Learning about shin splints and leg pain

Long distance runners are in the midst of both cross-country and marathon running seasons. Running on trails or asphalt can lead to lower leg pain. Shin splints, also known as medial tibial stress syndrome, is a general term used to describe lower leg pain.

The lower portion of the leg consists of two large bones: the tibia and the fibula. A membrane between these bones, the interosseous membrane and the anterior intermuscular septum, form four compartments. These compartments consist of an intricate network of muscles, arteries, veins and nerves that allows the ankle to move in multiple directions.

Shin splints are often associated with changes in running patterns. They can be attributed to using different types of footwear including excessively worn running shoes, rapidly increasing running distances and association with other injuries in the same or opposite extremity.

Compartment syndrome is among the most serious conditions that may be mistaken for shin splints. This syndrome consists of increased pressure within one of the four compartments of the lower leg. The increased pressure is a direct result of an injury causing swelling within a closed space.

The increased compartment pressure results in an inability for venous blood to drain and arterial blood to enter. The consequence is a lack of nutrients and oxygenated blood to muscles and nerves causing these tissues to atrophy and cease to function.

“The first step in treating shin splints is to find the cause,” reports Ms. Janeen Beetle, head athletic trainer at Norwich Free Academy. “Ice cup massage combined with anti-inflammatory medications provides the best treatment. Strengthening lower extremity muscles can help prevent recurrences.” 

Careful evaluation of lower leg pain can avoid serious complications.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

What does CTE really mean?

The recent information that former New England Patriots football player, Aaron Hernandez, was found to have evidence of Chronic Traumatic Encephalopathy (CTE) at autopsy has been followed by multiple opinions and at least one lawsuit.

Before drawing conclusions it is important to understand CTE and what the initial scientific studies really mean.

CTE is a diagnosis based on post-mortem findings of the brain. The diagnosis is actually a refinement of the previous findings of Dr. Harrison Martland, a medical examiner in Newark, N.J., who first described post-mortem changes in the brains of boxers in 1928.

A hallmark of CTE is the presence of tau protein, a substance that naturally occurs in nerve cells and appears to leak from the cells with repeated head trauma. The amount and distribution of the staining for tau coincide with the severity of CTE.

Although the predominant studies have been done on a group of deceased football players, many of whom have faced some life challenges, a direct causation between football and CTE has not been established.

One challenge with this condition is the fact that this can only be diagnosed after death. A study published last week in the journal PLOS ONE reports the identification of a potential biomarker to diagnose CTE in the living. The protein, known as CCL11, can be found in the spinal fluid of patients suspected of suffering from CTE.

It is important to note that no one has firmly linked the actions of someone with the CTE findings. The only thing we do know is that there are changes in the brain after repeated blows.

CTE research is ongoing and there is much to learn about chronic brain injury and its relation to sports. It is unfair and dangerous to make clinical assumptions that affect society and peoples’ lives at this early stage of investigation.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu






Ankle sprains becoming more common among athletes

As athletes are drawn to more extreme sports that involve increasingly challenging terrain, the frequency of ankle injuries increases. Depending on the severity, ankle injuries can require an extended period of rehabilitation.

The ankle joint is made up of three bones — the tibia and fibula that make up the lower part of the leg and the talus that is part of the foot. A complex network of ligaments that allow the foot to bend upward and downward holds the joint together.

The principal mechanism of injury involves a forceful overpowering of the ligaments in a variety of directions. This type of injury is known as a sprain. The most common ankle injuries are the inversion, eversion and high ankle sprains.

The inversion ankle sprain is the result of suddenly turning the foot inward and damaging the ligaments on the outside of the ankle joint. An eversion sprain is the consequence of the foot turning outward and stressing the ligaments on the inside of the ankle.

A high ankle sprain is the result of injury to the ligaments that attach the tibia and fibula. It is caused by the sudden rotation of the foot outward.

The best treatment approach to an ankle sprain is the RICE protocol (Rest, Ice, Compression, Elevation). Reducing blood circulation to ligaments diminishes the availability of factors that aid healing.

“Sprains can take a long time to recover,” states Dr. Lauren Geaney, Assistant Professor of Orthopedic Surgery at the University of Connecticut, who specializes in foot and ankle injuries. “Ice and elevation in the early stages and early mobilization and strengthening as soon as the swelling and pain allow. Surgery is rarely needed and almost never indicated during early recovery.”

Appropriate treatment of ankle sprains can avoid having them develop into a chronic problem.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu.

Ex-UConn, sports medicine doctor will be missed

Last week, with the sudden passing of Dr. Jeffrey Anderson, the UConn athletics family and athletes everywhere lost a compassionate physician and strong advocate for health and safety in sports. Dr. Anderson was head team physician for UConn from 1993-2014. He left that position to take on the challenges of directing student health services at UConn while serving as the impartial administrator for Major League Baseball and the Major League Baseball Players Association Joint Drug Prevention and Treatment Program.

Dr. Anderson graduated from the University of Michigan Medical School, where he did his residency in Family Medicine. This provided him with a broad medical background that he decided to apply to sports medicine. He did a fellowship in Primary Care Sports Medicine (PCSM) before taking the position at UConn.

PCSM, a relatively new field thirty years ago, has continued to grow and attract many bright young physicians. Prior to the increased involvement of primary care physicians, orthopedic surgeons managed most of sports medicine.

The increasing complexities of sports performance have resulted in the expansion of the sports medicine team. Dr. Anderson saw the need before others and invited a variety of specialists to join him including this writer.

PCSM fellowships are open to physicians who have completed residencies in family medicine, emergency medicine, pediatrics or internal medicine. The principal focus of these specialists is non-operative orthopedic problems and general medical conditions.

Another crucial role of the PCSM physician is preventing injury. This often involves counseling athletes and creating an effective rehabilitation program.

Knowledge of performance enhancing drugs and how they are used has become another important facet to PCSM. In many of these situations athletes are trying to gain an edge by taking supplements that unknowingly contain banned substances. These circumstances can only be avoided by education.

Dr. Anderson was masterful at treating and protecting athletes while providing an example for other physicians.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu.






Health protocols vital for scholastic sports

Millions of students will be returning to scholastic sports in the coming weeks. Reducing the risk of catastrophic injury is a priority for everyone involved in sports.

The most common causes of sudden death in athletes are cardiac, neurologic and heat-related. Measures to minimize tragedies associated with these conditions include effective screening of athletes and the availability of established protocols with appropriate resuscitative equipment in the event of an emergency.

Cardiac conditions can be effectively screened based on careful evaluation of symptoms and testing performed on athletes who have a significant personal or family history of cardiac arrhythmias. The availability of an AED (automated external defibrillator) at all athletic events has proven to be lifesaving.

Traumatic brain injuries result from high-velocity impact causing hemorrhage and swelling in the brain. Recognizing the signs and symptoms of this injury and taking immediate steps can avoid a tragedy. Any athlete who sustains head trauma should be removed from play and evaluated.

Exertional heat stroke occurs when the body temperature reaches 105 degrees Fahrenheit. Symptoms include confusion, lightheadedness and headache. If untreated, persistent hyperthermia will result in coma and death.

One effective way to avoid these catastrophes is to have appropriate protocols and policies in place. Among these are emergency action plans (EAPs) that apply to each situation.

In a recent report published in the Orthopedic Journal of Sports Medicine, Connecticut ranked 38th in a survey of all states with respect to having the proper protocols in place.

“EAPs are a no-cost way to facilitate communication across all key stakeholders for athletics programs and reduce critical delays in care for athletes,” reports Samantha Scarneo, Director of Sport Safety at the Korey Stringer Institute at UConn and one of the study’s authors.

Every school should have a plan that can be easily put into action to deal with medical emergencies on the athletic field.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

New CTE study provides uncertain link to football

A recent study published in the Journal of the American Medical Association-Neurology looks at the first large-scale study of the brains of deceased American football players. This study has attracted the attention of the media and comes at a time when parents must decide whether to permit their children to play football this season.

The study reports the results of neuropathological and clinical studies performed on 202 football players. The athletes studied played at multiple levels of competition: 14 high school, 53 college, 14 semiprofessional, eight Canadian Football League and 110 National Football League.

The principal neurological condition studied was Chronic Traumatic Encephalopathy (CTE). This entity has been studied in a variety of forms since Dr. Harrison Martland published his original studies in JAMA in 1928 titled “Punch Drunk.”

In 2009, Dr. Ann McKee and her colleagues at Boston University published a seminal paper in the Journal of Neuropathology describing CTE in three professional athletes. That same group published this most recent study. The pathology in CTE is based on brain atrophy and the deposition of tau protein. Tau protein is a normal constituent of the brain that is believed to leak after trauma.

Clinical findings in CTE are primarily changes in behavior, motor abnormalities and dementia. These features can be present in isolation or in total. Several of the athletes studied committed suicide.

The recent study reports an escalating frequency of CTE based on the level of football played. The percentage of players affected increased from 21 per cent of high school players to 99 per cent of NFL players.

Although this study demonstrates an association between CTE and football it does not prove that football is the cause of this condition. Among the faults in this study is “selection bias.” This refers to the fact that the only athletes who volunteered were those who had clinical symptoms. Healthy football players who went on to successful careers and stable family lives were not part of this study. 

Unfortunately, this study provides little direction for parents who are faced with a difficult decision. Several important factors to consider are whether a child has had previous concussions, if the child is of high school age and how important playing football is to the child’s overall well being.

Football is a great sport but parents must make responsible decisions regarding participation in any high-velocity collision sport.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

MMA fighters risk lives during bouts

Recent deaths during combat sports events have attracted the attention of fans and officials. The circumstances surrounding these catastrophes require further review.

As opposed to boxing, Mixed Martial Arts allows the application of multiple fighting disciplines including: wrestling, judo, Brazilian Jiu-Jitsu, boxing and Muay Thai kickboxing. The variety of these skills has helped attract fans who follow and participate in these martial arts primarily for fitness and self-defense.

Unfortunately, the operative word in these contests is “combat” and it is meant to be taken literally. These amateur and professional fighters are placed in a situation where the body invokes the “fight or flight” response. This reflex causes the heart to race, muscles to tighten, blood pressure to rise and glucose to elevate. Essentially, these changes prepare the human body for battle. This level of stress demands that the athlete be in excellent condition.

Since 2007, at least 15 MMA fighters have died either preparing for or during a contest. Two of those deaths have occurred in the last six weeks.

Tim Hague, an MMA fighter, died in a boxing match in Edmonton, Alberta, after a punishing blow resulted in a brain hemorrhage. Donshay White died of what is believed to be a cardiac event after an amateur MMA event.

Pre-fight medical requirements vary among states and Native American tribal jurisdictions. Although not perfect, these studies are important to screen for potential tragedies. 

“Deaths in combat sports are unfortunate occurrences. Uniform medical requirements across all state and tribal commissions must be established,” reports Mr. Michael Mazzulli who heads the Mohegan Tribe Department of Athletic Regulation and currently serves as president of the United States Association of Boxing Commissions. “In Connecticut, the medical regulations are identical for the State, Mashantucket-Pequot and Mohegan commissions.”

Despite its popularity, participants in MMA contests must realize that potential death is a very real risk.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

Patellar tendon injuries are more common than you think

Dustin Fowler recently made his major league debut in the outfield for the New York Yankees. Unfortunately, his appearance was cut short when he ran into a wall trying to make a play. As a result, he suffered an open rupture of his patellar tendon requiring urgent surgery and months of rehabilitation.

Although rupture is uncommon, injuries to the patellar tendon are often seen in athletes. The patellar tendon is the principal connection between the patella (knee cap) and the tibia. The fact that it connects two bones actually makes it a ligament by definition.

The quadriceps tendon attaches the quadriceps muscle to the patella. Together with the patellar tendon, it plays a crucial role in the extensor mechanism of the knee. This provides stability when the leg is straightened. Weakness and swelling from sprain or rupture will result in a loss of power when extending the leg and potentially the leg collapsing.

Early symptoms include knee pain that worsens with any exertion. This increasing discomfort is often a warning to an impending rupture. An athlete should begin a regimen of rest, ice and possibly anti-inflammatory medications. If the inflammation becomes chronic the tendon will lose elasticity over time and lead to tearing and rupture.

“Common scenarios for injury include: a misstep when going downstairs, stepping into a hole unexpectedly, or slipping on wet grass in which one leg has to sustain body weight,” states Dr. Cory Edgar, Assistant Professor of Orthopedics at the University of Connecticut and Head Team Physician at the Coast Guard Academy.

“The good news is rupture of the patellar tendon is very easy to repair surgically but requires 3-6 months of recovery during which the first 2-3 weeks are very limiting.”

In the case of Dustin Fowler, the rupture was the result of direct trauma without warning signs. Careful attention to knee pain on exertion can avoid serious injury.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

Hip pain in athletes not easy to diagnose

Hip pain is a frequent injury in athletes who participate in sports requiring running and jumping. The variability of presenting symptoms and pathology make correct diagnosis and treatment a challenge. 

The hip joint is a ball and socket joint between the femur (thigh) and the pelvis. The head of the femur articulates with the acetabulum of the pelvis.

The pelvis is made up of three bones: the ilium, ischium and pubis. These bones come together in the acetabulum. A cartilaginous rim around the acetabulum called the labrum holds the femur in place.

A complex network of ligaments, nerves and blood vessels holds this joint together. Injury to any of these structures can result in pain that is often difficult to localize.

Athletes typically suffer from a variety of overuse syndromes of the hip. The pain in these syndromes is the result of inflammation, arthritis and fractures. Hip pain in young athletes is often related to overuse and can lead to lifetime difficulties unless activities are restricted.

Direct trauma to the pelvis can result in hip and pelvic fractures. A “hip pointer injury” is often seen in high-velocity collision sports like football and hockey when a blow to the rim of the pelvis results in hemorrhage.

Hip pain can also be referred to the low back and be mistaken for a spine injury. Only after careful examination by a qualified physician can the differential be clarified.

“The treatment of hip injuries in elite and recreational athletes is finally beginning to catch up to the treatments we know are routinely successful for shoulder and knee injuries,” reports Dr. Michael Joyce, Co-Director Connecticut Sports Medicine Institute. “Minimally invasive arthroscopic procedures allow athletes the potential to come back from injuries that were once considered career-ending.”

Early diagnosis and treatment are critical to resolving hip pain in athletes.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu

Be wary of skin conditions during summer sports

Summer sports present new challenges for protection from skin conditions that can potentially affect athletic performance. Specifically, sunburn and skin cancers have become increasingly troublesome. 

The human skin constitutes the largest organ in the human body. It is designed to protect the body from harmful microbes. It also has a system of glands, nerves and blood vessels that allow the skin to regulate temperature.

The skin is divided into three levels: the epidermis, dermis and hypodermis. The epidermis is the outermost layer that provides a barrier against the elements. The dermis contains the sweat glands, hair follicles and connective tissue. The hypodermis consists of adipose tissue that insulates the human body. Blood vessels dilate and constrict to allow for cooling and warmth.

Chronic and acute exposure to harmful ultraviolet rays will result in skin damage. Acute damage typically appears in the form of a burn with reddening of the skin and blistering. This leads to pain and the blisters create the potential for infection.

Chronic exposure can result in skin cancer. Skin cancer is the most common form of cancer in the United States, affecting one in five Americans according to the American Academy of Dermatology. 

Basal cell carcinoma and melanoma may be prevented through the use of lotions containing an SPF (skin protection factor) of 30 or greater. Athletic clothing should have a UPF (ultraviolet protection factor) of 50 or more.

“Most skin conditions that come as a result of summer sports can be prevented if precautions are taken ahead of time,” reports Dr. Jennifer Pennoyer, a board certified dermatologist practicing at Pennoyer Dermatology in Bloomfield. “Anticipating potential exposure as well as regular skin checks can avoid a lot of anguish.”

Athletes rely on skin and sweat glands to regulate large variations in climatic conditions during workouts. Skin care can keep an athlete competing longer.

Dr. Alessi is a neurologist in Norwich and serves as an on-air contributor for ESPN. He is director of UConn NeuroSport and can be reached at agalessi@uchc.edu