Vary your workouts to avoid compartment syndrome

The intense feeling of aching pain in a limb during exertion is a common complaint.  When the pain is easily replicated with progressively less exertion, a compartment syndrome should be considered.

A syndrome is a group of symptoms.  In chronic exertional compartment syndrome the pain may be burning or cramping in nature along with tightness, weakness or numbness in the affected limb.  These symptoms typically clear within 30 minutes of rest.

Although most common in the lower extremities and associated with running, it can also affect the upper extremities.

Muscles provide the engine behind motion.  They are fueled by a steady supply of blood and stimulated into action by nerves.  When injured, a muscle will swell and unless the connective tissue that provides an envelope around a muscle expands, pressure will build up within the muscle. The increased pressure can cause nerve damage and muscle breakdown.

Compartment syndrome is most commonly seen in athletes under the age of 30 who participate in sports that involve repetitive impact.  Athletes who use supplements like anabolic steroids or creatine are especially vulnerable.

Adequate warm up, hydration and resting if pain becomes intense are all ways of avoiding this condition.  Varying workouts and the mechanics involved in a particular sport will decrease the repetitive trauma and allow for muscular recovery.

“Symptoms of chronic exertional compartment syndrome may be relieved by decreasing the intensity and impact of training,” said Dr. Giselle Aerni, a sports medicine physician at the University of Connecticut and team physician for the Connecticut Sun.  “If symptoms persist, surgery may be helpful to release the fascia surrounding the muscles to allow more room for swelling,” said Aerni.

If surgery is necessary, it should be carried out by a physician who treats athletes and can help guide the athlete back to safe participation in a particular sport.

Children with ADHD can excel when the right choices are made

Among the most inspiring stories in sports involve those where an athlete is forced to overcome a physical disability.  Special Olympics, Paralympics and other events celebrate these physical challenges.  Unfortunately, athletes who suffer from Attention Deficit Hyperactive Disorder (ADHD) face less obvious obstacles in life and in sports.

ADHD is a chronic condition that includes difficulty maintaining attention, hyperactivity and impulsive behavior. It is believed to affect as many as ten percent of children in the United States.  Although children with ADHD are a major concern, these symptoms may persist into adulthood.

There are varying levels of severity of ADHD.  Some patients require medication while others respond to behavioral therapy alone or a combination of both.

The most effective medications for the treatment of ADHD are psychostimulant medications like Ritalin and Adderall.  These medications serve to balance the concentration of neurotransmitters in the brain.

Sports can play an important role in development.  Physical fitness, team interaction, discipline and strategic planning are all valuable lessons.  Choosing an appropriate sport for a child with ADHD may avoid frustration and anxiety.

High velocity collision sports and combat sports like football and boxing should be avoided.  Recent studies have shown that athletes with ADHD have more severe symptoms and longer recovery periods from concussions.

Sports that rely on individual effort for success are best suited for children with inattention and impulsivity like those who suffer from ADHD.

Swimming, running, gymnastics and tennis demand individualized attention by an athlete.  This allows coaches to modify workouts that will suit each child and create an environment for maximum enjoyment and success.

Judo, karate and other martial arts are among the best activities for children with ADHD.  These sports emphasize coordination, balance and strength.

Organized sports and fitness provide an essential component to child development.  Children with ADHD can excel when the right choices are made.   

Epilepsy can be managed with proper attention to detail

University of Minnesota head football coach Jerry Kill recently had an epileptic seizure on the sideline.  While this isn’t the first time it has happened, it is the first time this event has gained national attention.

The brain consists of a network of nerve cells that function similarly to a mass of electrical wires.  Electrical impulses are the result of changes in the balance of chemical ions along the nerve cells.

A generalized tonic-clonic seizure, previously referred to as grand mal, is an event that results from an abnormal spark along these nerve cells.  This creates a short circuit that spreads across the brain causing muscles throughout the body to contract uncontrollably.

Epilepsy is best defined as a condition of unprovoked recurrent seizures.  It affects 3 million Americans.  Controlling epilepsy is accomplished through the use of medications, lifestyle changes and possibly surgery. 

The human body functions best when it reaches a state where everything is kept constant.  That means eating, sleeping and exercising at the same time every day.  Unfortunately, this presents a great challenge to controlling seizures in patients who have erratic schedules, including athletes and coaches.

The recent episode that involved Jerry Kill drew the attention of the press and fans, but his players and coaches were able to adjust and proceed with the game.  This is due to the fact that he has been open about his condition and prepared them for this situation.

“How can a school continue to employ a football coach who has had four seizures during or after the 16 home games he has coached for the school?” wrote Jim Souhan, a Minneapolis sportswriter.

Souhan’s insensitive comments have raised the attention of many regarding epilepsy in athletes. 

In order to more effectively manage epilepsy, athletes and coaches must carefully monitor workout, sleep and travel schedules.

The pitfalls of "cutting weight"

Losing dramatic amounts of weight prior to an athletic event has become a common practice in some sports.  Unfortunately, “cutting weight” can be a deadly practice.

In sports where an athlete’s weight determines the level of competition, losing weight in order to compete at a lower weight class has become a strategic move.  The goal is to lose weight for the weigh-in and then gain the weight back before the event.

Wrestling, rowing, boxing and mixed martial arts (MMA) are sports where this dangerous practice has become an acceptable part of preparation.

Human physiology is based on a delicate balance of fluid and electrolytes that allow vital organs to function efficiently.  Large shifts of fluid and electrolytes disrupt this balance, resulting in organs shutting down.

Common symptoms include dizziness, weakness, nausea, confusion and heart palpitations.  Physical signs of rapid pulse, low blood pressure and concentrated urine are indicative of impending danger.

Dehydration and rehydration over a short period of time raises the chances of severe brain injury.  This is especially dangerous in combat sports like boxing and MMA where head trauma is common.

A recent MMA weigh-in at the Mohegan Sun Casino emphasizes the problem.  Two athletes arrived at the weigh-in with clear signs that they had cut weight. The medical staff and Department of Athletic Regulation, in cooperation with the promoter, took the rare action of cancelling those bouts.  Those athletes lost an opportunity to earn a significant purse.  One athlete landed in a local emergency room with kidney failure.

"It is imperative that sports which utilize weight classes also utilize a hydration check at weigh-ins to assure that athletes do not reach dangerous levels of dehydration in order to make weight,” said Dr. Douglas Casa, professor of kinesiology at the University of Connecticut and an expert in the field of hydration in sports.  “The recent cancellation of MMA events at the Mohegan Sun highlight the risks associated with this,” said Casa.

Education of athletes about the dangers of cutting weight can be lifesaving.

Diagnosing numbness has its challenges

Numbness is among the most difficult problems for a physician to evaluate.  It is an equally daunting task in sports medicine.

The vagueness of the complaint makes numbness a challenge to assess.  It can represent sensory loss or distortions of sensation like “pins and needles,” “burning” and “crawling.”

A 23-year-old, left-handed pitcher presented with a chief complaint of left hand numbness.  His symptoms included an “electrical shock” sensation that radiated from his elbow to the fourth and fifth digits of his left hand.  His symptoms only came on when throwing a “change up.”

After further questioning, he has a unique throwing motion when finishing this pitch that places an unusual amount of torque on his elbow.

A neurological examination combined with electrodiagnostic testing demonstrated that he was suffering from an injury to the ulnar nerve at the elbow.

The ulnar nerve originates from the cervical nerve roots, proceeds down the arm and over the extensor surface of the elbow before terminating in the fourth and fifth digits of the hand. 

It is the only nerve positioned over an extensor surface where it is vulnerable to pressure as opposed to other nerves that are located on more protected flexor surfaces.

Most people have experienced temporary ulnar sensory symptoms when hitting their “funny bone.”

Nerve injuries can result from mild compression, more severe prolonged compression or complete severing of the nerve.

The pitcher noted above improved with rest, physical therapy and changing his throwing mechanics.  Sometimes athletes who ignore their early symptoms often require surgery to remove scar tissue or move the nerve to the flexor surface.

This case demonstrates the need for some detective work when dealing with vague complaints.  A patient who carefully observes actions that worsen or improve a condition can expedite a correct diagnosis and early recovery.

Learning the hard way about protecting the brains of athletes

Former boxing champion Emile Griffith recently passed away at the age of 75.  He died while living in a nursing facility where he required full personal care.  He suffered from dementia pugilistica.

Dr. Harrison Martland first described “dementia pugilistica “ (boxer’s dementia) in 1928 while working as a forensic pathologist in Newark, NJ.  He reported consistent changes in the brains of fighters on whom he had performed autopsies.

Now known as Chronic Traumatic Encephalopathy (CTE) this form of dementia is accompanied by disorders of movement similar to Parkinson’s disease as well as dramatic changes in personality.

CTE is not restricted to combat sports like boxing and MMA but is also seen in participants of high velocity collision sports like football and hockey.  Repeated blows to the head will alter the function of the complex network that allows for normal neurological function.

Neurologic research has now centered on trying to determine why some athletes will develop CTE and others will not.  Imaging studies of the brain and genetic testing have thus far failed to provide a reliable screening tool for athletes.

Studies have shown that young, developing brains are more vulnerable to traumatic injury from concussive blows. These injuries can result in chronic headaches and learning disabilities if they are not managed properly.

The most important approach to treatment is removing the athlete from an athletic contest to avoid further injury.  A period of rest that includes avoiding reading, computer work and texting allows the brain to recover.

On Aug.  8, Backus will host an educational session for parents, coaches and officials involved in youth sports events.  Anyone interested in participating should contact Backus Hospital at 860-889-8331, ext. 4211 for details. 

The single most effective way of dealing with this potentially disabling problem is through education.

Ultrasound technology growing in sports medicine

The use of ultrasonic sound waves to produce images of structures deep within the human body is very common. Applying this technology to the diagnosis and treatment of sports injuries is gaining popularity.

On my most recent trip to Haiti, I was asked to participate in a series of lectures sponsored by the American Medical Society for Sports Medicine for the Haitian Olympic Federation.  Among the other faculty members was Dr. Thomas Trojian, a primary care sports medicine specialist and associate professor at the University of Connecticut. 

Dr. Trojian finds ultrasound to be an important part of his practice.  “Ultrasound is an emerging imaging study that provides a new dimension to the physical examination of athletes,” said Trojian.

The science of acoustics has fascinated scientists since ancient times.  Over the past 60 years, ultrasound has gained popularity in medical imaging.

Ultrasound can provide increasingly detailed studies of soft tissue within the human body.  In utero, pictures of fetuses have become so refined that they allow physicians to perform corrective procedures at this early stage of life.

In sports, ultrasound produces dynamic images of tendons and muscles as a limb or appendage is moving.  This is a distinct advantage over the static (non-moving) images seen in X-ray, CT or MRI.

In sports, these images can specifically demonstrate tears, inflammatory changes or bleeding within muscles and tendons.  One great advantage is that ultrasound does not expose the patient to radiation therefore making it safe to use in young athletes.

Most recently, ultrasound is being used to guide the placement of therapeutic injections to areas of injury resulting in pain relief and rapid healing.

Ultrasound provides a safe office-based technology to get injured athletes at any level back to their sport sooner. 

Time to rethink how to protect young pitchers

Among the most dreaded scenes to witness in sports is a baseball player, coach or fan being struck in the head by a line drive.  The damage that results from being struck by a ball coming off a bat can be very serious and even deadly.

Recently, baseball fans witnessed two pitchers, J. A. Happ and Alex Cobb being struck in the head by line drives.  To many, it was the sound of the ball striking the skull that was most upsetting.

One of the most severe injuries happened last September when Brandon McCarthy, a pitcher for the Oakland A’s, was struck in the head by a line drive that resulted in a fractured skull and hemorrhage that required surgery.  This June he suffered a seizure while in a restaurant and currently requires anti-convulsive medications.

It is no secret that athletes have become bigger, stronger and faster.  While this is a big concern in high-velocity collision sports like football, it is also a factor in baseball.  A baseball typically leaves the wooden bat of a major league baseball player at approximately 100 miles per hour (faster with a metal bat).

The human skull is made of bone and is designed to protect the brain and the blood vessels that supply the brain.  A direct blow to the skull can result in fracture and tearing of these blood vessels. It may also cause a shearing of nerve cells with subsequent long-term symptoms of concussion including headache, dizziness, nausea and confusion.

The challenge at this time is how to protect the brains of pitchers at all levels of play.  The obvious answer is to have pitchers begin wearing helmets.  Many pitchers find this impractical, but newly available Kevlar and gel liners that fit into a standard baseball cap may be a partial solution.

Cycling helps maintain fitness for active seniors

As the baby-boomer generation reaches older age, the number of athletes over the age of 65 will continue to grow.  Among the sports most attractive to seniors who wish to remain active is cycling.

Riding a bicycle is among the earliest activities children learn. It helps to develop agility and coordination through the use of training devices and eventually two wheels.  As adults grow older, these same skills deteriorate.

Specifically, the cerebellum is the principal area of the brain responsible for coordinating movement.  A network of nerve cells that begins in the limbs and extends through the spinal cord to the brain carries crucial information to the cerebellum.  That information is shared with other regions of the brain resulting in balance.

Through activities like cycling, yoga, tai chi and ballroom dancing, humans are able to refresh these pathways.  Older athletes participating in any sport are faced with physical challenges.

Cardiovascular fitness is an issue that should be addressed before beginning any sports activity.  Every athlete should discuss the new activity with their personal physician although many who are older than age 45 should consider a stress test before participation.

Musculoskeletal problems are a consideration for every master-level athlete.  Muscle, tendon and ligamentous injuries are common but in many cases avoidable through adequate pre-activity stretching.  When cycling, using low-resistance gears for the first several miles and avoiding the temptation to push against high-resistance may avoid injury.

Urogenital issues including genital numbness, erectile dysfunction and elevations of prostate-specific antigen (PSA) are related to hours spent on the bicycle saddle. Proper fitting for this essential part of a bicycle should be carried out with the help of a bicycle sales expert.

Bicycling may be a way back to a healthier and longer life but based on years of data from trauma centers around the country, it may all end in tragedy unless a helmet is worn.

Rowing fitness provides high intensity workouts in a limited time

Fitness enthusiasts often face the challenge of balancing sufficient workout time with work and family obligations.  One potential option is rowing.  As one of the oldest competitive sports, rowing uses multiple large muscle groups to attain an excellent workout in a short period of time.

The Yale-Harvard rowing regatta was first held in 1852 and is the oldest intercollegiate sporting event in the United States.  On-water rowing consists of sweep rowing (both hands on one oar) and sculling (one oar in each hand).

In 1981, Concept 2 produced an indoor rowing machine that revolutionized training and helped many athletes gain the fitness benefits of rowing.

Workouts, both on and off water, consist of short intense sprints and longer, moderately paced sessions.  Due to the intense cyclic exercise of major muscle groups and the aerobic demands, rowing results in superior cardiovascular endurance.

Cardiac ultrasound studies of elite rowers demonstrate increased cardiac muscle mass.  These studies show the ability of a trained heart to pump more blood with less effort.

The rowing stroke starts with an explosive pushing-off motion by the legs, extending the back and pulling the oar through with the arms at the finish.

Rowing injuries most commonly affect the low back, upper and lower extremities.  The action of the low back moving from flexion to extension against resistance puts tremendous torque on the ligaments, muscles and discs.  This can result in sprain, strain and disc herniation.

Upper extremity injuries from rowing are a result of overuse.  Joints become inflamed causing bursitis and tendonitis.

The most common lower extremity joint injury affects the tendons holding the patella (knee cap) in place.  Rapid extension of the knee can cause the patella to divert from its usual track resulting in tendon pain.

Rowing is a sport worth exploring when looking for an intense workout in a limited period of time.

Mackey-White Committee delves deeper into head trauma

The potential for injury while participating in violent collision sports has become more apparent in recent years.  Athletes are now bigger, stronger and faster since the inception of sports like football and hockey.  The problem is clear but the solution is not.  The Mackey-White Traumatic Brain Injury (TBI) Committee is making an effort to solve this problem.

Named after NFL Hall of Fame players John Mackey and Reggie White, the committee was established in 2009 under the direction of the National Football League Player Association (NFLPA) Executive Director DeMaurice Smith.

"The Mackey-White Committee is the forum which helps guide the NFLPA on workplace safety and the health of our players,” said Thom Mayer, the NFLPA medical director.  “While it originally focused on concussions and traumatic brain injury, its scope now encompasses all aspects of player safety.  Its membership comprises a "Pro Bowl" team of physicians, scientists, and current and former players whose work has been extremely impressive," said Mayer.

Among the most productive features of the meeting is discussion with current and former athletes, some of whom suffer from the chronic effects of TBI.  One request is to protect athletes from themselves when they make bad decisions to keep playing after brain injuries.

Positioning neurologists and other sports concussion experts on each sideline during games is one recommendation that is still being considered by the National Football League.  At collegiate and youth levels of the sport, a recent study confirmed that the association of a licensed health care professional with a team improves the diagnosis and recovery from concussion.

Empowering on-field officials to report concussion and remove injured athletes from play has already been productive.  Instituting a “battle buddy” program that has helped military personnel is under consideration.

It has become clear that football must continue to evolve in order to continue its current level of popularity.

The long road ahead for Kevin Ware

Many Americans recently witnessed one of the most gruesome sports injuries during this year’s NCAA basketball championship.  Kevin Ware, a guard for the University of Louisville, shattered his right lower leg leaving the bone protruding through the skin.

The tibia and fibula are the bones that make up the lower leg.   The tibia is larger and is subject to the most pressure. These bones provide support for the muscles that allow ankle mobility.

Bones consist of two principal components. The outer, cortical layer consists of dense, compact bone.  The inner, trabecular portion of bone is less dense and consists of a porous structure that contains blood vessels and bone marrow. Bone is primarily made up of calcium phosphate.  The structure of bone allows excellent resistance to compressive forces with poor resistance to torsional pressure.

Despite intense physical training, fractures are not uncommon in athletes due to demands placed on the skeletal system and previous injuries that result in micro fractures.  Vitamin D deficiency is another potential risk factor in the general population as well as in athletes.
The injury suffered by Kevin Ware involved multiple forces.  Landing firmly on the foot produced a compressive, vertical force on the tibia.  Unfortunately, there was also an angular, horizontal force that produced torsional pressure.  This combination resulted in a severe, displaced fracture.

The injury was further complicated when the fractured bone tore through the skin.  A compound fracture like this now creates an opportunity for infection.

Treating a fracture like the one suffered by Kevin Ware consists of immediately protecting the open wound to avoid infection and immobilizing the limb so that the sharp bone edges do not tear into vital blood vessels and nerves.

Surgical repair includes connecting the fractured segments and allowing them to fuse.  Early, partial weight bearing will hasten the healing process and allow rehabilitation to begin.

After witnessing the injury suffered by Kevin Ware, it will be exciting to follow his recovery and return to playing basketball at a high level.

Guidelines for protecting the brain

Concussion is a group of symptoms that result from an injury to the brain.  The injury may occur after impact to the brain from an outside force or the brain striking the inner skull.  It affects between 1.6 and 3 million American athletes each year.

The American Academy of Neurology first published a series of guidelines for the evaluation and management of concussion in athletes in 1997.  Over the course of the past 15 years much has been learned on this vital topic.

Last week, this same group published the most comprehensive scientific review of concussion in sports that has ever been undertaken. This multi-disciplinary study looked at over 14,000 published studies from 1955 to 2012. The reviewers included neurologists, psychologists, physiatrists and athletic trainers.

The original guidelines were based on a grading system with the mildest being a grade 1 and most severe grade 3.  The current information shows that each patient who suffers a concussion has to be treated individually.

Some of the most important conclusions from the study include:

•  The presence of a licensed health care professional with experience diagnosing and treating concussion at an athletic event improved early recognition and recovery.
•  A concussed athlete was at greatest risk for a second concussion within 10 days of the first injury.
•  Body checking in youth hockey, hockey players wearing half visors, quarterbacks and any athlete playing on artificial turf is more susceptible to having a prolonged recovery period after concussion.
•  Male athletes playing football, Australian rugby and hockey were most susceptible, while soccer and basketball had the highest risk for females.
“The most effective treatment for concussion continues to be removal from the game as soon as a concussion is suspected,” said Dr. Jeffrey Kutcher, one of the principal authors of the study.

This review not only presents new information but confirms the slogan that “when in doubt, sit it out.” 

The power of teamwork

The concept of “team building” is often used in the business environment.  It best applies to bringing together a group of people with a singular purpose.  In sports that purpose is usually a championship but it is often the events that lead up to attaining that goal that are most significant.

This week the Healthy Sports spring training tour is in full swing and one story that seems to dominate the headlines is the New York Yankee injury roster.  Six of the top nine productive players are either injured or recovering from an injury.  Some sports pundits are already predicting a last-place finish.

The only place where these dire predications are not being heard is among the Yankees themselves.  Instead, they have chosen to remain positive and confident that they will win another championship.

That same positive team approach also has great value when facing a health-related problem.

Recently, TV viewers have been able to witness the recovery of anchorwoman Robin Roberts from a bone marrow transplant.  The transplant was necessary after her previously successful battle with breast cancer.  A team of doctors, nurses, family members and close friends was carefully assembled for the long ordeal.  Their principle job was to provide encouragement and remain positive throughout the ordeal. 

It is no coincidence that Roberts was previously an outstanding college basketball player and ESPN host who understood the importance of having the right team in place.  In fact, studies have shown that patients who have a support team are more successful in conquering an illness and those who face a terminal condition have a better quality of life in their final days.

Little league baseball season is about to begin and for many children this will be their first experience with the concept of a team.  It is the responsibility of the adults involved to make sure that their experience is one that will serve them for the rest of their lives.

Too early to link tau proteins to dementia

Many scientific studies present initial data that can provide a promising basis for future experiments.  Unfortunately, those studies are often misrepresented in the popular press and falsely raise the hopes of affected individuals.

In a study published this week in the American Journal of Geriatric Psychiatry researchers performed PET scans on the brains of five former NFL players.  The results indicated that the tau protein, believed to be responsible for chronic traumatic encephalopathy (CTE), could be identified in living subjects.  Tau could previously only be identified by staining brains recovered at autopsy.

CTE was actually first described in 1928 based on studies of deceased boxers.  It was called “Dementia Pugilistica” or “Boxer’s Dementia.”  Modern staining techniques have identified the deposition of the tau protein in certain areas of the brains of athletes who have suffered repetitive brain trauma.

The clinical presentation of CTE consists of cognitive decline, personality changes and movement disorders.  Although there is a clear correlation between tau protein and CTE, not everyone who has tau protein also has the syndrome of CTE.

The current report gives the impression that the scan performed as part of the research can now identify patients who will develop dementia.  This is not true and very misleading.

“Tau can be a marker of the presence of disease but may not be a biomarker of disease activity. Placing too much emphasis on a marker of disease as a true biomarker without years of clinical disease correlation may lead to treating a finding without clinical relevance,” said Dr. Kevin Crutchfield, a neurologist and Director of the Comprehensive Sports Concussion Program at Sinai Hospital of Baltimore.

Another criticism of the proposed correlation is the fact that this study involved only five athletes. 

While many researchers and clinicians are hopeful that we will someday be able identify and treat all forms of dementia before they cause significant impairment, this is many years away.