to the muscle or musculotendinous unit from violent contraction or excessive forcible stretch. Can also be caused by a sudden blow. It can be difficult to know when you have strained a muscle or tendon. Bodybuilders and strength athletes are so used to pain and chronic injuries they find it easy to ignore discomfort in a muscle. You may feel something pulling loose or feel a ripping sensation. Or, you may just feel a mild pain in a muscle or tendon. It is best to take any unusual pain or discomfort seriously.

Strains are classified into one of three categories:

Grade I: overstretching of a few muscle fibers with less than 10 percent actual fibers tearing. No palpable defect in the muscle.

Grade II: a partial tear of the muscle fibers usually between 10 and 50 percent of the fibers. A definite palpable defect in the muscle belly.

Grade III: an extensive tear or complete rupture of the muscle fibers. From 50 to 100 percent destruction. Very large palpable depression in the muscle. The muscle may be torn away completely. There is no possibility of normal contraction.

Sprain: A trauma, tear, or rupture to a ligament or joint capsule. Many of us have suffered a sprain at some point and it is usually fairly obvious when you have sustained and Grade II or III. Sometimes even a “pop” is heard. A mild sprain can sometimes be easily overlooked so it is important to take even a mild sudden discomfort in a joint seriously.

They are classified similarly:

Grade I: mild injury caused by an overstretching or slight tear of the ligament with minimal pain, swelling and little or no loss of function. Weight can usually be put of the affected joint.

Grade II: a moderate injury that causes partial tearing of the ligament with bruising, moderate pain and swelling. There is some difficulty putting weight on the affected joint and there is some loss of function.

Grade III: a severe injury with complete tearing or rupture of the ligament. Pain, swelling and bruising are usually severe and the patient is unable to put weight on the joint.

First Aid:

If you experience this type of injury or even suspect you have there are some important first steps you can take to lessen damage and speed recovery. What you do in the period immediately following an injury is the most important part of your recovery. It can make or break you. I cannot stress this enough.

Step 1: Stop! Stop training. Stop moving around as soon as you can and try to asses the inury. Just don’t damage it further. If you hurt yourself somewhere in your upper body that doesn’t mean you should ignore it and switch to legs. The sooner you begin treatment, the better.

Step 2: R.I.C.E. This is still the most common and most effective treatment for strains and sprains. It has been shown to significantly reduce recovery time.

It will help alleviate the bleeding around the injury site and the resultant swelling and pain. It will help prevent further tissue damage and aid in the healing process.

Rest: This goes back to step one. A soon as possible begin keeping the injured area as still. Even moving it around while working other body parts can speed up the blood flow to the area and cause further damage. If it hurts even a little don’t do it. Use some kind of sling or brace to support the injured area if necessary.

ICE: This is the most important of all. Apply ice ASAP using crushed ice in a plastic bag, commercial cold packs or even frozen vegetables such as peas.Chemical ice packs are ok but some can be too cold or not cold enough. Real ice melting in water is best.

Use some kind of buffer between the skin and ice. A damp towel is best. It’s going to be slightly uncomfortable but not painful. You don’t want to get ice burns so only apply it for as long as is tolerable. Go for around 10 minutes but if this is too long then apply it for shorter times more often. Rotate it on and off every 30 minutes, several times a day for the first 24 to 48 hours. Avoid prolonged use of ice on the extremities such as hands and feet/toes and face.

Compression: Wrap snugly, but not to tight, with an elastic bandage. Begin wrapping area farthest from heart. You should be able to slip a finger underneath but even so make sure that it doesn't start to tingle or become numb. I have not been able to find consistent recommendations on whether strained muscles or tendons should always be wrapped. It should help with the bleeding and swelling and in some instances it may help to stabilize the injured area. In general I would say to use a bandage if it helps to reduce the pain. With joint injuries, especially those of the ankle, knee, or wrist it is generally recommended. It is best not to wrap the joint in a circle but to wrap over the joint in a zig-zag or figure eight pattern, anchoring below and above. I would recommend that you have your medical professional tell you whether this step is necessary or warranted based on your injury and have him or her instruct you in the correct method. They may provide you with a special wrap. Included below is specific instructions on wrapping an ankle.

Elevation: Raise the injured area above the level of the heart whenever possible. This will help further reduce the bleeding, swelling, and pain.

For the first 24 to 72 hours avoid any type of heat to the inured area. It would be best to even take lukewarm or cold showers. Avoid any massage or movement. There sould be NO STRETCHING AT ALL during this period.

The following is a cut and paste from here: http://www.thestretchinghandbook.com/archi...njuries-pt2.htm.

Lets move on. What happens after the first 48 to 72 hours? Lets take a quick look at how your soft tissue (muscle, tendon, ligament, etc.) repairs itself.

When any sort of damage occurs to the soft tissues, like a strain or sprain, the body immediately goes into a process of repair. Where the individual fibres have been ruptures, or torn, the body begins to bind the damaged fibres together using a fibrous protein called collagen. Or, as it's more commonly known, scar tissue!

You see, when a muscle is torn, you would expect that the body would repair that tear with new muscle. In reality, this doesn't happen. The tear, or rupture, is repaired with scar tissue.

Now this might not sound like a big deal, but if you have ever suffered a soft tissue injury, you'll know how annoying it is to keep re-injuring that same old injury, over and over again. Untreated scar tissue is the major cause to re-injury, usually months after you thought that injury had fully healed.

Scar tissue is made from a very brittle, inflexible fibrous material. This fibrous material binds itself to the damaged soft tissue fibres in an effort to draw the damaged fibres back together. What results is a bulky mass of fibrous scar tissue completely surrounding the injury site. In some cases it's even possible to see and feel this bulky mass under the skin.

When scar tissue forms around an injury site, it is never as strong as the tissue it replaces. It also has a tendency to contract and deform the surrounding tissues, so not only is the strength of the tissue diminished, but flexibility of the tissue is also compromised.

So what does this mean for the athlete? Firstly, it means a shortening of the soft tissues which results in a loss of flexibility. Secondly, it means a weak spot has formed within the soft tissues, which could easily result in further damage.

Lastly, the formation of scar tissue will result in a loss of strength and power. For a muscle to attain full power it must be fully stretched before contraction. Both the shortening effect and weakening of the tissues means that a full stretch and optimum contraction is not possible.

Now, if you've taken the advice from part 1, and used the R.I.C.E.R. regime to treat the initial reaction to a soft tissue injury, you're well on your way to a complete recovery. If however, you didn't use the R.I.C.E.R. regime, you're behind the eight-ball, so to speak. Let me explain.

From last months issue we learnt that when an injury occurs the body responds by sending large amounts of blood to the injury site. If this isn't controlled, with the R.I.C.E.R. regime, it will result in massive bleeding, swelling and pain. More importantly, it will also result in a large formation of bulky, painful scar tissue.

As we know from last month, the R.I.C.E.R. regime will help to control the bleeding, swelling and pain, but more importantly, it will also control the formation of scar tissue. When the R.I.C.E.R. regime is used correctly, there will only be a minimal formation of scar tissue, which allows for optimal return of flexibility and strength.

(The last R here means Referral to a qualified medical specialist.)

The Next 10 to 14 Days

So, how do we put the finishing touches on your recovery? How do we get rid of that annoying formation of scar tissue?

After the first 72 hours most of the initial swelling will have subsided and you can start with some gentle active rehabilitation techniques.

The most effective treatment at this stage is the use of heat and massage, but including light, gentle static and passive stretching exercises after your heat and massage treatment will help to dramatically speed up the recovery process.

Firstly, you must keep active! Don't listen to anyone who tells you to do nothing. Now is the time to start active rehabilitation. Most of the swelling will have subsided after the first 48 to 72 hours and you are now ready to start light activity.

Light activity will not only promotes blood circulation, but it will also activates the lymphatic system. The lymphatic system is vital in clearing the body of toxins and waste products, which can accumulate in the body following a sports injury. Activity is the only way to activate the lymphatic system.

Before we move on, a quick word of warning. Never, Never, Never do any activity that hurts the injured area. Of course you may feel some discomfort, but NEVER, NEVER push yourself to the point where you're feeling pain. Listen to your body. Don't over do it at this stage of the recovery, you've come too far to blow it now.

To complete your recovery and remove most of the unwanted scar tissue, you now need to start two vital treatments. The first is commonly used by physical therapists (or physiotherapists), and it primarily involves increasing the blood supply to the injured area. The aim is to increase the amount of oxygen and nutrients to the damaged tissues.

Physical Therapists accomplish this aim by using a number of activities to stimulate the injured area. The most common methods used are ultrasound and heat.

Ultrasound, or TENS (Transcutaneous Electrical Nerve Stimulation) simply uses a light electrical pulse to stimulate the affected area. While heat, in the form of a ray lamp or hot water bottle, is very effective in stimulating blood flow to the damaged tissues.

Secondly, to remove the unwanted scar tissue it is vital that you start a course of deep tissue sports massage. While ultrasound and heat will help the injured area, they will not remove the scar tissue. Only massage will be able to do that.

Either find someone who can massage the effected area for you, or if the injury is accessible, massage the damaged tissues yourself. Doing this yourself has the advantage of knowing just how hard and deep you need to massage.

To start with, the area will be quite tender. Start with a light stroke and gradually increase the pressure until you're able to use deep, firm strokes. The more you massage the effected area the harder and deeper you will be able to push.

Use deep, firm strokes, moving in the direction of the muscle fibres. Concentrate your effort at the direct point of injury, and use your thumbs to get in as deep as possible to break down the scar tissue.

So what is static and passive stretching?

Static stretching is performed by placing the body into a position whereby the muscle (or group of muscles) to be stretched is under tension. Both the opposing muscle group and the muscles to be stretched are relaxed. Then slowly and cautiously the body is moved to increase the tension of the stretched muscle group. At this point the position is held or maintained to allow the muscles to lengthen.

Passive stretching is very similar to static stretching; however another person or apparatus is used to help further stretch the muscles. Due to the greater force applied to the muscles, this form of stretching is slightly more hazardous. Therefore it is very important that any apparatus used is both solid and stable. When using a partner it is imperative that no jerky or bouncing force is applied to the stretched muscle. So, choose your partner carefully, they must be responsible for your safety while stretching.

The important point to remember during this phase of the rehabilitation process is light, gentle stretching. Never, never, never do any activity that hurts injured area. Of course you may feel some discomfort, but never push yourself to the point where you're feeling pain. Be very careful with any activity you do. Pain is the warning sign; don't ignore it.

The Next 2 to 5 Weeks

The aim of this phase of your rehabilitation will be to regain all the fitness components that were lost as a result of the injury. Regaining your flexibility, strength, power, muscular endurance, balance, and co-ordination will be the primary focus.

Without this phase of the rehabilitation, there is no hope of completely and permanently making a full recovery from your injury. A quote from a great book called "Sporting injuries" by Peter Dornan & Richard Dunn will help to reinforce the value of this phase of the rehabilitation process.

"The injury symptoms will permanently disappear only after the patient has undergone a very specific exercise program, deliberately designed to stretch and strengthen and regain all parameters of fitness of the damaged structure or structures. Further, it is suggested that when a specific stretching program is followed, thus more permanently reorganizing the scar fibers and allowing the circulation to become normal, the painful symptoms will disappear permanently."

So what type of stretching is best to use during this phase? Stick with the static and passive stretching exercises described above, but also include PNF Stretching.

PNF stretching, or Proprioceptive Neuromuscular Facilitation, is a more advanced form of flexibility training that involves both the stretching and contraction of the muscle group being targeted. PNF stretching was originally developed as a form of rehabilitation and to that effect it is very effective. It is also excellent for targeting specific muscle groups, and as well as increasing flexibility, (and range of movement) it also improves muscular strength.

If you're interested, you can learn more about PNF stretching here.

Looking Long Term

Once you're over your injury and have started to regain the fitness components that were lost during the injury process, it's time to focus on making the injured area stronger and more flexible that it was before the injury occurred. To do this, the best types of stretches to use are dynamic and active stretching exercises.

Dynamic stretching uses a controlled, soft bounce or swinging motion to move a particular body part to the limit of its range of movement. The force of the bounce or swing is gradually increased but should never become radical or uncontrolled.

Active stretching is performed without any aid or assistance from an external force. This form of stretching involves using only the strength of your opposing muscles to generate a stretch within the targeted muscle group. The contraction of the opposing muscles helps to relax the stretched muscles. A classic example of an active stretch is one where an individual raises one leg straight out in front as high as possible and then maintains that position with out any assistance from a partner or object.

Just a few final points before we finish up. Be sure to drink plenty of fluid during your injury rehabilitation. The extra fluid will help to flush a lot of the waste products from your body.

Also see: 0311's Pec Tear

[AMB]

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There are some common tip-offs you should recognize as warning signs that you have an injury that needs your attention. While some sports injuries are immediately evident, others can creep up slowly and progressively get worse. If you don't pay attention to both types of injuries, chronic problems can develop. The following list of six injury tip-offs comes from Anybody's Sports Medicine Book, written by James Garrick, M.D. and Peter Radetsky, Ph.D.

1.

Joint Pain

Joint pain, particularly in the joints of the knee, ankle, elbow and wrist, should never be ignored. Because these joints are not covered by muscle, there is rarely a muscular origin. Joint pain that lasts more than 48 hours requires a physician diagnosis.

2.

Tenderness At A Specific Point

If you can elicit pain at a specific point in a bone, muscle or joint, by pressing your finger into it, you may have a significant injury. If the same spot on the other side of the body does not produce the same pain, you should probably see a physician.

3.

Swelling

Swelling is usually quite obvious, and can be seen, but occasionally you may feel swollen without outward signs. Swelling is always a sign of a sports injury and should never be ignored. Often, swelling within a joint will cause pain, stiffness, or may produce a clicking sound as the tendons snap over one another because they have been pushed into a new position due to swelling.

4.

Reduced Range Of Motion

If swelling isn't obvious, you can usually find it by checking for a reduced range of motion in a joint. If there is significant swelling within a joint, you will lose range of motion; the limb will only go so far in each direction. Again, compare one side of the body with the other to identify major differences. If there are any, you have an injury that needs attention.

5.

Comparative Weakness

Comparing one side to the other for weakness is often hard to do, but can be a good clue to identify significant injury. One way to tell is to left the same weight with the right and left side and look at the result. Often therapists will test comparative weakness manually or with special equipment.

6. Numbness and Tingling

Never ignore numbness or tingling. Often related to nerve compression, these warning signs may indicate serious injury and should always be seen by a physician.

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Anti-Inflammatory Treatment of Acute and Chronic Soft-Tissue Sports Injuries

from Medscape Pharmacotherapy

Louis C. Almekinders, MD, Associate Professor, Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill.

Introduction

Recreational and sports activities at any level have an inherent risk of injury. The majority of injuries affect the musculoskeletal system, which includes the bones, joints, muscles, tendons and ligaments. Several epidemiologic studies have shown that soft-tissue injuries comprise the largest part of all musculoskeletal injuries. The soft tissues include the ligaments, tendons, and muscles. Injuries to these soft tissues are classified as either acute or chronic injuries. Acute injuries include ligament sprains and muscle strains, whereas tendinitis is a common example of a chronic injury. All of these soft-tissue injuries are painful, and it is thought that, at least in part, the pain is due to the inflammatory response that the body generates following the injury. For that reason, treatment with anti-inflammatory medication is a popular choice of athletes and healthcare professionals. This article will review the current opinions on anti-inflammatory treatment of soft-tissue sports injuries.

Acute Injuries

Acute injuries are generally obvious to the athlete. They are caused by a sudden mishap such as a collision, fall, or twist. Pain is immediately present and medical attention is often quickly sought. The most common injuries are ligament tears or sprains and muscle tears or strains. The tears can range from a minor partial tear to a complete tear that may require surgical repair. In all cases, the body responds with a predictable inflammatory response. This response is, in essence, a physiologic reaction, as it is a necessary first step in the healing response. The inflammatory cells clear away injured debris and dead cells, paving the way for a proliferative phase as the next step in healing. The pain and swelling caused by the inflammation also keep the athlete from using the injured part and protect it from further injury. However, it is thought that the inflammatory response is generally excessive and prolonged. Therefore, anti-inflammatory medication is used to minimize this response. Oral nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly used drugs for this purpose.

NSAIDs all have in common the inhibition of the enzyme cyclo-oxygenase (COX), which allows formation of certain inflammatory mediators -- namely prostaglandins. Studies have shown that NSAIDs are effective in alleviating pain in acute soft-tissue injuries.[1,2] However, there is no convincing evidence that they are superior to analgesics that have no anti-inflammatory action, such as acetaminophen. The effects of NSAIDs on the inflammatory reaction following an acute soft-tissue injury are small and do not appear to change the natural history of these injuries to any great extent. NSAIDs may be most effective if they are used immediately following the injury, before the inflammatory response is fully established. Side effects, in particular gastrointestinal (GI) ulceration in elderly patients with other medical problems, remain a concern with most NSAIDs. However, in young, otherwise healthy athletes, short-term NSAID use is rarely associated with profound side effects beyond mild GI upset.

Recently, 2 new NSAIDs (celecoxib and rofecoxib) have become available. These selective COX-2 inhibitors have a significantly decreased incidence of side effects compared with the older NSAIDs. Research has shown that cyclo-oxygenase (COX) has at least 2 isoforms, COX-1 and COX-2. In addition it has been shown that inhibition of COX-1 results in some of the well-known side effects such as GI ulceration. Most traditional NSAIDs are nonselective inhibitors, inhibiting both COX-1 and COX-2. Selective COX-2 inhibitors have anti-inflammatory properties through their COX-2 inhibition but a marked decrease in their side-effect profile. There is no good reason to assume that their anti-inflammatory action is better than that of the traditional, nonselective inhibitors.

Corticosteroids belong to another class of drugs with anti-inflammatory properties. Derived from the hormone cortisol, corticosteroids are associated with much more pronounced and lasting anti-inflammatory effects compared with NSAIDs. Numerous studies have shown that they, in fact, can halt the healing process by virtually eliminating the inflammatory response. Inferior healing of ligament sprains and muscle strains has been observed in several animal models.[3] For this reason, most healthcare professionals believe that corticosteroids have no role in the treatment of acute soft-tissue injuries.[4]

Chronic Injuries

Chronic soft-tissue injuries are often less obvious to the athlete. They may start as a mild pain but with few functional limitations. Athletes usually do not seek medical care until the pain progresses to a point of limiting performance. Evaluation at that point can reveal several different problems. Most of these injuries are classified as overuse injuries. It is thought that repeated microtrauma beyond the reparative abilities of the musculoskeletal system eventually can lead to a macroscopic injury. Tendinitis is probably the most common problem diagnosed at that point. Recently, it has become clear that mechanical overuse is not the only factor that allows these injuries to occur. Several studies have found an age-related degeneration that affects many of the large tendons in both the upper and lower extremity.[5] This appears to predispose the tendon to painful lesions during athletic activity. Common examples are rotator cuff tendinitis, tennis elbow, and Achilles tendinitis. In addition, it has been shown that these lesions have mostly degenerative features rather than inflammatory changes. The term tendinopathy may therefore be more appropriate than tendinitis, which implies inflammatory changes.

Treatment of these chronic problems is traditionally through relative rest, physical therapy, and NSAIDs. Again, NSAID use can result in pain relief but does not appear to promote healing of these conditions. Several randomized studies have failed to show a significant advantage over other analgesics or even placebo.[6] Other treatment modalities may be more important to stimulate healing in these conditions.

Corticosteroids also remain a popular choice in the treatment of chronic soft-tissue injuries. Often they are used in a parenteral form and injected directly on and around the affected tendon. A corticosteroid injection can result in quick and dramatic relief of the pain symptoms associated with tendinopathy. The exact mechanism through which this is accomplished remains unclear, as inflammatory features are often absent in these lesions. Problems associated with corticosteroid use include weakening of the tendon and the possibility of tendon rupture. Although the exact rupture risk has not been determined, many healthcare professionals avoid using corticosteroids in weight-bearing tendons such as the Achilles tendon. In the upper extremity, corticosteroids are more frequently used. In addition, the pain relief obtained from a corticosteroid injection can be temporary. Recurrence of the pain after several weeks is not uncommon.

Summary

Although anti-inflammatory medication remains popular in acute and chronic soft-tissue injuries, their efficacy is limited. Some pain relief is often obtained, but dramatic effects on the healing of the injury cannot be expected. On the contrary, corticosteroids have the potential to actually delay or halt healing, particularly in acute injuries.

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References for:

Anti-Inflammatory Treatment of Acute and Chronic Soft-Tissue Sports Injuries

[Medscape Pharmacotherapy 2(2), 2000. © 2000 Medscape Portals, Inc]

1. Almekinders LC. Anti-inflammatory treatment of muscular injuries in sports. An update on recent studies. Sports Med. 1999;28:383-388.

2. Almekinders LC. The efficacy of nonsteroidal anti-inflammatory drugs in the treatment of ligament injuries. Sports Med. 1990;9:137-142.

3. Kennedy JC, Willis RB. The effects of local steroid injections on tendons: a biomechanical and microscopic correlative study. Am J Sports Med. 1976;4:11-21.

4. Cox JS. Current concepts in the role of steroids in the treatment of sprains and strains. Med Sci Sports Exerc. 1984;16:216-218.

5. Almekinders LC, Temple JD. Etiology, diagnosis and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc. 1998;30:1183-1190.

6. Astrom M, Westlin N. No effect of piroxicam on Achilles tendinopathy: a randomized study of 70 patients. Acta Orthop Scand. 1992;63:631-634.

NSAIDs and Musculoskeletal Treatment

What Is the Clinical Evidence?

Steven D. Stovitz, MD

Robert J. Johnson, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 31 - NO. 1 - JANUARY 2003

In Brief: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly prescribed for musculoskeletal injuries because the conditions are believed to be inflammatory in nature. However, because inflammation is a necessary component in the healing process, decreasing inflammation may prove counterproductive. Also, many tendon injuries called 'tendinitis' are, in fact, degenerative and not inflammatory conditions. An analysis of the pathophysiology and healing of musculoskeletal injuries questions the use of NSAIDs in many treatment protocols. Because NSAIDs have profound side effects, they should not automatically be the first choice for treating musculoskeletal injuries.

Musculoskeletal concerns rank with upper respiratory illness as the most common reason patients seek medical attention in family practice.1 Treatment algorithms for musculoskeletal injuries tend to reflexively include the use of nonaspirin, nonsteroidal anti-inflammatory drugs (NSAIDs). Currently, NSAIDs are among the most widely prescribed drugs in this country.2

Despite the widespread use of NSAIDs, we question their role in many treatment protocols for musculoskeletal complaints--in particular, the clinical value of their anti-inflammatory properties. Although originally marketed as the "safe" alternative to aspirin, NSAIDs are known to have serious gastrointestinal toxicity and other side effects. We review the pathophysiology and healing of musculoskeletal injuries and the clinical evidence regarding the efficacy of NSAIDs in treating a variety of nonrheumatic musculoskeletal injuries.

Mechanism of Action

NSAIDs are used for their analgesic, anti-inflammatory, and antipyretic properties. Their therapeutic actions are thought to stem primarily from their ability to block the formation of certain prostaglandins through inhibition of the cyclooxygenase (COX) enzymes (figure 1). In general, COX-1 catalyzes the production of several cytoprotective prostaglandins that coat the stomach lining with mucus and aid platelet aggregation, among other functions. COX-2 catalyzes the conversion of arachidonic acid into the inflammatory prostaglandins that are involved in three key biological functions: sensitizing skin pain receptors, elevating body temperature through the hypothalamus, and recruiting inflammatory cells toward injured body parts. (The delineation between COX-1 and COX-2 enzymes may be more complex, as described in the section on COX-2 inhibitors below.)

In addition to their effects on prostaglandins, NSAIDs exhibit other properties that have uncertain clinical relevance (eg, inhibition of neutrophil migration, oxidative phosphorylation, and lysosomal enzyme release).3

Inflammation and Healing

A major rationale for using NSAIDs in the treatment of musculoskeletal injuries has been their anti-inflammatory quality. The prevailing argument is that healthy tissue is not inflamed; therefore, if we stop the inflammation in an injured tissue, the tissue will be healthy. The problem with this viewpoint is that, in addition to being a sign of injury, inflammation is a necessary component of the healing process. As noted by Leadbetter,4 "inflammation can occur without healing, but healing cannot occur without inflammation."

Whether the injured tissue is a ligament, tendon, or muscle, the body responds to injury with a sequence of events that begins with an influx of inflammatory cells and blood. The inflammatory cells remove debris and recruit cytokines and other growth factors toward the injury site. This inflammatory phase is partly mediated by the same prostaglandins that are blocked by NSAIDs. In a healthy healing process, a proliferative phase consisting of a mixture of inflammatory cells and fibroblasts naturally follows the inflammatory phase. The fibroblasts build a new extracellular matrix and persist into the final phase of repair, the maturation phase, where, if all goes well, functional tissue is laid down. The key point is that each phase of repair is necessary for the subsequent phase. By blocking the inflammatory phase, NSAIDs can, at least theoretically, delay the healing of musculoskeletal injuries.

NSAIDs and Musculoskeletal Injuries

NSAIDs are commonly prescribed for the treatment of musculoskeletal complaints such as muscle injuries, ligament sprains, tendon injuries, low-back pain, and osteoarthritis. However, an examination of the pathophysiology and healing of such injuries, as well as a remarkable dearth of clinical trials supporting the efficacy of NSAIDs, raises questions about their use in many treatment protocols.

Muscle injuries. Whether caused by direct trauma or excessive strain, muscle injury is the most common sports injury.5 Although NSAIDs are commonly recommended in treatment protocols, clinical studies documenting their efficacy are notably lacking. We searched MEDLINE (1966 to 2002) using keywords "anti-inflammatories, nonsteroidal," "NSAIDs," "skeletal muscle," or "athletic injuries" and "randomized controlled trials" and found none involving oral NSAIDs. A recent review of studies on strains, contusions, and delayed-onset muscle soreness revealed minimal benefit at best when NSAIDs are compared with placebo.5

While some literature6,7 suggests that NSAIDs may delay the rate of muscle fiber regeneration, the clinical ramifications of this remain unclear. Clinical outcome studies of muscle injuries are difficult to conduct because the injuries tend to heal within days without intervention. Many clinicians in our sports medicine community are turning to short (24- to 48-hour) courses of NSAIDs, hoping to combine the benefits of pain relief and decreased swelling without affecting the regenerative phases of healing. Furthermore, several physicians in our community are now advocating the newer COX-2 inhibitors (discussed below) for muscle injuries with the idea that the drugs' lack of platelet inhibition might further diminish bleeding and swelling in the injured tissue. We are unaware of any studies to substantiate these claims.

Interestingly, users of anabolic steroids anecdotally report that these drugs--which actually increase inflammation--hasten the healing of muscle injuries. A recent animal study8 supports these claims. If anabolic steroids prove helpful for tissue healing in humans, the medical profession may be faced with some interesting ethical decisions.

Ligament injuries. Data on the efficacy of NSAIDs in the treatment of ligament sprains is extremely limited. In 1990, a review by Almekinders9 found only 15 studies that he felt were "carried out in a scientifically appropriate manner," and 8 of those focused on a single joint. NSAIDs were beneficial in half of these single-joint studies (2 of the 6 that examined ankle ligament sprains and the 2 that focused on knee ligament injuries). In 1995, a clinical review10 on treatment modalities for soft-tissue injuries of the ankle stated that "NSAIDs tended to offer significant improvement in recovery time and symptomatic relief over placebo." However, the authors do not state how the papers were selected for review or assessed for validity. Our own search of MEDLINE (1966 to 2002) using keywords "anti-inflammatories, nonsteroidal" or "NSAIDs," "ligaments," and "clinical trials" revealed no studies using oral NSAIDs in the outpatient setting. A 1997 study11 of 364 Australian army recruits who had ankle sprains showed that the group given NSAIDs returned to activity sooner, but had increased instability and decreased range of motion, compared with those given placebo.

The study of ligament sprains is limited, because sprains tend to heal with time and because the outcomes are subjective and favor NSAIDs, which are excellent analgesics. Controlled mobilization of injured ligaments assists healing,12 and, in this context, if NSAIDs decrease pain and thus encourage activity, they may provide some therapeutic benefit. It is unknown whether a similar effect could be obtained with other analgesics, including simply ice.

Tendon injuries. When it comes to tendinitis, the use of NSAIDs as anti-inflammatory agents becomes especially controversial. Contrary to what their name implies (the suffix "itis" denotes an inflammatory process), these injuries may not be inflammatory in nature. Indeed, several experts in this area have pointed out this misnomer and emphasized its unfortunate effect of furthering a false perception that an anti-inflammatory medicine should be used in treatment.13-15

Several large studies14,16,17 have looked at tissue biopsies from chronic injuries of the extensor carpi radialis brevis ("tennis elbow"), Achilles, patellar, and rotator cuff tendons. Results show the tendons to be degenerative and lacking in inflammatory cells. Thus, a more proper term would be either "tendinosis," meaning tendon degeneration, or "tendinopathy," signifying nonspecific tendon pathology. Some have argued that a poor inflammatory process is the precipitant that causes tendon degeneration.13,16

Controlled trials of NSAID use have not resolved this issue. A review15 of MEDLINE from 1966 to 1996 found only 9 prospective studies comparing NSAIDs with placebo. The review noted that NSAIDs provided better pain relief in 5 of the 9 studies. This result is hardly unexpected, given the potent analgesic effect of NSAIDs. The maximum study follow-up was only 1 to 4 weeks; therefore, the long-term effect of NSAIDs on these tendons is unknown.

Low-Back Pain and Osteoarthritis

NSAIDs are frequently used to treat common musculoskeletal conditions, such as low-back pain and osteoarthritis, though they are not classically sports-related injuries.

Low-back pain. The study of treatments for low-back pain is limited by its multiple and poorly understood causes. Two large meta-analyses18,19 were recently conducted, including a Cochrane review in 2000. Both searched MEDLINE for literature from the 1960s to the 1990s; the Cochrane study19 also included Embase studies from 1988 to 1998. Both found very few well-designed trials, and those that were found had small numbers of patients. There were some subtle differences in the reviews, but overall their methods and conclusions were similar.

Koes et al18 found 10 acceptable trials comparing NSAIDs with placebo and concluded that NSAIDs "might be effective for short-term symptomatic relief in patients with uncomplicated low-back pain." The Cochrane review19 identified 11 controlled studies of adequate design and concluded that there is "conflicting evidence that NSAIDs provide better pain relief than placebo for acute low-back pain." The Cochrane review found 5 "acceptable" studies comparing NSAID efficacy to that of acetaminophen and only 1 that was considered "high quality." This high-quality study included only 30 patients. It concluded that there is, at best, level 3 (ie, conflicting or limited) evidence that NSAIDs are more effective than acetaminophen for acute or chronic low-back pain.

Osteoarthritis. Eighty percent of individuals older than 65 have radiographic signs of osteoarthritis (OA), and a large percentage have symptoms.20 Given the chronic nature of the disease and the high incidence of medication side effects in the elderly, an understanding of the risks and benefits of NSAIDs in treating OA is crucial. The two main issues are pain relief and disease progression.

In reviews of clinical trials on OA of the hip and knee, NSAIDs perform significantly better as analgesics compared with placebo.21,22 Most studies comparing different NSAIDs have found no significant difference in their analgesic effects and provide no strong basis for recommending one NSAID over another. A recent randomized controlled trial23 comparing NSAIDs with acetaminophen found a significant benefit in using NSAIDs for moderate-to-severe OA. Previously, only two studies on OA had compared an NSAID with acetaminophen; neither supported a benefit for either medication. Given that the adverse effects of NSAIDs (see below) tend to disproportionately strike the elderly (hence, sufferers of OA), numerous guidelines, including those put forth by the American College of Rheumatology, recommend trying acetaminophen before an NSAID.24-26 An increasing number of small trials are being conducted that compare glucosamine and chondroitin sulfate with NSAIDs. The emerging evidence suggests a trend whereby pain relief during the first 4 weeks is superior with an NSAID, but then plateaus after 1 month.27,28

Whether NSAIDs hasten, attenuate, or have no effect on the progression of OA is unknown. In vitro studies are beginning to show evidence that certain NSAIDs stimulate the synthesis of glycosaminoglycan, whereas others either have no effect or degrade it.29,30 Given this variation in response among NSAIDs, their effects on articular cartilage are likely mediated by a mechanism other than prostaglandin inhibition. If certain NSAIDs prove beneficial to articular cartilage while others prove harmful, future treatment recommendations could change dramatically.

Weighing Side Effects

Although strong and consistent evidence is lacking that NSAIDs clinically benefit the healing of musculoskeletal injuries, they remain potent pain relievers. Their use in this capacity, however, is limited by notable side effects; gastrointestinal (GI) effects are the most common and serious.

GI bleeding secondary to NSAID use is the 15th leading cause of death in the United States.31 Unfortunately, dyspepsia cannot be used as a screening criterion, because only 40% of those who have NSAID-induced GI bleeding report abdominal symptoms before the bleed.32 This might be due to their analgesic effects. Perhaps as a result of their inhibition of platelet aggregation, individuals who have GI bleeding while taking NSAIDs have a significantly higher mortality than those with GI bleeds who are not taking NSAIDs.32

The renal and cardiovascular systems are also affected, because prostaglandins are necessary for renal blood flow and the secretion of sodium and chloride. Prostaglandin inhibition has been shown to raise mean arterial blood pressure by an average of 3 to 5 mm Hg, a small but potentially harmful amount.33 Endurance athletes are often hypohydrated as a consequence of prolonged training. NSAIDs can superimpose further decreases in renal blood flow through prostaglandin inhibition. This combination has been implicated in case reports of acute renal failure in marathoners.34,35 NSAIDs have historically been perceived to be either neutral or beneficial regarding cardiovascular occlusive events. However, a recent study36 suggests that the drugs' temporary platelet inhibition may limit the cardioprotective effects of aspirin by antagonizing aspirin's irreversible platelet inhibition.

Another potential complication for athletes involves the respiratory system. Blocking cyclooxygenase can shunt arachidonic acid toward the formation of the bronchoconstricting leukotrienes (see figure 1). It is estimated that 10% of patients who have asthma experience a decline in their respiratory function as a result of NSAID inhibition of cyclooxygenase.37

COX-2 Inhibitors

The new COX-2 inhibitors are being marketed as the safe alternative to other NSAIDs. Given the recent entry of COX-2 inhibitors into the market, little is known about their in vivo effects (either intended or adverse). Data from clinical trials suggest that their analgesic effects are similar to traditional NSAIDs.38

As their name implies, the COX-2 inhibitors preferentially block the COX-2 enzyme while allowing the pathways catalyzed by COX-1 to proceed. Theoretically, this inhibits the formation of the inflammatory prostaglandins while allowing the production of the homeostatic prostaglandins. Unfortunately, as Oscar Wilde said, "the pure and simple truth is rarely pure and never simple."39 In fact, increasing evidence indicates that the COX-2 enzyme also has some homeostatic functions.

Breyer and Harris40 suggest that the COX-2 enzyme plays an integral role in kidney function and will likely affect blood pressure to an extent similar to traditional NSAIDs. COX-2 inhibitors seem to cause fewer new GI ulcers, although this has not been definitively shown to decrease the number of complications from GI bleeds.41 Interestingly, this might be because the inflammatory pathway is necessary for healing preexisting ulcers.

A concern is that selective inhibition of antithrombotic prostaglandins might increase cardiovascular events. Patients receiving rofecoxib during the VIGOR study42 suffered cardiovascular events at a higher rate than those in the naproxyn group. This prompted a meta-analysis of trials with COX-2 inhibitors43 to state that "the available data raise a cautionary flag about the risk of cardiovascular events with COX-2 inhibitors." A more recent analysis44 suggests that the increased rate of cardiovascular events noted above was actually due to a cardioprotective effect of naproxen and not to increased events in the rofecoxib group.

The expense of COX-2 inhibitors is another major concern; treatment can cost as much as $70 or more than generic NSAIDs per month.45 Certainly, if this decreases other medical costs, this might prove beneficial. Finally, given their inhibition of the inflammatory pathway, all of the concerns regarding delayed healing of injured tissues remain the same when using COX-2 inhibitors.

Clarifying the Role of NSAIDs

Reviewing the most current updates on the use of NSAIDs in the treatment of musculoskeletal injuries is challenging. Although we mention randomized controlled trials, or lack thereof, this review is not intended to be a meta-analysis. Any attempt at a meta-analysis on this topic would be fraught with either a tremendous lack of data (if stringent criteria were used) or controversy (if criteria were loosened).

Given the paucity of data, we are unable to draw any definitive conclusion in support of or against the use of NSAIDs. We realize that many clinicians use anti-inflammatories for musculoskeletal conditions so routinely that any suggestion that little evidence supports their use is interpreted as a condemnation. This discussion is meant to clarify, not simply diminish, the role of NSAIDs. To effectively treat musculoskeletal injuries, the clinician must have realistic expectations about the capabilities of NSAIDs and convey them to the patient. NSAIDs are rarely a substitute for rehabilitation and activity modification.

When used properly, NSAIDs can be a useful, but limited, adjunct. They certainly play a key therapeutic role in the treatment of the crystalline and rheumatoid arthritides and may be beneficial in treating pathologic edema of bursa and synovial tissue (eg, tenosynovitis). For most common sprains, strains, and overuse injuries, however, their therapeutic properties are unproven. It is crucial to keep a proper perspective regarding the role of NSAIDs, especially given their risk of side effects and their potential to blunt the normal healing response. Too many physicians and patients view NSAIDs as critical to recovery. Additional research is needed to define more explicitly the role of NSAIDs in interfering with or delaying healing and the role of other, potentially safer, means to control the pain of musculoskeletal injuries.

References

Rosenblatt RA, Cherkin DC, Schneeweiss R, et al: The structure and content of family practice: current status and future trends. J Fam Pract 1982;15(4):681-722

Golden BD, Abramson SB: Selective cyclooxygenase-2 inhibitors. Rheum Dis Clin North Am 1999;25(2):359-378

Leadbetter WB: Anti-inflammatory therapy in sports injury: the role of nonsteroidal drugs and corticosteroid injections. Clin Sports Med 1995;14(2):353-410

Leadbetter WB: An introduction to sports-induced soft-tissue inflammation, in Leadbetter WB, Buckwalter JA, Gordon SL (eds): Sports-induced Inflammation: Clinical and Basic Science Concepts. Park Ridge, IL, American Academy of Orthopaedic Surgeons, 1990, p 13

Almekinders LC: Anti-inflammatory treatment of muscular injuries in sport: an update of recent studies. Sports Med 1999;28(6):383-388

Best TM, Hunter KD: Muscle injury and repair. Phys Med Rehab Clin N Am 2000;11(2):251-266

Weiler JM: Medical modifiers of sports injury: the use of nonsteroidal anti-inflammatory drugs (NSAIDs) in sports soft-tissue injury. Clin Sports Med 1992;11(3):625-644

Beiner JM, Jokl P, Cholewicki J, et al: The effect of anabolic steroids and corticosteroids on healing of muscle contusion injury. Am J Sports Med 1999;27(1):2-9

Almekinders LC: The efficacy of nonsteroidal anti-inflammatory drugs in the treatment of ligament injuries. Sports Med 1990;9(3):137-142

Ogilvie-Harris DJ, Gilbart M: Treatment modalities for soft tissue injuries of the ankle: a critical review. Clin J Sport Med 1995;5(3):175-186

Slatyer MA, Hensley MJ, Lopert R: A randomized controlled trial of piroxicam in the management of acute ankle sprain in Australian Regular Army recruits: the Kapooka Ankle Sprain Study. Am J Sports Med 1997;25(4):544-553

Frank CB: Ligament healing: current knowledge and clinical applications. J Am Acad Orthop Surg 1996;4(1):74-83

Khan KM, Cook JL, Taunton JE, et al: Overuse tendinosis, not tendinitis. Part 1: a new paradigm for a difficult clinical problem. Phys Sportsmed 2000;28(5):38-48

Khan KM, Cook JL, Bonar F, et al: Histopathology of common tendinopathies: update and implications for clinical management. Sports Med 1999;27(6):393-408

Almekinders LC, Temple JD: Etiology, diagnosis, and treatment of tendonitis: an analysis of the literature. Med Sci Sports Exerc 1998;30(8):1183-1190

Kraushaar BS, Nirschl RP: Tendinosis of the elbow (tennis elbow): clinical features and findings of histological, immunohistochemical and electron microscopy studies. J Bone Joint Surg Am 1999;81(2):259-278

Astrom M, Rausing A: Chronic Achilles tendinopathy: a survey of surgical and histopathologic findings. Clin Orthop 1995;316(July):151-164

Koes BW, Scholten RJ, Mens JM, et al: Efficacy of non-steroidal anti-inflammatory drugs for low back pain: a systematic review of randomised clinical trials. Ann Rheum Dis 1997;56(4):214-223

van Tulder MW, Scholten RJ, Koes BW, et al: Nonsteroidal anti-inflammatory drugs for low back pain: a systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 2000;25(19):2501-2513

Phillips AC, Polisson RP, Simon LS: NSAIDs and the elderly: toxicity and economic implications. Drugs Aging 1997;10(2):119-130

Towheed TE, Hochberg MC: A systematic review of randomized controlled trials of pharmacological therapy in osteoarthritis of the hip. J Rheumatol 1997;24(2):349-357

Towheed TE, Hochberg MC: A systematic review of randomized controlled trials of pharmacological therapy in osteoarthritis of the knee, with an emphasis on trial methodology. Semin Arthritis Rheum 1997;26(5):755-770

Pincus T, Koch GG, Sokka T, et al: A randomized, double-blind, crossover clinical trial of diclofenac plus misoprostol versus acetaminophen in patients with osteoarthritis of the hip or knee. Arthritis Rheum 2001;44(7):1587-1598

American College of Rheumatology Subcommittee on Osteoarthritis Guidelines: Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. Arthritis Rheum 2000;43(9):1905-1915

Cole BJ, Harner CD: Degenerative arthritis of the knee in active patients: evaluation and management. J Am Acad Orthop Surg 1999;7(6):389-402

Eccles M, Freemantle N, Mason J: North of England evidence based guideline development project: summary guideline for non-steroidal anti-inflammatory drugs versus basic analgesia in treating the pain of degenerative arthritis. The North of England Non-Steroidal Anti-Inflammatory Drug Guideline Development Group. BMJ 1998;317(7157):526-530

Deal CL, Moskowitz RW: Nutraceuticals as therapeutic agents in osteoarthritis: the role of glucosamine, chondroitin sulfate, and collagen hydrolysate. Rheum Dis Clin North Am 1999;25(2):379-395

McAlindon TE, LaValley MP, Gulin JP, et al: Glucosamine and chondroitin for treatment of osteoarthritis: a systematic quality assessment and meta-analysis. JAMA 2000;283(11):1469-1475

Pelletier JP: The influence of tissue cross-talking on OA progression: role of nonsteroidal anti-inflammatory drugs. Osteoarthritis Cartilage 1999;7(4):374-376

Lequesne MG: Is there preliminary in-vivo evidences of an influence of nonsteroidal anti-inflammatory drug treatment on osteoarthritis progression? Part 1. Osteoarthritis Cartilage 1999;7(3):350

Wolfe MM, Lichtenstein DR, Singh G: Gastrointestinal toxicity of nonsteroidal anti-inflammatory drugs. N Engl J Med 1999;340(24):1888-1899 [published erratum N Engl J Med 1999;341(7):548]

Hayllar J, Macpherson A, Bjarnason I: Gastroprotection and nonsteroidal anti-inflammatory drugs (NSAIDs): rationale and clinical implications. Drug Saf 1992;7(2):86-105

MacFarlane LL, Orak DJ, Simpson WM: NSAIDs, antihypertensive agents and loss of blood pressure control. Am Fam Physician 1995;51(4):849-856

Walker RJ, Fawcett JP, Flannery EM, et al: Indomethacin potentiates exercise-induced reduction in renal hemodynamics in athletes. Med Sci Sports Exerc 1994;26(11):1302-1306

Vitting KE, Nichols NJ, Seligson GR: Naproxen and acute renal failure in a runner, letter. Ann Intern Med 1986;105(1):144

Catella-Lawson F, Reilly MP, Kapoor SC, et al: Cyclooxygenase inhibitors and the antiplatelet effects of aspirin. N Engl J Med 2001;345(25):1809-1817

Szczeklik A, Stevenson DD: Aspirin-induced asthma: advances in pathogenesis and management. J Allergy Clin Immunol 1999;104(1):5-13

Noble SL, King DS, Olutade JI: Cyclooxygenase-2 enzyme inhibitors: place in therapy. Am Fam Physician 2000;61(12):3669-3676

Ruddy S, Harris ED, Sledge CB, et al (eds): Kelley's Textbook of Rheumatology, ed 6. Philadelphia, WB Saunders, 2001, p 801

Breyer MD, Harris RC: Cyclooxygenase 2 and the kidney. Curr Opin Nephrol Hypertens 2001;10(1):89-98

Lichtenstein DR, Wolfe MM: COX-2 selective NSAIDs: new and improved? JAMA 2000;284(10):1297-1299

Bombardier C, Laine L, Reicin A, et al: Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis: VIGOR Study Group. N Engl J Med 2000;343(21):1520-1528, 2 p following 1528

Mukherjee D, Nissen SE, Topol EJ: Risk of cardiovascular events associated with selective COX-2 inhibitors. JAMA 2001;286(8):954-959

Dalen JE: Selective COX-2 inhibitors, NSAIDs, aspirin, and myocardial infarction. Arch Intern Med 2002;162(10):1091-1092

Valdecoxib (Bextra): a new COX-2 inhibitor. Med Lett Drugs Ther 2002;44(1129):39-40

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The authors thank Anne Marie Weber-Main, PhD, for her editorial assistance with this manuscript.

Dr Stovitz is an assistant professor and coordinator of sports medicine education in the department of family practice and community health at the University of Minnesota in Minneapolis. Dr Johnson is the director of primary care sports medicine in the department of family practice at Hennepin County Medical Center in Minneapolis and is president of the American Medical Society for Sports Medicine. Address correspondence to Steven D. Stovitz, MD, Smiley's Clinic, 2615 E Franklin Ave, Minneapolis, MN 55406; e-mail to [email protected].

Disclosure information: Drs Stovitz and Johnson disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.

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Here is how to wrap a typical ankle sprain caused by inversion (ankle turned inwards):

1) Position the foot straight (in dorsiflexion), not pointed. You want the injury to heal in an unstretched position.

2) Wrap the elastic bandage around the foot several times for an anchor.

3) Coming from outside, bring the wrap over the ankle and around the back of leg just above the ankle, pulling the outer edge of the foot slightly upward (eversion, twisting outward, opposite of the injury), to counteract the inversion injury.

4) Complete several figure-8 wrapping patterns, again coming from the outside up and around the back of the leg, keeping the foot in dorsiflexion and slight eversion.Don't wrap too tightly. You want to slow the circulation, not stop it. Frequently check feeling, colour and temperature of areas beyond the injured portion; if they become numb, blue or cold, loosen the wrap.

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INFORMATION about TRIGGER POINTS and their TREATMENT

Compiled by Dr Diana Cross

What are trigger points [TPs]?

A trigger point is simply a small contraction knot in muscle. This knot feels like a pea buried deep in the muscle, and can feel as big as a thumb. It maintains a hard contraction on the muscle fibres connected to it, thus causing a tight band that can also be felt in the muscle. These trigger points in muscles and in the thin wrapping around each muscle [called fascia] are called myofascial trigger points, to distinguish them from trigger points which can occur in other soft tissues such as skin, ligaments and tendons, and also in scar tissue.

Are TPs the same as a muscle spasm or strain or tear?

No, a TP is not the same thing as a muscle spasm. A spasm involves a violent contraction of the whole muscle, whereas a TP is contraction in only a small part of a muscle. A strain or tear involves physical damage to the muscle or tendon fibres, Such damage has not been demonstrated in studies of TPs. [However, such injuries may predispose one to developing TPs there later on.]

Why are they called trigger points?

Pulling the trigger of a gun makes a noise in the gun but it also sends out a bullet that causes pain at a distant target site. Pressing firmly on muscle TPs hurts right where you are pressing, making you jump, wince and pull away. But, more importantly, TPs also send ['refer'] pain or tenderness to some other site, often quite far away. So, for example, a headache may not be caused by a problem in the head itself, but have been sent to the head from a TP on the side of the neck. Never assume the problem is at the place that hurts.

What does this referred pain feel like?

The referred pain caused by TPs is usually steady, dull and aching, often deep. It may occur at rest, or only on movement. It varies from being a low-grade discomfort to being severe and incapacitating.

Are TPs common?

Myofascial trigger points are among the most common, yet poorly recognised and inadequately managed, causes of musculoskeletal pain seen in medical practice. Unfortunately, many general practitioners and orthopaedic surgeons do not know about TPs, and as TPs do not show on XRays or scans, the patient may be told there is nothing wrong with them or that there is nothing that can be done to help fix their pain.

What common conditions are thought to be due to referred pain from TPs?

TPs are known to cause or contribute to headaches, neck and jaw pain, low back pain, the symptoms of carpal tunnel syndrome and tennis elbow, and many kinds of joint pain mistakenly ascribed to arthritis, tendonitis, bursitis, or ligament injury.

What other symptoms may TPs cause?

Apart from pain, TPs may cause numbness, tingling, weakness, or lack of normal range of movement. TPs can also cause earaches, dizziness, sinus congestion, nausea, heartburn, and false heart pain. And they may result in depression if pain has been chronic.

How can one know where the TPs are?

It is important to realize that the TPs themselves do not hurt, [other than when you are actually pressing firmly on them.] In other words, the gun has a silencer on it, so you don't know there is a gun or that it is being fired. You only know that you're wounded. Most patients are surprised when I locate a very painful tight spot in a muscle well away from where they tell me their pain is. They were usually completely unaware that this painful tight spot even existed, let alone that such a small spot could be the cause of all their pain.

So how did I know where to find that spot?

Fortunately, referred pain occurs in predictable patterns, which have been clearly mapped out in The Trigger Point Manual by Simons and Travell. Using their maps I know which areas to search for the TPs that characteristically send pain to the place where you are hurting. I then feel for a tight muscle in that area, feel for tight bands within that muscle, and localize an area within the band which is exquisitely tender and that is the TP. As I press or twang it, the muscle may twitch. As I keep pressure on it, it will cause your usual referred pain, thus confirming that we've got the spot.

Could there be more than one TP causing my problem?

Yes, TPs tend to gang together, so in practice it is common to find more than one TP in the tight muscle, and more than one muscle whose TPs refer pain to the area where you are hurting. All your TPs need to be hunted out and treated before you'll gain full relief of your symptoms. I will show you the relevant TPs for your problem, and after a while you'll become expert at finding them for yourself. .

What causes TPs to develop?

All of us develop tight bands in our muscles as we age, but some people have more than others, for various reasons that are listed in the red box labelled: 'Predisposing factors'. Then, some of these tight bands go on to develop TPs in them, when one or more 'Precipitating factors' arise. For example, a TP may develop following an acute muscular strain such as during a car accident, a fall, a sprain or fracture, or excessive or unusual exercise. Or following chronic overload of the muscles used to maintain posture because of poor sitting, working or sleeping habits, or by repetitive work tasks.

Could poor general health be making my TPs even worse?

Yes, particularly if your pain has been happening awhile, it is very likely that one or more of the following 'Perpetuating factors' is present: · Mechanical stresses such as a short leg, flat foot, poor posture, or immobility. · Nerve root pressure, eg sciatica. · Chronic internal diseases, and some prescription medications. · Nutritional deficiencies, especially vitamins C, B-complex and iron. · Hormone imbalances [low thyroid hormone levels, premenstrual or menopausal] · Infections [bacterial, viral or yeast] · Allergies [wheat and dairy in particular] · Poor oxygenation of tissues [aggravated by tension, stress, inactivity, poor sleep, smoking ] These factors MUST be detected and corrected if specific treatment of the TPs is to be successful or lasting, so your doctor will spend some time sorting these out with you. Chronic fatigue syndrome and fibromyalgia also predispose one to develop TPs, [in addition to all the other tender spots characteristic of those conditions].

So how long will the pain take to get better?

With TPs of recent onset, significant relief of symptoms often comes in just minutes, and most acute problems can be eliminated within 3 to 10 days. But longer-standing chronic conditions are more complex and less responsive to treatment. None the less, even some of these problems can be cleared [in as little as 6 weeks] IF you persist with treatment AND if you fix the Perpetuating factors referred to above.

How are TPs treated?

TPs can be treated in a number of different ways, depending on the speciality or training of the practitioner. Doctors may use local anaesthetic, saline, or cortisone injections, but acupuncture needling, use of a cold spray whilst stretching the muscle, or specific trigger point massage also works. Some physiotherapists or masseurs have a real knack in treating TPs, and I can guide you as to who they are. However there are good reasons to learn how to apply trigger point massage to yourself. With self-treatment you don't have to wait for an appointment, you can get help whenever you need it, and you don't pay a cent. You can be the expert in knowing how to get rid of your own pain.

How does massage work?

In 3 ways: · Massage breaks into the self-sustaining vicious circle that has kept the muscle contracted. · It increases the circulation, which has been restricted in the immediate area by the contracted fibres, thus enabling oxygen and nutrients to flow to the spot. · It directly stretches the trigger point's knotted muscle fibres.

What's the best way to massage them?

The Trigger Point Therapy Workbook by Clair Davies gives the following guidelines: 1. Use a tool if possible [such as a firm rubber ball] and save your hands. 2. Use deep stroking massage, [a repeated milking action] not static pressure. 3. Massage with short repeated strokes, moving the skin with your fingers, and releasing at the end of each stroke to go back to the starting point. 4. Do the massage stroke in one direction only, whether with the grain of the fibres or across them. 5. Do the massage stroke slowly, no more than one stroke per second. 6. Aim at a pain level of 7 on a scale of 1 to 10. 7. Limit massage to one minute per trigger point. 8. Work a trigger point 6 to 12 times per day, until pressure on it elicits a pain level of only 2 or 3. 9. If you get no relief, you may be working the wrong spot. Is there anything more I need to do after massage has relieved the symptoms? Yes. After massage it is very important to: · Apply a hot pack covered with a dampened flannel or towel to the treated area for a few minutes. · Then gradually and gently stretch the treated muscle through its full range of movement 3 times, with a pause to deep breathe and consciously relax between each cycle.

What else can I do or avoid to achieve lasting recovery?

· Learn respect for your muscles. They were not designed to be held for long periods in a sustained contraction or in a fixed position. Vary your tasks each day. Lift very carefully.

· Slow your working pace, and take short rests frequently, especially if feeling muscle fatigue.

· Do a daily program of passive stretches that puts the affected muscles through a full range of movement, and repeat the stretches throughout the day. Be like the cat-- it rarely tries to walk after a sleep without first stretching smoothly and slowly.

· Massage any TPs up to a dozen times a day, for a minute at a time, as described above.

· Learn relaxation techniques, [eg yoga, meditation].

· Always watch your posture when sitting, reading, using the computer car or phone. Don't stay too long in any one position.

· Work out what particular postures, movements and activities stir up your TPs. If you don't have to do that activity, then don't. If you do, then modify how its done.[eg use the other hand].

· Avoid getting the muscles cold, by wearing an extra warm layer of clothing, and adjusting heating etc.

· Correct any imbalances in your diet, and take vitamin and mineral supplements as recommended by your doctor.

What about exercise?

Exercise should be regarded as a prescription, and the kind of exercise prescribed depends largely on how active your TPs are at that time. Your physio will give you the details.

· When the TPs are very active and you have pain at rest, then gentle stretches and hot packs are your limit

· Once the TPs are inactivated and constant rest pain fades, then a carefully graded exercise program is needed to increase muscle endurance and strength. This involves muscle lengthening exercises [adding a new exercise on alternate days], before working up to shortening exercises. Post-exercise soreness and stiffness should not last longer than 3 days or the program needs altering.

· Then a regular conditioning program is recommended, at least twice a week, for example swimming or cycling.

Would the TPs get better if I just rested up?

Yes and no. Studies have shown that with a short period of rest and the avoidance of whatever activated the trigger point, the pain symptoms may disappear over a few weeks. This makes people believe their problems have gone away. But, if you examine the muscle properly you will find it is still tight stiff and weak, and still tender when pressed on. In other words, the TPs are still there; they are just lying dormant [latent], and not causing referred pain at that time. The bad news is that they can be very easily reactivated to cause pain again, by acutely overloading the muscle in a new or repetitive task, working or sleeping in an awkward position, chilling the muscle, or during emotional stress, fatigue, or viral infections. How much it takes to reactivate a latent TP will depend on the degree of muscle conditioning, so keeping fit can help reduce the likelihood of this. But the only way to get rid of the TPs for lasting relief is through actively hunting out and treating all the active and latent TPs. Although this involves more effort, its truly worth it in order to escape "the endless replay" of TP pain.

REFERENCES:

Travell J., Simons D.: Myofascial Pain and Dysfunction, the trigger point manual, Vol 1 & 2.Williams and Wilkins 1982 Davies C.

The Trigger Point Therapy Workbook, your self-treatment guide for pain relief. New Harbinger publications 2001

Trigger Point Diagram Cascade for Diagnosis and Management

(Large page download 96k )

By Dr D Cross

[AMB]

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All About Shoulder Pain

By: Michael Kurilla

Shoulders receive the lion's share of work in the gym. Nearly all upper body routines involve the shoulder to some extent, if only to be held fixed and motionless for the specific movement. Even during leg work, the shoulders are involved with the stacking and unstacking of plates for all the leg routines. Shoulder pain can greatly hamper any training routine and tends to require long periods of time for complete recuperation.

Severe injuries can prematurely terminate the careers of professional athletes such as baseball pitchers with rotator cuff problems. For the non-professional athlete, even minor shoulder pain can lead to disturbed sleeping patterns from the inability to find a comfortable position at night. Part I of this two part series will examine shoulder anatomy in sufficient detail to highlight the basis for skeletal variations that can predispose certain individuals to persistent shoulder problems. Part II will go on to present routines for strengthening lesser known shoulder muscles and lifting variations to minimize further trauma.

Bear in mind that severe pain, extreme muscle weakness, or inability to perform certain movements may indicate a condition requiring medical attention. Advice presented here should not serve in place of a thorough medical evaluation since certain conditions may require specialized medical intervention or even surgery.

Due to its extremely wide range of mobility, the shoulder is one of the most complex joints in the human body. Because of its unusual bone structure and large number of muscle attachments, shoulder pain can be a daunting challenge to most physicians who typically recommend merely rest and anti-inflammatory medications for weeks to months as therapy which may or may not solve the problem.

In addition, chronic degenerative changes that accumulate from repeated trauma will likely increase the frequency of shoulder problems for most individuals as they age and continue lifting. While any single article can hardly be exhaustive on the subject of shoulder issues (whole books 16,17 have been devoted to the subject), this discussion will focus on one of the more common problems that results from a combination of unlucky anatomy, undesirable lifting technique, and insufficient attention to auxiliary musculature.

The Anatomy Of The Shoulder

The shoulder is the anatomical structure that links the arm with the torso. A wide array of muscles of particular interest to bodybuilders traverse the shoulder including: pecs, lats, delts, and even the biceps. Given that the lats and delts contribute to a wide upper body desirable by bodybuilders, much attention is focused on these muscle groups and considerable stress is applied to the shoulder. Pain and discomfort can dramatically compromise nearly any weightlifting routine.

The shoulder as a joint is classically described as a ball and socket (similar in design to the hip joint)1. The ball portion is derived from the end of the upper arm bone, the humerus, and resembles a ball stuck on the end of a long shaft, and is referred to as the humeral head. The socket side is formed from one corner of a roughly triangular flat bone called the shoulder blade (the scapula), that rests over the rib cage, high on the back and extends over the rib cage to the front of the body. The triangular form of the scapula has one side close to the midline of the back with the lower corner angling up towards the shoulder.

The third side of the triangle runs parallel to the shoulders across the top. The shoulder blade is thicker in its upper portion than the lower portion, so that the very top of the shoulder blade has a surface (rather than just as edge as with the other two sides of the triangle) with two edges (one towards the body and one away). The top edge pointing away from the body is called the spine and the surface of the top of the shoulder blade is slightly depressed and called the supraspinous fossa (fossa is the technical term for a depression). Moving along the spine towards the shoulder, a bony extension, called the acromion, juts out and arches over the top of the scapula just above the humeral head and can be felt as the bony top of the shoulder.

The acromion arches over the top of the scapula from back to front and connects to the collarbone (clavicle) to complete the shoulder girdle. Arising off the top edge opposite the spine, also at the shoulder, across from where the acromion begins and pointing forward over the chest, is a small bony knob called the coracoid process. The short head of the biceps muscles attaches to this piece of bone as well as a small muscle called coracobrachialis and the pectoralis minor muscle (underneath pectoralis major, the main 'pecs'). In addition, a tough ligament connects the coracoid process with the acromion.

The socket portion of the scapula that contacts the humerus is called the 'glenoid fossa,' but rather than looking like a true socket, the glenoid fossa is more open with the appearance of a saucer or rather like a golf tee with the humeral head as the golf ball. The reason for the openness is to permit a large range of motion in the joint. The downside to this large range of motion is the propensity of the shoulder to dislocate. A dislocation occurs when the humeral head moves beyond the confines of the glenoid fossa and slips over the lip of the saucer (your golf ball falls off the tee).

When any muscle acts across a joint, opposing muscles are contracted as well to stabilize the joint. Imbalances in strength between opposing muscles can potentially lead to injuries. With the shoulder, the anatomy is not as simple as a one dimensional joint (such as the elbow). Movement of the shoulder requires many different muscles to create the movement as well as other muscles to stabilize the shoulder joint. In addition, since the shoulder blade is only attached (by other bones) to the upper arm and collar bone at one end, the blade portion must be held fixed by additional muscles.

For example, serratus anterior (best seen in a well muscled, lean individual) is a small group of muscles that arises from the rib cage in front just below the pecs with the muscle bellies extending up and around to the back and disappearing underneath the lats. Serratus anterior attaches to the scapula along the edge closest to the middle of the back. Serratus's job is to prevent the shoulder blade from winging during shoulder movements; in other words, serratus pins the scapula to the back and so serves to stabilize the joint during movements.

The Rotator Cuff

As discussed above, the shoulder joint has an extremely wide range of motion. A key structure supporting the shoulder joint is the rotator cuff. The rotator cuff is concerned with two major functions, rotating the shoulder and cuffing the joint 5,34. Rotation may not appear as an obvious movement with regard to the shoulder.

To visualize shoulder rotation, place your arm at your side and bend the elbow to 90o, as if to shake hands, but maintain the upper arm against your side and keep you palm in (thumb up).

Keeping your upper arm against your side, bring your forearm and hand across your body to rest your palm on your stomach. That movement is internal shoulder rotation (the upper arm bone, the humerus, is rotating relative to the shoulder; internal is used to denote a movement towards the midline of the body). A more extreme form of internal rotation is to place the back of your hand on the small of your back, again with your elbow bent at 90o. Now keeping your elbow bent, lift your hand away from your body. One muscle of the rotator cuff, subscapularis arises from the underneath side of the shoulder blade (the side against the rib cage) and attaches to the humerus in such a way as to produce rotation of the humerus when contracted.

If the lifting of your hand away from your back produces extreme pain or is simply impossible to perform, injury to this muscle (or a tear in its tendon) may be the source. This problem requires medical attention. The opposite motion to internal rotation is external rotation (rotating your forearm away from your stomach with your upper arm against your side) and is produced by contracting two other muscles of the rotator cuff group, infraspinatus and teres minor. These muscles also arise from the shoulder blade, but on the outer side, and also attach to the humerus.

These three muscles are responsible for shoulder rotation, but the rotator cuff complex has four muscles and this is where the cuff component is involved. The fourth muscle is called supraspinatus and arises over the top of the shoulder blade (in the supraspinous fossa) and crosses the shoulder joint traveling underneath the acromion and attaching to the humerus just below the humeral head. Altogether, these four muscles (the three true rotators and supraspinatus) are the innermost set of muscles surrounding the shoulder joint and form a cuff around the joint.

Bearing in mind the shallow nature of the glenoid fossa and the propensity for the humeral head to dislocate, the contraction of all four muscles forms a tight wall around the lip of the socket to help hold the humeral head in position (centered in the glenoid fossa) 5. During almost any shoulder movement, these muscles are contracting to stabilize the joint throughout the movement by maintaining the humeral head centered in the glenoid fossa 34.

When you throw an object, the entire movement is designed to throw your arm away from your body. The object is thrown because you release your grip on it. Your arm and shoulder joint stay in place because the rotator cuff is holding the upper arm bone in place. This is why rotator cuff injuries are so devastating to baseball pitchers; a strong, intact rotator cuff is needed to allow for high velocity pitches without injuring the shoulder joint. Weakness or worse, injury to the rotator cuff can place undue stress on the shoulder joint during heavy lifting routines (because the humeral head does not stay centered in the glenoid fossa).

Strengthening the rotator cuff muscles, particularly the three involved with rotation is straightforward and basically involves movements as described above for internal and external rotation, but with light weights while lying on your side. The remaining muscle, the supraspinatus, is less straightforward and unfortunately, much advice over the years has served to compound problems 30, especially for those who are anatomically predisposed to have problems in the first place.

Impingement Syndrome

The supraspinatus muscle is involved with some of the most common causes of shoulder pain 15. To understand its involvement and how some individuals are predisposed to suffer more than others, an appreciation of the surrounding anatomy of supraspinatus is important. As discussed above, the supraspinatus muscle arises from the roof of the scapula (shoulder blade) and attaches to the upper arm bone (humerus) on the shaft just below the humeral head. Following along the muscle's path, supraspinatus travels between the shoulder joint itself (from below) and the acromial arch (from above).

This arrangement has supraspinatus traversing a nearly complete bony tunnel with a tough ligament closing the only non-bone portion (coracoacromial ligament - connecting the coracoid process with the acromion). In addition, being part of the innermost layer of muscle would have supraspinatus moving directly on bone which is not ideal. To cushion the muscle, supraspinatus sits (and slides over) on a 'bursa', a fluid filled sack that reduces friction between moving muscles and bones.

The attachment site on the humerus bone also deserves some attention. While the humerus is described as a shaft of bone with a ball-like end, bone shafts are rarely, evenly smooth across their surface. In particular, points of muscle attachments are typically raised and referred to as 'tuberosities.' Just below the humeral head are two such structures, the greater tuberosity, just below the acromion (on the side with your arm at your side), and the lesser tuberosity to the left in the forward direction (basically facing forward). The valley between the two tuberosities is a groove for the one of the heads of biceps' tendon to follow. Supraspinatus attaches to the upper edge of the greater tuberosity, just below the humeral head, adjacent to the biceps tendon.

The greater tuberosity has the potential to produce impingement in certain individuals who posses a specific hooked shape to their acromion 19,23,26,29,32,33,35. In some people, the hook is exaggerated (see www.aafp.org/afp/980215ap/fongemie.html for excellent visuals). As the arm is raised (as in a side lateral raise), the greater tuberosity and acromion come quite close (they 'impinge' on one another) with the bursa and the supraspinatus muscle sandwiched in between.

Compression alone can damage either the bursa (producing inflammation called bursitis 27, a common condition among older individuals) or the supraspinatus muscle itself (or its tendon) and is called impingement syndrome. The result is pain whenever, the arm is raised since supraspinatus when contracted, is pressing against the bursa to hold the humeral head centered in the joint. Also, with too much inflammation, while supraspinatus is cushioned from bone below with the bursa, the confined bony space (the bony tunnel it passes through) can cause the muscle to scrape the underside of the acromion from above the muscle which is also painful 10,25,28.

As discussed, the propensity for problems usually begins with an anatomical predisposition. Individuals with a more hooked acromion are at greater risk for impingement syndrome such as swimmers for example, due to repetitive overhand motions of the freestyle stroke 3,4,6,8,14. X-ray and other imaging studies have demonstrated that those individuals with the acromial shape most likely to cause impingement in fact, suffer the most from the syndrome 6,9,10,12,14,18,19,25,29,31,32.

Whether someone is born with an impingement prone condition or it develops over time is still a matter of debate; 13,23,24,33,35,36 but clearly, the presence of a hooked acromion is found more commonly in those individuals with impingement syndrome. The shape of the ligament connecting the acromion and the coracoid process can also influence the likelihood of impingement 20.

Past trauma to the shoulder can also lead to bone spurs that will also increase the likelihood of or aggravate impingement, by reducing the space in that bony tunnel for supraspinatus and the bursa to move through 11.Thus, there are many routes to creating the conditions for impingement syndromes. Once established, the chronic nature of inflammation and degenerative changes have a high probability of creating a state of ongoing trauma and further contributing to more inflammation and accelerating degenerative changes.

Thus, an individual who has suffered with shoulder discomfort in the past during upper body work is very likely to continue to suffer unless modifications in their routine are employed. There are several indications of potential a impingement syndrome 2,7,11,21,22. One clue to either bursitis in this region or injury to the supraspinatus muscle itself is tenderness just below the acromion. Another clue to supraspinatus problems is pain during movements that increase the chance of impingement. Pain or discomfort during a movement while your shoulder is in an internally rotated position is also a tipoff. Simply put, routines with palms down will position the greater tuberosity in the best position for impingement. Overhand wide grip lat pulldowns can do this.

Also, performing a lateral side raise and pointing your thumb down near the top of the lift is most likely to produce impingement because the shoulder is internally rotated and positions the greater tuberosity optimally for impingement. Finally, shoulder pain at night during sleep can also be a subtle clue to minor irritation from impingement. If someone is anatomically predisposed to these problems, pain and discomfort is likely when traditional lifting routines are employed. This is not a problem that can be 'worked through' in the classical sense; modifications to technique are required.

Part II will focus on exercises to strengthen the supraspinatus muscle. These exercises differ in form and style from common lifting routines. In addition, modifications from simple to extensive in standard lifting routines to employ for overall upper body work to reduce the likelihood of further aggravating suprapinatus will be suggested.

Reference List

1. 1972. Cunningham's Textbook of Anatomy. Oxford University Press, London.

2. Almekinders, L. C. 2001. Impingement syndrome. Clin. Sports Med. 20:491-504.

3. Arroyo, J. S., S. J. Hershon, and L. U. Bigliani. 1997. Special considerations in the athletic throwing shoulder. Orthop. Clin. North Am. 28:69-78.

4. Banas, M. P., R. J. Miller, and S. Totterman. 1995. Relationship between the lateral acromion angle and rotator cuff disease. J. Shoulder. Elbow. Surg. 4:454-461.

5. Bigliani, L. U., R. Kelkar, E. L. Flatow, R. G. Pollock, and V. C. Mow. 1996. Glenohumeral stability. Biomechanical properties of passive and active stabilizers. Clin. Orthop.13-30.

6. Bigliani, L. U., J. B. Ticker, E. L. Flatow, L. J. Soslowsky, and V. C. Mow. 1991. The relationship of acromial architecture to rotator cuff disease. Clin. Sports Med. 10:823-838.

7. Brossmann, J., K. W. Preidler, R. A. Pedowitz, L. M. White, D. Trudell, and D. Resnick. 1996. Shoulder impingement syndrome: influence of shoulder position on rotator cuff impingement--an anatomic study. AJR Am. J. Roentgenol. 167:1511-1515.

8. Cohen, R. B. and G. R. Williams, Jr. 1998. Impingement syndrome and rotator cuff disease as repetitive motion disorders. Clin. Orthop.95-101.

9. Epstein, R. E., M. E. Schweitzer, B. G. Frieman, J. M. Fenlin, Jr., and D. G. Mitchell. 1993. Hooked acromion: prevalence on MR images of painful shoulders. Radiology 187:479-481.

10. Farley, T. E., C. H. Neumann, L. S. Steinbach, and S. A. Petersen. 1994. The coracoacromial arch: MR evaluation and correlation with rotator cuff pathology. Skeletal Radiol. 23:641-645.

11. Fongemie, A. E., D. D. Buss, and S. J. Rolnick. 1998. Management of shoulder impingement syndrome and rotator cuff tears. Am. Fam. Physician 57:667-2.

12. Gagey, N., E. Ravaud, and J. P. Lassau. 1993. Anatomy of the acromial arch: correlation of anatomy and magnetic resonance imaging. Surg. Radiol. Anat. 15:63-70.

13. Gill, T. J., E. McIrvin, M. S. Kocher, K. Homa, S. D. Mair, and R. J. Hawkins. 2002. The relative importance of acromial morphology and age with respect to rotator cuff pathology. J. Shoulder. Elbow. Surg. 11:327-330.

14. Gohlke, F., T. Barthel, and A. Gandorfer. 1993. The influence of variations of the coracoacromial arch on the development of rotator cuff tears. Arch. Orthop. Trauma Surg. 113:28-32.

15. Green, A. 1995. Arthroscopic treatment of impingement syndrome. Orthop. Clin. North Am. 26:631-641.

16. Horrigan, J. and J. Robinson. 1991. The 7-Minute Rotator Cuff Solution. Health for Life, Los Angeles, CA.

17. Humphreys, C. L. 1999. Shoulder Injuries & Weight Training. MuscleMag International, Mississauga, ON CA.

18. Hyvonen, P., M. Paivansalo, H. Lehtiniemi, J. Leppilahti, and P. Jalovaara. 2001. Supraspinatus outlet view in the diagnosis of stages II and III impingement syndrome. Acta Radiol. 42:441-446.

19. Kitay, G. S., J. P. Iannotti, G. R. Williams, T. Haygood, B. J. Kneeland, and J. Berlin. 1995. Roentgenographic assessment of acromial morphologic condition in rotator cuff impingement syndrome. J. Shoulder. Elbow. Surg. 4:441-448.

20. Kopuz, C., S. Baris, M. Yildirim, and B. Gulman. 2002. Anatomic variations of the coracoacromial ligament in neonatal cadavers: a neonatal cadaver study. J. Pediatr. Orthop. B 11:350-354.

21. Neer, C. S. 1972. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J. Bone Joint Surg. Am. 54:41-50.

22. Neer, C. S. 1983. Impingement lesions. Clin. Orthop.70-77.

23. Nicholson, G. P., D. A. Goodman, E. L. Flatow, and L. U. Bigliani. 1996. The acromion: morphologic condition and age-related changes. A study of 420 scapulas. J. Shoulder. Elbow. Surg. 5:1-11.

24. Pfahler, M., S. Haraida, C. Schulz, H. Anetzberger, H. J. Refior, G. S. Bauer, and L. U. Bigliani. 2003. Age-related changes of the glenoid labrum in normal shoulders. J. Shoulder. Elbow. Surg. 12:40-52.

25. Prato, N., D. Peloso, A. Franconeri, G. Tegaldo, G. B. Ravera, E. Silvestri, and L. E. Derchi. 1998. The anterior tilt of the acromion: radiographic evaluation and correlation with shoulder diseases. Eur. Radiol. 8:1639-1646.

26. Prescher, A. 2000. Anatomical basics, variations, and degenerative changes of the shoulder joint and shoulder girdle. Eur. J. Radiol. 35:88-102.

27. Santavirta, S., Y. T. Konttinen, I. Antti-Poika, and D. Nordstrom. 1992. Inflammation of the subacromial bursa in chronic shoulder pain. Arch. Orthop. Trauma Surg. 111:336-340.

28. Suenaga, N., A. Minami, K. Fukuda, and K. Kaneda. 2002. The correlation between bursoscopic and histologic findings of the acromion undersurface in patients with subacromial impingement syndrome. Arthroscopy 18:16-20.

29. Toivonen, D. A., M. J. Tuite, and J. F. Orwin. 1995. Acromial structure and tears of the rotator cuff. J. Shoulder. Elbow. Surg. 4:376-383.

30. Townsend, H., F. W. Jobe, M. Pink, and J. Perry. 1991. Electromyographic analysis of the glenohumeral muscles during a baseball rehabilitation program. Am. J. Sports Med. 19:264-272.

31. Umans, H. R., H. Pavlov, M. Berkowitz, and R. F. Warren. 2001. Correlation of radiographic and arthroscopic findings with rotator cuff tears and degenerative joint disease. J. Shoulder. Elbow. Surg. 10:428-433.

32. Wang, J. C., G. Horner, E. D. Brown, and M. S. Shapiro. 2000. The relationship between acromial morphology and conservative treatment of patients with impingement syndrome. Orthopedics 23:557-559.

33. Wang, J. C. and M. S. Shapiro. 1997. Changes in acromial morphology with age. J. Shoulder. Elbow. Surg. 6:55-59.

34. Wilk, K. E., C. A. Arrigo, and J. R. Andrews. 1997. Current concepts: the stabilizing structures of the glenohumeral joint. J. Orthop. Sports Phys. Ther. 25:364-379.

35. Worland, R. L., D. Lee, C. G. Orozco, F. SozaRex, and J. Keenan. 2003. Correlation of age, acromial morphology, and rotator cuff tear pathology diagnosed by ultrasound in asymptomatic patients. J. South. Orthop. Assoc. 12:23-26.

36. Yazici, M., C. Kopuz, and B. Gulman. 1995. Morphologic variants of acromion in neonatal cadavers. J. Pediatr. Orthop. 15:644-647.

See also Shoulder Pain Management

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The principles of rotator cuff injury management come down to these things:

1) Activity modification - People with acute pain can stay active but should avoid extremely painful movements. Activity can be increased as pain settles.

2) Analgesia - Simple pain killers or Non-steroidal anti-inflammatory drugs (NSAIDs) provide short-term pain relief.

3) Rehabilitation - There is some evidence that supervised exercise is beneficial.

4) Referral - Refer people to an orthopaedic specialist at six months if there is a poor response to treatment. However, if there is a massive tear it is best to refer immediately for orthopaedic evaluation. Delay compromises optimal outcomes for patients.

For an acute injury (one thats happened recently):

- Basic first aid measures – RICE (rest, ice, compression and elevation)

- Apply ice to decrease swelling. Wrap the ice in a cloth to avoid freezing the skin. Apply the wrapped ice 10-15 minutes at a time. This is most helpful in the first 1-2 days.

- Support the arm in a sling to rest the rotator cuff muscles. The sling may be taken off at night. Anti-inflammatory medications may help reduce pain and swelling.

- Make an appointment with your doctor for assessment. The physician may ask you to be seen for follow-up, either by a primary care doctor or an orthopedic surgeon (specialist).

- Further imaging may be required to determine the degree and involvement of muscle tear. This is often done via magnetic resonance imaging (MRI).

- Early surgery (within 3 weeks) to repair the tendon is often needed, especially for younger, more active people with larger tears.

- Indications for surgical treatment:

o Usually for people younger than 50 years with complete or significant tears

o An option after failure to improve after 6 weeks of proper rehab

o If the person has a job that requires constant shoulder use

The major objectives of rehabilitation from a rotator cuff injury are to increase flexibility, obtain pain-free range of motion, and strengthen the muscles of the shoulders, upper back, front chest, and upper arms. In severe cases, you should avoid activity that causes shoulder pain altogether. In these cases, you can still maintain cardiovascular fitness by cycling, unless otherwise prescribed by your doctor.

Stretching and stregthening of the 4 shoulder rotator cuff muscles (subscapularis, infraspinatus, supraspinatus and teres minor - for diagram, see link ive given to Marc's post. There he gives a good website outlying the basic anatomy of the shoulder musculature), as already mentioned the foundation of rehabilitation of rotator cuff injuries. Initially, soon after injury, after the pain has died down a little, it is best to start performing shoulder exercises to maintain the range of motion inthe shoulder and prevent scarring from the inflammation. This is best performed initially by isolating each muscle group and selectively training that muscle (known as Isometrics) - with no weights.

Phase 1 - Isometric exercises

The subscapularis is the anterior stabilizer of the rotator cuff and responsible for internally rotating the shoulder. It is best strengthened by holding your arm in front of the body, with the arm flexed to 90 degrees, and rotating the hand to touch the belt. The exercise can be performed while lying on your back with the elbow close to your side and flexed ninety degrees. Lift the weight until it is pointing toward the ceiling and then lower it slowly. Add small amounts of weight as you progress, making sure you are in minimal pain at all times. If it gets too painful, stop and rest.

The supraspinatus is strengthened by holding out your arm straight in front of the body, with the thumbs pointed toward the floor. Slowly elevate the weight to above the head. Stop if pain is produced in any portion of this motion, as the rotator cuff is under maximal stress in this position. As you feel better, you can slowly introduce small amounts of weight to continue strengthening of the muscles.

The infraspinatus is strengthened by holding you arm (and later on, a weight) in the position of the ski pole just prior to planting the pole. By rotating the arm from the neutral straight ahead position, to the externally rotated (out to the side) position, the infraspinatus and teres minor are strengthened. Again, this exercise can also be performed while lying on your side with the elbow close to your hip, and flexed ninety degrees. Rotate the weight until it is pointing toward the ceiling. Shoulder exercises are best performed with relatively light weights and multiple repetitions.

The logic behind stretching and strengthening the inflamed rotator cuff in order to speed healing and functional performance is as follows: the inflamed tissue is characterized by increased fluid between the cells, increased numbers of new blood vessels and inflammatory type cells. As a result of this inflammatory reaction, new collagen tissue is laid down in an effort by the body to heal the injured tissue. If the shoulder is immobilized during this time, the new collagen is laid down in a disorganized fashion, creating scar. The goal of gentle stretching, strengthening and anti-inflammatory medication, is to stimulate the cells to lay down collagen along the lines of stress, forming normal strong tendons. The combination of a good warm up, gentle stretching, strengthening below the limits of pain, icing after working out and anti-inflammatory medication has been consistently shown to speed recovery time in the strongest possible fashion.

After you are comfortable with these stretches and have minimal pain and good/fair range of motion in your shoulder, you can move onto resistance exercises. These usual start with what is known as tubing exercises. The 'tubing' is also known as a theraband, which is just a big rubber elastic band that you tie, at one end, to something and you hold the other end and pull the band thereby stretching it and providing resistance for your shoulder.

Phase 2 - Tubing exercises

External rotation: Stand resting the hand of your injured side against your stomach. With that hand grasp tubing that is connected to a doorknob or other object at waist level. Keeping your elbow in at your side, rotate your arm outward and away from your waist. Make sure you keep your elbow bent 90 degrees and your forearm parallel to the floor. Repeat 10 times. Build up to 3 sets of 10.

Internal rotation: Using tubing connected to a door knob or other object at waist level, keep your elbow in at your side and rotate your arm inward across your body. Make sure you keep your forearm parallel to the floor. Do 3 sets of 10.

As you feel more confident and you find your strength increasing, you can add more resistance - either in terms of shortening the length of the theraband so you need more resistance to stretch it or by increasing hand held weights in small increments.

Of course, these arent the only exercises for shoulder rehabilitation. There are many more. Ive listed a few more below that ive found from a good website:

Overhead stretch

Lie on your back with your arms at your sides. Lift one arm straight up and over your head. Grab your elbow with your other arm and exert gentle pressure to stretch the arm as far as you can.

Cross-body reach

Stand and lift one arm straight out to the side. Keeping the arm at the same height, bring it to the front and across your body. As it passes the front of your body, grab the elbow with your other arm and exert gentle pressure to stretch the shoulder.

Towel stretch

Drape a towel over the opposite shoulder, and grab it with your hand behind your back. Gently pull the towel upward with your other hand. You should feel the stretch in your shoulder and upper arm.

Shrugs

Stand with hands at sides with no weight in either hand. Raise shoulders to the point of pain and hold for five seconds. Relax for five seconds. Perform this sequence 10 times, 3 times daily. As pain permits, hold dumbbells of equal weight in each hand while performing this exercise. Add weight by using hand-held dumbbells as pain permits.

Bicep curls

Stand with arms fully extended at sides while grasping 2- to 5-pound weights in each hand, held palm forward. Flex the arms at the elbow to approximately 100 degrees, or to the point of pain, whichever comes first. Hold this position for 5 to 10 seconds. Return to the start position. Rest for 5 seconds. Repeat this exercise 10 times. You can increase the weight as pain allows and strength develops.

Triceps curls

Stand with elbows directed upward over the shoulders and with arms relaxed. Extend arms at the elbow so that the hands proceed upward to the point of pain. Hold this position for five seconds. Return to the starting position and relax for five seconds. Perform this sequence 10 times, 3 times daily. As pain permits, add weight by using hand-held dumbbells.

Chest raises

Lie on belly with hands extended along sides of the body. Raise the upper chest from the floor to the point of pain and hold this position for 5 seconds. Return to the start position and relax for 10 seconds. Repeat this sequence 10 times, 3 times daily.

Saws

Reach out and place the unaffected side hand on a corner of a table. Bend at the waist. Flex the injured side arm at the elbow and pull the injured side arm backward and upward as if sawing wood. Slowly bring the shoulder blades as close together as pain will permit. Slowly bring the injured side arm down to its beginning position. Repeat this sequence 10 times, at least three times daily.

Pendulum swings

Stand with the hand of the unaffected arm resting on the corner of a table and supporting some of the body weight. Slightly bend the knee on the unaffected side and extend the other leg sideways. Allow the injured arm to hang loosely over the unaffected side foot. By shifting the body weight, cause the relaxed injured arm to swing in circles to the fullest extent possible as limited by pain. Perform 25 swings in a clockwise direction. Allow the injured arm to cease swinging. Perform 25 swings of the injured arm in a counterclockwise direction. Repeat this sequence at least three times daily.

Flexed elbow pull

Bend and raise the injured side elbow to shoulder height. Grasp the injured side elbow with the uninjured side hand. Gently pull the injured side elbow toward the opposite shoulder until limited by first significant pain. Hold this position for 10 seconds. Relax for 10 seconds. Repeat this sequence 10 times at least three times daily.

Im sure there are other exercises that i havent mentioned.

Now people often say, when can i start weight training again? or when can i return to sport? There is no definite answer for that. It depend on the degree of your injury, how dedicated you are to your rehab and the rate at which your body heals. some people with minor tears can return to full contact sports in as short as 4 weeks. Other with larger tears have to have surgery and can be out for a year.

My advise to you is, dont rush it. Let your body take its time to heal. Be religious in doing your exercises and the results will come with time. Impatience is one of the biggest causes of re-injury.

And most importantly, always consult your physician for advice. While we can help you on these forums and point you in a right direction, nothing can replace a one-on-one physical examination and a good chat with your physician. This is essential.

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Knee Pain

From Elizabeth Quinn,

Part 1 Anatomy and Physiology

Injuries to the knee are the most common reason people see an orthopedic physician. The structure and stress placed upon the knee make it vulnerable to a variety of injuries. The largest joint in the body is the knee. It is comprised of the lower end of the femur and the upper end of the tibia. The patella (kneecap) slides in a groove on the end of the femur, and covers the joint. Several large ligaments support the knee on either side. The meniscus and cartilage cushion the knee and act as a shock absorber during motion.

Muscles

In addition to these structures, there are two groups of muscles at the knee. The quadriceps muscle in front straightens the leg from a bent position. The hamstring muscles, in the back, bend the knee.

Ligaments

Ligaments are strong, elastic bands of tissue that connect bone to bone. They provide strength and stability to the joint. Four ligaments connect the femur and tibia:

The medial collateral ligament (MCL) provides stability to the inner (medial) aspect of the knee.

The lateral collateral ligament (LCL) provides stability to the outer (lateral) aspect of the knee.

The anterior cruciate ligament (ACL), in the center of the knee, limits rotation and the forward movement of the tibia.

The posterior cruciate ligament (PCL), also in the center of the knee, limits backward movement of the tibia.

Tendons

Tendons are tough cords of tissue that connect muscle to bone. In the knee, the quadriceps tendon connects the quadriceps muscle to the patella and provides power to extend the leg. The patellar tendon connects the patella to the tibia.

Types of Knee Pain

Ligament Injuries

Knee injuries are very common in sports that require stopping and starting or quickly changing directions. These extreme forces on the knee can result in torn ligaments. The anterior cruciate ligament (ACL) and the medial collateral ligament (MCL) are the most often injured, but the posterior cruciate ligament (PCL) can also be injured.

ACL tears can occur when an athlete changes direction rapidly, twists the upper body and hips while the feet are planted, slows down when running, or lands a jump awkwardly. Injuries to the MCL usually are caused by a blow to the outside of the knee. Such contact forces often are encountered in sports such as football, rugby or soccer. The PCL can be injured during a sports activity when the athlete receives a blow to the front of the knee or makes a simple misstep on the playing field, and hyperextends the knee.

Injury to a cruciate ligament may not cause pain, but may cause a loud popping sound, and the leg may buckle. An MRI is usually used to diagnose an ACL tear, but arthroscopy may be the only reliable means of detecting a partial tear.

An MCL injury may result in a pop and the knee may buckle to the side. Pain and swelling are common. An MRI is helpful in diagnosing injuries to these ligaments.

Torn Knee Cartilage

Torn cartilage in the knee can occur in any athlete. When people talk about torn knee cartilage, they usually are referring to a torn meniscus. The meniscus is a tough, rubbery cartilage that is attached to the knee's ligaments. It acts like a shock absorber. In athletic activities, meniscus tears usually occur when twisting, cutting, pivoting, decelerating, or being tackled. This is typically a contact injury.

There are several manual tests that a physician may use to detect torn cartilage.

Chondromalacia

This term refers to softening of the surface on the underside of the kneecap. This injury can occur in young adults and is often caused by trauma, overuse, poor alignment of the knee joint, or muscle imbalance. Such rubbing can result in a slight abnormality of the surface of the cartilage or a surface that has been worn away completely to the bone. It is often identified by a dull pain around or under the kneecap that worsens when walking down stairs or hills. Pain with stair climbing or other weight bearing exercise can also indicate chondromalacia.

Arthritis of the Knee

Osteoarthritis is the most common type of arthritis experienced by athletes. It is a degenerative disease where cartilage in the joint gradually wears away. Stress on the knee joint, overuse, structural abnormalities, or excess body weight can cause osteoarthritis. Typical signs and symptoms of osteoarthritis include knee pain, swelling, and a decrease in the range of motion of the knee. Morning stiffness is common.

Tendonitis and Ruptured Tendons

Tendonitis is simply an inflammation of a tendon whereas a ruptured tendon has torn. Overuse often leads to an inflammation of the tendons, often called jumper's knee, because sports requiring jumping can strain the tendon. The tendon may become inflamed or tear after repeated stress. Acute traumatic movements (trying to break a fall) more often result in excessive contraction of the quadriceps muscles and tear the quadriceps tendon. Tendonitis is often identified due to tenderness at the point where the patellar tendon meets the bone. It may also cause pain during faster movements, such as running, cycling, or jumping.

Iliotibial Band Syndrome

This is typically an overuse inflammatory condition due to constant rubbing of the tendon over the lateral condyle of the knee. It causes an ache or burning sensation at the side of the knee during activity.

There are a variety of methods used by orthopedic surgeons to treat knee injuries in athletes. The most important advice is to seek treatment as soon as possible. A common method used by orthopedic surgeons to treat mild knee injuries is R.I.C.E. (rest, ice, compression, and elevation). Rest the knee by staying off it or walking only with crutches. Apply ice to control swelling. Use a compressive elastic bandage applied snugly but loosely enough so that it does not cause pain. Finally, keep the knee elevated.

Specific Treatments for Knee Injuries

Chondromalacia

Many doctors recommend that patients with chondromalacia perform low-impact exercises that strengthen muscles, without injuring joints (swimming, cycling, walking).

At times a physician may perform arthroscopic surgery to smooth the surface of the articular cartilage and clean and smooth out cartilage fragments that rub on the surface of the femur.

Meniscus Tear

If the tear is minor and the pain and other symptoms go away, the doctor may recommend a visit to a Physical Therapist for a muscle-strengthening program. If the tear to a meniscus is more extensive, arthroscopic surgery may be performed. The meniscus can be repaired in some cases. If the tear is more extensive, a small piece may be removed to even the surface. In some cases, the doctor removes the entire meniscus. However, degenerative changes, such as osteoarthritis, are more likely to develop in the knee if the meniscus is removed. Researchers are developing procedures that may replace a meniscus in the near future.

Cruciate Ligament Tears

For an incomplete CL tear, a doctor may recommend a visit to a Physical Therapist to strengthen surrounding muscles. A knee brace may also be warranted. If the ACL is completely torn, surgery may be indicated. The torn ends of the ligament may be reattached or completely reconstructed with a graft.

Medial Collateral Ligament

Most sprains of the collateral ligaments will heal if the patient follows a prescribed exercise program, including R.I.C.E. and bracing.

Osteoarthritis

Most often osteoarthritis of the knee is treated with analgesics such as aspirin or acetaminophen, and anti-inflammatories, such as ibuprofen (Motrin, Nuprin, Advil). Exercises may be warranted to strengthen the knee, as well as encourage weight loss.

Knee Tendon Injuries

Tendonitis is typically treated with R.I.C.E. and ibuprofen to relieve pain and decrease inflammation and swelling. If the tendon is completely ruptured, surgery is necessary to reattach the tendon.

Iliotibial Band Syndrome

Usually, iliotibial band syndrome eases with reduced activity. Strengthening and stretching exercises can also alleviate the IT band pain.

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From Jonathan Cluett, M.D.,

What is causing my knee pain?

Understanding what is causing your knee pain must be understood in the context of the pain. How old are you? Was there a traumatic event? Where is the pain located? Did the symptoms develop immediately or over time?

Once these questions are answered, you can begin to investigate the symptoms. Putting the symptoms together with the history often leads to a diagnosis.

Common Knee Symptoms

Popping

Popping and snapping within the knee is quite common, and often not a symptom of any particular problem. When the pops or snaps are painless, there is usually no problem--the bigger concern is when these sounds are associated with pain. A pop is often heard or felt when a ligament, such as the ACL, is torn.

Crunching/Grinding

A sense of grinding or crunching is most often associated with bone grinding against bone once the cartilage is worn away.

This is commonly found in arthritis. Patients who are young (under 50 years old) seldom have arthritis that will cause these severe symptoms, unless there has been a severe injury to the knee in the past.

Locking

Locking is a symptom that occurs when a patient cannot bend or straighten their knee. The locking can either be due to something actually blocking motion of the knee (this can occur when a piece of cartilage wedges within the joint) or when pain prevents the patient from moving the knee. These two causes must be differentiated, as something physically caught in the joint should be evaluated in a timely manner. Often injecting the knee with numbing medication can help determine the cause of locking.

Giving-Way/Instability

The stability of the knee is provided by the ligaments that connect the shin bone (tibia) to the thigh bone (femur). When the ligaments are stretched or torn, the knee may feel as though it is giving way beneath the patient. A sensation that the knee may give out from beneath you is a common symptom of ligament injury.

Swelling

Swelling of the knee is common with several different knee problems. When there is swelling immediately after an injury (within an hour), the most common causes are an injury to the anterior cruciate ligament or a fracture of the top of the shin bone. When swelling develops gradually over hours to days, the injury is more likely a tear of the meniscus or a ligament sprain. Swelling that occurs without the presence of a known injury can be due to arthritis (common), gout (less common), or a joint infection (uncommon).

Location of Pain

The location of the pain can be an important part of tracking down the symptoms.

Front of the knee: Pain over the front of the knee is most commonly related to the knee cap. Kneecap pain can be caused by several different problems.

Inside of the knee: Pain on the inside, or medial aspect, of the knee is commonly caused by medial meniscus tears, medial collateral ligament injuries, and arthritis of the joint.

Outside of the knee: Pain on the outside of the knee, or lateral aspect of the knee joint, is commonly caused by lateral meniscus tears, lateral collateral ligament injuries, IT band tendonitis, and arthritis of the joint.

Pain in the back of the knee: Pain in the back of the knee can be due to the formation of a cyst, called a Baker's Cyst, in the back of the knee joint. Also common is for kneecap pain to be felt in the back of the knee.

Timing of Pain

Some common situations cause pain typical of certain conditions.

While going down stairs: Pain while walking down steps is very commonly associated with kneecap problems, such as chondromalacia.

Morning pain: Pain after first waking in the morning that resolves with gentle activity is typical of early arthritis. Often patients loosen the knee over the course of the day.

What tests can be performed to detect problems within the knee?

A skilled examiner can often detect the injury to the knee prior to ordering tests such as x-rays or MRIs. These tests and maneuvers are performed to detect specific problems within the knee joint. While any one test may not be diagnostic of a particular problem, by performing a good knee examination most common knee problems can be properly diagnosed.

Tests to Detect a Meniscus Tear

Joint Line Tenderness

Joint line tenderness is a very non-specific test for a meniscus tear. The area of the meniscus is felt, and a positive test is considered when there is pain over the area where the meniscus is found.

McMurray's Test

McMurray's test is performed with the patient lying flat (non-weight bearing) and the examiner bending the knee. A click is felt over the meniscus tear as the knee is brought from full flexion to 90 degrees of flexion.

Ege's Test

Ege's test is a specific maneuver to detect a meniscus tear. With a patient squatting, an audible and palpable click is heard/felt over the are of the meniscus tear. The patient's feet are turned outwards to detect a medial meniscus tear, and turned inwards to detect a lateral meniscus tear.

Tests to Detect Ligament Injury

Lachman Test

The Lachman test is the best test to diagnose an ACL tear. With the patient lying flat and relaxed, the examiner bend the knee slightly, about 20 degrees. The examiner then stabilizes the thigh while pulling the shin forward. Both the amount of translation (shifting) as well as the feel of the endpoint offer information about the ACL.

Anterior Drawer Test

The anterior drawer test is also performed with the patient lying flat. The knee is bent 90 degrees and the shin is pulled forward to check the stability of the ACL. An intact ACL will only allow the shin to come forward slightly. A torn ACL will allow the shin to move further forward.

Pivot Shift Test

The pivot shift test is a difficult maneuver to perform on a patient who is not under anesthesia. This test places a stress on the knee joint that forces a subluxation (partial dislocation) in patients who do not have an ACL. This test recreates the type of instability that caused the ACL injury.

Posterior Drawer Test

The posterior drawer is performed similarly to the anterior drawer test. This test detects injury to the PCL. By pushing the shin backward, the integrity of the PCL is tested. Excessive movement of the shin backwards is a sign of PCL injury.

Varus and Valgus Instability

Varus and valgus instability tests check the LCL and MCL, respectively. With the patient lying flat, and the knee held at about 30 degrees of flexion, the shin is shifted to each side. Insufficiency of the LCL or MCL will allow the knee to "open up" excessively. The test is repeated with the leg straight. If the knee still opens up excessively, then more than just the LCL or MCL was torn.

Dial Test

The dial test checks the rotation allowed at the knee joint. Patients who have posterolateral rotatory instability, may have excessive rotation at the knee joint. The test is done with the patient lying face down, and the knees bent about 30 degrees. The feet are turned outwards and compared to each other. Excessive rotation is a sign of posterolateral corner injury.

Tests to Detect Kneecap Problems

Patellar Grind Test

Patellar grinding is a nonspecific test where the examiner feels for abnormal grinding sensations under the kneecap with movement of the joint. If pressure on the kneecap recreates the symptoms this may indicate the kneecap is the culprit.

Patellar Facet Tenderness

The examiner can slightly lift up the kneecap and place direct pressure on the undersurface of the kneecap. By doing so, the examiner is looking for sensitive regions of cartilage underneath the kneecap.

Patellar Apprehension Test

Patellar apprehension is a sign of an unstable kneecap. While the examiner places pressure on the kneecap, the patient may complain of the sensation that the kneecap is going to 'pop out' of its groove. This is a sign of kneecap instability.

Some common knee tests with explanations, pictures, and vids:

http://www.sportsdoc.umn.edu/Clinica...m/lachmans.htm

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Common Weightlifting Injuries and Recommendations from Chiropractor

TYPES OF WEIGHT TRAINING INJURIES

Dr. Ben Weitz

A wide range of weight training injuries has been documented in the literature. These reports include a number of unusual injuries such as: subarachnoid aneurysmal hemorrhage (19); ruptures of the pectoralis major, (20) biceps,(21) triceps,(22) and quadriceps muscles (23); fracture of the dome of the talus(24); and Kienbock's syndrome (25) among others. This article will focus on some of the more common weight training injuries involving the lumbar spine, the cervical spine, the shoulder, and the knee.

The lower back is the site of greatest injury.(26-28) A number of reports point to the shoulder and the knee as the next most frequent sites of injury during weight training.(3,27-29) At least one epidemiologic study suggests a significant statistical link between weight training and cervical disc herniation.(30)

LUMBAR SPINE INJURIES

In both youths(26-29,31) and adults(32,33) the most common weight training injuries involve the lower back. The mechanisms of injury include hyperflexion, hyperextension, torsion, and overdevelopment and excessive tightening of the iliopsoas muscles. The most common back problems are mechanical sprains and strains; however, disc injury or spondylolisthesis may also occur. Spondylolisthesis may be due to the stress imposed at the neural arch while performing exercises that involve repetitive lumbar spine flexion and extension under load. It is particularly true of dead-lifts.(34)

The greatest number of weight training-related back injuries result from exercises in which the trainee is in the flexed posture, such as rows and dead-lifts. A bent barbell row is often performed standing with heavy weight held at arm's length while bent at the waist and the legs held straight. This position creates perhaps the greatest amount of contractile tension on the lumbar spine musculature and the greatest lumbar disc pressure.(35)

A frequent error is to allow the back to round and then to jerk the weight up using the hip muscles to generate power. Lumbar flexion while lifting results in the load being shifted from the back muscles to the posterior ligaments, the thoracolumbar fascia, and the lumbar discs. The lower back muscles stop contracting when the spine is sufficiently flexed, a phenomenon known as the flexion relaxation response of the erector spinae.(36) It may result in injury to ligaments or discs.

The seated cable row exercise may also result in a hyperflexion injury to the lumbar spine, a problem often encountered in this author's practice. The injury usually results from leaning forward at the starting point of each rep, allowing the spine to flex, in an effort to get a good stretch (see Figs 1 and 2).

Extremely heavy weights are sometimes used in weightlifting exercises. As much as 1,000 lb can be used in the squat and dead-lift. While steadily applied compressive forces alone rarely injure the disc, rupture of the vertebral end plate or fatigue microfractures of the trabeculae of the vertebral bodies may result.(37,38) Research(39) reveals that retired heavyweight lifters exhibit significantly greater reduction of disc height on X-ray compared with controls.

Hyperextension injury to the spine may result from arching backward while performing unsupported overhead presses,(32) moving into a hyperextended position while performing the back extension exercise ballistically, or while performing prone leg curls. During the leg curl, there is a strong tendency for the spine to be pulled into hyperextension as the psoas comes into play to assist the hamstrings. Hyperextension can cause abnormal loading of the facet joints and the capsules, resulting in an inflammatory response. It can also increase the load on a preexisting spondylolisthesis, resulting in greater strain to the supporting tissues. The solution is to contract the abdominals while pulling the hips against the bench in order to maintain a neutral lumbar positive. In addition, patients should be advised to avoid using too heavy a weight or overstraining at the end of a set.

Injury to either the facets or the discs may occur from rotational exercises such as twists or from the rotary torso machine. The lumbar spine is particularly vulnerable to torsional forces. Due to the sagittal orientation of the facets, only a limited amount of rotation can occur in the lumbar spine. Additional rotation may result in injury to the facets or shearing of the discs.(40,41) Research (42) suggests a link between twisting while lifting and an increased risk of disc herniation.

Twisting exercises are often performed in an attempt to isolate the transverse abdominus muscle and create a thinner waistline. However, the transverse abdominus does not contract while rotating the torso, and twisting exercises will not trim the waist. Despite its horizontal fiber orientation, the transverse abdominus functions mainly to compress the abdomen during functions such as forced expiration and defecation.(43,44)

Many commonly performed abdominal exercises may contribute to lower back injury through overdevelopment and tightening of the hip flexor, iliopsoas muscles. When the iliopsoas Muscle contracts, it exerts both increased compressive and shear forces on the lumbar spine.(45) Many abdominal exercises are actually exercises in which the hip flexor muscles rather than the abdominals perform much or all of the work. These exercises include full sit-ups, straight leg raises, high chair and hanging leg raises, crunches with the feet hooked under a sofa or an apparatus in the gym, V-ups, Roman Chair rocking crunches, and most abdominal machines. Hooking the feet under a stationary object for support increases the tendency for the hip flexors to be recruited during sit-ups.

CERVICAL SPINE INJURIES

While not as common as back injuries, neck injuries occur fairly frequently in weight lifters. Cervical spine problems include mechanical sprains and strains, disc injuries, and brachial plexus injuries. Soft tissue injuries may result from protruding the head forward or from unnecessarily tensing the neck while weight training. Some problems result from a muscle imbalance syndrome similar to the "upper crossed syndrome" described by Janda.(46) This problem occurs because of imbalance in training programs that involve an inordinate amount of exercise for the pectorals, the front delts, the lats, and the biceps and very little training of antagonist muscle groups. The result can be overly developed and tight pectoralis major and minor, latissimus dorsi, front deltoids, trapezium, biceps, and stemocleidomastoid muscles, especially if proper attention has not been given to maintaining flexibility in these muscle groups. It is often accompanied by relative weakness of the middle and lower trapezium, rhomboids, the upper thoracic extensors, the deep neck flexors, the rear delts, and the external shoulder rotators (the infraspinatus and the teres minor).(33) It results in the rounded shoulder, forward head posture frequently seen in bodybuilders.

Exercises in which the head is allowed to nod or protrude forward may contribute to cervical spine injury by either promoting the postural defect noted previously, or by predisposing the athlete to cervical disc problems. The tendency to jut the head forward in exercises such as shrugs (Figs 3 and 4), behind the neck presses (Fig 5), behind the neck pulldowns, lateral shoulder raises (Fig 6), triceps extensions, curls, incline leg presses, and abdominal crunches promotes the development of the rounded shoulder, forward head posture. This posture is associated with abnormal mechanical function of the cervical spine. It is characterized by adaptive shortening of the suboccipital muscles, the stemocleidomastoid and the anterior scalene muscles, and excessive tension and weakening of the long cervical extensor muscles, the levator scapulae and the scapular retractor muscles. Trigger points and/or muscle strain may result in any of these muscles. Either upper cervical or cervico-thoracic joint dysfunction may result. Not only do cervical pain syndromes occur, but also temporomandibular joint dysfunction and headache. (47,48)

Protraction (protrusion) of the head during exercises in which the neck muscles are under load has also been linked with an increased risk of cervical disc derangement (herniation).(49) The forward head posture results in anterior shearing and increased compression of the lower cervical discs as the head slides forward and the upper cervical spine becomes hyperextended. Forceful contraction of the trapezium, the sternocleidomastoid, and the other cervical muscles will increase the load on the cervical discs and the facets. This finding correlates with an epidemiologic study that found that weight training, particularly with free weights, was associated with an increased risk of cervical disc herniation.(30) Cailliet(5O) claims that this forward head posture also leads to accelerated degenerative changes in the cervical spine. He notes that each inch the head protrudes forward of the trunk results in the equivalent load of an extra head that the neck must support.

It should be noted that during the performance of some exercises, untrained lifters commonly not only protract the head but also tense and flex the neck forward during the performance of exercises. This action occurs most frequently with curls, lateral raises, and leg presses. This habit may be even more damaging than simply protruding the head. Beginning with the novice athlete, bench presses-both flat and incline-are commonly incorporated into weight training and may be involved in the cause of cervical spine injury. It is not clear whether the injury occurs from protrusion of the head as the bar is lowered or from forcibly hyperextending the neck (ie, driving the head backward into the bench) as the weight is pushed up.

Neck strengthening is a controversial topic. Little research has investigated the role of neck strengthening in injury prevention. Mobility of the cervical spine is important and may be emphasized to the exclusion of strengthening. Some experts(48) recommend that rehabilitative exercises be directed toward strengthening the scapular muscles with the cervical spine held in the neutral position. However, others(51,52) have achieved good results with direct neck strengthening exercises, especially those directed at the cervical extensors.

SHOULDER INJURIES

As a trade-off for mobility, the shoulder lacks some of the stability found in other joints.(53) The shoulder is under considerable stress during many commonly performed weight training exercises and, as a result, is frequently injured.(3,31,54,55) Shoulder pain is often taken for granted or ignored by many bodybuilders. For example, anterior shoulder pain felt secondary to performing bench presses (ie, achieving a "burn") is frequently assumed to be a sore anterior deltoid muscle from a hard workout. It may, in fact, represent a sign of rotator cuff strain or impingement.

Impingement syndrome and anterior instability are the most common types of shoulder conditions associated with weight training. It is important to recognize that these conditions often coexist.(54) Rotator cuff strain/tendinitis/tear, proximal biceps tendinitis, and subacromial bursitis frequently result from subacromial impingement. However, primary tendinitis resulting from overload may also occur. Less common types of shoulder injuries include brachial plexus neuropathy, suprascapular nerve impingement, posterior glenohumeral instability (due to heavy bench presses), acromio-clavicular joint sprains (AC), proximal biceps tendon tears, pectoralis major strains or tears, and osteolysis of the distal clavicle.

Impingement syndrome

Impingement syndrome refers to impingement of the rotator cuff tendons, especially the supraspinatus tendon, under the subacromial arch. The biceps tendon or the subacromial bursa may also be impinged under the subacromial arch. The position that appears to be most damaging is abduction with internal rotation. It is not clear whether rotator cuff muscle/ tendon overload precedes impingement or is caused by it.(53,56)

A major factor in shoulder impingement injuries in weight lifters is the muscle imbalance syndrome mentioned earlier, highlighted by overly tight shoulder internal rotators and weak shoulder external rotators.(53,57) A substantial portion of the typical training program is dedicated to training the pectorals and the lats. Both tend to produce internal rotation of the shoulders. The external shoulder rotators (the infraspinatus and the teres minor) are often neglected.

There is considerable stress imposed on the rotator cuff muscles during the performance of many exercises, such as the bench press. Too many sets of exercises for the same body part with excessive weight can result in fatigue and overload injury to the rotator cuff. Therefore, weight lifters should be encouraged to perform fewer sets and no more than 12 sets per body part, including warm-ups.

A common exercise is the lateral raise with the shoulder in internal rotation (Fig 6). The lifter is often instructed to point the thumb down as though pouring water from a pitcher in an effort to better isolate the side deltoid. It may be true, but there is a risk of accelerating or aggravating an impingement syndrome. The clinician should suggest that lateral raises be performed face down on an incline bench positioned at about 75 degrees up from the ground. This position will isolate the side delts without creating impingement (Fig 7).

Another common mistake is raising the arms above 90 degrees while performing side raises. Unless the thumb is pointing up, this position may increase the risk of impinging the rotator cuff tendons under the subacromial arch. Shoulder protraction is associated with narrowing of the subacromial space.(58) Allowing the shoulders to become protracted forward beyond the neutral position during the performance of exercises such as bench presses may increase the strain to this area.

Anterior instability of the glenohumeral joint

Instability may be due to a single-event trauma where the capsule and glenoid labrum are torn or may be atraumatic representing a tendency toward a loose joint capsule. When either inherently loose or torn loose, the capsule may be unable to support the shoulder in the extremes of abduction and external rotation. Therefore, exercises that place the shoulder in this position should be modified or avoided such as the behind-the-neck press, the behind-the-neck pulldown, and the pec deck(59) (Figs 5, 9, and 10). It may also occur from repeatedly hyperextending the shoulder during the performance of bench presses, flyes, and the pec deck by lowering the bar or dumbbells to the point where the elbows are behind the back. Weight lifters not only place their shoulders in an abducted/externally rotated or hyperextended position, but also do it with considerable weight held in their hands. The general principle to use in advising patients is to avoid positions in which the elbows extend behind the coronal plane of the body. It is important to remind the patient that overhead positions are less stable and therefore more risky. While instability is often caused by gradual repetitive capsular stretching injury, Olympic lifters tend to suffer instability resulting from a single-event traumatic injury. They often lose control of a weight while holding the weight in an overhead position.(54)

It should be noted that the diagnosis of anterior instability may be overlooked due to a misleading response to testing. Patients often experience pain in the posterior shoulder when the arm is placed in an abducted/externally rotated position. It is thought that this posterior pain arises from traction or compression of the posterior structures as the shoulder subluxates forward. Also, anterior instability may be misdiagnosed as a rotator cuff strain.

The load and shift test is a form of instability testing that involves passively translating the humeral head while stabilizing the glenoid. This test may be performed with the patient in various positions, including seated with arm by the side, seated with the arm in the abducted and externally rotated position, and supine with the arm abducted and externally rotated. Excessive forward excursion of the humerus associated with either pain, apprehension, or clicking may all be considered positive signs. The relocation test should reduce the positive findings. This test involves restabilizing the humerus by pushing the head of the humerus from anterior to posterior while placing the arm in the "apprehension" position of abduction/external rotation. The relocation test is performed with the patient supine. Care should be taken to support the arm to avoid protective muscle spasm.(53)

Impingement may occur secondary to shoulder instability.(60) The response to testing includes pain felt with the apprehension test that is relieved by the relocation test. Apprehension is usually not the primary response to testing. In such cases, the underlying instability and the subsequent impingement should both be addressed.

Less common shoulder injuries related to weight training

There have been a number of reports in the literature of suprascapular nerve injury either via stretch or compression. Abduction of the arm against resistance has been implicated as the mechanism of injury.(61) The lateral raise and the shoulder press are two exercises that involve abduction against resistance.

A number of reports(5,20,62) document the occurrence of tears of the pectoralis major muscle or tendon, usually from bench pressing. The tendon may either avulse from the bone, tear at the musculotendinous junction, or tear in the muscle itself, usually near the musculotendinous junction. Most of these injuries occur while the arms are extended behind the chest.(20) To prevent such injuries the lifter should avoid lowering the bar to the point at which the shoulder is hyperextended.(5,20,62) Regular stretching may be helpful.

An entity known as atraumatic osteolysis of the distal clavicle has been reported in a number of studies as being related to weight training. This condition, referred to as weight lifter's shoulder, is marked by pain at the acromioclavicular joint while performing the dip, bench press, clean-and-jerk, and overhead presses. Radiographs show osteoporosis and loss of subchondral bony detail at the distal clavicle. In addition, cystic changes may also be present.(63,64) Atraumatic osteolysis is believed to result from repetitive loading of the acromioclavicular joint resulting in neurovascular compromise to the distal clavicle. Management is difficult given that most patients are serious lifters. Either a dramatic reduction in weight, elimination of the offending maneuver, or substitution of exercises may be suggested. Alternatives to the bench press include a narrow grip bench, cable crossovers, and the incline or decline press. If unsuccessful, elimination of heavy lifting for 6 months is recommended. There is some evidence that those treated surgically with amputation of the distal I to 2 cm of the clavicle are able to return to some lifting. However, many athletes are not able to return to a pre-injury level of lifting.(63)

KNEE INJURIES

Knee pain secondary to weight lifting is often caused by an overuse injury involving the patellofemoral joint, or the quadriceps or patellar tendons. However, tears to the menisci may also occur. Patellofemoral pain syndrome may or may not include chondromalacia. Ligamentous problems are rare except when caused by trauma during Olympic weight lifting.

One study(65) found that former elite weight lifters had a 31% incidence of osteoarthritis of the knee as compared with former runners who had only a 14% increased incidence of osteoarthritis of the knee. The patellofemoral joint was the most common location. One should keep in mind that Olympic lifts require ballistically dropping into a very deep squat, to the point where the hamstrings rest against the calves. Such extreme squatting positions result in very high meniscal compressive forces and patellofemoral contact forces. Also, competitive lifters often lift maximal weights. Elastic knee wraps are frequently worn while performing squats and other heavy leg exercises with the intention of protecting the knee joint. Such wraps may increase the friction between the patella and the underlying cartilage, thus increasing the risk of knee injury.(9,40)

Some general rules of thumb for athletes with patellofemoral pain are:

*Do not perform squats through a painful range of motion(often in the midrange).

*Do not perform lunges or squats with the knees caving inward (keep the knees over the toes).

*Focus on the last 10' to 15' of knee extension when performing knee extension exercises.

*Take care not to press the kneecaps into the bench when performing leg curls (or any prone position of exercise). In other words, move toward the foot of the bench so that the patellae are not compressed while the knees are extended.

(A grain of Salt may be needed here)

If the weight lifter has had damage to the anterior cruciate ligament it is important to:

*Avoid knee extension exercises (especially from 70' of flexion to full extension).

*Substitute seated knee extensions with closed chain exercises such as partial squats and leg presses.

*Focus on hamstring development (adds some dynamic support).

This author has seen the greatest number of knee injuries occur as the result of hack squats. However, regular squats, leg presses, knee extensions, lunges, step-ups, and leg curls may all play a role in overuse injuries. In particular, bouncing at the bottom of a squat has been implicated as a cause of patellar tendon strain due to the high eccentric forces generated during this technique.(9) One case report even documents a bilateral quadriceps tendon rupture that occurred while squatting.(23)

CONCLUSION

Weight training is a wonderful form of exercise when practiced sensibly and in moderation. Helping athletes and other patients to continue performing their strength training exercises by modifying their programs in an attempt to prevent injuries is a great benefit. We should consider the advice given by Hippocrates 2,400 years ago: "Exercise should be mild at first, gradually increasing, gently warming and not taking too much from the available strength . . . exercise should be as far as possible natural and there should be plenty of them; violent exercise should be sparingly used, and only when necessary."(66, p.289)

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8. Parrillo J. Parrillo Performance Training. Cincinnati, Ohio: Parrillo Performance; 1990.

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18.Smith CA. The warm-up procedure: to stretch or not to stretch. A brief review. J Orthop Sports Phys Ther. 1994;19(l):12-17.

19.Haykowsky MJ, Findlay JM, Ignaszewski AP. Aneurysmal subarachnoid hemorrhage associated with weight training: three case reports. Clin J Sports Med. 1996;6(l):52-55.

20.Wolfe SW, Wickiewicz TL, Cavanaugh JT. Ruptures of the pectoralis major muscle. Am J Sports Med. 1992;20(5):587-593.

21.D'Alessandro DF, Shields CL, Tibone JE, Chandler RW. Repair of distal biceps tendon ruptures in athletes. Am J Sports Med. 1993;21(1):114-119.

22.Bach BR, Warren RF, Wickiewicz TL. Triceps rupture. Am J Sports Med. 1987;15(3):285-289.

23.Grenier R, Guimont A. Simultaneous bilateral rupture of the quadriceps tendon and leg fractures in a weightlifter. Am J Sports Med. 1983;11:451-453.

24.Mannis CI. Transchondral fracture of the dome of the talus sustained during weight training. Am J Sports Med. 1983;11:354-355.

25.McCue FC, Hussamy OD, Baumgarten TE. An unusual source of wrist pain: Kienbock's disease in a weightlifter. Physician Sportsmed.1995;23(12):33-38.

26.Brady TA, Cahill BR, Bodnar LM. Weight training-related injuries in the high school athlete. Am J Sports Med. 1982;1 0(l):1-5.

27.Brown EW, Kimball RG. Medical history associated with adolescent powerlifting. Pediatrics. 1983;72(5):636-644.

28.Webb DR. Strength training in children and adolescents. Ped Clin North Am. 1990;37(5):1187-1210.

29.Risser WL. Musculoskeletal injuries caused byweighttraining. Clin Pediatr. 1990; 29(6):305-310.

30.Mundt DJ, Kelsy JL, Golden AL, et al. An epidemiological study of sports and weight lifting as possible risk factors for herniated lumbar and cervical discs. Am J Sports Med. 1993;21(6):854-860.

31.Risser WL, Risser JMH, Preston D. Weight training injuries in adolescents. AJDC. 1990;144:1015-1017.

32.Alexander MJL. Biomechanical aspects of lumbar spine injuries in athletes:a review. Can J Appl Sport Sci. 1985;10(l):l-20.

33.Fortin JD. Weight lifting. In: Watkins RG, ed. The Spine in Sports. St. Louis, Mo: Mosby-Year Book; 1996.

34.Kotani PT, Ichikawa N, Wabayashi W, Yoshii T, Koshimune M. Studies of spondylosis found among weightlifters. Br J Sports Med 1971;6:4-8.

35.Nachemson A. The load on lumbar discs in different positions of the body. Clin Orthop. 1966;45:107-122.

36.Floyd WF, Silver PHS. The function of the erectores spinae muscles in certain movements and postures in man. J Physiol 1955;129:184-203.

37.Adams MA, Dolan P. Recent advances in lumbar spine mechanics and their clinical significance. Clin Biomech. 1995;10(1):3-19.

38.Brinckmann P, Biggemann M, Hilweg D. Fatigue fracture of human lumbar vertebrae. Clin Biomech. 1988;3(suppl 1):51-523.

39.Granhed H, Morelli B. Low back pain among retired wrestlers and heavyweight lifters. Am J Sports Med. 1988;1 6:530-533.

40.Bogduk N, Twomey LT. Clinical Anatomy of the Lumbar Spine. 2nd ed. New York, NY: Churchill Livingstone; 1991.

41.Farfan HF, Cosette JW, Robertson GH, et al. The effects of torsion on the lumbar intervertebral joints: the role of torsion in the production of disc degeneration. J Bone Joint Surg. 1970;52A:495.

42.Kelsey JL, et al. An epidemiologic study of lifting and twisting on the job and risk for acute prolapsed lumbar intervertebral disc. J Orthop Res. 1984;2:61-66.

43.Gray H, Clemente CD, ed. Gray's Anatomy. 13th ed. Philadelphia, Pa: Lea & Febiger; 1985.

44.Robinson J. Beyond Legendary Abs. Los Angeles, Calif: Health for Life; 1986.

45.Bogduk N, Pearcy M, Hadfield G. Anatomy and biomechanics of psoas major. Clin Biomech. 1992;7:109-119.

46.Janda V. Muscles and motor control in cervicogenic disorders: assessment and management. In: Grant R, ed. Physical Therapy of the Cervical and Thoracic Spine. 2nd ed. New York, NY: Churchil I Livingstone; 1994.

47.Porterfield JA, De Rosa C. Mechanical Neck Pain. Philadelphia, Pa: W.B. Saunders; 1995.

48.Chek P, Curl DD. Posture and head pain. In: Curl DD, ed. Chiropractic Approach to Head Pain. Baltimore, Md: Williams & Wilkins; 1994.

49.Lefavi RG, Smith DE, Deters TC, et al. Lower cervical disc trauma in weight training: possible causes and preventative techniques. Natl Strength Conditioning Assoc J. 1993;15(2):34-36.

50.Cailliet R. Neck and Arm Pain. 2nd ed. Philadelphia: Davis Co; 1981.

51.Jordon A, Ostergaard K. Rehabilitation of neck/shoulder patients in primary health care clinics. JMPT. 1996;1 9(l):32-35.

52.Jordon A, Ostergaard K. Implementation of neck/shoulder rehabilitation in primary health care clinics. JMPT. 1996;19(l):36-40.

53 Souza TA, ed. Sports Injuries of the Shoulder. New York, NY:Churchill Livingstone; 1994.

54.Navasier TJ. Weight lifting-risks and injuries to the shoulder. Clin Sports Med. 1991;10:615-621.

55.Harman E. Weight training safety: a biomechanical perspective. Strength Conditioning. 1994; 16(5):55-60.

56.Sharkey NA, Marder RA. The rotator cuff opposes superior translation of the humeral head. Am J Sports Med. 1995;23(3):270-275.

57.Horrigan J, Robinson J. The 7-Minute Rotator Cuff Solution. Los Angeles, Calif: Health for Life; 1991.

58.Solem-Bertoft E, Thomas KA, Westerberg CE. The influence of scapular retraction and protraction on the width of the subacromial space. Clin Orthop. 1993;296:99-103.

59.Gross ML, Brenner SL, Esformes I, Sonzogni JJ. Anterior shoulder instability in weight lifters. Am J Sports Med. 1993;21(4):599-603.

60.Ticker JB, Fealy S, Fu FH. Instability and impingement in the athlete's shoulder. Sports Med. 1995;19(6):418-426.

61.Collins K, Peterson K. Diagnosing suprascapular neuropathy. Physician Sportsmed. 1994;22(6):59-69.

62.Liu J, Wu JJ, Chang CY, Chou YH, Lo WH. Avulsion of the pectoralis major tendon. Am J Sports Med. 1992;20(3):366-368.

63.Slawksi DP, Cahill BR. Atraumatic osteolysis of the distal clavicle. Am J Sports Med. 1994;22(2):267-271.

64.Scavenius M, Iversen BF. Nontraumatic clavicular osteolysis in weight lifters. Am J Sports Med. 1992;20:463.

65.Kujala UM, Kettunen J, Paananen H, et al. Knee osteoarthritis in former runners, soccer players, weight lifters, and shooters. Arthritis Rheum. 1995;38(4):539-546.

66.Hippocrates; Jones WHS, trans. Regimen 1. In: On the Universe. London, England: William Heineman Ltd, London: G. P. Putnam and Sons; 1931.

APPENDIX D. PRACTICE AID

Recommendations for Preventing Low Back Injuries While Weight Training

1. Keep the lower back in the neutral (lordotic) position during the performance of most lifts, such as dead-lifts, rows, and squats. To maintain this position lightly co-contract the abdominals and the glutes, making sure to avoid hyperextension. Abdominal co-contraction helps to raise intra-abdominal pressure and stiffen the spine. A weight-lifting belt may also facilitate maintaining this posture. If necessary employing trunk stabilization exercises as a regular part of your workout may help you learn to maintain this posture.

2. Keep the knees at least slightly bent during all rowing and flexed exercises.

3. Keep the trunk as vertical as possible during squats.

4. Avoid hip flexor dominant abdominal exercises. These exercises include straight leg raises, Roman Chair leg raises, full sit-ups, and most abdominal machines, especially those where the feet are hooked in. To decrease psoas involvement during crunches, plantar flex the feet and pull down with the heels to contract the hamstrings.

5. Maintain adequate strength and endurance in the lumbar extensor muscles.

6. Perform repeated prone extensions (cobra) prior to training and following all abdominal training that involves spinal flexion.

[Well, okay, if you're interested:

Prone Cobra:

Lay face down (prone) arms at sides. Raise the torso off the ground using your low back muscles. You may initiate the movement by contracting the glutes. Once up however use the low back to hold the torso up and relax the gluteals. Now that you are up externally rotate the arms and point the thumbs toward the sky. Now squeeze your shoulder blades together. Keep the chin tucked and hold the position.]

7. Avoid rotational exercises for the obliques such as twists and rotary torso machines, unless you are involved in sports in which rotation forces commonly occur. Substitute diagonal and lateral movements instead.

8. Keep the hamstrings, psoas, and other hip muscles flexible through regular, slow, static stretching. Avoid standing bent-over stretches as these can overstretch the posterior ligaments of the spine.

Recommendations for Preventing Neck Injuries While Weight Training

1. Keep the cervical spine in a neutral position. Avoid pushing or holding the head forward, flexed, or extended. Avoid turning the head during the performance of exercises in which the neck muscles are involved. Tuck the chin in slightly and look straight ahead.

2. Make sure to perform range of motion and flexibility exercises for the neck as part of your warm-up and cooldown.

3. Avoid behind-the-neck presses and behind-the-neck pull-downs. These exercises promote development of the forward head posture and may contribute to neck injury. Substitute presses and pull-downs in front.

4. Avoid unnecessarily tensing the neck and jaw musculature while training. Try to direct all of your energy to the working muscles. During the bench press keep your head resting on the bench and relaxed. A doubled towel placed under the head and neck may help.

5. Correct or balance postural flaws, such as increased thoracic kyphosis and the forward head posture, with specific rehabilitative exercises.

6. Strengthen the neck. Use light weights and greater repetitions, and progress very slowly. Isotonic exercises are probably best. However, if moderate to severe arthritis is present, isometric exercises may be better.

Recommendations for Preventing Shoulder Injuries While Weight Training

1. Do not ignore shoulder pain. Training through the pain will only lead to further and more severe injury.

2. Avoid exercises where the arm is abducted (raised to the side) in an internally rotated position, such as upright rows and thumbs-pointed-down laterals. Also, do not raise the arms above 90' while performing lateral raises.

3. Strengthen the external rotator muscles of the shoulder and keep them strong. This process involves regularly performing rotator cuff strengthening exercises-not just when you have an injury. The strength of the rotator cuff muscles should keep pace with the strength of the pectoral and deltoid muscles.

4. Keep the internal shoulder rotators flexible to avoid shortening. Be careful to avoid instability. Forceful stretching and stretching with weights should be avoided.

[Towel Stretch - Internal Rotation

Place right hand behind back.

With the left hand, dangle a towel behind the back.

Grasp the towel with the right hand.

Gently pull the right hand upward by raising the left arm to stretch the right shoulder.

Towel should be in vertical position.

Hold for 30 seconds. Repeat on other side. - Eric]

5. Avoid exercises where the rotator cuff is under extreme load.

6. Warm up the shoulders carefully before exercising them.

7. Strengthen the middle and lower traps and rhomboids to increase shoulder stability and ensure better scapular stabilization. Avoid protracted shoulder postural problems.

8. Avoid the pullover exercise or use with extreme caution. Care should be taken not to extend the arms back too far.

Recommendations for Preventing Knee Injuries While Weight Training

1. Avoid rapidly lowering your body or the weight while performing leg presses or squat variations.

2. Avoid allowing the knee to bend more than 90 degrees during the performance of leg exercises such as the squat, leg press, or lunge. Keep the knee from traveling forward of the foot and also do not drop too low in the squat or bring the carriage back too far in the leg press exercises.

3. Make sure that the knee tracks over the center of the foot. Avoid the tendency for the knees to bend to the side as the weight is pushed up during the performance of a leg press or squat or similar exercise. Elastic tubing can be placed around the knees while squatting to help train this proper tracking of the knee. A large ball such as a 55-cm ball can be squeezed between the knees while squatting to help the tracking and also to co-contract the adductor muscles and the vastus medialis.

4. Avoid the use of elastic knee wraps.

[AMB]

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This is an excellent article that I had to include here. Just the kind of thing I've been looking for.

By Will Brink, author of:

Muscle Building Nutrition

http://musclebuildingnutrition. Joint Troubles com

Muscle Gaining Diet, Training Routines by Charles Poliquin & Bodybuilding Supplement Review

Diet Supplements Revealed

http://aboutsupplements.com

Real World Fat Loss Diet & Weight Loss Supplement Review

“Joint Troubles”

One of the most common problems faced by strength training athletes is joint pain. "Oh my shoulder is killing me" or "my knee has been bothering me for months" or "I have been living on pain killers to get rid of this ache in my elbow" are common complaints that can be heard in any gym at any time. Oddly enough however, this topic is not covered very often in most bodybuilding/fitness magazines. Maybe the topic is just not all that "sexy" or "cutting edge," but if you're one of the thousands of people whose gains in muscle are being side tracked by joint troubles, then you don't give a damn about sexy or cutting edge-you just want relief!

In the past few years I have noticed an increase in letters and e-mail from people complaining about their joints. In all honesty, I would estimate 80% or more of most bodybuilders joint pain is totally avoidable. If you look at people who have chronic joint pain, nine out of ten times you can see why they would have an aching appendage that causes them pain. More often that not, they (1) rarely warm up adequately, (2) they train too long and/or too often, (3) they use overly heavy weights/low reps more often than they should, (4) they don't take time off to allow their joints, tendons, muscles, etc., to recuperate from heavy workouts, (5) they use less than perfect form during heavy lifts, (6) they don't take in adequate nutrients, or (7) all of the above!

Now of course we have all had an ache or pain in a knee, elbow , or other joint at times, but chronic long term pain is another story. This article is going to assume that the reader has joint pain NOT because he (or she) is doing any one of the above seven common mistakes, but has joint pain due to some other factor out of their control. If you warm up and stretch thoroughly, train for no longer than an hour three-four days per week, cycle your weights and reps, take time off when you need it, have good form, take in adequate nutrients, and still have joint problems... then this might be the article for you.

Types of joint problems

There are of course different types of problems that cause common joint pain in athletes and "normal" people alike. Bursitis, tendinitis, various types of arthritis, and other afflictions, can be the cause of a person's aching joints. Briefly, here is a description of the most common types and causes of joint pain that afflict athletes:

Arthritis: There are many different forms of arthritis. The two most common are osteoarthritis and rheumatoid arthritis. Of the two, osteoarthritis is by far the most common to bodybuilders and other athletes. Caused by wear and tear on the joints, osteoarthritis is characterized by a deterioration of the cartilage at the ends of the bones. The once smooth cartilage becomes rough thus causing more and more friction and pain. Left untreated and unchecked, this can become very debilitating for the hard training athlete. Chronic osteoarthritis has ended the career of numerous athletes.

Bursitis: In our joints there are small fluid filled sacks called bursae. The bursae's job is to assist in the muscle/joints movement by cushioning the joints and bones against friction. If these sacks become inflamed and/or injured due to various causes (see above training mistakes), a chronic pain called "bursitis" can result. It's most often found in the shoulder or elbow (A.K.A tennis elbow) but can also be found in other joints of the body. It hurts like hell and can ruin a workout quickly if left untreated.

Tendonitis: Tendonitis is probably the most common cause of pain to bodybuilders and other athletes and is (luckily) the easiest to treat. However, if left untreated and the person just "works through the pain," it can become a real problem that will put a quick end to your gains in muscle. Basically, tendinitis just means the tendon(s) around a joint have become severely inflamed from overuse, micro injury, etc. Though it might sound simple enough, for people who suffer from chronic tendinitis it's no joke and a real pain in the...joint!

Treatment options

Again, this article is going to assume that the reader warms up properly before working out, does not severely overtrain, yada, yada, yada, as mentioned in the beginning of this article. If the reader (you?) is in the gym all day, thinks one set on the bench press is a warm up, and feels anything over 3 reps is high rep training, than you need go no further to find the answers to what's bothering your joints!

The treatment options we are going to look at relate to natural compounds, or mixtures of natural compounds, that could save a person with aching joints years of pain and possibly even more. Unfortunately, the treatments offered by traditional medicine at this time are generally of little use to highly active people. Most of the treatments for joint problems address the symptoms (pain, swelling, etc) rather than the cause and can often make the problem worse in the long run. Non-steroidal anti- inflammatories, cortical steroid injections, joint replacement, and the always useful "stay off it" advice does not tend to yield the results most athletes want.

If you look at the names of the aforementioned types of joint problems, you will notice they all end with the term "itis," as in tendin-itis, arthr-itis, and burs-itis. The suffix "-itis" means "inflammation of " according to The American Medical Association Encyclopedia of Medicine. Knowing this, you can see that bursitis means inflammation of the bursea sack, tendinitis means inflammation of the tendons, and arthritis means....well you get the point. Medical terms for afflictions that end in "-itis" tell us that though the causes and manifestations are different, the final problems is one of inflammation. Inflammation is characterized by pain, swelling, redness, and less obvious symptoms. This leads us finally to our list of natural compounds/products that might just save the joints of the person reading this article who thought their workouts would never be the same because their joints are giving them so much trouble. These products tend to address not only the symptoms of the problem-that is the inflammation-but the underlying causes as well.

Jello Anyone?

As strange as it might seem, the main ingredient (gelatin) in good old Jello might be just what the doctor ordered for painful joints. Gelatin has been market world wide for many years as a food and as a supplement. Gelatin is made from animal collagen. In all animals-including man- collagen is an essential structural protein that forms an important part of bones, tendons, and connective tissues. It is a tough insoluble protein that is essential for keeping the many cells and tissues of the body together.

Gelatin contains an exceptionally high content of two amino acids which play an important part in collagen formation, namely proline and glycine.

In fact, it takes 43 grams of dried egg whites or 35 grams of dried non fat milk or 89 grams of lean beef to equal the amount of proline in just 10 grams of hydrolyzed gelatin. Though the body can form these two amino acids on its own, it has been suggested that under certain conditions the rate of synthesis may be insufficient to provide essential body requirements and degradation can exceed synthetic processes (i.e. there is a steady loss of body collagen). The intake of hydrolyzed gelatin appears to be an alternative route to getting chondrocytes (cartilage producing cells) and osteoblasts (bone forming cells) of the body sufficient amounts of these important amino acids for making structural proteins. Although chondrocytes are critical for collagen formation, their number is limited and their ability to form this much needed protein is influenced by heredity, age, physical activity (too little or too much), injury, and availability of nutrients.

Although bone metabolism is quite complex and not fully understood, there is a growing number of studies showing the intake of just ten grams per day of hydrolyzed gelatin is effective in greatly reducing pain, improving mobility and overall bone/cartilage health. Several randomized, double-blinded, crossover trials have shown improvements in symptoms related to joint pain (Adem et. al. Therapiewoche, 1991). The people at Knox (the Jello people) have made a product specifically for bone health and joints called NutraJoint. It contains hydrolyzed gelatin, calcium , and vitamin C. Calcium is of obvious importance to bone health and vitamin C is an essential and limiting nutrient for connective tissue formation. NutraJoint is cheap, has no side effects, and tastes good. I recommend one packet mixed with OJ with breakfast for people suffering from joint pain.

Cetyl Myrist..what?

A fatty acid with the long and hard to pronounce name of Cetyl Myristoleate has been receiving a good deal of attention by researchers concerned with joint pain and health. Being it's difficult for the reader to pronounce-or for me to write for that matter-I will just call it CMT for the remainder of this article, OK?

Discovered by a researcher at the National Institutes of Health (NIH), CMT looks very promising as a compound that greatly reduces joint pain due to a variety of causes. In animals CMT was found to be very protective of joints from different chemicals that would normally cause arthritis in these animals. Though the human research at this time is not as solid as we would like, CMT has already developed a following with some alternative medical practitioners and by those who suffer from joint pain. Several bodybuilders I work with swear by the stuff though I cant vouch for it at this time as I have had no personal experience with this product. Also, its effects seem to work rather quickly and relatively small amounts can be used. 12-15 grams spread out over an entire month appear to be effective. Exactly how CMT works is unclear but it might have something to do with a reduction in pro-inflammatory prostaglandins (see below) or some other mechanism. EHP Products Inc. makes a CMT product that is endorsed by the researcher who discovered it. They can be reached at 888-EHP-0100. A company called G nS Marketing also sells CMT (they call it CMO) and can be contacted by calling 800-829-1514.

Flax oil for everything!

Many bodybuilders and other athletes are starting to see the many benefits of flax oil for all sorts of uses. One obvious use of flax oil is a reduction in pain due to any type of inflammatory condition, including joint troubles. To understand why this is so, the reader must now endure a crash course in the topic of essential fatty acids and the many products made by these fatty acids found in the body. If you already know all this stuff you can skip over this material, but if you don't know it, you will need this information for the rest of the article.

The definition of an essential nutrient is anything the body cannot make itself and therefore must be obtained from the diet. We need to eat an assortment of vitamins and minerals, approximately nine to eleven amino acids, and two fatty acids to stay alive and healthy. The two essential fatty acids (EFAS) are called linoleic acid and alpha-linolenic acid. The first being an Omega-6 fatty acid and the latter being an Omega-3 fatty acid. If the term "Omega-3 fatty acid" rings a bell for you it should. Fish oils are also well publicized and researched Omega-3 fatty acids (see below) that have been shown to have many benefits. "So what does all this have to do with my aching joints?" you are thinking. Ok, here is the skinny on why you had to endure that previous section. Flax oil is exceptionally high in Omega-3 fatty acids (alpha-linolenic acid). Omega-3 fatty acids, from fish, flax, etc., have been shown in the scientific/medical literature to reduce inflammation of any kind.

Remember the "-itis" part of the word relating to joint problems? How do you think non- steroidal anti- inflammatories work? They reduce inflammation, but they also come with potential side effects and health problems. So how does flax oil do this wonderful thing? From both of the essential fatty acids the body makes something called prostaglandins. Prostaglandins are very short lived hormone-like substances that regulate cellular activity on a moment to moment basis. Prostaglandins are directly involved with regulating blood pressure,inflammatory responses, insulin sensitivity, immune responses, anabolic/catabolic processes, and hundreds of other functions known and yet unknown. The long and the short of all this, without going into a long and boring biochemical explanation, is: Omega 3 fatty acids are responsible for forming the anti -inflammatory prostaglandins and the Omega 6 prostaglandins are responsible for making many of the pro-inflammatory prostaglandins, and other products derived from EFAS. A high intake of Omega 3 oils reduces inflammation (and pain) by this mechanism. Obviously, it's a lot more complicated than that, but hey, I only have so much space to write.

People who add in 1-3 tablespoons a day of flax oil to a protein drink, or over a salad, often notice a reduction in pain in their joints, not to mention all the other great things EFAS can do for the hard training bodybuilder. Flax oil can be found in any large health food store under such brands as Flora, Omega, Barleans, and several other names (Even better than flax perhaps, Udo's Choice oil is a great blend of different oils. More info can be found at Udo's site connected to the links section of this web page).

High quality kitchen sink formulas

I call these products "kitchen sink formulas" because they add in just about everything you could want in a formula for painful joints. Two high quality product of this type that come to mind are the Natural Pain Relief products by Inholtra and The Life Extension Foundation. These products contain Glucosamine(s), Chondroitin Sulphate, the fish oils EPA/DHA, Gamma-linoleic acid (GLA), vitamin E, fat soluble vitamin C (ascorbyl palmitate), and Manganese aspartate. "So what does all this stuff do?" you are asking yourself. Briefly:

Glucosamine is considered by many as one of the best natural products for the treatment and prevention of cartilage degeneration. It is in essential part of cartilage, synovial fluid, and other components of joints. Chondroitin sulphate is related to glucosamine and is part of a family of modified sugars that form structural molecules in cartilage. As mentioned previously, the Omega 3 fish oils (EPA/DHA) are renowned for improving pain and inflammation in joints and other areas of the body. GLA is a fatty acid derived from the Omega-6 class of fatty acids but has been shown to have many properties similar to that of the fish oils/flax oil in its ability to reduce inflammation through the production of the favorable anti-inflammatory/anti-auto immune prostaglandins.

The anti - oxidants vitamin E and C are added because it is well known that free radical pathology is part of the damage that takes place in the joints. Finally, the trace element manganese is needed as a co- factor in many enzymatic processes related to cartilage synthesis and cartilage integrity. Now you know why I call them kitchen sink formulas! Taken singularly, the above ingredients appear to have marginal effectiveness. Taken as a complex, they appear to be very synergistic.

These are very well rounded and complete-though slightly different-formulas for people looking for some relief to their joint troubles, or any chronic inflammatory condition for that matter. However, I have found most people will need to take more than the manufacturer recommends to see real results, though this is not true 100% of the time. The Life Extension Foundation can be contacted by calling 800-826-2114 or http://www.lef.org

Conclusion and Recommendations

If you are one of the millions of people who suffer from chronic joint pain when you hit the gym, first make sure you are not making any of the most common mistakes outlined in the beginning of this article. Secondly, get an opinion from a good sports medicine doctor as to exactly what your problem is. You don't want to self diagnose what could be a serious problem. Finally, start with one of the above products and see if it improves your condition. Wait at least a few months before you make your assessment. Add in a second or third product if you don't think you are getting the results you want, which would be of course less pain and greater mobility through the joint in question. Hey, I never said it was going to be cheap and easy, but if serious joint pain is taking all the fun out of your workouts, it will be worth your time and money. See you in the gym...

Diehl-HW and May EL. "Cetyl myristoleate isolated from Swiss albino mice: an apparent protective agent against adjuvant arthritis in rats." J. Pharm-Sci, 83(3):296-9, 1994.

Cochran C. and Dent R., "Cetyl Myristoleate - A unique natural compound valuable in arthritis conditions." Townsend Letter for doctors, #168:70-74, 1997.

About the Author - William D. Brink

Will Brink is a columnist, contributing consultant, and writer for various health/fitness, medical, and bodybuilding publications. His articles relating to nutrition, supplements, weight loss, exercise and medicine can be found in such publications as Lets Live, Muscle Media 2000, MuscleMag International, The Life Extension Magazine, Muscle n Fitness, Inside Karate, Exercise For Men Only, Body International, Power, Oxygen, Penthouse, Women’s World and The Townsend Letter For Doctors.

He is the author of Priming The Anabolic Environment and Weight Loss Nutrients Revealed. He is the Consulting Sports Nutrition Editor and a monthly columnist for Physical magazine and an Editor at Large for Power magazine. Will graduated from Harvard University with a concentration in the natural sciences, and is a consultant to major supplement, dairy, and pharmaceutical companies.

He has been co author of several studies relating to sports nutrition and health found in peer reviewed academic journals, as well as having commentary published in JAMA. He runs the highly popular web site BrinkZone.com which is strategically positioned to fulfill the needs and interests of people with diverse backgrounds and knowledge. The BrinkZone site has a following with many sports nutrition enthusiasts, athletes, fitness professionals, scientists, medical doctors, nutritionists, and interested lay people. William has been invited to lecture on the benefits of weight training and nutrition at conventions and symposiums around the U.S. and Canada, and has appeared on numerous radio and television programs.

William has worked with athletes ranging from professional bodybuilders, golfers, fitness contestants, to police and military personnel.

Article References:

(1) Farnsworth E, Luscombe ND, Noakes M, Wittert G, Argyiou E, Clifton PM. Effect of a high-protein, energy-restricted diet on body composition, glycemic control, and lipid concentrations in overweight and obese hyperinsulinemic men and women. Am J Clin Nutr. 2003 Jul;78(1):31-9.

(2) Baba NH, Sawaya S, Torbay N, Habbal Z, Azar S, Hashim SA. High protein vs high carbohydrate hypoenergetic diet for the treatment of obese hyperinsulinemic subjects. Int J Obes Relat Metab Disord. 1999 Nov;23(11):1202-6.

(3) Parker B, Noakes M, Luscombe N, Clifton P. Effect of a high-protein, high-monounsaturated fat weight loss diet on glycemic control and lipid levels in type 2 diabetes. Diabetes Care. 2002 Mar;25(3):425-30.

(4) Skov AR, Toubro S, Ronn B, Holm L, Astrup A.Randomized trial on protein vs carbohydrate in ad libitum fat reduced diet for the treatment of obesity. Int J Obes Relat Metab Disord. 1999 May;23(5):528-36.

(5) Piatti PM, Monti F, Fermo I, Baruffaldi L, Nasser R, Santambrogio G, Librenti MC, Galli-Kienle M, Pontiroli AE, Pozza G. Hypocaloric high-protein diet improves glucose oxidation and spares lean body mass: comparison to hypocaloric high-carbohydrate diet. Metabolism. 1994 Dec;43(12):1481-7.

(6) Layman DK, Boileau RA, Erickson DJ, Painter JE, Shiue H, Sather C, Christou DD. A reduced ratio of dietary carbohydrate to protein improves body composition and blood lipid profiles during weight loss in adult women. J Nutr. 2003 Feb;133(2):411-7.

(7) Golay A, Eigenheer C, Morel Y, Kujawski P, Lehmann T, de Tonnac N. Weight-loss with low or high carbohydrate diet? Int J Obes Relat Metab Disord. 1996 Dec;20(12):1067-72.

(8) Meckling KA, Gauthier M, Grubb R, Sanford J. Effects of a hypocaloric, low-carbohydrate diet on weight loss, blood lipids, blood pressure, glucose tolerance, and body composition in free-living overweight women. Can J Physiol Pharmacol. 2002 Nov;80(11):1095-105.

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Shoulder Rehabilitation by Dr. David Ryan

Shoulder Rehabilitation

by Dr. David T. Ryan,

Winner of the Cecil Award, National Arthritis Foundation

Introduction

The most common question that I get asked is how to strengthen an injured shoulder. Some athletes train around a shoulder injury for years, others try every insane treatment, including magnets and various injectables, instead of realizing they can correct the problem with proper training.

The shoulder is the most complicated joint in the body to rehabilitate. Why? It has more mobility and speed than any other joint in the body. The shoulder moves at 5730 degrees per second (dps), approximately 80% faster than the knee at top speed (2000 dps).

Because of its seemingly complex nature, most individuals take up knitting or 12 ounce curls to avoiding training. Recently, I returned a professional hockey player to the ice in just 10 days with a shoulder separation. Previous attempts at shoulder surgery failed to provide shoulder stability, the injury was reviewed and an intense training schedule mixed with some ultrasound and medications was implemented. That's right, a step by step exercise program to increase flexibility and strength. Injuries to the shoulders supraspinatous muscle are the most common sports medical injury.

Many times the shoulder injury will have several additional components, including the back/neck/shoulder girdle, etc. Most good orthopedic surgeons are very reserved about attempting surgery unless there is a major tear, since there is a better chance to rehab the shoulder. For example, when trying to repair a torn pec tendon is associated with how it is made. Most tendons are very fibrous and thick, but the pec tendon looks like Jello flattened out by a rolling pin with parallel strings running through it. Your best chance at repairing partial tears is by rehabilitating the tissue and doing it the right way with plyometric/speed training.

This article will instruct you on how to increase range of motion and strengthen the shoulder area. This article will not allow you to begin diagnosing your lifting pals. It is best to see a chiropractic physician or a good orthopedic surgeon who specializes in shoulders. Beware that not all orthopedic surgeons or chiropractic physicians are created equally. A good general rule is if you don’t see improvement in a couple of weeks, then move on. Try another type of doctor or physical therapist or acupuncturist, etc.

Find a Chiropractic Physician at www.chiroweb.com

Find an Orthopedic Physician at http://www.aaos.org

When a doctor tells you to quit lifting and get on NSAIDS (Non Steroidal Anti-Inflammatory Drugs). Well, since over 16,500 people died in the US from reactions from those drugs you might want to consider using a non-drug approach. (British Medical Journal, June, 1999.) Short-term use of Advil, Aleve, Nuprin, Motrin, Asprin (white willow bark) and other NSAIDS (less than three weeks) are usually safe, but continued use will distroy your protective lining of your stomach and your heart. I have seen several athletes who have been unable to compete or came close to death with long term NSAID use. One of the best NSAIDs - Bextra is one of the safest anti-inflammatory drugs you can use, ask your doctor about it. It is 4000 times more selective, which means it leaves your heart and stomach alone.

Read this article and then take it to your healthcare professional and have them read it.

Please note that most physicians don’t have any training in rehabilitation. Some chiropractors do and most physical therapist are a good place to start then apply other references of this article to your training.

Take on the shoulder Step by Step. Try to workout without passing the 60% pain level. In time your strength will improve and your pain level will reduce.

One of the first steps to understanding shoulder rehabilitation is

learning anatomy. I know it might not be fun, but it is necessary.

BONES 1. Bones of the shoulder

A. Clavicle (Commonly known as the collar bone)

B. Scapula (Also known as the wing bone)

C. Humerus (The upper bone in your arm)

JOINTS 2. There are three joints (where bones come together) of the shoulder region.

The first two listed below make up the shoulder girdle.

A. Acromioclavicular (A-C joint) -- this joint is formed by the upper part of the scapula and the clavicle. Mainly it is active with shrugging movements. When this joint is injured a grading scale of 1 (minor) through 3 (severe) is used to evaluate the degree of separation as seen on a x-ray.

B. Glenohumeral -- the combination of the upper arm bone and the

outside area of the scapula make up this joint. This joint is responsible for most all the movements of the shoulder. Shoulder dislocation always refers to this joint. These can occur in any direction, but the anterior-inferior (forward and down) normally occurs the most frequent.

C. Sternoclavical -- composed of the clavicle (collar bone) and the

sternum (breast bone). This joint primarily operates during the shrugs, although, part of its function is to stabilize the shoulder girdle in place. Normally, this area becomes injured when the entire shoulder girdle is forced backwards or towards the center of the body (like getting slammed into the wall in Hockey).

MUSCLE 3. Muscles of the shoulder.

Here is a simple definition of what they do, in particular how they effect the more common movements such as the bench press.

The rotator cuff (SITS) Supraspinatus, Infraspinatus, Teres Minor, Subscapularis, others muscles of the shoulder include

the Teres Major, Latissimus Dorsi, Trapezius, Pectoriallis Major and Minor; corico- brachiallis, Biceps, Deltoid, Sternocleidomastoid, Rhomboid Minor and Major, Serratus Anterior.

SOME KINESIOLOGY WITH YOUR EGGS?

The humerus (your upper arm) is flexed (drawn forward, bench press) by the Pectoralis major, anterior fibers of the Deltoideus, Coracobachialis, and when the forearm is flexed, by the Biceps brachii; extended (drawn backward, bent-over rows) by the Latissimus Dorsi, Teres major, Posterior fibers of the Deltoideus and when the forearm is extended, by the Triceps brachii; it is abducted (arm drawn away from the body, lateral raises) by the Deltoideus and Supraspinatus; it is adducted (arm is drawn toward the side of the body, like one arm rows) by the Subscapularis, Pectoralis major, and by the weight of the limb; it is rotated outward /external rotation (similar to bent-over lateral raises) by the Infraspinatus and Teres Minor; and it is rotated inward /internal rotation (cable cross-overs) by the Subscapularis, Latissimus Dorsi, Teres major, Pectoralis major, and the anterior fibers of the Deltodeus.1 With the arm over head, any motion is stabilized or controlled by the Coracobachialis. Circumduction (similar to a underarm throw in fast pitch softball) is the combination of the above movements to allow the greatest degree of movement of any joint.

IMPORTANT POINTS ABOUT THESE MUSCLES

•Some muscles are major movers of the joints, others only stabilize.

•If you were to cut away the tendons of the rotator cuff, the

Glenohumeral joint goes from completely closed to a 2.5 cm gap. Now you can

understand how important the rotator cuff muscles are in stabilization of the

shoulder. Some of the research done by Dr. Richard Fisher at OSU (also

Director of Orthopedics, Arnold Fitness/Classic Expo) showed,

the more weight placed on the shoulder in the bench press resulted in a more

stablization of the glenohumeral joint. Less shifting with more weight!

•Muscles are accompanied by surrounding soft tissue, these include bursa sacs,

major ligaments, nerves and arteries. It is possible to have scar tissue associated on any of these structures. It may be necessary in some cases to have a surgical procedure to remove that scar tissue.

Now that we have a clear understanding of anatomy and how it works the next step is learning the steps to evaluating your problem.

Your physician/physical therapist must help you with this phase.

The First step: Find the limited movement.

Movement of a joint is called Range Of Motion (ROM). There are standards or normal movement ranges. Comparing the normal side to the damaged side is an easy way to determine your limits. Some individuals who have injuries on both sides must have a physician or physical therapists assist them in discovering their limits of motion.

There are two forms of ROM:

ACTIVE (AROM)--where you move the joint.

PASSIVE (PROM)--where the doctor moves the joint for you while you relax.

NOTE WHERE THE PAIN OCCURS DURING THE RANGE OF MOTION TESTING, RECORD THAT FOR COMPARISON LATER.

The ranges of motion to be examined are:

• Abduction and Adduction: With the arms straight at your side

raise the arms over your head. (Fig. 1)

• External rotation and Abduction: reach behind your head and

touch the top of the opposite scapula.

• Adduction and Internal rotation: reach in front of your head

and touch the opposite shoulder.

• Internal rotation and Adduction: reach behind your lower back

and raise the arm to the bottom of the scapula.

• Scapular movement: 2:1 ratio of arm abduction to scapular

movement. For every 2° of arm abduction 1° of scapular

movement should also occur. This important area is commonly

overlooked during examination. Frozen shoulder syndrome starts here.

There are other areas of ROM, but these will be uncovered during the next section of muscle testing.

Note any deficiencies or improvement in your journal. Check your progress in the future by comparing your good side to your injured side in a mirror.

The Second step: Begin testing your muscles in particular movements. Realize some of your strength testing can be done in the gym during your workout. You may need to adapt your exercises and use dumbbells to compare one side to the other; However, during rehabilitation bilateral movements (using a barbell) promotes faster strength gains.

The nine motions we are going to test are: Flexion, extension, abduction, adduction, external rotation, internal rotation, scapular elevation (shoulder shrug), scapular retraction (position of attention), shoulder protraction (reaching) and overhead flexion (throwing a ball).

Test these movements with the following exercises

Flexion & scapular protraction: Reverse grip-bench press.

Extension: One-arm bent over rows

Abduction & external rotation: Lateral shoulder raises

Adduction & internal rotation: Cable cross-overs/ Dips

Scapular elevation & retraction: Dumbbell shrugs up and back

Overhead flexion: One-arm dumbbell pull-overs.

Another excellent exercise to consider is the "Rotator Cuff Shoulder Roll." Performed with your arm holding a dumbbell, elbow bent at 90 degrees, upper arm perpendicular to the bench, midway down on a flat bench, only the shoulder blade (Scapula) touching the bench; keep your thumb pointing to the ground as you move the dumbbell from above your head to below your shoulder. (SEE ILLUSTRATION-1) A more advanced way to do this exercise is with a barbell. Grab the barbell a little wider than shoulder width with palms facing inward. Now raise your elbows (keeping your upper arm only rolling- your upper arm is parallel with the ground) start with your forearms pointing down to the ground (like a scar crow). Now raise the forearm in a circular motion, in that you rotate the upper arm, making a half circle as you raise the bar over your head. Keep your elbow at the same height throughout the movement. (SEE ILLUSTRATION-2)

I would strongly discourage you from doing any behind the neck military presses below the earlobe. They tend to separate the shoulder joint to an abnormal degree. Do military presses in front of the neck and not lower than the earlobe.

STAY BALANCED

With all your exercises work on balancing the strength of the joint equally in all directions. An unbalanced joint, especially the shoulder, will eventually cause further injury or ligamentous laxity and osteoarthritis. The head of the humerous will wear on the ball and socket joint and eventually tear the Teflon-like covering in joint called the glenoid labrum.

Write Down your weaknesses in a journal and we’ll cover the correct exercises to

The Third Step: Work on increasing your range of motion.

When your tissue is injured it heals with scar tissue, not fresh new cells, just protein branches called collagen. For about the first three weeks scar tissue is forming therefore, lifting weight too early is counter productive; however, it is quite essential to work on passive then active ROM. You should be aware that once the scar tissue has stabilized you must begin exercising the area with weights as soon as possible. Please note that some research has shown that use of NSAIDS on a repetitive basis results in additional scar tissue formation. Additional research indicates that cross frictional massage and deep tissue massage to the tendon, helps promote new blood vessel growth and speed healing.

INJURY EVALUATION

At this point you should be past the initial 48 hours of ice treatment. Also, you should have been seen by a health care professional to properly assess your injury. After that point, we will discuss each level relative to your range of motion improvement. In other words the more movement without pain the better you are. Your Physician will usually grade your injury as severe, moderate or mild. Remember any NUMBNESS should be evaluated by a doctor immediately. Long term radiating pain or numbness (over six weeks) should be evaluated by a Neurologist prior to exercise. Never train with pain greater than 6 on a scale of 0-no pain to 10-worst pain possible.

Many doctors use several evaluating levels to rate your injury.

If your injury is rated as:

Severe: (As evaluated by a professional).

If this is your diagnosis discuss your use of:

Passive Range of Motion (PROM): Injured joint is moved through a painful range of motion by another person, usually a licensed Physical Therapist. PROM is done for three weeks. Do not lift on that joint for three weeks. You may even need to get manipulated under anesthesia. You can still do isometric exercises twice a day. Contract the muscle for 12 seconds at 60% of your maximum ability for 6 sets. Do 6 different positions in the range of movement.

Then re-evaluate, if your PROM is within 80% when compared to your uninjured side you can begin speed training, if not, you must complete two more weeks of PROM and isometrics until you meet that 80% range. Then move on to speed training.

Moderate: (As evaluated by a professional).

Passive Range of Motion (PROM) for two weeks. You can still do isometric exercises twice a day. Contract the muscle for 12 seconds at 60% of your maximum ability for 6 sets. Do 6 different positions in the range of movement.

Then re-evaluate, if your PROM is within 80% when compared to your uninjured side you can begin speed training, if not, you must complete two more weeks of PROM and isometrics until you meet that 80% range. Then move on to speed training.

Mild: (As evaluated by a professional).

PROM for one week: You should be within 80% of the unaffected side. You should continue to lift, but not if your pain is greater than 6 (scale 0-10) Once your range of motion has returned to normal compared to the opposite side, it is time to begin the speed program.

Keep in mind you are still healing so you need to continue stretching (after a workout is best since the area is warm). The stretch should be held steady for 15-20 seconds and repeated three times. Continued three times a week for the rest of your life. Yes, the rest of your life. When you injure the ligament and muscle, these areas heal with scar tissue. That scar tissue needs to be kept mobile. Over time, with inactivity, the scar tissue will form adhesions and loose what little blood supply it has. Flexibility is just like strength, it is easier to keep the flexibility than trying to regain range of motion. Manipulation or chiropractic adjustments provide maximum full range of motion in the spine and/or extremities, but are no substitute for the athlete doing self-stretching.

Always continue to train the opposite side even though you can't train the injured side. This actually helps you recover the injured side quicker. 4

STRETCHING REHAB

Various forms of stretching are rather aggressive. Propreoceptive Neurofacilitation (PNF) is one of the best ways to overcome many chronic limited range of motion. This is a type of stretch where you contract the muscle very hard to cause it to fatique and then you use the antognistic reflex to allow the muscle to lengthen. Sound confusing? There are two references at the end of the article for text on stretching; get them, read them, do them. More than half of the chronic athletic injuries out there could be helped by simply having the person begin a prescriptive PNF stretching program.

STRENGTH REHAB

Strength: (Rehabilitation) To begin only after a professional consultation and return to exercise has been approved by your physician. ROM should be 80% of the unaffected side or of normal range of motion.

PUTTING IT ALL TOGETHER

Now, if you thought the previous part was tough, get up, pour a glass of filtered water with ice and get ready. With rehabilitation various parameters of the lift allows you to control the level of rehabilitation you are in. These parameters include:

1. Frequency: How often you lift.

2. Sets: A group of repetitions.

3. Repetitions: Lifting through a range of motions and return to the starting position.

4. Weight: Using less is better. Better to contract the muscles in the shoulder while performing the

movement.

5. Speed of movement: Speed of reps. Slower is better in the early phase.

Increased speed must be explosive as you progress.

6. Rest period: Time between sets. More rest between sets at the early phase, less at the end.

7. Amount of movement (Range of motion): Detailed later in this article

8. Intensity: How hard you try

The most common mistake that everybody makes is lifting too much weight too early and doing reps too fast. We will review the two most commonly misused parameters for rehabilitation with weights; speed and ROM. Follow the advice to the letter if you want to continue to improve your strength. If you don't follow the protocol, you will eventually plateau off in your strength prior to your maximum pre-injury strength. If you have already plateaued in lifting strength, start by dropping your weight in half and follow one of the following protocols to regain and improve your strength. Just a brief mention to you employers out there: (QUICK HINT) Have some type of light duty work available to your workers, it allows them to return to full duty quicker.

REHAB LEVEL ONE – RANGE OF MOTION (ROM)

The first variable we will adapt is the ROM. When an injury occurs the body splints the area with muscle spasm to prevent further injury. This spasm restricts the range of motion. You must regain as much joint mobility as possible after an injury to prevent the onset of arthritis and/or athropy. Osteoarthritis (Os-tea-O-arth-ri-tis) is the most common form of arthritis. It is merely the body forming calcium growths to stabilize an unstable area. Arthritic changes can begin as early as one week after an injury. Unnecessary immobilization of the shoulder can arthritic changes as quickly as two days. 5

Most physical therapists recognize five phases of rehabilitation. Range of motion is closely coordinated with the progression of exercise.

Phase 1: Forming complete passive range of motion

Phase 2: Initiating movement, muscular contraction

Phase 3: Initiating movement with full active range of motion

Phase 4: Strengthening with full range of motion

Phase 5: Functional rehabilitation: The special action of retraining the athlete to their level of previous competition speed.

REHAB LEVEL TWO – SPEED OF MOVEMENT

As range of motion improves, you will need to improve the joints speed of improvement without pain. As movement begins with weight we usually follow these steps:

Phase 1-3 Slow - partial movement (isometric)

Avoid training painful areas with weight. Begin by contracting the muscle (isometrically) for six seconds at 60% (a little more than half of what you can do before you feel pain begin). Repeat for 6 sets resting one minute between sets. Train around the painful area of movement. By training around the areas of pain this allows you to actually effect the injured area since there is a physiologic overlap of about 15 degrees beyond the ROM, to each side of the area you training. 6 Once you have obtained 80% of your AROM most physicians will instruct you to proceed to the next phase.

Phase 4 Slow - complete movement (isotonic)

Fast - partial movement (isokinetic)

Slow movement with weight, full range of motion. Then shorter movements with quick contractions in the middle of the ROM.

See illustration (a picture here of a curl with the whole ROM in blue, like a sweep, with a middle range of motion in red would-demonstraighting movement in the center about 60 degrees, would be easiest to understand)

Phase 5 Fast - complete movement (isokinetic)

Special machines called Orthotrons (Orth-o-trons) are designed to allow you to exercise over a particular range of motion at a particular speed. This is where the value of a well equipped rehab facility and a well trained physical therapist is judged. You aren’t likely to find machines like this in a gym, they are very expensive.

Slow movement (six seconds concentric-up, six seconds eccentric-down).

mid-Fast movement (two seconds concentric, two seconds eccentric).

Fast movement (less than one second concentric, less than one second eccentric).

~~Wondering if the slow movement (Constant motion-NO SHOCK) really works, Joe Montana returned to the football field very quickly when it was used on his lower back injury. ~~

Eventually you want to move explosively fast, slowly increase your speed as well. This helps coordinate the muscles to work together at faster speeds which resembles true athletic activity and causes the muscles to grow in a way that strengthens there connective tissue. Realistically, you should train like this at least once a month for the rest of your life to work on only explosive (plyometric) movements. For example if you typically bench 315 then you should try doing 135 for 8 sets of 8 reps with only 30 seconds between sets. Moving the bench press so fast that you are doing about two reps per second. This plyometric training thickens the ligaments and tendons. It is necessary to do this to improve the strength of the area. You can also judge it by doing a push up and trying to clap your hands after you have pushed yourself off the ground. As you improve you can try to clap your hands twice before lowering back to the ground. I have never seen a shoulder problem exist after an athlete can clap twice on a push up for 25 reps.

USING STRAPS FOR SPEED

Training with rubber straps will allow for constant tension during high speed training. You must have some experience using them and one of the best groups around to explain this is Westside Barbell and Elete Fitness Systems. Look you can either buy the straps for less than a hundred bucks or buy an Orthotron machine starting around $200,000.

Contact them at http://www.elitefitnesssystems.com/

Lastly, the importance of training for speed is involved with the speed of the shoulder. You need to coordinate your muscles to work at higher speeds. Explosiveness is more important than strength in any sport. Ever try to stop a tiny “speeding” bullet?

Putting together your functional rehabilitation program

Weight, Sets and Reps: Get out the calculator and the pencil cause here comes the math. Start with how often you should train an injured joint? In a study done by Matthews in 1957 and redone in 1981, research found that if you rehabilitate 5 days a week is more beneficial than only training 4 or 3 days a week. Both studies only used a five day work week not a six or seven day program (couldn’t get the researchers to work weekends). Since Dr. Don Matthews was a professor and friend of mine, I feel that I can extrapolate off this study and suggest that you work the injured area 7 days a week until you reach phase 5, then reduce to 3 then 2 days a week. You can train more frequent due to the reduced intensity of rehabilitation and your body will recover much faster than doing high intensity body- building.

More technical stuff

Zinovieff, DeLorme-Watkin and McQueen are just a few of the techniques that explain how many Sets, Reps and the amount of weight you should use. They all base their principles on the progressive resistive theory. In general, most recommend ten repetition maximum. As far as how much weight to use? Enough to just get ten reps! Real tough, Huh? Some of the best results increase the number of sets you perform as your shoulder strengthens. In other words, you start with doing 3 sets, once you are able to perform 11 reps on your last set, simply add a set until you are doing 5 sets. When you can perform 11 reps on your last set, then add 1 to 1.5 pounds and drop your sets back to 3. This allows you to work on strength first and then develop speed and endurance. One of the important factors in healing an injury is to promote increased circulation in the scar tissue. Remember, if you are board with your rehab program, you are probably right on track. You should always leave and feel that you could do more.

Here is an example of how a program should progress:

Exercises: Dips, cable cross-overs, reverse bench press and Pullovers.

Day 1 2 3 4 5 6 7

Weight (#'s) 10 10 10 10 11 11 11

Sets 3 4 4 5 3 3 4

Reps 10-10-11 10-10-10-8 10-10-10-10 10-10-10-10-11 10-10-8 10-10-10 10-10-10-10

Speed slow slow slow slow faster fast fast

OTHER EXERCISES THAT ARE USEFUL ARE:

Floor Presses are done by lying on the floor with your legs straight, lowering the weight and resting/relaxing on the elbows for a second then pushing the weight up. Similar to box squats. It is sort of a plyometric training that allows for increased coordination of the muscles and increased fiber recruitment. This exercise can be modified by returning to the bench and placing various thickness of boards on your chest and resting the weight on the board, then quickly pressing the weight off. This technique is commonly used by the members of Lou Simmons's West Side Barbell (Where most world record holders train), who also constantly vary their grip. Simply find your weak point in the movement of the bench press or military press and work on the plyometric program from there. This is also sometimes referred to as pin presses however the use of a cage and pins is not as realistic as the free form bench press movement. Remember that this is a quick movement and requires you to be in the Phase 5 level of rehab. You must lower the weight slowly to the floor and then explode the weight to the top. This is great for a majority of injuries such as the Torn Pec, separated A-C, rotator cuff tear, etc.

Use bands to train

Pullovers- (Straight Arm) exercise works the coricobachialis, which is responsible for a majority of the stabilization of the A-C joint.

Bicep Curls- should be modified to bring the bar to your forehead at the end of the movement. The bicep helps stabilize the A-C joint better when the arc of the movement ends with the bar at your eyebrows.

Rotator Cuff Roll - see prior description in this article.

Reverse grip Bench press-Like it says your grip is backwards, this forces you to keep your elbows in to your sides and lower the bar to your stomach, (hint, this movement will help you overcome bad bench techniques which halt your progress) varied width is also used on this movement.

Dumbbell Fly/Press- which ever hurts the most.

Once your strength is approximately 80% of your preinjury strength it is time to increase your speed of movement (phase 4).

Partial movements/Lock-outs Bench press- by simply holding more weight than you normally bench as a PR, you build psychological confidence and you will stabilize the golgi-tendon organs (little switches located in your tendons that tell your brain that the weight is to heavy and cause your muscle to let go). It is very important to overload after an injury since the golgi-tendon organ is very hypersensitive to weight.

That's it No tricks, No gimmicks, just hard work and lots of it. Each program requires some modification so check with your physician if you note any of the following:

•Pain in the chest (clutching-type pain)

•Radiating pain in the arms, wrist or hands.

•Any numbness

•If your strength doesn't increase 14% in 4 weeks

Continue utilizing the suggested exercises until you die or the take the evening news off the air, which ever comes first. You may be avoiding Bench day or hate shoulder day since the strength is gone or the pain is too much. Try the above stated program in its entirety; you have a lot to lose if you don't. Many of the principles explained will apply to the rehabilitation of all the joints after injury. I recommend that you discuss you progress with your physician to best accommodate your exercise program.

Working out with less pain

Several other medical approaches may assist with a more painless workout.

Arthroscopic surgery-is a simple technique of cleaning off the rough edges on the tissues to allow them to work with less friction. Recovery is quick and usually uncomplicated.

Acupuncture – needles!!!! Calm down, it is painless, this technique uses the stimulation of some nerves to calm others down, this is a retraining treatment and requires several visits to work; however, you should see some improvement within a few visits. A word of caution, states vary in their requirements for license. Some of the best training is with Doctors of Oriental Medicine (DOM) and MD or DO and DC’s. Several Medical schools are beginning to teach this technique. Remember the Chinese have used this as a main form of medicine for over 11,000 years.

Supplements-Most effective from the literature and my personal experience are products with Glucosamine Sulfate and Chondrotin Sulfate and MSM (Organic Sulfur). Now please note you shouldn’t take herbs with medications unless you check with your pharmacists. Not your doctor-your pharmacist. Also note that taking NSAID’s (Advil, Motrin, Ibuprophin-containing drugs) will lower your Sulfur content and cause more scar tissue to form and also lower the effectiveness of the aforementioned chemicals. Note also that the Center for Disease Control, Atlanta, GA. Indicated that in 1998, that 16,500 deaths were associated with the use of NSAID’s. Bextra is a newer NSAID that is out, which is 4000 times more selective, meaning that it leaves your heart and stomach alone.

Bio

Dr. David Ryan, practices in Columbus, Ohio at the Columbus Chiropractic Centers and was a team physician for three of the capital cities' pro teams. Medical Director, Arnold Classic and Fitness Expo, the 1994/1995 WPC World Powerlifting Championships. Ring side Physician USA BOXING. Former assistant Strength Coach, Ohio State University. In 1994 the Arthritis Foundation honored him with a national award. He also works with professional football, basketball, rodeo and various professional and Olympic athletes. Send questions in a self addressed/stamped envelope to 5870 Cleveland Ave. Columbus, Ohio 43231

Dr. Richard Fisher (Orthopedic Surgeon) practices in Columbus, Ohio (again, thank god) he is the orthopedic director of the Arnold Classic/Expo.

Bibliography

1. Gray, H., Goss, C.M. (Ed.): GRAY'S ANATOMY, PHILADELPHIA,

PENNSYLVANIA: Lea & Frebiger, 1976.

2. O'Donaghue, D.: TREATMENT OF INJURIES TO ATHLETES,

PHILADELPHIA, PENNSYLVANIA: W.B. Saunders, 1976.

3. Hellerbandt, F.A., et al: Influence of Bilateral Exercise on

Unilateral Work Capacity. Journal of Applied Physiology, 2:

446-452, 1950.

4. Moore, J.: Excitation Overflow; An Electomyographic Investigation

Archives of Physical Medicine and Rehabilitation, 56:115-

120,1975.

5. Videman, T.: Experimental Models of Osteorthritis: Role of

Immobilization. Clinical Biomechanics, 2: 223-229, 1987

6. Davies, G.J.: Compendium of Isokinetics, S & S Publishers, 1984.

Suggested Reading

Voss. D., et al: Proprioceptive Neurofacilitation: Patterns &

Techniques. PHILADELPHIA, PENNSYLVANIA: Harper & Rowe, 1985.

Glossary

Tendon-The tissue the connects the muscle to the bone.

Rehabilitation-Scientifically designed exercise program for injuries or illnesses.

Arthritis-Deterioration of cartilage and general wear on the joint surfaces, due to a ligament's instability.

Atrophy-Shrinking of tissues like muscles.

Range of motion-The distance that a joint allows the bones to move in.

PNF- Proprioceptive Neurofacilitation, a complex stretching technique (read the book).

http://www.elitefitnesssystems.com/d...lder-rehab.htm

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Shin Splints

The repeated running cycle of pounding and push off results in muscle fatigue, which may then lead to higher forces being applied to the fascia, the attachment of fascia to bone, and finally the bone itself. Respectively, this represents a spectrum from mild to severe. On the relatively more severe end of the scale the injury may progress from stress reaction within the bone to an actual stress fracture.

In the early stage of shin splints a runner will describe a pain that is present when the training run first begins, but then disappears as running continues. The pain will often return after exercise or the following morning. As the injury progresses the athlete will experience more time with the pain, and less time without it. There is frequently a tender zone along the medial edge of the tibia that one can map out by pressing with the fingertips as they “march up” along the bone. Eventually, if ignored and training continued, the pain may become quite sharp and may focus on a very small area of the bone. If this happens a stress fracture should be considered.

The treatment for shin splints is rest. Depending upon severity it is often necessary to completely stop running for a period of time. Generally this is done until day-to-day activities are pain free. When running is resumed – and this is where many injured runners make a mistake – it must be significantly different from the routine that lead to the injury. The concept of relative rest employs lengthening the interval between training as well as decreasing the volume and intensity of training. One can often substitute cross-training activities (e.g., bicycling) for running to help increase the interval between running days. There should be a graded and gradual increase in run training, keeping an eye out for the return of any shin splint symptoms.

Stretching and strengthening the calf muscles can help prevent the injury from returning. However the most important preventive strategy is not to repeat the mistakes that lead to the injury. Examine all the training variables – surface, shoes, training volume, intensity, workout type, hills, weather conditions, etc. Seek help from a qualified trainer or coach. This all takes time and effort, but it is well worth it.

Now skip on your heels

Once the skipping exercises are comfortable, try some light skipping on your heels. Gradually build up your ability to heel-skip with toes straight ahead, pointed out, and pointed in for 20 metres at a time. Heel skipping is a great way to build dorsiflexor strength, but carry it out only on a padded or grassy surface to avoid impact injury to your heels.

5. Once you've completed your walking, jogging, and skipping routines, it's time for rhythm bounding. This isn't the kind of bounding you're probably envisioning - we don't mean progressing forward with extra-long strides, at least not at first. Rather, you should jog along with very springy, short steps, landing on the mid-foot area with each contact and springing upward after impact. As you rhythm bound, your ankles should act like coiled springs, compressing slightly as you make your mid-foot landing and then recoiling quickly - causing you to bound upward and forward. Move along for 20 metres or so with these quick, little, spring-like strides, alternating right and left feet as you would during running. After 10 to 20 metres of regular jogging, rhythm bound for 20 more metres, alternating three consecutive spring-like contacts with the right foot with three with the left. After 10 to 20 more metres of regular jogging, close the set by bounding along for the full 20 metres on your right foot only, followed by 20 metres on the left (making certain that you land on the mid-foot area with each ground contact and that your ankle area, not your knee or hip, is doing most of the work). Make sure (at least at first) that all of this is done on a padded surface or soft grass. As you become stronger and more skilled, you can increase the length and amplitude (vertical height) of each bound and include additional sets of bounds (work your way up to four sets).

6. Complete some 'dorsiflexion bounces'. To do these, simply begin jumping vertically and repetitively at close to maximal height, landing in the mid-foot area with both feet and then springing upward quickly after each contact with the ground. The interesting part of this exercise is that you should dorsiflex your ankles - pulling the tops of your feet toward your shins - on each ascent, before plummeting back toward earth and plantar flexing your ankles just before making contact with the ground. Do 10 dorsiflexion bounces, rest for 10 seconds or so, and then repeat. Over time, you can add additional sets and increase the number of reps to 30. When you are really strong and skilled, perform this exercise on just one foot at a time, but only on a low-impact surface.

7. Finally, carry out rhythm bouncing. Rhythm bouncing is actually just jumping around, but what jumping! You should start with 10 jumps in place, moderately fast, with medium height, and with maximal motion at the ankles - but little flexion and extension at the knees and hips (over time, you can work up to 30 jumps). Then, after resting for a few seconds, change the amplitude (height) of your jumps to less than an inch, and complete 20 jumps as fast as you possibly can (pretend that your feet are hitting a hot stove - so that you must minimize your impact time with the ground). Again, almost all of the action should take place at your ankles, not at your knees and hips. As you become more skilled, work up to 40 quicksilver jumps.

After resting for a few seconds, complete five 'high-impact' jumps, increasing the amplitude (vertical height) of your jumping as much as possible. Over time, progress to 30 of these maxi-jumps.

So far, all of the rhythm bounces have been carried out in place, so make things interesting by jumping forward and then backward as quickly as possible. After you have made 20 'contacts' (each time your feet strike the ground is one contact), rest for a few seconds and then jump from side to side for 20 contacts. Rest again, and then jump in a direction which is about 45 degrees from straight ahead, alternating directions (first towards the right, then towards the left) for 20 contacts as you move ahead in a zig-zag manner. Remember to use your ankle muscles to propel you, not the big muscles at the knees and hips.

As you gain skill and strength, you can increase the number of sets of each type of rhythm bouncing from one to three, and then - the fun part - carry out each type of bouncing on one foot only. Moving in different directions as you bounce increases the ability of your shin muscles to handle all of the forces created during running - the side-to-side and rotational stresses, in addition to the less-overlooked front and back forces.

Other considerations

Of course, carrying out these exercises doesn't mean that your risk of MTSS is zero. If you suddenly change your weekly volume of running from 25 to 75 miles because you've been bitten by the marathon bug, for example, something will have to give, and it might well be your shin muscles and tendons. So, be certain to avoid dramatic changes in the frequency, volume, or intensity of your training; always gradually progress to more difficult levels of work.

Sports-medicine experts often recommend stretching the ankle area by slowly moving the ankle to 'each' end of its range of motion in the straight-back and straight-ahead plane, eg, to the fully dorsiflexed and then completely plantar-flexed positions, holding each position for anywhere from five to 60 seconds. The problem with that, of course, is that you are only stretching your muscles in one plane of motion and thus not adequately mimicking the stretching which takes place during running. At the very least, in addition to carrying out the plantar-flexed and dorsiflexed stretches, you should also stretch each ankle by fully rotating it outward and inward - and by plantar flexing and dorsiflexing the ankle while the foot is pointed both outward and inward to various degrees - not just straight ahead.

The experts also recommend strengthening the ankle area by adding resistance to the above stretching movements with the use of surgical tubing or elastic bands. That is indeed a way to increase general strength of the ankle, and it will certainly make you stronger when you carry out surgical-tubing exercises in the future. The problem, of course, is that you run with your feet on the ground - not poised in the air in the clutches of elastic bands. So, to fully prepare your ankles and shins for the rigours of running, you're better off focussing on the specific exercises we are recommending.

Does stretching actually help to prevent MTSS? No scientific evidence indicates that it does, but the idea that stretching might be protective is a logical one (overly taut muscles seem more likely to be damaged by pulling forces, compared to relaxed fibres). Don't stretch your ankle area until after your muscles are warm, however; a good time would be after a warm-up and/or at the end of your training session.

Other lower-leg injuries

Of course, all problems in the lower part of the leg are not necessarily examples of MTSS. In particular, two conditions - compartment syndromes and tibial stress fractures - can sometimes be confused with shin splints.

Compartment syndromes owe their name and origin to the fact that the leg muscles are not simply loose straps which run from bone to bone. In reality, the muscles are often grouped together into little sections of the leg which are enclosed by a tough wrapper of connective tissue. Such an arrangement of muscles tucked into a wrapper is called a 'compartment'.

During the act of running, excess fluid can build up within one of these compartments, putting pressure on muscle fibres, nerve cells, and blood vessels - and also causing a great deal of pain. Frequently, the pain will be so severe that a runner must curtail a workout or come to a standstill during a race. And the pain will usually be accompanied by the two telltale symptoms of a compartment syndrome - numbness and weakness.

Numbness occurs because the excess pressure within a compartment hampers the activity of sensory nerves carrying messages to the brain. As a result, the runner with compartment syndrome may lose feeling in the 'web' of the foot - between the first and second toes, or the insensitivity may extend up the foot toward the ankle. Weakness is experienced because motor nerves carrying impulses towards the muscles are also damaged by the high pressures within the compartment. If a compartment in the front of the leg is involved, a runner may have trouble dorsiflexing the ankle, and the foot may seem to flop loosely. In a posterior-compartment problem involving muscles in the back of the leg, there is often weakness when an individual tries to 'toe off'.

If you truly have a compartment syndrome, you will usually observe swelling in your lower leg which tends to subside when your leg is elevated. A doctor can tell for sure if you have this troubling problem by placing a catheter into one of your compartments and measuring pressure before, during, and after running (you will usually have to run long enough to produce pain during this test).

What about stress fractures?

Stress fractures are small breakdowns in bony tissue, and tibial stress fractures, which are sometimes confused with MTSS, are the most common of all stress fractures in athletes, accounting for about 50 per cent of the total. In addition to producing a lot of pain, stress fractures can actually progress into dislocation fractures, in which two parts of the bone actually separate. Stress fractures also may be 'warning signals' for an underlying nutritional or hormonal problem.

Unfortunately, traditional X-rays often fail to detect stress fractures, so a more costly procedure called a bone scan must frequently be performed to confirm the diagnosis. In a bone scan, radioactive material is actually injected into the blood. Bony tissue which is remodelling and rebuilding itself at the site of a stress fracture will accumulate more of this infused radioisotope, causing the affected bony area to show up as a dark splotch on a 'scintigram'. While it's often said that stress fractures take two to three months to heal, up to six months may be required to restore the bone to normal and remove most traces of pain, and a few athletes need more than a year to fully recover.

Sometimes called 'crescendo pain,' the agony associated with stress fractures tends to build up steadily during running, beginning as an annoying irritation and becoming a throbbing torment as an individual continues to run. There is usually little of the numbness, weakness, and swelling associated with compartment syndrome, and pain is usually not present when an athlete is at rest. Often, the bone will hurt when it is tapped near the damaged area, and occasionally a hard nodule will appear on the surface of the bone at the trouble site.

If you're diagnosed with a stress fracture, you should be sure to have a nutritional analysis carried out (your problem might be the result of inadequate calcium intake or poor calcium absorption). In addition, athletes who develop stress fractures should get their sex-hormone levels checked (adequate testosterone concen-trations in males and oestrogen levels in females are required for optimal bone maintenance).

How can you differentiate MTSS from stress fractures and compartment syndromes? The pain of MTSS is usually less localized, compared to stress-fracture pain (it tends to run up and down a region of the lower leg near the tibia), and usually can't be produced merely by tapping on the tibia. In addition, MTSS produces none of the numbness associated with compartment syndromes.

How long does MTSS last?

If you are unfortunate enough to come down with MTSS, your recovery period will usually last from one to six weeks, depending on how severely you are stricken. If you have a mild case of MTSS (your shin hurts moderately, and only after workouts), immediately cut your weekly mileage by about 30 per cent, and start doing our recommended exercises (we're assuming that your busy schedule prevented you from carrying out the routines faithfully, allowing MTSS to crop up). Start easily with the exercises, doing only one set of each, and stop if you feel any pain. Ice the affected area down thoroughly after activity, and of course keep the whole area as loose and flexible as possible. Within a week or two, you should be able to get back to your normal training, but be sure to carry out the shin-splints-preventing exercises steadfastly.

If you have a somewhat tougher case of MTSS (mild pain crops up during workouts but doesn't seem to slow you down much), trim weekly mileage by around 50 per cent, ice and stretch religiously, consider taking non-steroidal anti-inflammatory medications (but only if you are not prone to the gastrointestinal upsets which have been linked with these compounds), and become a devotee of our shin-strengthening exercises (start gradually with them, though, since they can further inflame tender shins if overdone). Use bicycling workouts to maintain fitness. In two to three weeks, you should be ready for regular training.

If your MTSS produces sharp pain while you are training, stop all running workouts, ice and stretch, take NSAIDS as directed by your doctor, and - when pain subsides - systematically begin utilizing our exercises, starting with a few two-legged wall shin raises at first and gradually progressing to the others. Use the exercise bike to maintain fitness, and return to normal training in four to six weeks.

Remember that if you carry out our shin splints treatment routine several times a week and refrain from making bizarre and sudden changes in your training, your encounters with MTSS should drop to a frequency rate of zero.

Owen Anderson and Walt Reynolds

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Shoulder Pre-hab

Here are some in depth articles on shoulder pre-hab:

Shoulder Savers part 1, 2 og 3

http://www.tmuscle.com/free_online_article...r_savers_part_i

http://www.tmuscle.com/free_online_article...8896ED288.hydra

http://www.tmuscle.com/free_online_article...savers_part_iii

[macholasse]

Achilles Tendonitis (Achilles Heel Pain)

========================================

Hi guys,

I have had Achilles Heel Problems for the last ten years and know I have finally found a solution.

I have written an article on the topic over at Ezinarticles.

http://ezinearticles.com/?The-Story-Behind-Eccentric-Rehab-Training---The-Number-One-Way-to-Treat-Your-Achilles-Tendonitis&id=5284645

Best!

Lars

__________________________________

http://www.achillestendonitisx.com

Edited December 11, 2010 by macholasse