THE NEED-TO-KNOW INFORMATION ABOUT MUSCLE CRAMPS

You have over 600 muscles in your body. These muscles control everything you do, from breathing to putting food in your mouth to swallowing.

When it comes to muscle cramps, the most commonly affected muscles are the muscles of your upper arms, the muscles behind your thighs, and the muscles in the front of your thighs.

This guide will help you understand

• what muscle cramps are
• how the problem develops
• what treatment options are available
• how muscle cramps can be prevented

Anatomy

What parts of the body are involved?

Muscles are composed of many fibers bundled together; the bigger, more frequently used muscles have more fibers than the smaller, lesser used ones. Among the muscles are voluntary and involuntary muscles. Voluntary, or striated muscles are those that we move by choice (for example, the muscles in your arms and legs). These muscles are attached to bones by tendons, a sinewy type of tissue. Involuntary muscles, or smooth muscles, are the ones that move on their own (for example, the muscles that control your diaphragm and help you breathe). The muscles in your heart are called involuntary cardiac muscles.

When it comes to muscle cramps, the most commonly affected muscles are the gastrocnemius (calf muscles), triceps (the muscles in your upper arms), the hamstrings (the muscles behind your thighs), and the quadriceps (the muscles in front of your thighs).

Causes

What causes muscle cramps?

To move your muscles, your brain sends signals to the voluntary muscles and coordinates the movements that you want. The voluntary muscles contract as they're being used and they become tighter. The muscles then relax when the movement is complete. When the contraction/relaxation cycles are done repeatedly, as in exercising, the fibers become stronger and the muscles get larger and stronger. However, sometimes the muscles, or just a few fibers within the muscle, contract on their own, causing a muscle spasmor cramp. The difference between a spasm and a cramp is the force of the contraction. If it's a quick contraction and release of muscle, without pain, it's a spasm. If the contraction is prolonged and painful, it's a cramp. Occasionally, cramps are so intense that you can't use your muscle because it's so tight and painful. Cramps can be short-lived, a minute or less, or as long as a couple of days. When researchers tested the cramping muscles of some athletes, they found rapid repetitive muscle firing, which could be described as the muscle fibers being hyperactive, in a sense.

Cramps can happen in one muscle, like the hamstring, or they can happen in a number of muscles together, like in your hands if you have writer's cramp. They can happen once and then not again, or there can be a series of on-again-off-again cramping.

There are several reasons why muscle cramps may occur, including the most common one that is seen in both professional and weekend athletes. These are called exercise-associated muscle cramping or EAMC. These types of cramps fall under the category of paraphysiologic cramps. Those are cramps that affect normally healthy people but are brought on by an event, such as exercise. 

Researchers have estimated that marathon runners and triathletes may have a 30 to 67 percent lifetime risk of developing these cramps. Although the exact cause of the cramping isn't known, researchers do believe that they can be caused by inadequate stretching, muscle fatigue, or lack of oxygen to the muscle. Other causes can also include heat, dehydration, and/or lack of salt and minerals (electrolytes). New research suggests that there may be abnormal motor neuron (nerve) activity at the level of the spine.

Researchers also have noticed that the athletes who suffer from a lot of cramping tend to be older, marathon runners, or have a high body mass index. They don't stretch regularly, and have a family history of muscle cramps.

Cramps can also happen if you use the same muscles in the same way for too long a period. This could be as you crouch down to work in the garden, type on a keyboard, or write out long lists with paper and pen. The muscles contract and cause the pain.

Occasionally, these types of cramps seemingly come out of nowhere. For example, as we stretch, we often point our toes downward. This motion contracts the muscle in the calf of the leg and can cause a severe cramp or charley horse.

Women who are pregnant may also find that they get more muscle cramps during their pregnancy, but the reason why isn't clear. Again, these are considered to be paraphysiologic cramps because they are brought on by the pregnancy. Along the same vein, seniors may also be prone to developing muscle cramps. Doctors believe this is due to loss of muscle mass as people age plus inactivity.

Muscle cramps can also occur as a side effect of medications. Diuretics, or water pills, cause you to eliminate fluid from your body. If too much fluid is eliminated too quickly, the resulting dehydration could cause muscle cramps. Other medications can also cause muscle cramps.

Skeletal problems can increase the chances of leg cramps. For example, people with problems like Scoliosis (curvature of the spine) could have one leg longer than the other. This imbalance can cause cramping in the leg.

Symptomatic cramps are, as the name suggests, symptoms of an illness that may be causing the cramping. Examples of a few illnesses that can cause muscle cramping are: Parkinson's disease, tetanus, diabetes, and heart disease. Atherosclerosis (hardening of the arteries) makes it hard for blood to circulate throughout the body as it should. Often, one of the first signs of atherosclerosis is a symptom called claudication or intermittent claudication. Someone who has atherosclerosis may start feeling cramping in one or both legs after walking for a while. At rest, the pain disappears, but it comes back when the person resumes walking.

radiculopathy (irritation of the nerve root at the spine) is a known cause for muscle cramping, usually at night. Some other illnesses that can cause muscle cramping are cirrhosis of the liver, Black Widow spider bites, and malignant hyperthermia, among others. 

Finally, idiopathic muscle cramps are cramps that have no known cause but they are symptoms of a disease, or can be inherited. Sudden nocturnal (occurring at night) leg cramps are an example of this type of cramping.

Symptoms

What do muscle cramps feel like?

Muscle cramps are painful, there's no doubt about it. The symptoms of muscle cramps usually come on quickly and intensely. They can be so strong that you may have to stop what you're doing, the discomfort of the cramping making it too difficult to continue. There are also cramps that occur after the fact. These delayed or nocturnal cramps can affect athletes.

The most obvious symptom of a muscle cramp is a sharp, acute pain in the affected muscle or muscles. If it's a large muscle that is involved, like the one in the calf of your leg, you may be able to feel a knot or hard lump in the muscle, just under the skin.

Diagnosis

How do doctors identify muscle cramps?

Generally, people know what they are experiencing when they have a muscle cramp so they don't seek medical help to find out what they are and what caused them. However, sometimes muscle cramps are more serious and they are frequent, lengthy, and unbearably painful. If they are caused by an illness, rather than overexertion, the reason for them will need to be found.

Your doctor will first do a physical examination and take your medical history. Let your doctor know is you have been ill recently with vomiting, diarrhea, or fever. Anything that may cause dehydration is important information and should be shared with the doctor. 

You'll be asked when the cramps began, how long have you been having them, how long they last, and what are you usually doing when they start. Other questions, such as are you pregnant, taking any medications (including over-the-counter and natural or herbal remedies), do you smoke, and how much alcohol do you drink, will be asked. Your doctor will also need to know how much and how often you exercise.

Your doctor will want to know exactly where the cramping is occurring. Let your doctor know if there are any other types of pain that happen at the same time. Your doctor will want to know if the cramps are always in the same place or if they occur elsewhere. 

Further testing may recommended. Blood tests are usually first since muscle cramping may be caused by dehydration and depletion of salt and minerals (electrolytes). Since pregnant women can be more prone to muscle cramping, a pregnancy test may be ordered for women along with other blood tests.

Additional blood tests may be ordered to check if your thyroid and kidneys are working properly. Your thyroid is a small gland that is just below your voice box and is responsible for making and distributing hormones.

If the blood tests are all within normal range and negative for pregnancy, there are more tests that may be ordered. A vascular Doppler ultrasound uses ultrasound waves to make images on a screen. Using the Doppler (small machine), your doctor looks to see if there are any blockages in the blood vessels.

If your doctor thinks there may be a neurological (nervous system), disorder causing the cramping. One test that may be done is called an electromyography(EMG). To perform an EMG, your doctor will insert a needle into the muscle that has been cramping. The needle has an electrode that will relay to a recording device any electrical activity from your muscle. After the needle has been inserted, you'll be asked to contract (flex, tighten) your muscle and then relax it.

A magnetic resonance imaging (MRI) scan may also be done. The MRI is a radiological test that uses magnetic waves and a computer to create pictures of the parts of the spine. To perform this test, you must lie in a tube for about an hour. No needles or dye are usually required. The machine takes pictures of the spine one slice at a time. It can do this in multiple directions. It allows the doctor to see the bones and soft tissues of the spine - including the nerves. Your doctor will be looking for anything that may show an injured disc, pinched nerve, or injured nerve that could represent a cause for the cramping.

Treatment

What can be done to relieve the pain from muscle cramps?

The type of treatments required for muscle cramps depends on what is causing them. If you're having occasional muscle cramps from physical activity or overusing certain muscles, you can usually take care of the cramps yourself. Simply stopping the activity will stop the cramping. If the cramps continue, stretching the cramping muscle - although painful - should release the tension of the muscle. For example, if it is your calf muscle that is cramping, stand facing a wall or solid object that you can hold on to for balance. Keeping your heel of the sore leg as close to the floor as possible, tilt your body (slowly) to the wall or object, stretching the calf muscle. If you're lying in bed when the cramping starts, you can try pointing your toes straight up towards the ceiling, or grab hold of your toes and pull your foot up towards you.

Some people find that using ice packs can help relax the tense muscles, others have better luck with heat such as from heating pads, warming packs, even warm towels. Be careful when applying ice or heat to a sore part of your body. Ice should never be held directly on the skin. Ice should always be buffered with at least one layer of cloth. Heating pads can get very warm and can cause burns, so be sure to monitor the heat level and keep a layer of fabric between the heat and the skin. Massage may help as well, although it can be painful as the knot is being worked out. If the cause of the cramping is dehydration, then fluids with electrolytes (sports drinks, for example) are essential to balance the fluid loss.

For athletes who experience a lot of cramping good nutrition is important. Adequate fluid and electrolytes may help limit the cramping. This could mean meeting with a dietitian to discuss diet and eating habits.

Some muscle cramps can be caused as a side effect of certain medications. Talk to your doctor. Adjusting the dosages or changing the medication may help the cramping problem. Don't change any of your prescription drugs or stop taking them without your doctor's knowledge and approval.

If the cramps are caused by an illness, they should subside by treating the illness. Medications are generally not recommended or used for muscle cramps because of their side effects. Most muscle cramps are short-lived. By the time the medication has started working the cramping has already stopped. There are some cases where doctors may use Botox® to stop cramping in certain muscles. This is decided on an individual basis and depends on the cause and the impact of the cramping.

Because muscle cramps come on so quickly and suddenly, usually resolving just as fast as they came, the best treatment is prevention. Anyone who is about to do something strenuous or athletic should warm up and stretch their muscles first. If you're moving furniture, digging up a garden, painting, or doing general maintenance that you're not used to, the muscles you will be using can get fatigued. By stretching them, this should be prevented.

It's also important to stretch correctly. Don't stretch quickly. Stretch slowly and hold each stretch for 30 seconds. Any shorter than 30 seconds and there's no benefit. There is also no benefit for holding it longer than 30 seconds. Some experts suggest that athletes continue to stretch daily. This may keep the muscles flexible. Also remember to stretch after the activity to allow the muscles to cool down.

Other important tips include staying hydrated; drink enough fluids to keep your body's electrolytes from depleting - but don't overdo the fluids either. Finally, don't overdo the exercising, especially in hot weather.

Call us at 913-291-2290 to schedule a consult for more information!

CHRONIC PAIN MANAGEMENT

According to the National Center for Health Statistics chronic pain health care costs and lost productivity has reached nearly $100 billion a year. It affects approximately 76.2 million people - more individuals than diabetes, heart disease and cancer combined.

The primary goals in chronic pain management are to assess, understand and treat your pain condition. Along with physical therapy, there are many aspects of your daily life that can be adjusted to help minimize the effects of chronic pain on your daily lifestyle. 

This sounds simple. It is not simple or easy. The process requires a great deal of time and effort on both the part of the pain management team and you.

This guide will help you understand

• what chronic pain is
• what pain management is
• how chronic pain is managed
• what you can expect from pain management

What is chronic pain?

Chronic pain is sometimes defined officially as pain lasting more than 6 months. It may also be accurate to define chronic pain as pain that has no clear end in sight. It may be something that you will have to learn to live with - or around. Anyone who has lived with chronic pain, or has treated patients with chronic pain, eventually comes to the understanding that the chronic pain is a disease in itself, regardless of what is causing the pain. It is this disease - chronic pain - that pain management specialists treat.

This does not mean that the team will ignore what is causing your pain. The first goal is to assess your pain. This means that your healthcare provider must try to determine, if possible, what is causing your pain..

The first question that should be asked is: "Does the pain have a source that can be eliminated by doing something to you - such as a medical treatment or surgery?"

Usually, the doctors that you have seen before you arrive at a pain management center have already done this. They refer you to the pain management center because they have not found anything that will reliably eliminate your pain. The pain management team will start from scratch and review all the tests and imaging studies that have been done and examine you. Sometimes the pain specialist may uncover new things or make new diagnoses. Usually they do not.

Once your pain management specialists have satisfied themselves that there is no reliable way to eliminate your pain through a medical treatment or surgery, they will begin the process of understanding your pain. This is a complex process. It does not end as long as you have the pain. The pain management team will constantly reevaluate what they think about your pain, how it is affecting you and what is needed to change the approach to helping you live with your pain.

Understanding your pain and treating your pain go hand in hand. How you respond to certain treatments gives your pain specialists a better understanding of your pain. They probably will not get the right, or best, combination on the first try - or the second. But they will continue to work with you to refine the treatment plan so that you get the best plan that can be can offered. Understanding your pain is a never ending process - for you or for your healthcare providers. Have patience both with yourself and with your pain management team.

In the majority of chronic pain patients, the sensation of pain will NOT be eliminated. BUT, with treatment you can drastically change how much the pain affects your life. Chronic pain is a disease that can be managed effectively. You should expect your pain management team to work with you and your primary care provider to effectively manage your chronic pain condition with all of the expertise and tools available as long as you need help.

Once the process of creating a treatment plan with you begins, there are many different options that can be explored. An important thing for you to realize is that these options are divided into two groups: 

• Things people do to you 
• Things you learn to do for yourself

Each of these approaches are important and have value in treating your pain. The goal is to find a balance where you are in control of as much of your treatment plan as possible - while you minimize the treatment options that require something to be delivered that is controlled by someone else. This situation just makes more sense in the long run - because it puts you more in control of managing your pain. It's cheaper, requires less time spent in providers' offices and ultimately it is more effective.

Most chronic pain patients do require some passive modalities -- "things people do to you" - such as medications, massage and injections to deaden the pain at times. Early on this seems to be more important as you learn the skills that will allow you to move beyond dependence on some of these passive modalities. Remember, the main goal is to help you manage your pain in a way that is effective for you. If that requires some passive modalities, then so be it. 

Things People Do To You

In our current healthcare culture, we are used to going to see a practitioner when we are ill and saying, "Fix it!" Most practitioners are quite willing to try to do just that - give you a prescription medication or suggest a surgical procedure that is designed to cure or fix your problem. Our expectation is that everything can be fixed if we just find the real problem and match this with the real cure. 

Pain doesn't necessarily work that way. In fact, most things in healthcare don't really work that way, but we all pretend they do - patients and doctors alike. With the exception of things like appendicitis and broken bones, most healthcare conditions have lifelong effects that must be dealt with sooner or later. In chronic pain, it just happens sooner rather than later. Quit fooling yourself early and get on with the business of managing chronic pain.

Most of the passive modalities in the category of "things people do to you" are temporary fixes rather than cures. They are useful in managing symptoms while you and your providers work on the category of "things you learn to do for yourself". That is not to say that many of these things people do to you are not beneficial. Some may control your symptoms for years. Some may need to be returned to and used even years from now when you are having a flare up of pain. Just don't think of them as a "cure". They are tools in your toolbox. Use the right tool for the job. If a small tap is needed - don't use a sledgehammer. 

Some of the more common things that fall into the "things people do to you" category are:

• Invasive interventions 
• Medications
• Physical modalities

Invasive Interventions

Invasive interventions are treatments that require surgery or some type of procedure that involves physically invading the body - such as an injection. Clearly, many surgical and invasive procedures are done to reduce or eliminate pain. Many are successful - some are not. You may already have had one or several invasive procedures. You may need more in the future. 

Many of the patients in chronic pain management programs are not expecting any invasive procedures in the near future. This is usually because there are no procedures to recommend that have a reasonable chance of success. Your pain specialist never stops considering invasive interventions to help treat your pain because things constantly change. BUT, continuing to look for the ultimate cure can lead to delays in getting down to managing the chronic pain disease itself.

Medications

Medications treat the symptoms of chronic pain - not the disease itself. Nearly every patient with chronic pain will have the following symptoms at some point in their management program:

• Depression 
• sleep difficulty
• Anxiety

Medications can help control these symptoms to a degree. Medications alone are not the answer. Any medication treatment must be combined with other treatments. For example, many studies show that depression responds exceedingly well to exercise and psychotherapy - possibly better than to medications. The same is true for sleep difficulty and anxiety - both cannot be adequately treated with medications alone. 

Anytime a medication is used for control of the symptoms of chronic pain, realize that you must weigh the side effects versus the benefits. All medications have side effects. No medications are risk free. 

Narcotic pain medications are especially difficult to use due to the side effects of physical dependence and addiction. Chronic pain patients use narcotic medications frequently - but do so with a respect for the potential harm that they can cause. The real goal is to treat your pain effectively so that you do not need narcotic pain medications if possible. That is not always achievable.

Medications are one piece of the puzzle - not the total answer. The goal is to use the minimum amount of medication necessary to treat your pain. If that is a lot of medications then fine, if it is none, that's fine too. In general, the less medication the better.

Physical Modalities

Physical modalities include things like massage, acupuncture, ultrasound, TENS and chiropractic. These are treatments that require someone else to touch you, stick a needle in you or manipulate your body. In some cases (such as TENS), you need to attach yourself to some type of machine that does something to you. None of these things are necessarily bad or good. If they help relieve any of the symptoms of chronic pain, then they may be useful. 

Unlike medications and invasive treatments, most of these modalities are relatively risk free. But, similar to medications, these modalities usually provide temporary relief. Pain specialists use these modalities frequently as part of a comprehensive symptom management program. The biggest risk in coming to rely more and more on these passive modalities for reducing symptoms is that you give up some control of your management program.

As is true in every aspect of managing chronic pain, reaching a balance is necessary.

Things You Learn To Do For Yourself

The things you learn to do for yourself to manage your chronic pain are the most important in the long run. 

That bears repeating:

The things you learn to do for yourself to manage your chronic pain are the most important in the long run.

The more pain management skills you master, the more YOU control your chronic pain without relying on other people to do something to you or control your treatment. You become more empowered. You are in charge, not the healthcare provider.

Some of the more common things that fall into "the things you learn to do for yourself" category are:

• Ergonomics 
• Exercise
• Mind body techniques

Ergonomics

Ergonomics is simply a fancy word for describing a relatively simple concept - how we use our bodies to interact with our physical surroundings. Learning about good ergonomics means learning how to get things done without aggravating your underlying condition and causing pain. It is amazing how many people come into a pain program who never realize how many things they do during the day are actually causing problems. Once they learn new ways of doing things and new ways to arrange their home and work environment, their pain decreases.

Exercise

Developing an exercise routine is critical in the management of chronic pain. You will not be able to effectively manage your pain without incorporating some form of exercise as part of your daily routine. This is not a one-size-fits-all approach to exercise. We realize that each patient is different, with a different set of physical problems that affect what type of exercise is reasonable. Everyone will have a different program designed specifically with their unique problems in mind.

Exercise will reduce many of the symptoms of chronic pain. Even small doses of regular exercise cause physiologic changes in the body chemistry that are beneficial. Exercise increases the body's internal pain killing chemicals called endorphins. These chemicals act just like morphine to reduce pain. Exercise is effective in reducing depression and can help burn off the excess adrenaline that causes anxiety. Most chronic pain patients find that they sleep much better when they begin a regular exercise program.

If you allow chronic pain to greatly reduce your activity level, deconditioning of muscles and ligaments occurs. Bones become weaker. Injury is more likely and pain actually increases. Moderate amounts of exercise will protect you from the effects of deconditioning and help you improve your ability to function.

Remember, the goal is not necessarily to become pain free, but to strike a balance between reducing pain and maintaining function. Some degree of discomfort is not necessarily a bad thing. Many people are afraid that discomfort means they are doing some type of damage to their body. That is not necessarily true. A bit of discomfort is warranted to maintain a higher level of function as long as you are not doing further damage. Doing nothing will certainly result in further damage to your body. Part of what you will be learning is how to tell when enough is enough.

Mind Body Techniques

Many of the symptoms of chronic pain disease are actually made much worse by our minds. The way we react to the sensation of pain is a combination of primitive reflexes (designed or evolved to protect us from harmful things) and learned behavior (not necessarily useful to us at all). For example, think about the muscle pain you might have when you have overdone your spring gardening. You know by experience that it is a simple muscle soreness and you are certain it will go away in a few days. You are not too concerned. You ignore it. It goes away.

Now imagine you wake up one morning with a pain for no good reason. It doesn't go away in a few days. You become concerned because you don't know what the pain MEANS. Is it serious? Does the pain mean I am damaging my body when I do things that make the pain worse? You become anxious. This releases chemicals in your body that increase the sensitivity of your nerves to the pain - the pain feels worse! 

All of these changes occur at the subconscious level - so you are not necessarily aware of this change that comes over you. The result is that you are turning the volume up on your pain. Mind body techniques teach you how to turn down the volume on your pain. The pain song might still be playing in the background - but it's more like elevator music than hard rock.

Most mind body techniques try to tap into what we call physiologic quieting. The mind has a great deal of influence over the hormones and chemicals that are released when we are stressed. These are the chemicals that increase the volume of your pain. You can train yourself to reduce the release of these chemicals and turn down the volume. These are very powerful tools to have in your toolbox. No chronic pain management program will be successful without incorporating some of these mind body techniques.

TOTAL JOINT REPLACEMENT - QUESTIONS PATIENTS SHOULD ASK THEIR SURGEONS

The goal of orthopaedic treatment is to relieve pain and restore function. In planning your treatment, your doctor will consider many things, including your age, activity level, and general health. If nonsurgical treatment methods, such as medication and physical therapy, do not relieve your symptoms, your doctor may recommend total joint replacement. 

Your doctor and healthcare team will provide you with information to help you prepare for surgery. Never hesitate to ask questions. The following list of questions can help you in your discussions with your doctor before your surgery.

• What are the major and/or most frequent complications of surgery? 
• Is the skill and experience of the orthopaedic surgeon more important than the device or procedure? 
• Can you give me any information on outcomes and complication rates? 
• If I do not have surgery, what is the risk? 
• How much pain can I expect, and how will it be managed in the hospital and after I go home? 
• How long will the device last, and what can I do to make it last as long as possible? 
• What are the pros and cons of minimally invasive (mini-incision) surgery? Does it really make a meaningful difference in the result, or does it pose unnecessary risks? 
• What will I be able to do/not do after my total joint replacement? 
• Is therapy necessary after surgery? 
• How long will I be in the hospital? 
• Will I be able to contact you after the surgery if I have a question or problem?
  
  It will be a process deciding what is the best option for your body and your situation - keep an open mind when discussing possible treatment options. Most insurances require you to attempt physical therapy before a doctor can consent to performing a total joint replacement, and it is vital that the patient go into therapy as if that is their only option. No need to have surgery when your quality of life could possibly be improved by therapy, alone.  Regardless of whether or not you choose to follow through with joint replacement surgery, the Champion Performance and Physical Therapy staff will ensure you understand all your precautions and are carefully guided through each step of the process, during both before and after stages of your joint replacement.  Our new facility is sectioned in half, one side more suitable for a slower pace, and the other more suitable for our higher level patients. You'll feel safe and comfortable during your time here - we guarantee it!

"FLAT FEET" IN CHILDREN

Flatfeet (also known as pes planus) describes a condition in which the longitudinal (lengthwise) and/or medial (crosswise) arches of the foot are dropped down or flat. The entire bottom of the bare foot is in contact with the floor or ground surface during standing, walking, and other weight bearing activities. The condition is often present at birth (congenital) in one or both feet. When only one foot is affected, the problem is referred to as unilateral pes planus or flatfoot. When both feet are involved, the condition is bilateralflatfeet.

This guide will help you understand:

• what parts of the foot are affected
• how the problem develops
• how doctors diagnose the condition
• what treatment options are available

Anatomy

What parts of the foot are involved?

The Anatomy of the foot is very complex. When everything works together, the foot functions correctly. When one part becomes damaged, it can affect every other part of the foot and lead to problems. With a flatfoot deformity, bones, ligaments, and muscles are all affected. A combination of malalignments results in the flatfoot appearance. 

Bones

The skeleton of the foot begins with the talus, or ankle bone, that forms part of the ankle joint. The two bones of the lower leg, the large tibia and the smaller fibula, come together at the ankle joint to form a very stable structure known as a mortise and tenon joint. 

The two bones that make up the back part of the foot (sometimes referred to as the hindfoot) are the talus and the calcaneus, or heel bone. The talus is connected to the calcaneus at the subtalar joint. The ankle joint allows the foot to bend up and down. 

The subtalar joint allows the foot to rock from side to side. People with flatfeet usually have more motion at the subtalar joint than people who do not have flatfeet. The increased flexibility of the subtalar joint results in many compensatory actions of the foot and ankle in order to keep proper foot alignment during standing and walking.

Just down the foot from the ankle is a set of five bones called tarsal bones. The tarsal bones work together as a group. They are unique in the way they fit together. There are multiple joints between the tarsal bones. When the foot is twisted in one direction by the muscles of the foot and leg, these bones lock together and form a very rigid structure. When they are twisted in the opposite direction, they become unlocked and allow the foot to conform to whatever surface the foot is contacting. 

The tarsal bones are connected to the five long bones of the foot called the metatarsals. The two groups of bones are fairly rigidly connected, without much movement at the joints. Finally, there are the bones of the toes, the phalanges. 

Ligaments and Tendons

Ligament are the soft tissues that attach bones to bones. Ligaments are very similar to tendons. The difference is that tendons attach muscles to bones. Both of these structures are made up of small fibers of a material called collagen. The collagen fibers are bundled together to form a rope-like structure. 

The large Achilles' tendon is the most important tendon for walking, running, and jumping. It attaches the calf muscles to the heel bone to allow us to rise up on our toes. The posterior tibial tendon attaches one of the smaller muscles of the calf to the underside of the foot. This tendon helps support the arch and allows us to turn the foot inward. Failure of the posterior tibial tendon is a major problem in many cases of pes planus.

Many small ligaments hold the bones of the foot together. Most of these ligaments form part of the joint capsule around each of the joints of the foot. A joint capsule is a watertight sac that forms around all joints. It is made up of the ligaments around the joint and the soft tissues between the ligaments that fill in the gaps and form the sac.

The spring ligament complex is often involved in the flatfoot condition. This group of ligaments supports the talonavicular joint. The spring ligament complex works with the posterior tibial tendon and the plantar fascia to support and stabilize the longitudinal arch of the foot. Failure of the ligaments that support this arch can contribute to flatfoot deformity. Injury, laxity(looseness), or other dysfunction of the ligament and tendon structures can result in deformity of the foot and/or ankle resulting in pes planus. 

Muscles

Most of the motion of the foot is caused by the stronger muscles and tendons in the lower leg that connect to the foot. Contraction of the muscles in the leg is the main way that we move our feet to stand, walk, run, and jump.

There are numerous small muscles in the foot. While these muscles are not nearly as important as the small muscles in the hand, they do affect the way that the toes work. Damage to some of these muscles can cause problems.

Most of the muscles of the foot are arranged in layers on the sole of the foot (the plantar surface). There they connect to and move the toes as well as provide padding underneath the sole of the foot.

Causes

What causes this problem?

Flexible flatfoot refers to a foot that looks flat when standing but appears to have an arch when the foot isn't resting on the floor or against a flat surface. Sometimes the term fallen arches is used, but doctors prefer not to use this term in favor of the more accurate medical term pes planus. 

Most babies and young children have what looks like flat feet. This is normal. Before the bones are formed, much of the foot and ankle are still made up of soft tissue, fat, and cartilage. The arch has not formed fully yet. The joints are still hypermobile when the child starts to get up on feet to walk. This is when the flatfoot deformity becomes obvious and parents may become concerned that something is wrong with their child's foot. The vast majority of children will grow out of their flat foot deformity. Even if the deformity does not fully correct with age, it is unlikely to cause the child any difficulty in the future.

Stress and activities during early childhood requiring strength in the feet are actually the training needed to develop normal muscle, tendon, ligaments, and bone in the foot and ankle. But in some cases, the arch doesn't form and the foot remains flat into adulthood. Flatfeet do tend to occur in families as an inherited condition.

There are many possible causes for the flatfoot condition. Biomechanically, many soft tissue structures must connect and support one another to prevent a flatfoot deformity. Tibial (lower leg bone) rotation, hindfoot alignment, and position of the joints of the foot, midfoot, hindfoot, and ankle are all important factors. There is no one cause of flatfoot deformity that can be identified.

In the flexible flatfoot, the bones are usually normal - but the supporting ligaments are lax or loose. The joints are hypermobile. As the soft tissues and joints of the foot and ankle try to maintain a normal foot position, increased stress is placed on them. This can lead to fatigue and loss of strength resulting in a sagging of the arch. This can affect the chain of anatomical structures all the way up the leg.

There are some uncommon causes of flatfoot that do affect the bones. A Tarsal Coalition refers to a condition where two or more bones in the midfoot or hindfoot fail to form separately during development. They remain connected together, altering the bone structure of the foot and limiting flexibility of the foot. This is a different type of flatfoot deformity altogether and is commonly referred to as a spastic flatfoot. This type of flatfoot deformity is not flexible. In fact, the foot is quite rigid due to the abnormal connection between the bones of the foot. This condition can be painful. 

Symptoms

What does the condition feel like?

For most children, the flexible flatfoot deformity causes no symptoms. They do not suffer from pain, swelling, or sore feet. Children with flexible flatfoot deformity may wear out shoes a bit different from a normal person, but there usually is not any reason to be concerned.

In moderate to severe cases, the patient may report fatigue and tired, sore feet after standing on them all day. During those times, they may limit their own activities.

In the uncommon severe cases, calluses may appear where pressure occurs as the bones make contact with the floor or hard surface. The loss of joint stability may alter the foot's ability to absorb the load and conform to uneven ground or surfaces.

Rarely, the flatfoot deformity may get worse with age. Excess pressure on the surrounding soft tissues (ligaments, capsules, tendons, muscles) can lead to other problems such as malalignment of the patella (kneecap), hallux valgus (Bunions), and rotation of the knee and hip.

When the flatfoot deformity is the result of a tarsal coalition, the situation is different. The foot may become painful. The child may begin to complain of foot and ankle pain after a minor twisting injury and the pain not resolve after a normal healing period. The symptom of pain combined with decreased motion and flatfoot deformity should suggest a more serious problem in the foot. 

Diagnosis

How do doctors diagnose the problem?

The history and physical examination are probably the most important tools the physician uses to diagnose this condition. Clinical tests can be done to differentiate flexible flatfoot from rigid flatfoot. The examiner will check mobility in the forefoot, hindfoot, and ankle. Muscle weakness and/or muscle tightness will be assessed. The wear pattern on the shoes can offer some helpful clues. 

X-rays or other more advanced imaging such as CT scans or MRIs may be ordered but these are rarely needed. The examiner may be able to see and feel a prominent bump with tenderness around the area when an Accessory Navicular bone is present. X-rays will show if there is an accessory navicular or tarsal coalition as part of the problem.

A very simple test called the wet footprint can be done at home or in the doctor's office. The patient places the foot in water and then places the foot down on a piece of paper or thin cardboard. After making a footprint, the foot is lifted off the paper. Someone with a flat foot will leave a complete footprint where the sole makes contact with the paper.

The physician may have you perform a single heel raise. You will be asked to stand on one foot and rise up on your toes. You should be able to lift your heel off the ground easily while keeping the calcaneus (heel bone) in the middle with slight inversion (turned inward). 

Treatment

What treatment options are available?

Nonsurgical Treatment

There may be no treatment needed for mild cases of flatfeet, especially flexible flatfeet. This condition often corrects itself in time as the child grows and develops. Young children should be encouraged to walk barefoot whenever it is safe to do so. This will increase sensory input into the foot. At the same time, navigating various floor and ground surfaces helps build strength and stability.

For older children and adults, a simple modification to the shoe may reduce the fatigue and discomfort in the foot. Sometimes purchasing shoes with a good arch support is sufficient. Try to find a comfortable shoe with an arch support, firm heel counter (back of the heel), and a flexible sole (bottom). Supporting the arch helps decrease the tension in the posterior tibialis tendon. Stretching the Achilles' tendon helps maintain normal motion of the hindfoot, which in turn, helps maintain alignment of the midfoot.

For other patients, an off-the-shelf (prefabricated) shoe insert works well. The goal is to support the foot and prevent further stretching of lax ligaments and tendons. These supports will not reverse the structural deformity and they will not build and arch by wearing them over time. These inserts simply help the shoe better fit the foot and support the structures of the foot. Improving alignment can take tension off the soft tissue structures, reduce fatigue, and improve the biomechanics of standing and gait (walking).

Further treatment is usually not needed for the flexible flatfoot deformity. Surgery is rarely needed for this condition. Patients with severe symptoms that do not respond to conservative care may benefit from further orthopedic evaluation and treatment. In rare cases, surgical intervention to correct the problem and realign the foot may be suggested.

Surgery

For children with a shortened Achilles' tendon, a program of stretching exercises or serial casting may help reduce pressure on the talus bone and offer significant pain relief. Severe cases of flatfoot (pes planus) may require surgery to reconstruct the arch or fuse the bones. This is very rare as conservative (nonoperative) care is usually sufficient.

Children with tarsal coalition or an accessory navicular bone require orthopedic evaluation and management. Surgery is done to correct the problem by the early teen years (before skeletal maturity). 

Rehabilitation

What should I expect after treatment?

Nonsurgical Rehabilitation

Flatfeet seen in very young children just starting to walk often resolve with time. The very act of gripping with the toes to maintain support and balance along with the development of the bones forms the arches.

For older children who still have flatfeet, stretching and strengthening exercises won't cause an arch to form where there isn't one anatomically. But these activities can help ease any pain or discomfort caused by the condition. The same is true for any supports or shoe inserts that are used. However, shoe inserts or shoes specially-made to improve their condition tend to allow them to increase their desire to perform physical activity, as it does not correlate with a conditioned response to expect pain following exercise.  We recommend seeing a specialist then coming into us here at Champion Performance and Physical Therapy for exercises to improve your child's ability to be active and get exercise without pain. 

After Surgery

Corrective surgery is only done in cases of severe, painful and disabling flatfoot position. This is very rare. Reconstructive surgery for tarsal coalition or an accessory navicular bone requires a period of immobilization in a cast followed by rehabilitation to restore strength in the foot and ankle. In some cases, more than one operation is needed as the child grows and develops. Pain relief and joint stability are the goals.

MENISCUS TEARS - WHAT ARE THEY AND WHAT DOES RECOVERY LOOK LIKE?

Meniscus tears are among the most common knee injuries. Athletes, particularly those who play contact sports, are at risk for meniscus tears. However, anyone at any age can tear a meniscus. When people talk about torn cartilage in the knee, they are usually referring to a torn meniscus.

They are not uncommon to see in an athlete and with physical therapy and minimal complications, can be recovered from within the year. Here at Champion Performance and Physical Therapy, we specialize in musculoskeletal injuries and pre/post-operational recovery, among others, and take pride in the quick recovery many of our patients succeed in!

Normal Knee Anatomy

Three bones meet to form your knee joint: your thighbone (femur), shinbone (tibia), and kneecap (patella).

Two wedge-shaped pieces of cartilage act as "shock absorbers" between your thighbone and shinbone. These are called meniscus. They are tough and rubbery to help cushion the joint and keep it stable.

Description

Menisci tear in different ways. Tears are noted by how they look, as well as where the tear occurs in the meniscus. Common tears include bucket handle, flap, and radial.

Sports-related meniscus tears often occur along with other knee injuries, such as anterior cruciate ligament tears.

Cause

Sudden meniscus tears often happen during sports. Players may squat and twist the knee, causing a tear. Direct contact, like a tackle, is sometimes involved.

Older people are more likely to have degenerative meniscus tears. Cartilage weakens and wears thin over time. Aged, worn tissue is more prone to tears. Just an awkward twist when getting up from a chair may be enough to cause a tear, if the menisci have weakened with age.

Symptoms

You might feel a "pop" when you tear a meniscus. Most people can still walk on their injured knee. Many athletes keep playing with a tear. Over 2 to 3 days, your knee will gradually become more stiff and swollen.

The most common symptoms of meniscus tear are:

• Pain
• Stiffness and swelling
• Catching or locking of your knee
• The sensation of your knee "giving way"
• You are not able to move your knee through its full range of motion

Without treatment, a piece of meniscus may come loose and drift into the joint. This can cause your knee to slip, pop, or lock.

Doctor Examination

Physical Examination and Patient History

After discussing your symptoms and medical history, your doctor will examine your knee. He or she will check for tenderness along the joint line where the meniscus sits. This often signals a tear.

One of the main tests for meniscus tears is the McMurray test. Your doctor will bend your knee, then straighten and rotate it. This puts tension on a torn meniscus. If you have a meniscus tear, this movement will cause a clicking sound. Your knee will click each time your doctor does the test.

Imaging Tests

Because other knee problems cause similar symptoms, your doctor may order imaging tests to help confirm the diagnosis.

X-rays. Although x-rays do not show meniscus tears, they may show other causes of knee pain, such as osteoarthritis.

Magnetic resonance imaging (MRI). This study can create better images of the soft tissues of your knee joint, like a meniscus.

Treatment

How your orthopaedic surgeon treats your tear will depend on the type of tear you have, its size, and location.

The outside one-third of the meniscus has a rich blood supply. A tear in this "red" zone may heal on its own, or can often be repaired with surgery. A longitudinal tear is an example of this kind of tear.

In contrast, the inner two-thirds of the meniscus lacks a blood supply. Without nutrients from blood, tears in this "white" zone cannot heal. These complex tears are often in thin, worn cartilage. Because the pieces cannot grow back together, tears in this zone are usually surgically trimmed away.

Along with the type of tear you have, your age, activity level, and any related injuries will factor into your treatment plan.

Nonsurgical Treatment

If your tear is small and on the outer edge of the meniscus, it may not require surgical repair. As long as your symptoms do not persist and your knee is stable, nonsurgical treatment may be all you need.

RICE. The RICE protocol is effective for most sports-related injuries. RICE stands for Rest, Ice, Compression, and Elevation.

• Rest. Take a break from the activity that caused the injury. Your doctor may recommend that you use crutches to avoid putting weight on your leg.
• Ice. Use cold packs for 20 minutes at a time, several times a day. Do not apply ice directly to the skin.
• Compression. To prevent additional swelling and blood loss, wear an elastic compression bandage.
• Elevation. To reduce swelling, recline when you rest, and put your leg up higher than your heart.

Non-steroidal anti-inflammatory medicines. Drugs like aspirin and ibuprofen reduce pain and swelling.

Surgical Treatment

If your symptoms persist with nonsurgical treatment, your doctor may suggest arthroscopic surgery.

Procedure. Knee arthroscopy is one of the most commonly performed surgical procedures. In it, a miniature camera is inserted through a small incision (portal). This provides a clear view of the inside of the knee. Your orthopaedic surgeon inserts miniature surgical instruments through other portals to trim or repair the tear.

Knee arthroscopy

• Partial meniscectomy. In this procedure, the damaged meniscus tissue is trimmed away. 
• Meniscus repair. Some meniscus tears can be repaired by suturing (stitching) the torn pieces together. Whether a tear can be successfully treated with repair depends upon the type of tear, as well as the overall condition of the injured meniscus. Because the meniscus must heal back together, recovery time for a repair is much longer than from a meniscectomy.

Rehabilitation. After surgery, your doctor may put your knee in a cast or brace to keep it from moving. If you have had a meniscus repair procedure, you will need to use crutches for about a month to keep weight off of your knee.

Once the initial healing is complete, your doctor will prescribe rehabilitation exercises. Regular exercise to restore your knee mobility and strength is necessary. You will start with exercises to improve your range of motion. Strengthening exercises will gradually be added to your rehabilitation plan.

For the most part, rehabilitation can be carried out at home, although your doctor may recommend physical therapy. Rehabilitation time for a meniscus repair is about 3 months. A meniscectomy requires less time for healing — approximately 3 to 4 weeks.

Recovery

Meniscus tears are extremely common knee injuries. With proper diagnosis, treatment, and rehabilitation, patients often return to their pre-injury abilities.

HEALTHY BONES AT EVERY AGE

Bone health is important at every age and stage of life. The skeleton is our body's storage bank for calcium — a mineral that is necessary for our bodies to function. Calcium is especially important as a building block of bone tissue, as well as exercise.  

We must get calcium from the foods we eat. If we do not have enough calcium in our diets to keep our bodies functioning, calcium is removed from where it is stored in our bones. Over time, this causes our bones to grow weaker.

Loss of bone strength can lead to osteoporosis — a disorder in which bones become very fragile and more likely to break. Older adults with osteoporosis are most vulnerable to breaks in the wrist, hip, and spine. These fractures can seriously limit mobility and independence.

Fortunately, there are many things we can do at every age to keep our bones strong and healthy - the first being exercise. Exercise equals forces being put upon the bones, and while joints may swell slightly out of protest, forces increase osteoclast activity.  Osteoclasts are the basic starter-cell to bone production.  The more forces implemented upon the bones, the more dense the bone.  This can help to prevent osteoporosis or slow it's symptoms later in life. Here at Champion Performance and Physical Therapy, we can give you an exercise program to gradually increase your daily activity, and therefore, increase your bone density and strengthen the muscles around the bones.

Peak Bone Mass

Our maximum bone size and strength is called peak bone mass. Genes play a large role in how much peak bone we have. For example, the actual size and structure of a person's skeleton is determined by genetic factors.

Between the ages of 10 and 20 we can greatly increase our peak bone mass with a calcium-rich diet and regular weightbearing exercise.

© Thinkstock, 2012

Although peak bone mass is largely determined by our genes, there are lifestyle factors — such as diet and exercise — that can influence whether we reach our full bone mass potential.

There is a limited time that we can influence our peak bone mass. The best time to build bone density is during years of rapid growth. Childhood, adolescence, and early adulthood are the times when we can significantly increase our peak bone mass through diet and exercise. Not surprisingly, we can also make choices that decrease peak bone mass, such as smoking, poor nutrition, inactivity, and excessive alcohol intake.

Most people will reach their peak bone mass between the ages of 25 and 30. By the time we reach age 40, however, we slowly begin to lose bone mass. We can, however, take steps to avoid severe bone loss over time. For most of us, bone loss can be significantly slowed through proper nutrition and regular exercise.

Although everyone will lose bone with age, people who developed a higher peak bone mass when young are better protected against osteoporosis and related fractures later in life.

Some people, however, are at higher risk for bone loss and osteoporosis because of problems with the way their bodies remodel bone. A healthy diet and exercise can help, but bone will still be lost at a faster rate. The good news is that in recent years, medications have been developed to treat this metabolic problem. In severe cases, bone loss may even be reversed with newer, bone-forming medications.

Gender and Peak Bone Mass

Men have a higher peak bone mass than women. Men accumulate more skeletal mass than women do during growth, and their bone width and size is greater. Because women have smaller bones with a thinner cortex and smaller diameter, they are more vulnerable to developing osteoporosis. Although men have a higher peak bone mass, they also are at risk for osteoporosis, especially after age 70 when bone loss and fracture risk increases significantly.

This chart shows bone mass in women as it relates to age.

Reproduced from J Bernstein, ed: Musculoskeletal Medicine. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2003.

Bone Health at Every Stage

There are things we can do at every stage of life to ensure good bone health. Especially important is making sure we get enough calcium and Vitamin D. The sections below provide guidelines from the Food and Nutrition Board (FNB) at the Institute of Medicine of the National Academies on calcium and Vitamin D daily intake at every age for the general public.

Please note that some people may require different dosages of these supplements. For example, people who live in areas with little sun, those with darker skin, and people who are obese may need more Vitamin D than the recommended daily amount. The upper safe limit for people older than 9 years of daily Vitamin D is 4000 IU, but talk to your doctor about the best dose for you. Also, be aware that taking calcium and Vitamin D at higher than recommended levels may cause adverse side effects.

For a complete overview of calcium and Vitamin D Recommended Dietary Allowances (RDAs), as well as Tolerable Upper Intake Levels (ULs), refer to "Calcium, Nutrition, and Bone Health"

• Birth to Age 9

Calcium is an essential mineral for babies and young children to ensure they are able to grow strong bones and teeth. Because our bodies need Vitamin D to absorb calcium from our diets, getting enough Vitamin D goes hand-in-hand with getting enough calcium. Young children who do not get enough Vitamin D are at risk for rickets, a disease that can cause bone weakness, bowed legs, and other skeletal deformities.

First year. According to the FNB, infants, age birth to 6 months, need 200 milligrams (mg) of calcium each day, and infants, ages 7 to 12 months, 260 mg. During this first year, both breast milk and infant formula provide sufficient calcium.

The FNB daily recommendation of Vitamin D for infants birth to 12 months is 400 International Units (IU). Although Vitamin D can be found in breast milk and infant formula, it is not in sufficient amounts. The American Academy of Pediatrics now recommends that babies take daily Vitamin D supplement drops, unless they are drinking 32 oz. of infant formula each day.

Ages 1 to 3 years. The amount of calcium and Vitamin D that a young child needs increases with age.

The FNB recommended dietary allowance (RDA) for children ages 1 to 3 are 700 mg of calcium and 600 IU of Vitamin D. Milk is one of the best sources of calcium for children — plus a cup of milk is fortified with 100 IU of Vitamin D. Doctors recommend whole milk for children between the ages of 1 and 2 years. Lowfat and skim milk are good options after age 2.

The American Academy of Pediatrics recommends that all children take Vitamin D supplements.

© Thinkstock, 2012

Because very few foods contain substantial levels of Vitamin D, the American Academy of Pediatrics recommends that all children — from infancy through adolescence — take Vitamin D supplements.

Ages 4 to 8 years. Children ages 4 through 8 need 1,000 mg of calcium each day, or the equivalent of about two cups of yogurt and one glass of milk.

The FNB recommends 600 IU of Vitamin D for everyone from age 1 through 70 years. Recent research, however, supports that the body needs at least 1000 IU per day for good bone health, starting at age 5 years. Taking a Vitamin D supplement is the most effective way for your child to get 1000 IU of Vitamin D every day.

• Between 10 and 20 Years of Age

This is the stage of life when peak bone mass is established.

Puberty. Puberty is a very important time in the development of the skeleton and peak bone mass. Half of total body calcium stores in women and up to 2/3 of calcium stores in men are made during puberty. At the end of puberty, men have about 50% more body calcium than women.

Adolescents grow rapidly and need 1,300 mg of calcium each day for the best possiblle development of the skeleton.

© Thinkstock, 2012

On average, girls begin puberty at age 10 and start having menstrual periods about age 12. Having a regular period is important to girls' and women's bone health because it indicates that sufficient estrogen is being produced. Estrogen is a hormone that improves calcium absorption in the kidneys and intestines.

The average girl grows the fastest in height between the ages of 11 and 12 years, and stops growing between the ages of 14 and 15 years. About 95% of a young woman's peak bone mass is present by age 20, and some overall gains in mass often continue until age 30.

The average boy has his fastest rate of growth in height between ages 13 and 14, and stops growing between ages 17 and 18. Peak bone mass occurs 9 to 12 months after the peak rate in height growth.

Early or late onset of puberty affects peak bone mass. Boys with late puberty generally have less bone mass for life than those who start puberty at the typical time, about age 11 1/2. Obesity delays the start of puberty in boys and, therefore, may have a negative effect on peak bone mass.

Obesity in girls, however, accelerates the onset of puberty. The effect that obesity and early puberty have on the peak bone mass is variable in girls.

Nutrional requirements. Many adolescents and young adults do not get enough calcium. Both boys and girls age 10 to 20 years need at least 1,300 mg of calcium each day, the equivalent of:

• One cup of orange juice with added calcium
• Two cups of milk
• One cup of yogurt

Other dairy products, green leafy vegetables, fish, and tofu are also good sources of calcium.

A Vitamin D supplement is necessary to ensure the calcium that adolescents do take in is absorbed in the intestines. Sodas and carbonated beverages should be avoided for many nutritional reasons, including for bone health and to prevent obesity. Sodas decrease calcium absorption in the intestines and contain empty calories. Milk, calcium-fortified juices, and water are better beverage alternatives for all age groups.

Adolescent pregnancy. Like other adolescents, young women who are pregnant and/or breastfeeding between the ages of 14 and 18 should have 1300 mg of calcium each day. The RDA for Vitamin D remains 600 IU, although as mentioned above, recent research supports a daily dosage of 1000 IU for better bone health.

Exercise. Weightbearing exercise during the teen years is essential to reach maximum bone strength. Examples of weightbearing exercise include walking and running, as well as team sports like soccer and basketball.

Young women who exercise excessively can lose enough weight to cause hormonal changes that stop menstrual periods (amenorrhea). This loss of estrogen can cause bone loss at a time when young women should be adding to their peak bone mass. It is important to see a doctor if there have been any menstrual cycle changes or interruptions.

• Between 20 and 30 Years of Age

Although your body is no longer forming new bone as readily as before, your bones will reach their peak strength during these years. It is important to get adequate calcium and exercise to help achieve peak bone density. Both men and women need at least 1,000 mg of calcium each day, and probably a Vitamin D supplement because it is difficult to get 1000 IU of Vitamin D even from a healthy diet.

To promote good bone health, adults need at least 30 minutes of weightbearing activity (such as a brisk walk), 4 or more days per week. Muscle-strengthening activities at least two days of the week are also recommended.

Pregnancy and breastfeeding. The calcium requirement for pregnant or breastfeeding women is the same for any adult in this age range: 1,000 mg. Of course, getting the recommended calcium and Vitamin D daily allowance is especially important when you are pregnant or breastfeeding. Without it, a growing baby in the womb may pull calcium out of the mother's bones in order to build its own skeleton. A nursing baby also requires calcium, and a mother can lose bone mass during the time she breastfeeds. In most cases, once breastfeeding ends, a healthy diet and exercise will help a mother regain any bone lost.

• Between 30 and 50 Years of Age

After you reach your peak bone mass, you will begin to gradually lose bone. All through your life, your body is continually removing old bone and replacing it with fresh bone. This process is called remodeling. Up until about age 40, all the bone removed is replaced. After age 40, however, less bone is replaced. At this stage in life, getting enough exercise and calcium (1,000 mg) and Vitamin D (1,000 IU) every day, are crucial to minimizing bone loss. Exercise is also important for maintaining your muscle mass, which preserves and strengthens surrounding bone and helps prevent falls.

• Older Than 50 Years of Age

The daily calcium recommendation for men over 50 remains the same at 1,000 mg. Many women over 50 are entering or have gone through menopause, and the FNB recommends that women over 50 increase their daily calcium intake to 1,200 mg.

Menopause. Most women enter menopause between the ages of 42 and 55. As the levels of estrogen drop dramatically, women undergo rapid bone loss. In fact, in the 10 years after menopause, women can lose 40% of their spongy, inner bone and 10% of their hard, outer bone. This reduces bone strength and increases a woman's risk for fracture. It also helps explain why osteoporosis is much more common in women than in men (who do not experience this acute loss of hormone in middle age).

In the past, estrogen replacement therapy was frequently used to protect aging women from bone loss. Research has since shown that there are significant risks in taking estrogen long-term after menopause. These include increased risk of serious blood clots, stroke, heart attack, breast and ovarian cancers, gall bladder disease, and possibly dementia.

If your period becomes irregular, or, if you develop signs of menopause, such as hot flashes, talk with your doctor. You also may want to ask about bone density testing. This is a safe, painless, x-ray technique that compares your current bone density with the peak bone mass someone your same gender and ethnicity should have reached at 20 to 25 years of age.

A duel-energy x-ray absorptiometry (DXA) scan is the "gold standard" of bone mineral density testing.

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010

Age 70 and above. Both men and women should get 1,200 mg of calcium each day. The RDA for Vitamin D at this age is 800 IU.

After they reach the age of 70, men are more likely to experience low bone mass and fractures. Men over age 70 should discuss bone density testing with a doctor.

Fall prevention becomes especially important for people over age 70. Falls are the leading cause of injury to elderly people in the United States. Falls cause many seniors to lose their independence, requiring a change in living arrangements, such as moving to a nursing home or assisted living facility. Fortunately, many falls can be prevented, and having strong bones can help prevent fractures.

No matter your age, adequate calcium intake and exercise can limit bone loss and increase bone and muscle strength.

Source: National Institutes of Health (NIH) (Dietary Supplement Fact Sheet: Calcium) ; Institute of Medicine of the National Academies (Dietary Reference Intakes for Calcium and Vitamin D).

FROZEN SHOULDER

We, at Champion Performance and Physical Therapy have seen all too many victims of frozen shoulder.  It's commonly occurring, although rare in the population. Frozen shoulder, also called adhesive capsulitis, causes pain and stiffness in the shoulder. Over time, the shoulder becomes very hard to move.

Frozen shoulder occurs in about 2% of the general population. It most commonly affects people between the ages of 40 and 60, and occurs in women more often than men.

Anatomy

Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

The head of the upper arm bone fits into a shallow socket in your shoulder blade. Strong connective tissue, called the shoulder capsule, surrounds the joint.

To help your shoulder move more easily, synovial fluid lubricates the shoulder capsule and the joint.

The shoulder capsule surrounds the shoulder joint and rotator cuff tendons.

Reproduced and modified from The Body Almanac. (c) American Academy of Orthopaedic Surgeons, 2003.

Description

In frozen shoulder, the shoulder capsule thickens and becomes tight. Stiff bands of tissue — called adhesions — develop. In many cases, there is less synovial fluid in the joint.

The hallmark sign of this condition is being unable to move your shoulder - either on your own or with the help of someone else. It develops in three stages:

Freezing

In the"freezing" stage, you slowly have more and more pain. As the pain worsens, your shoulder loses range of motion. Freezing typically lasts from 6 weeks to 9 months.

Frozen

Painful symptoms may actually improve during this stage, but the stiffness remains. During the 4 to 6 months of the "frozen" stage, daily activities may be very difficult.

Thawing

Shoulder motion slowly improves during the "thawing" stage. Complete return to normal or close to normal strength and motion typically takes from 6 months to 2 years.

In frozen shoulder, the smooth tissues of the shoulder capsule become thick, stiff, and inflamed.

Cause

The causes of frozen shoulder are not fully understood. There is no clear connection to arm dominance or occupation. A few factors may put you more at risk for developing frozen shoulder.

Diabetes. Frozen shoulder occurs much more often in people with diabetes, affecting 10% to 20% of these individuals. The reason for this is not known.

Other diseases. Some additional medical problems associated with frozen shoulder include hypothyroidism, hyperthyroidism, Parkinson's disease, and cardiac disease.

Immobilization. Frozen shoulder can develop after a shoulder has been immobilized for a period of time due to surgery, a fracture, or other injury. Having patients move their shoulders soon after injury or surgery is one measure prescribed to prevent frozen shoulder.

Symptoms

Pain from frozen shoulder is usually dull or aching. It is typically worse early in the course of the disease and when you move your arm. The pain is usually located over the outer shoulder area and sometimes the upper arm.

Doctor Examination

Physical Examination

Your doctor will test the range of motion in your shoulder.

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

After discussing your symptoms and medical history, your doctor will examine your shoulder. Your doctor will move your shoulder carefully in all directions to see if movement is limited and if pain occurs with the motion. The range of motion when someone else moves your shoulder is called "passive range of motion." Your doctor will compare this to the range of motion you display when you move your shoulder on your own ("active range of motion"). People with frozen shoulder have limited range of motion both actively and passively.

Imaging Tests

Other tests that may help your doctor rule out other causes of stiffness and pain include:

X-rays. Dense structures, such as bone, show up clearly on x-rays. X-rays may show other problems in your shoulder, such as arthritis.

Magnetic resonance imaging (MRI) and ultrasound. These studies can create better images of problems with soft tissues, such as a torn rotator cuff.

Treatment

Frozen shoulder generally gets better over time, although it may take up to 3 years.

The focus of treatment is to control pain and restore motion and strength through physical therapy.

Nonsurgical Treatment

More than 90% of patients improve with relatively simple treatments to control pain and restore motion.

Non-steroidal anti-inflammatory medicines. Drugs like aspirin and ibuprofen reduce pain and swelling.

Steroid injections. Cortisone is a powerful anti-inflammatory medicine that is injected directly into your shoulder joint.

Physical therapy. Specific exercises will help restore motion. These may be under the supervision of a physical therapist or via a home program. Therapy includes stretching or range of motion exercises for the shoulder. Sometimes heat is used to help loosen the shoulder up before the stretching exercises.. Below are examples of some of the exercises that might be recommended.

External Rotation - Passive Stretch

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Forward Flexion - Supine Position

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

Crossover Arm Stretch

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

• External rotation — passive stretch. Stand in a doorway and bend your affected arm 90 degrees to reach the doorjamb. Keep your hand in place and rotate your body as shown in the illustration. Hold for 30 seconds. Relax and repeat.
• Forward flexion — supine position. Lie on your back with your legs straight. Use your unaffected arm to lift your affected arm overhead until you feel a gentle stretch. Hold for 15 seconds and slowly lower to start position. Relax and repeat.
• Crossover arm stretch. Gently pull one arm across your chest just below your chin as far as possible without causing pain. Hold for 30 seconds. Relax and repeat.

Surgical Treatment

If your symptoms are not relieved by therapy and anti-inflammatory medicines, you and your doctor may discuss surgery. It is important to talk with your doctor about your potential for recovery continuing with simple treatments, and the risks involved with surgery.

The goal of surgery for frozen shoulder is to stretch and release the stiffened joint capsule. The most common methods include manipulation under anesthesia and shoulder arthroscopy.

Manipulation under anesthesia. During this procedure, you are put to sleep. Your doctor will force your shoulder to move which causes the capsule and scar tissue to stretch or tear. This releases the tightening and increases range of motion.

Shoulder arthroscopy. In this procedure, your doctor will cut through tight portions of the joint capsule. This is done using pencil-sized instruments inserted through small incisions around your shoulder.

In many cases, manipulation and arthroscopy are used in combination to obtain maximum results. Most patients have very good outcomes with these procedures.

These photos taken through an arthroscope show a normal shoulder joint lining (left) and an inflamed joint lining damaged by frozen shoulder.

Recovery. After surgery, physical therapy is necessary to maintain the motion that was achieved with surgery. Recovery times vary, from 6 weeks to three months. Although it is a slow process, your commitment to therapy is the most important factor in returning to all the activities you enjoy.

Long-term outcomes after surgery are generally good, with most patients having reduced or no pain and greatly improved range of motion. In some cases, however, even after several years, the motion does not return completely and a small amount of stiffness remains.

Although uncommon, frozen shoulder can recur, especially if a contributing factor like diabetes is still present.

AVASCULAR NECROSIS OF THE HIP

You may have heard this term before, or had a friend or family member who struggled with the same, but what exactly is it?

Avascular necrosis is the death of bone tissue due to a lack of blood supply. Also called osteonecrosis, avascular necrosis can lead to tiny breaks in the bone and the bone's eventual collapse.

The blood flow to a section of bone can be interrupted if the bone is fractured or the joint becomes dislocated. Avascular necrosis is also associated with long-term use of high-dose steroid medications and excessive alcohol intake.

Anyone can be affected by avascular necrosis. However, it's most common in people between the ages of 30 and 60. Because of this relatively young age range, avascular necrosis can have significant long-term consequences. Although it can happen in any bone at any joint, osteonecrosis is most likely to occur at the epiphysis (end) of a bone, and more commonly in the ball-and-socket joint, such as the shoulder or hip. 

Symptoms

Many people have no symptoms in the early stages of avascular necrosis. As the condition worsens, your affected joint may hurt only when you put weight on it. Eventually, the joint may hurt even when you're lying down.

Pain can be mild or severe and usually develops gradually. Pain associated with avascular necrosis of the hip may be focused in the groin, thigh or buttock. In addition to the hip, the areas likely to be affected are the shoulder, knee, hand and foot.

Some people develop avascular necrosis bilaterally — for example, in both hips or in both knees.

When to see a doctor?

See your doctor if you have persistent pain in any joint. Seek immediate medical attention if you believe you have a broken bone or a dislocated joint.

Causes

Avascular necrosis occurs when blood flow to a bone is interrupted or reduced. Reduced blood supply can be caused by:

• Joint or bone trauma. An injury, such as a dislocated joint, might damage nearby blood vessels. Cancer treatments involving radiation also can weaken bone and harm blood vessels.
• Fatty deposits in blood vessels. The fat (lipids) can block small blood vessels, reducing the blood flow that feeds bones.
• Certain diseases. Medical conditions, such as sickle cell anemia and Gaucher's disease, also can cause diminished blood flow to bone.

For about 25 percent of people with avascular necrosis, the cause of interrupted blood flow is unknown.

Risk Factors

• Trauma. Injuries, such as hip dislocation or fracture, can damage nearby blood vessels and reduce blood flow to bones.
• Steroid use. High-dose use of corticosteroids, such as prednisone, is the most common cause of avascular necrosis that isn't related to trauma. The exact reason is unknown, but one hypothesis is that corticosteroids can increase lipid levels in your blood, reducing blood flow and leading to avascular necrosis.
• Excessive alcohol use. Consuming several alcoholic drinks a day for several years also can cause fatty deposits to form in your blood vessels.
• Bisphosphonate use. Long-term use of medications to increase bone density may be a risk factor for developing osteonecrosis of the jaw. This complication has occurred in some people treated with these medications for cancers, such as multiple myeloma and metastatic breast cancer. The risk appears to be lower for women treated with bisphosphonates for osteoporosis.
• Certain medical treatments. Radiation therapy for cancer can weaken bone. Organ transplantation, especially kidney transplant, also is associated with avascular necrosis.

Medical conditions associated with avascular necrosis include:

• Pancreatitis
• Diabetes
• Gaucher's disease
• HIV/AIDS
• Systemic lupus erythematosus
• Sickle cell anemia

Possible Complications

Untreated, avascular necrosis worsens with time.  Eventually the bone may become so weakened that it collapses.  Avascular necrosis also causes bone to lose its smooth shape, potentially leading to severe arthritis and residual pain.

Questions to Ask Your Doctor

• What's the most likely cause of my symptoms?
• What kinds of tests do I need?
• What treatments are available?
• I have other health conditions. How can I best manage them together?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask other questions.

Testing and Diagnosis

During a physical exam your doctor will likely press around your joints, checking for tenderness. Your doctor may also move the joints through a variety of positions to see if your range of motion has been reduced.

Imaging tests

Many disorders can cause joint pain. Imaging tests can help pinpoint the source of pain. The options include:

• X-rays. They can reveal bone changes that occur in the later stages of avascular necrosis. In the condition's early stages, X-rays usually appear normal.
• MRI and CT scan. These tests produce detailed images that can show early changes in bone that may indicate avascular necrosis.
• Bone scan. A small amount of radioactive material is injected into your vein. This tracer travels to the parts of your bones that are injured or healing and shows up as bright spots on the imaging plate.

Treatment Options

The goal is to prevent further bone loss. Specific treatment usually depends on the amount of bone damage you already have.

Medications and Therapy

In the early stages of avascular necrosis, symptoms can be reduced with medication and therapy. Your doctor might recommend:

• Nonsteroidal anti-inflammatory drugs. Medications, such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve, others) may help relieve the pain and inflammation associated with avascular necrosis.
• Osteoporosis drugs. Medications, such as alendronate (Fosamax, Binosto), may slow the progression of avascular necrosis, but the evidence is mixed.
• Cholesterol-lowering drugs. Reducing the amount of cholesterol and fat in your blood may help prevent the vessel blockages that can cause avascular necrosis.
• Blood thinners. If you have a clotting disorder, blood thinners, such as warfarin (Coumadin, Jantoven), may be recommended to prevent clots in the vessels feeding your bones.
• Rest. Reducing the weight and stress on your affected bone can slow the damage. You might need to restrict your physical activity or use crutches to keep weight off your joint for several months.
• Exercises. You may be referred to a physical therapist to learn exercises to help maintain or improve the range of motion in your joint.
• Electrical stimulation. Electrical currents might encourage your body to grow new bone to replace the area damaged by avascular necrosis. Electrical stimulation can be used during surgery and applied directly to the damaged area. Or it can be administered through electrodes attached to your skin.

Surgical and Other Procedures

Because most people don't start having symptoms until avascular necrosis is fairly advanced, your doctor may recommend surgery. The options include:

• Core decompression. The surgeon removes part of the inner layer of your bone. In addition to reducing your pain, the extra space within your bone stimulates the production of healthy bone tissue and new blood vessels.
• Bone transplant (graft). This procedure can help strengthen the area of bone affected by avascular necrosis. The graft is a section of healthy bone taken from another part of your body.
• Bone reshaping (osteotomy). In this procedure, a wedge of bone is removed above or below a weight-bearing joint, to help shift your weight off the damaged bone. Bone reshaping might allow you to postpone joint replacement.
• Joint replacement. If your diseased bone has already collapsed or other treatment options aren't helping, you might need surgery to replace the damaged parts of your joint with plastic or metal parts. An estimated 10 percent of hip replacements in the United States are performed to treat avascular necrosis of the hip.
• Regenerative medicine treatment. Bone marrow aspirate and concentration is a novel procedure that in the future might be appropriate for early stage avascular necrosis of the hip. Stem cells are harvested from your bone marrow. During surgery a core of dead hip bone is removed and stem cells inserted in its place, potentially allowing for growth of new bone.

Source: Mayo Clinic Diseases and Conditions Education

FINISHING TOUCHES, NEW LOOK INSIDE

After moving in in October to our new location on 75th and State Line Road, things have finally slowed down just long enough to put the finishing touches on the new facility and the layout!  Plenty of room for our run-jump-hop athletes and a quieter space for manual and those patients still in their slings or on crutches. 

A huge thanks to Ryan, Jason, and the whole FastSigns - Westport crew for their decorative touches; you guys are the best!

Click on the title to take a look.

SHIN SPLINTS - INFO AND PREVENTION

Shin Splints

Shin splints are a common exercise-related problem. The term "shin splints" refers to pain along the inner edge of the shinbone (tibia).

Shin splints typically develop after physical activity. They are often associated with running. Any vigorous sports activity can bring on shin splints, especially if you are just starting a fitness program.

Simple measures can relieve the pain of shin splints. Rest, ice, and stretching often help. Taking care not to overdo your exercise routine will help prevent shin splints from coming back.

Description

Shin splints (medial tibial stress syndrome) is an inflammation of the muscles, tendons, and bone tissue around your tibia. Pain typically occurs along the inner border of the tibia, where muscles attach to the bone.

Shin splint pain most often occurs on the inside edge of your shinbone.

(Reproduced and adapted with permission from Gruel CR: Lower Leg, in Sullivan JA, Anderson SJ (eds): Care of the Young Athlete. Rosemont, IL, American Academy of Orthopaedic Surgeon, 2000.)

Cause

In general, shin splints develop when the muscle and bone tissue (periosteum) in the leg become overworked by repetitive activity.

Shin splints often occur after sudden changes in physical activity. These can be changes in frequency, such as increasing the number of days you exercise each week. Changes in duration and intensity, such as running longer distances or on hills, can also cause shin splints.

Other factors that contribute to shin splints include:

• Having flat feet or abnormally rigid arches
• Exercising with improper or worn-out footwear

Runners are at highest risk for developing shin splints. Dancers and military recruits are two other groups frequently diagnosed with the condition.

Flat feet can increase stress on lower leg muscles during exercise.

Symptoms

The most common symptom of shin splints is pain along the border of the tibia. Mild swelling in the area may also occur.

Shin splint pain may:

• Be sharp and razor-like or dull and throbbing
• Occur both during and after exercise
• Be aggravated by touching the sore spot

Doctor Examination

After discussing your symptoms and medical history, your doctor will examine your lower leg. An accurate diagnosis is very important. Sometimes, other problems may exist that can have an impact on healing.

Your doctor may order additional imaging tests to rule out other shin problems. Several conditions can cause shin pain, including stress fractures, tendinitis, and chronic exertional compartment syndrome.

• Stress Fracture

If your shin splints are not responsive to treatment, your doctor may want to make sure you do not have a stress fracture. A stress fracture is a small crack(s) in the tibia caused by stress and overuse.

Imaging tests that create pictures of anatomy help to diagnose conditions. A bone scan and magnetic resonance imaging (MRI) study will often show stress fractures in the tibia.

• Tendinitis

Tendons attach muscles to bones. Tendinitis occurs when tendons become inflamed. This can be painful like shin splints, especially if there is a partial tear of the involved tendon. An MRI can help diagnose tendinitis.

• Chronic Exertional Compartment Syndrome

An uncommon condition called chronic exertional compartment syndrome causes symptoms like shin splints. Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. In chronic exertional compartment syndrome, this is brought on by exercise. Pain usually resolves soon after the activity stops.

The tests used to diagnose this condition involve measuring the pressure within the leg compartments before and after exercise.

Treatment

Nonsurgical Treatment

Rest. Because shin splints are typically caused by overuse, standard treatment includes several weeks of rest from the activity that caused the pain. Lower impact types of aerobic activity can be substituted during your recovery, such as swimming, using a stationary bike, or an elliptical trainer.

Non-steroidal anti-inflammatory medicines. Drugs like ibuprofen, aspirin, and naproxen reduce pain and swelling.

Ice. Use cold packs for 20 minutes at a time, several times a day. Do not apply ice directly to the skin.

Compression. Wearing an elastic compression bandage may prevent additional swelling.

Flexibility exercises. Stretching your lower leg muscles may make your shins feel better.

Supportive shoes. Wearing shoes with good cushioning during daily activities will help reduce stress in your shins.

Orthotics. People who have flat feet or recurrent problems with shin splints may benefit from orthotics. Shoe inserts can help align and stablize your foot and ankle, taking stress off of your lower leg. Orthotics can be custom-made for your foot, or purchased "off the shelf."

Return to exercise. Shin splints usually resolve with rest and the simple treatments described above. Before returning to exercise, you should be pain-free for at least 2 weeks. Keep in mind that when you return to exercise, it must be at a lower level of intensity. You should not be exercising as often as you did before, or for the same length of time.

Be sure to warm up and stretch thoroughly before you exercise. Increase training slowly. If you start to feel the same pain, stop exercising immediately. Use a cold pack and rest for a day or two. Return to training again at a lower level of intensity. Increase training even more slowly than before.

Surgical Treatment

Very few people need surgery for shin splints. Surgery has been done in very severe cases that do not respond to nonsurgical treatment. It is not clear how effective surgery is, however.

Prevention

There are things you can do to prevent shin splints.

• Wear a proper fitting athletic shoe. To get the right fit, determine the shape of your foot using the "wet test." Step out of the shower onto a surface that will show your footprint, like a brown paper bag. If you have a flat foot, you will see an impression of your whole foot on the paper. If you have a high arch, you will only see the ball and heel of your foot. When shopping, look for athletic shoes that match your particular foot pattern.

In addition, make sure you wear shoes designed for your sport. Running long distances in court-type sneakers can contribute to shin splints.

• Slowly build your fitness level. Increase the duration, intensity, and frequency of your exercise regimen gradually.
   
• Cross train. Alternate jogging with lower impact sports like swimming or cycling.
   
• Barefoot running. In recent years, barefoot running has gained in popularity. Many people claim it has helped to resolve shin splints. Some research indicates that barefoot running spreads out impact stresses among muscles, so that no area is overloaded. However, there is no clear evidence that barefoot running reduces the risk for any injury. 

Like any significant change in your fitness regimen, a barefoot running program should be started very gradually. Begin with short distances to give your muscles and your feet time to adjust. Pushing too far, too fast can put you at risk for stress injuries. In addition, barefoot runners are at increased risk for cuts and bruises on their feet. Several brands of minimalist shoes with "toes" are available and these also require a slow working in period as your body adjusts to this different activity.

If your shin splints do not improve after rest and other methods described above, be sure to see a doctor to determine whether something else is causing your leg pain.

Come visit us at Champion Performance and Physical Therapy if you are interested in finding exercises to strengthen the lower leg and improve shin splint problems before pain has a chance to reoccur.