MENISCUS TEARS

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, and by doing any activity. Here at CHAMPION, many of our meniscus patients injured theirs while running - felt a pop, the knee gave out - and they still finished the race.  Many times, you'll know something's wrong but it's not like a quad tendon rupture or an achilles tendon rupture, where you won't be able to walk on that leg. You'll definitely have pain later on as the day continues and your body recognizes the injury, but many times, no one recognizes the severity of the injury that just occurred. When people talk about torn cartilage in the knee, they are usually referring to a torn meniscus.  

The menisci are 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. Physical therapy may be necessary to strengthen the muscles around the joint to somewhat replicate the aspects of stability you lose when the meniscus is severely damaged so as to return to higher level activity. Immediately, however, the RICE protocol is going to manage swelling and pain until strengthening becomes an option. 

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.  Meniscus tears can occur concurrently with another injury, such as an ACL rupture, or alone. An ACL rupture would not usually require weight-bearing limitations, but adding a meniscus repair in will require weight-bearing restrictions until the meniscus heals because of the pressure it endures from the joint.

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 is carried out at a physical therapy clinic. Rehabilitation time for a meniscus repair is about 3 months. A meniscectomy requires less time for healing — approximately 3 to 4 weeks.

SPRING SPORT ATHLETES: HOW TO END YOUR SEASONS

Spring sport Athletes:

You've spent months by now preparing for these next few weeks of your seasons. Your coaches are most likely going to begin tapering your workouts so as to improve your abilities to give 100% come time for competition, but there are things you can be doing outside of practice to end your season by beating a personal record (and possibly, earning a trip to the state championship).

At Practice:

1.  Listen to your coach. 

When your coach says give 65/75/85%, DO IT. They're doing it for a reason. If you're used to going harder, understand to keep your body performing at a high level, it's imperative that the workouts decrease in intensity to maximize your body's ability to peak at the end of the season.

2.  Minimize change.

Do your best to not add anything new to your routine within a week of a big game, or meet. Your body's ability to adapt will be thrown off, as many of your workouts aren't changing during the season. You'll likely be sore, and will not be able to run as fast, or jump as high.  Any changes to your routine, including adding different lifts in the weight room, should be included at least 8 days prior to a big competition.

At Home:

1.  Get your rest.

Make sure you're getting an adequate amount of rest each night.  I won't say you need at least 8 hours, because some bodies just don't struggle to function on less sleep, but sleeping is a massive part of rebooting your brain function for mental stamina, and allows your muscles to repair. 

2.  Ice down any sore spots.

If you have a prior injury that could potentially be affected by the sport you're currently playing, make sure to listen and respond to what your body is telling you.  If an old injury is inflamed, be sure to ice and take ibuprofen as needed to minimize swelling. 

3.  Communicate with your coach.

If you have old injuries that are acting up, make sure to let your coach know so that he's aware you're trying to preserve your body for competition. Take it easy during practice, and make sure to visit your athletic trainer so he can help you manage your symptoms. If you saw a physical therapist for treatment of that injury, give them a call and ask what you can do to improve your symptoms. It may get you back to practicing at 100% faster, and allow you to feel more confident going into competition.

4.  Eat well. 

Make sure you're eating plenty of proteins to fuel your muscles as they recuperate from the breakdown that follows trying practices. Carb load around 12-24 hours prior to a big competition, and make sure you EAT the day of your competition - even if you're nervous.  Be sure to get carbs and proteins in following your competition, as that's when your body is most receptive to the nutrients. And as always, drink plenty of water to help flush toxins out of your system, both before and after. 

5.  Seniors - you're not done just yet. 

Seniors: this one goes out specifically to you. We know how difficult it is to see your friends who aren't involved in spring sports enjoying the end of their senior year, and how hard it is to not be able to be a part of that yet. However, you still are a member of a team that you've made a commitment to, and your commitment was to give your team the best you have. Spending your weekends partying will not only inhibit your ability to perform, but can get you into serious trouble if you're caught and turned in. Most schools don't hesitate to remove athletes from competition, or even the team, who get in trouble outside of school.  Not only might you not be able to compete in your most important games of the season, but you may not earn your athletic letters. Don't make this season a bust by taking the risk and making a mistake, you have all summer to enjoy your friends before you leave for college - and you want to be proud of the way you end your season. 

THROWING INJURIES

As with many orthopedic injuries, repetitive motion like throwing can create an excessive stress on shoulder and elbow tendons and ligaments. Repeated stress can also tear the ligament and tendon away from the bone and can even pull off tiny bone fragments. In the case of children, normal bone growth can be affected if this condition is left untreated.  As children are starting to play sports competitively much younger and continue to play at a high level throughout their entire career, injury recognition is key to preventing further damage that could potentially lead to career-ending problems. 

Symptoms of Injury

The symptoms of a throwing injury can include shoulder pain or elbow pain, a reduced range of motion and, with the elbow, the tendency for the joint to lock.  Tendonitis or frayed tendons are most commonly caused by, surprisingly enough, a lack of functional strength in certain muscles. 

These athletes have been conditioned to throw using a certain technique throughout the majority of their lives.  The muscles necessary to recreate that technique time and time again are very strong, but the surrounding muscles may not be activated nearly as much as they should be. Muscles insert via a tendon to bone, and will usually cross bony prominences, or bumps on the bones, to get to their insertion point.  For a strong, healthy muscle, tendons have enough slack to reach their insertion point without obstacles, but remain taut enough to keep the tendinous portion from rubbing on the bony prominences they cross. 

When the muscles are not activated regularly (strengthened properly), these muscles will get pulled in whichever direction the strong, frequently-utilized muscles are willing the bones.  For example: if pectoral muscles in the chest are tight and the scapular stabilizers between the shoulder blades aren't fired enough, their weakness will allow the tightness of the pectorals to round the shoulders forward.  This will lead to poor posture, and potentially cervical issues. 

When these weak muscles get pulled in a different direction due to lack of strength, their tendons rub constantly over the bony prominences - and this is worsened by repetitive motion, such as throwing. This will fray the tendinous portion of the weak muscles over time, until eventually there is too much inflammation, causing fairly debilitating pain, or until the tendon tears. 

Treatment Options

The most common treatments include resting and icing the affected area to reduce inflammation. As difficult as it is to pull players out of games and practice at such a high level, it's vital that any injury be treated as soon as possible to prevent further damage.

NSAIDs such as ibuprofen may be helpful to ease pain and inflammation, and physical therapy may be recommended by an orthopedic specialist. Physical therapy will strengthen the muscles around the damage to relieve them from the strain of bony prominences. This can relieve pain, but will likely not repair damages in the tendons. In some cases, surgery may be necessary to repair rotator cuff tendons in the shoulder or ligaments on the inside of the elbow to restore proper function and throwing mechanics and reduce pain.  Surgery is a more common solution for older athletes - high school and up, and most likely due to chronic symptoms and extensive damage over time as compared to a single incident. 

Common Throwing-related Conditions

Click below for further information.

• BURSITIS/ROTATOR CUFF TENDINITIS
• ROTATOR CUFF TEAR
• SHOULDER LABRAL TEAR

SO YOU THINK YOU RUPTURED A TENDON

When to Seek Medical Care

Especially if this has never happened to you before, call a doctor if you hear or feel a snap or pop, have severe pain, rapid/immediate, excessive bruising after an accident, and are unable to use the affected arm or leg. You may have a tendon rupture.

Visit the hospital's emergency department whenever an injury occurs that produces severe pain and is accompanied by a pop or snap. Weakness, inability to move the area involved, inability to bear weight, and deformity of the area in shape and color are other key symptoms that require a visit to the emergency department.

Because you know your body the best, if something appears to be serious to you, it is usually the best course to have an evaluation.

If this has happened to you before, like a repeat ACL tear or someone who works in healthcare, a trip to the emergency room is less beneficial. Most insurance plans have Emergency Room co-pays when you could wait to talk to a specialist in the morning. We recommend calling your primary doctor for an orthopedic specialist referral, or a friend or family member who works in the medical profession. They may be able to point you in the right direction. Your best bet for helpful information would be a primary care physician, an orthopedic specialist, or a physical therapist. 

Ruptured Tendon Diagnosis

Tendon rupture is usually diagnosed using a physical examination. Any imaging is done to confirm the diagnosis and decide the severity of the rupture.

Quadriceps

• X-rays often show that the patella (kneecap) is lower than its normal position on a side view of the knee.
• Using an MRI, your doctor can tell whether your rupture is partial or complete.

Achilles tendon

• Your doctor may do a Thompson test. In this test, your doctor will have you kneel on a chair and dangle your foot over the edge. The doctor will then squeeze your calf in a particular place. If the toes on your foot don't point downward when the doctor squeezes, then you probably have a ruptured Achilles tendon.
• In a test called the blood pressure cuff test, your doctor will place a blood pressure cuff on your calf. The cuff is then inflated to 100 mm Hg. The doctor will then move your foot into a toes-up position. If your tendon is intact, it will cause the pressure to rise to about 140 mm Hg. If you have a tendon rupture, the pressure will increase only a small amount.
• You may be able to flex your foot downward because your supporting muscles are intact. You will be unable to support yourself on your tiptoes on the affected side, however.
• X-rays taken from the side may show darkening of the triangular fatty tissue-filled space in front of the Achilles tendon or a thickening of the tendon.
• MRI or ultrasound may be used to determine the severity of the rupture, although these tests are usually not needed to make the diagnosis.

 

Rotator cuff

• You will be unable to initiate bringing your arm out to the side.
• Your doctor may do a drop arm test. In this test, your arm is passively raised to 90 degrees, and you are asked to hold your arm at this position. If you have rotator cuff rupture, slight pressure on the forearm will cause you to suddenly drop the arm.
• X-rays may show that the long bone in your upper arm (the humerus) is slightly out of place.
• Shoulder arthrography is most helpful in identifying a suspected rotator cuff tear. In this test, a dye that shows up on X-rays is injected directly into the shoulder joint, and the joint is then moved around. Then an X-ray of the shoulder is taken. If any dye is seen leaking from the joint, then it is highly likely that you have a ruptured rotator cuff.
• MRI provides a noninvasive means of assessing the integrity of the rotator cuff although it is more costly and not as specific as arthrography.

Biceps

• X-rays may show that your upper arm bone is out of place or that the site of muscle attachment has changed.
• If your biceps tendon is completely ruptured, the biceps retracts toward the elbow causing a swelling just above the crease in your arm. This is called the Popeye deformity.
• You will experience decreased strength of elbow flexion and arm supination (moving the hand palm up).
• You will have decreased ability to raise the arm out to the side when the hand is turned palm up.

TRACK + BASEBALL + SOCCER = SPRAINED ANKLES

This spring season is prime time for strained and sprained ankles.  An ankle sprain occurs when the strong ligaments that support the ankle stretch beyond their limits and tear. Ankle sprains are common injuries that occur among people of all ages. They range from mild to severe, depending upon how much damage there is to the ligaments.

Most sprains are minor injuries that heal with home treatments like rest and applying ice. However, if your ankle is very swollen and painful to walk on — or if you are having trouble putting weight on your ankle at all, be sure to see your doctor.

Without proper treatment and rehabilitation, a more severe sprain can weaken your ankle—making it more likely that you will injure it again. Repeated ankle sprains can lead to long-term problems, including chronic ankle pain, arthritis, and ongoing instability.

Description

Ligaments are strong, fibrous tissues that connect bones to other bones. The ligaments in the ankle help to keep the bones in proper position and stabilize the joint.

Most sprained ankles occur in the lateral ligaments on the outside of the ankle. Sprains can range from tiny tears in the fibers that make up the ligament to complete tears through the tissue.

If there is a complete tear of the ligaments, the ankle may become unstable after the initial injury phase passes. Over time, this instability can result in damage to the bones and cartilage of the ankle joint.

A twisting force to the lower leg or foot can cause a sprain. The lateral ligaments on the outside of the ankle are injured most frequently.

Cause

Your foot can twist unexpectedly during many different activities, such as:

• Walking or exercising on an uneven surface
• Falling down
• Participating in sports that require cutting actions or rolling and twisting of the foot—such as trail running, basketball, tennis, football, and soccer
• During sports activities, someone else may step on your foot while you are running, causing your foot to twist or roll to the side.

Symptoms

A sprained ankle is painful. Other symptoms may include:

• Swelling
• Bruising
• Tenderness to touch
• Instability of the ankle—this may occur when there has been complete tearing of the ligament or a complete dislocation of the ankle joint.

If there is severe tearing of the ligaments, you might also hear or feel a "pop" when the sprain occurs. Symptoms of a severe sprain are similar to those of a broken bone and require prompt medical evaluation.

Doctor Examination

Physical Examination

Your doctor will diagnose your ankle sprain by performing a careful examination of your foot and ankle. This physical exam may be painful.

• Palpate. Your doctor will gently press around the ankle to determine which ligaments are injured.
• Range of motion. He or she may also move your ankle in different directions; however, a stiff, swollen ankle usually will not move much.

If there is no broken bone, your doctor may be able to tell the severity of your ankle sprain based upon the amount of swelling, pain, and bruising.

Imaging Tests

X-rays. X-rays provide images of dense structures, such as bone. Your doctor may order x-rays to rule out a broken bone in your ankle or foot. A broken bone can cause similar symptoms of pain and swelling.

Stress x-rays. In addition to plain x-rays, your doctor may also order stress x-rays. These scans are taken while the ankle is being pushed in different directions. Stress x-rays help to show whether the ankle is moving abnormally because of injured ligaments.

Magnetic resonance imaging (MRI) scan. Your doctor may order an MRI if he or she suspects a very severe injury to the ligaments, damage to the cartilage or bone of the joint surface, a small bone chip, or another problem. The MRI may not be ordered until after the period of swelling and bruising resolves.

Ultrasound. This imaging scan allows your doctor to observe the ligament directly while he or she moves your ankle. This helps your doctor to determine how much stability the ligament provides.

Grades of Ankle Sprains

After the examination, your doctor will determine the grade of your sprain to help develop a treatment plan. Sprains are graded based on how much damage has occurred to the ligaments.

Grade 1 Sprain (Mild)

• Slight stretching and microscopic tearing of the ligament fibers
• Mild tenderness and swelling around the ankle

Grade 2 Sprain (Moderate)

• Partial tearing of the ligament
• Moderate tenderness and swelling around the ankle
• If the doctor moves the ankle in certain ways, there is an abnormal looseness of the ankle joint

Grade 3 Sprain (Severe)

• Complete tear of the ligament
• Significant tenderness and swelling around the ankle
• If the doctor pulls or pushes on the ankle joint in certain movements, substantial instability occurs

Treatment

Almost all ankle sprains can be treated without surgery. Even a complete ligament tear can heal without surgical repair if it is immobilized appropriately.

A three-phase program guides treatment for all ankle sprains—from mild to severe:

• Phase 1 includes resting, protecting the ankle and reducing the swelling.
• Phase 2 includes restoring range of motion, strength and flexibility.
• Phase 3 includes maintenance exercises and the gradual return to activities that do not require turning or twisting the ankle. This will be followed later by being able to do activities that require sharp, sudden turns (cutting activities)—such as tennis, basketball, or football.

This three-phase treatment program may take just 2 weeks to complete for minor sprains, or up to 6 to 12 weeks for more severe injuries.

Home Treatments

For milder sprains, your doctor may recommend simple home treatment.

The RICE protocol. Follow the RICE protocol as soon as possible after your injury:

• Rest your ankle by not walking on it.
• Ice should be immediately applied to keep the swelling down. It can be used for 20 to 30 minutes, three or four times daily. Do not apply ice directly to your skin.
• Compression dressings, bandages or ace-wraps will immobilize and support your injured ankle.
• Elevate your ankle above the level of your heart as often as possible during the first 48 hours.

Medication. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen can help control pain and swelling. Because they improve function by both reducing swelling and controlling pain, they are a better option for mild sprains than narcotic pain medicines.

Nonsurgical Treatment

Some sprains will require treatment in addition to the RICE protocol and medications.

Crutches. In most cases, swelling and pain will last from 2 to 3 days. Walking may be difficult during this time and your doctor may recommend that you use crutches as needed.

Immobilization. During the early phase of healing, it is important to support your ankle and protect it from sudden movements. For a Grade 2 sprain, a removable plastic device such as a cast-boot or air stirrup-type brace can provide support. Grade 3 sprains may require a short leg cast or cast-brace for 2 to 3 weeks.

Your doctor may encourage you to put some weight on your ankle while it is protected. This can help with healing.

Physical therapy. Rehabilitation exercises are used to prevent stiffness, increase ankle strength, and prevent chronic ankle problems.

• Early motion. To prevent stiffness, your doctor or physical therapist will provide you with exercises that involve range-of-motion or controlled movements of your ankle without resistance.
• Strengthening exercises. Once you can bear weight without increased pain or swelling, exercises to strengthen the muscles and tendons in the front and back of your leg and foot will be added to your treatment plan. Water exercises may be used if land-based strengthening exercises, such as toe-raising, are too painful. Exercises with resistance are added as tolerated.
• Proprioception (balance) training. Poor balance often leads to repeat sprains and ankle instability. A good example of a balance exercise is standing on the affected foot with the opposite foot raised and eyes closed. Balance boards are often used in this stage of rehabilitation.
• Endurance and agility exercises. Once you are pain-free, other exercises may be added, such as agility drills. Running in progressively smaller figures-of-8 is excellent for agility and calf and ankle strength. The goal is to increase strength and range of motion as balance improves over time.

Once you are pain-free, resistance exercises may be added to your therapy program.

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

Surgical Treatment

Surgical treatment for ankle sprains is rare. Surgery is reserved for injuries that fail to respond to nonsurgical treatment, and for patients who experience persistent ankle instability after months of rehabilitation and nonsurgical treatment.

Surgical options may include:

• Arthroscopy. During arthroscopy, your doctor uses a small camera, called an arthroscope, to look inside your ankle joint. Miniature instruments are used to remove any loose fragments of bone or cartilage, or parts of the ligament that may be caught in the joint.
• Reconstruction. Your doctor may be able to repair the torn ligament with stitches or sutures. In some cases, he or she will reconstruct the damaged ligament by replacing it with a tissue graft obtained from other ligaments and/or tendons found in the foot and around the ankle.

Immobilization. There is typically a period of immobilization following surgery for an ankle sprain. Your doctor may apply a cast or protective boot to protect the repaired or reconstructed ligament. Be sure to follow your doctor's instructions about how long to wear the protective device; if you remove it too soon, a simple misstep can re-tear the fixed ligament.

Rehabilitation. Rehabilitation after surgery involves time and attention to restore strength and range of motion so you can return to pre-injury function. The length of time you can expect to spend recovering depends upon the extent of injury and the amount of surgery that was done. Rehabilitation may take from weeks to months.

Outcomes

Outcomes for ankle sprains are generally quite good. With proper treatment, most patients are able to resume their day-to-day activities after a period of time.

Most importantly, successful outcomes are dependent upon patient commitment to rehabilitation exercises. Incomplete rehabilitation is the most common cause of chronic ankle instability after a sprain. If a patient stops doing the strengthening exercises, the injured ligament(s) will weaken and put the patient at risk for continued ankle sprains.

Chronic Ankle Sprains

Once you have sprained your ankle, you may continue to sprain it if the ligaments do not have time to completely heal. It can be hard for patients to tell if a sprain has healed because even an ankle with a chronic tear can be highly functional because overlying tendons help with stability and motion.

If pain continues for more than 4 to 6 weeks, you may have a chronic ankle sprain. Activities that tend to make an already sprained ankle worse include stepping on uneven surfaces and participating in sports that require cutting actions or rolling and twisting of the foot.

Abnormal proprioception—a common complication of ankle sprains—can also lead to repeat sprains. There may be imbalance and muscle weakness that causes a reinjury. If you sprain your ankle over and over again, a chronic situation may persist with instability, a sense of the ankle giving way, and chronic pain. This can also happen if you return to work, sports, or other activities before your ankle heals and is rehabilitated.

Prevention

The best way to prevent ankle sprains is to maintain good muscle strength, balance, and flexibility. The following precautions will help prevent sprains:

• Warm up thoroughly before exercise and physical activity
• Pay careful attention when walking, running, or working on an uneven surface
• Wear shoes that are made for your activity
• Slow down or stop activities when you feel pain or fatigue

CALCIUM, NUTRITION, & BONE HEALTH

The health and strength of our bones rely on a balanced diet and a steady stream of nutrients, most importantly, calcium and Vitamin D.

Calcium is a mineral that people need to build and maintain strong bones and teeth. It is also very important for other physical functions, such as muscle control and blood circulation.

Calcium is not made in the body — it must be absorbed from the foods we eat. To effectively absorb calcium from food, our bodies need Vitamin D.

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 and may lead to osteoporosis — a disorder in which bones become very fragile.

Postmenopausal women are most vulnerable to osteoporosis. Although loss of estrogen is the primary reason for this, poor lifelong calcium and Vitamin D intake, as well as lack of exercise, play a role in the development of osteoporosis.

Note that men also are at risk for osteoporosis — typically later in life than women — and it is important for them to keep track of calcium intakes, as well.

Calcium

Calcium needs vary with age. The Food and Nutrition Board (FNB) of the Institute of Medicine of the National Academies provides guidelines on the amount of calcium needed each day.

Recommended Daily Allowance in Milligrams (mg)

Women and Men 9 to 18 years: 1,300 mg
Women and Men 19 to 50 years: 1,000 mg
Women 51 to 70 years: 1,200 mg
Men 51 to 70 years: 1,000 mg
Women and men > 70 years: 1,200 mg
Pregnant or nursing women 14 to 18 years: 1,300 mg
Pregnant or nursing women 19 to 50 years: 1,000 mg

Reprinted and adapted with permission from Tables S-1 and S-2, Dietary Reference Intakes for Calcium and Vitamin D, 2011 by the National Academy of Sciences, Courtesy of the National Academies Press, Washington, D.C.

Dietary Sources of Calcium

People can get the recommended daily amount of calcium by eating a healthy diet that includes a variety of calcium-rich foods. Milk, yogurt, cheese, and other dairy products are the biggest food sources of calcium. Other high-calcium foods include:

• Kale, broccoli, Chinese cabbage (bok choy) and other green leafy vegetables
• Sardines, salmon, and other soft-bone fish
• Tofu
• Breads, pastas and grains
• Calcium-fortified cereals, juices, and other beverages.

Good sources of calcium include milk, cheeses, leafy green vegetables, and almonds.

A more complete listing of calcium-rich foods is included at the end of this article.

Some foods make it harder for the body to absorb calcium. In particular, sodas and carbonated beverages should be avoided, not just for bone health but for many nutritional reasons, including preventing 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.

Calcium Supplements

Although adequate calcium can be obtained through your diet, it is difficult for many people, particularly for those who avoid dairy products. People who are lactose-intolerant or vegetarians who do not eat dairy products have a harder time getting enough calcium from foods.

It is also hard to get enough calcium from the diet during certain times of our lives, such as in adolescence when our bodies require more calcium to build strong bones for life. Postmenopausal women and men older than age 70 also require more calcium to slow down bone loss.

Doctors recommend calcium supplements to those who do not get enough calcium from the foods they eat. Although calcium is sometimes found in multivitamins, it is typically not in significant amounts. Many people need to take separate calcium supplements to ensure they reach the Recommended Dietary Allowance for their life stage.

Not all the calcium consumed — whether through food or supplement — is actually absorbed in the intestines. Research shows that calcium is absorbed most efficiently when it is taken in doses less than 500 mg. Because many calcium supplements come in 500 mg doses, people who require 1,000 mg of supplementation each day should take their doses at separate times. Newer daily slow release formulations of calcium citrate that supply 1200 mg have recently become available.

Most calcium supplements also contain Vitamin D, which helps the body absorb calcium.

Vitamin D

Without Vitamin D, our bodies cannot effectively absorb calcium, which is essential to good bone health.

Children who lack Vitamin D develop the condition called rickets, which causes bone weakness, bowed legs, and other skeletal deformities, such as stooped posture. Adults with very low Vitamin D can develop a condition called osteomalacia (soft bone). Like rickets, osteomalacia can also cause bone pain and deformities of long bones.

Vitamin D Recommended Dietary Allowance

The FNB recommends 400 International Units (IU) of Vitamin D for infants during the first year of life. The RDA for everyone from age 1 through 70 years is 600 IU. Recent research, however, supports that the body needs at least 1000 IU per day for good bone health, starting at age 5 years.

Many foods contain some Vitamin D, however, few contain enough to meet the daily recommended levels for optimal bone health.

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

In the 19th and early 20th centuries, children were routinely given cod liver oil for a range of medicinal purposes. When cod liver oil was tied to the prevention and treatment of rickets, Vitamin D was discovered. Soon after, Vitamin D was added to milk — one glass of milk contains about 100 IU of Vitamin D. As a result, parents stopped using cod liver oil. Because today's children do not drink as much milk as in the past, it is difficult for them to get enough Vitamin D from milk. In addition, other dairy products are not typically supplemented with Vitamin D. Getting enough Vitamin D from what we eat is very difficult.

Although our bodies can make Vitamin D in our skin when it is exposed to good sunlight, it is very important to protect our skin by using sunscreen when we are outdoors. This blocks the excessive UV radiation that can cause skin cancer. Sunscreen does, however, also block our skin's ability to make Vitamin D. This is why doctors often recommend Vitamin D supplements for both adults and children. The American Academy of Pediatrics recommends that all children — from infancy through adolescence — take Vitamin D supplements.

Safe Levels of Calcium and Vitamin D

Too much calcium and/or Vitamin D can be harmful and cause serious side effects. In addition to establishing RDA guidelines, the FNB has established Tolerable Upper Intake Levels (ULs). These represent the highest levels of calcium and Vitamin D that can be consumed by the average individual and still be safe.

These ULs are important guidelines for people who 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.

Note that ULs are not levels that people should try to reach — they are the safe limits based on current research. When intake goes beyond the ULs listed below, the risk for serious side effects increases.

Upper Safe Limit for Calcium Intake

Life Stage: Upper Safe Limit

Birth to 6 months: 1,000 mg
Infants 7-12 months: 1,500 mg
Children 1-8 years: 2,500 mg
Children 9-18 years: 3,000 mg
Adults 19-50 years: 2,500 mg
Adults 51 years and older: 2,000 mg
Pregnant and breastfeeding teens: 3,000 mg
Pregnant and breastfeeding adults: 2,500 mg

Upper Safe Limit for Vitamin D Intake

0-6 months: 1,000 IU1,000 IU  
7-12 months: 1,500 IU1,500 IU  
1-3 years: 2,500 IU2,500 IU  
4-8 years: 3,000 IU3,000 IU  
≥9 years: 4,000 IU4,000 IU4,000 IU4,000 IU

Reprinted and adapted with permission from Tables S-1 and S-2, Dietary Reference Intakes for Calcium and Vitamin D, 2011 by the National Academy of Sciences, Courtesy of the National Academies Press, Washington, D.C.

More foods in the U.S. are being fortified with calcium and Vitamin D, and awareness of the importance of these nutrients for bone health is growing. In recent years, the media has reported on the potential health benefits of taking high levels of Vitamin D, such as in the areas of cancer prevention, diabetes management, and heart health. As a result, it is becoming more likely that people may consume unsafe quantities of these nutrients.

The FNB conducted an extensive review of the medical literature and found enough evidence of bone health benefits to support raising the UL levels on Vitamin D in adults from 2000 IU to 4000 IU. What was also determined, however, is that very high levels of Vitamin D (above 10,000 IUs per day) can cause kidney damage and dangerously high serum calcium levels. Too much calcium from dietary supplements can also cause adverse health effects, including kidney stones, higher risks for heart problems, and possibly increased risk for prostate cancer.

Calcium and Vitamin D are essential for good bone health, but must be consumed safely. If you are not sure what intake levels are right for you and your health needs, be sure to talk to your doctor.

Other Key Nutrients in Bone Health

Many other nutrients — most found naturally and at sufficient levels in a typical diet — contribute to bone health and growth. They include:

• Phosphorus. A major mineral in the body's bone crystal, phosphorus is found in dairy products and meat. Vitamin D improves phosphorus absorption in the intestine and kidney.
• Magnesium. Primarily found in bone crystals, magnesium improves bone strength. Older adults are more likely to be deficient in magnesium. Calcium supplements that contain magnesium can help.
• Vitamin K. Necessary for bone formation and mineralization, Vitamin K also is important for blood clotting, and may assist in channeling calcium directly to the bone rather than the blood vessels.
• Vitamin C. Collagen is the main protein in bone, and Vitamin C is necessary for collagen synthesis. Vitamin C is present in citrus fruits and tomatoes and in many vegetables.
• Vitamin A. Vitamin A is necessary for cells to differentiate normally and for normal skeletal growth, and also is extremely important for eye health. Vitamin A is available in liver, eggs, butter, green leafy vegetables and carrots. Too little vitamin A is a major cause of blindness worldwide. In contrast, too much vitamin A can cause bone loss and increase the risk of hip fracture. The animal source supplements (retinols) may cause toxicity but plant sources (B carotene) do not. Daily intake of retinols should be less than 10,000 IU.

Dietary Sources of Calcium

Selecting foods high in calcium is one way to help you achieve your targeted daily calcium intake. Here are some major food sources of calcium to assist your meal planning.

Selected Food Sources of Calcium

FoodMilligrams (mg) per servingPercent DV*
Yogurt, plain, low fat, 8 ounces
Orange juice, calcium-fortified, 6 ounces
Yogurt, fruit, low fat, 8 ounces
Mozzarella, part skim, 1.5 ounces
Sardines, canned in oil, with bones, 3 ounces
Cheddar cheese, 1.5 ounces
Milk, nonfat, 8 ounces
Milk, reduced-fat (2% milk fat), 8 ounces
Milk, buttermilk, 8 ounces
Milk, whole (3.25% milk fat), 8 ounces
Tofu, firm, made with calcium sulfate, 1/2 cup***
Salmon, pink, canned, solids with bone, 3 ounces
Cottage cheese, 1% milk fat, 1 cup
Tofu, soft, made with calcium sulfate, 1/2 cup
Instant breakfast drink, various flavors and brands, powder prepared with water, 8 ounces
Frozen yogurt, vanilla, soft serve, 1/2 cup
Ready-to-eat cereal, calcium-fortified, 1 cup
Turnip greens, fresh, boiled, 1/2 cup
Kale, fresh, cooked, 1 cup
Kale, raw, chopped, 1 cup
Ice cream, vanilla, 1/2 cup
Soy beverage, calcium-fortified, 8 ounces
Chinese cabbage (bok choy) raw, shredded, 1 cup
Bread, white, 1 slice
Pudding, chocolate, ready to eat, refrigerated, 4 ounces
Tortilla, corn, ready-to-bake/fry, one 6" diameter
Tortilla, flour, ready-to-bake/fry, one 6" diameter
Sour cream, reduced fat, cultured, 2 tablespoons
Bread, whole-wheat, 1 slice
Broccoli, raw, 1/2 cup
Cheese, cream, regular, 1 tablespoon

* DV = Daily Value. DVs were developed by the U.S. Food and Drug Administration to help consumers compare the nutrient contents among products within the context of a total daily diet. The DV for calcium is 1,000 mg for adults and children aged 4 years and older. Foods providing 20% of more of the DV are considered to be high sources of a nutrient, but foods providing lower percentages of the DV also contribute to a healthful diet. The U.S. Department of Agriculture's Nutrient Database Web site lists the nutrient content of many foods. It also provides a comprehensive list of foods containing calcium.

** Calcium content varies slightly by fat content; the more fat, the less calcium the food contains.

*** Calcium content is for tofu that is processed with a calcium salt. Tofu processed with other salts does not provide significant amounts of calcium.

Source: National Institutes of Health (NIH) (Dietary Supplement Fact Sheet: Calcium): U.S. Department of Agriculture, Agricultural Research Service. 2011. USDA National Nutrient Database for Standard Reference, Release 24. Nutrient Data Laboratory Home Page; Institute of Medicine of the National Academies Dietary Reference Intakes for Calcium and Vitamin D.

FOAM ROLLING - HOW DOES IT WORK?

Foam rolling is very popular. Athletic trainers use it as a part of the warm-up. Physical therapists use it as part of their treatment strategy, often to improve extensibility of “short” tissues. There is very limited evidence about what benefit, if any, foam rolling confers. But there are a few studies showing it leads to short term increases in range of motion that are not accompanied by strength loss. (This is interesting because stretching interventions tend to show increased range of motion that are associated with a loss of strength and power.)

The purpose of this article is not to question whether foam rolling is effective for anything. I’m willing to assume it works in some way for some people. It is hard for me to believe that so many intelligent trainers such as Mike Boyle would be singing its praises unless it was good for something. So I’ll give it the benefit of the doubt for purposes of this article.

The question for this post is the following: if foam rolling can actually reduce pain or improve mobility, what is the mechanism? I do not find the common explanations very convincing. But there is one (less commonly heard) explanation which I really like. Here’s my critical analysis of the different theories for why foam rolling works, including my favorite one.

1. Does Foam Rolling “Improve Tissue Quality”? 

This is one we hear quite frequently, usually without any specifics as to which “qualities” are at issue. I think some people imagine that foam rolling can smooth out bumps in their tissues like a rolling pin over pizza dough. To be fair, this explanation is usually intended for lay people and not scientists, so we can cut some slack about the lack of specifics. Perhaps the qualities to be improved involve the presence of fascial adhesions or trigger points. I’ll address those claims specifically below.

2. Does Foam Rolling Lengthen Or “Melt” Fascia? 

For some reason people just tend to assume that foam rolling works by changing the fascia. I honestly have no idea why. A foam roller puts pressure on all the other tissues in the body, and they all communicate with the CNS, which controls how we move and feel. Isn’t the CNS the most obvious place to look for changes after foam rolling?

No, it always has to be the fascia.

But fascia is tough stuff. Sure it has some interesting adaptive properties, but at the end of the day its purpose is to form a solid structure for the body. Is it really plausible that we can significantly change our structure just by leaning on a foam roller a little bit? We must be made of stronger stuff than that. If fascia started to break down, or elongate, or "melt" every time it felt a little sustained pressure, we would be pretty fragile creatures. Every time we sat on a rock our posterior chain would lengthen. So for me the idea that foam rolling lengthens or melts some important structural stuff in our body does not pass the common sense test.

And, more importantly, the research does not support this idea either. There are a few research studies (here and here) which try to determine the degree of pressure necessary to cause permanent deformation in mature human connective tissue. The upshot is that if you want permanent change, you better be prepared (as Paul Ingraham notes) to "get medieval." Steam roller maybe, foam roller, no. It’s not going to happen in any of the places where the roller is most commonly applied, which are usually the strongest parts of the body - the ITB band, lumbar fascia, plantar fascia, etc.

 3. Does Foam Rolling Break Up Fascial Adhesions?  

Maybe a foam roller can’t lengthen the IT band, which is stronger than steel, but could it break up some little fascial adhesions that prevent sliding between different muscle groups? One of the studies I referenced above show that manual pressure might be enough to deform nasal fascia. Now I don’t see many people foam rolling their nose, but maybe there are tiny little adhesions between large muscles groups that are as weak and deformable as nasal fascia.

Again this seems highly speculative to me. How do we know where these adhesions are, or what angle will help break them? A foam roller is a blunt non specific instrument that delivers force in a diffuse manner into the tissue. Smash! Part of the job of fascia is to diffuse force, so it would be hard to target a specific point here. Also, the angle of pressure is always straight in. The foam roller would have limited ability to provide the kind of precise oblique force that might be able to slide one layer of tissue with respect to the other.

Another problem I have with the idea that foam rolling breaks up fascial adhesions is that the effects are often temporary. People do some foam rolling, they feel better for a while, and then tomorrow or even later that same day, they feel the need to roll the same area again. If the mechanism of effect is breaking fascial adhesions, then why do we need to repeat the process? Did the fascia knit itself back together again? The temporary nature of the results strongly suggests a nervous system mediated mechanism for efficacy, not a structural one.

4.  Does Foam Rolling Get Rid Of Trigger Points?

Many foam rolling proponents explain that proper procedure involves finding a “trigger point” and staying on that point for a while. Is foam rolling a way to treat trigger points?

It should be noted that the term trigger point means different things to different people. For some it just means a sore spot, but for others it refers to a specific pathology. The technical definition involves several elements such as a hyperirritable nodule within a palpably taut band that elicits a twitching response to snapping palpation. Trigger points are thought to be caused by some sort of metabolic crisis in the muscle cells which causes chemical irritation in the local area and for some unknown reason refer pain to other areas when pressed.

Trigger points are controversial to say the least. There is substantial debate as to whether they even exist. Whether they can be reliably identified is another debate. And whether they can be effectively treated is another. There are many recommended treatments - stretching, post-isometric relaxation, sticking needles into them, pressing on them, etc. I definitely don't have the time or anything approaching the knowledge to address all these debates.

But given all these uncertainties, I’m disinclined to believe that foam rolling works by getting rid of a trigger point. There are just too many unanswered questions here. The experts in trigger point therapy will tell you that not every sore spot is a trigger point, that not all trigger points are clinically relevant, and that their identification and treatment takes practice and expertise. So I don't think shotgun fascia smashing with a foam roller is a plausible trigger point treatment (assuming they exist and can be treated with pressure.)

5. Does Foam Rolling Work By Proprioceptive Stimulation?

I often hear claims that foam rolling works by proprioceptive enhancement – stimulating mechanoreceptors in the muscles and/or fascia, such as golgi tendon organs, or muscle spindle fibers, or ruffinis, or pacinis, or Pacinos or DeNiros. This could have some beneficial effect of encouraging relaxation of muscular or fascial tone, or causing the brain to reorganize its sensory or movement maps in the local area.

I think this is a very plausible explanation and definitely on the right track. But I doubt it is the main mechanism which explains why people like to foam roll. If stimulating these mechanoreceptors explains the claimed benefits of foam rolling, then why wouldn't you just stretch and move around, and get probably even more stimulation to these organs, but within the context of functional movements? Can the foam roller, which doesn’t really provide that much movement or stretch to the target muscle or fascia, provide more proprioceptive stimulation then functional movements like the squat, lunge or reach? I think not.

Perhaps what foam rolling has to offer over movement is novel proprioceptive stimulation. I think novelty is great and of huge potential benefit. It helps get the brain’s attention, which is what you need to do if you want the brain to change. But here’s something else that you need to do. You need to provide the brain with information that is relevant to something that the brain cares about. The brain cares about how to move your body through functional patterns such as squats, lunges and hip hinges. How is the information derived from foam rolling relevant to these tasks? The brain is not interested in information just because it’s novel. The information must also help it solve movement problems. Why would the nervous system be interested in how it feels to have a lacrosse ball jammed into your butt?

6. Does Foam Rolling Work By Diffuse Noxious Inhibitory Control?

This is my favorite explanation. And this is probably the mechanism with which readers will have the least familiarity. Here’s a description of what it is, how it works, and why I think it's the major reason for the potential efficacy of foam rolling (and many other forms of manual therapy).

Diffuse noxious inhibitory control (DNIC) is one of several varieties of “descending modulation”, by which the brain adjusts the “volume” on nociception (danger signals which originate in the body). DNIC means that the brain inhibits nociceptive signals from traveling up the spinal cord to the brain.

DNIC is reliably triggered by a sustained nociceptive input, such as immersing your hand in cold water. The inhibition is diffuse – it suppresses nociception not just from the local area, but distant areas as well. In other words, if your leg hurts, and you stick your hand in icewater for a while, the resulting DNIC will cause both the hand and the leg to hurt less. This dynamic of fighting pain in one area by creating it in another likely explains the success of many therapies, and is sometimes called counterirritation. The effect is temporary of course.

How powerful is the effect of DNIC? Very powerful. When a soldier loses a limb in battle, he will often feel no pain so long as the emergency persists, and DNIC is a major reason. David Butler refers to DNIC as the “drug cabinet in the brain.” Here’s a video where he explains this idea in a little more detail, including the fact that some of the drugs in the brain are stronger than morphine.

Pain expert Lorimer Moseley views descending modulation and DNIC as a way for the brain to “second-guess” the periphery about the threat posed by a particular stimulus. For example, if the periphery is communicating information suggesting there is a large amount of mechanical threat in a particular area, the brain, which has access to a wealth of additional information about what is actually going on in the periphery, may decide that the problem is not so serious, and therefore inhibit the transmission of nociceptive signals to the brain.

There is significant research showing that many chronic pain conditions such as fibromyalgia, irritable bowel syndrome, and TMJ are characterized by relative failure of the DNIC mechanism.

The effectiveness of DNIC in suppressing pain is highly dependent on the expectation that the counterirritant will have an analgesic affect. In this interesting study, researchers immersed the hands of participants in cold water, shocked them with an electric blast to the sural nerve, and then measured the level of nociceptive activity in the spine, as well as the self-reported pain level. Importantly, the participants were divided into two groups. The first group, called the “analgesia group”, was told that the cold water immersion would reduce the amount of pain they felt from the shock. The other group, called the “hyperalgesia group” was told the opposite – that the cold water immersion would make the pain in the leg worse.

The analgesia group experienced 77% less pain, and less spinal cord nociceptive activity than the hyperalgesia group, who experienced almost no reductions in pain or spinal cord nociceptive activity. In other words, expectation of relief was a huge factor in determining whether DNIC worked.

Now let's put this all together. DNIC is a powerful but temporary way to reduce pain in one area by creating pain in another. It depends on a decision by the brain to ignore danger signals from the body. Expectation of benefit from the irritating stimulus plays a strong role.

There are several aspects of foam rolling that are very consistent with the hypothesis that its main benefit is achieved by creating DNIC. Rule number one in foam rolling is to find a sore spot and stay on it for some time. You need to create some pain. Of course, the pain is often a "good pain", which is exactly the type of feeling that would correlate with the brain's conclusion that the irritation is somehow beneficial - which is what gets DNIC going.

Foam rolling often creates pain relief, not just in the area of pressure, but in other areas as well. People also tend to feel more freedom of motion, which could easily be explained by suppression of nociceptive activity, which tends to create muscle guarding, stiffness, and compensatory patterns of movement.

Further, the results of foam rolling are often temporary and need to be repeated (and often repeated harder the next time- are people becoming addicted to the drug cabinet in the brain?) This suggests a CNS mediated mechanism.

So here is the story I tell about foam rolling. You put a foam roller into your butt and create some significant nociceptive signalling. The brain receives it and says something like: "OK, the butt is telling me that there is some danger down there right now. But I happen to know that this is a therapeutic situation because my trainer said so. So, let's send some drugs down the spinal cord to block all this talk about danger. And, we'll make this feel like a "good" pain, not an injury." The drugs reduce pain and thereby improve movement temporarily.

Practical Implications On Foam Rolling 

Now some people will read this and say “well who cares about how it works, all I care about is that it works.” And in some sense that is fine, but this lack of curiosity ignores the potential improvements one might make to a therapeutic regime by understanding the real mechanism of effect.

If foam rolling really works by nothing other than DNIC, then perhaps it would be easier to get the same effect by just pinching yourself or putting your hand in ice water. Or maybe this would mess with expectations, which we know are important to get the effect.

Here's another interesting question that arises from the consideration that foam rolling may work purely on the basis of DNIC. If the results are only temporary, can there be any progressive benefit? I think the answer is: it depends. Pain relief and improved movement open a window of opportunity that one might climb through. If you are feeling better only for an hour, this provides enough time to train movements that would not normally be accessible, learn new skills, develop new capacities, and reduce the perceived threat associated with certain movements. This could have permanent benefit. But of course if you just sit on the couch, the benefits would probably be temporary.

Here's another question I have in regard to foam rolling. If the major reason it works is release of the drug cabinet in the brain, then can one become addicted? I have no real evidence of this, but I swear I've seen a disturbing pattern. Someone gets relief from a foam roller, and then graduates to the lacrosse ball, and then to the wooden ball, until they are bruising themselves with steel in an effort to get that fix! Avoiding this type of situation is one reason it's a good idea to know why something works.

TA MUSCLES AND BACK PAIN

WHAT IS IT?

You may not have heard of the transverse abdominis (TA) muscle, but it's an important muscle that acts as a stabilizer of the low back and core muscles. It is one of the main core stabilizing muscles of the lumbar spine. A weak TA is often indicated in low back pain. If you're looking to alleviate lower back pain, strengthening your TA muscle may be the ticket.

WHERE IS IT?

The TA is the deepest layer of abdominal muscles and runs between the ribs and the pelvis, horizontally from front to back. When activated, the TA muscles create a deep natural "corset" around the internal organs and lumbar spine. This activation flattens the abdominal wall, compresses the viscera (internal organs), supports the internal organs and helps expel air during forced exhalation. One major function of the TA muscles is to stabilize the spine and pelvis during movements that involve the arms and legs.

WHAT HAPPENS WHEN YOUR TA ISN'T BEING UTILIZED

If the TA muscles are weak, the abdominal wall will begin to bulge forward and the pelvis may rotate forward and increase lordosis (inward curvature) in the spine. This can result after pregnancy and may also be associated with weight gain or lack of exercise.

A recent study shows that weak TA muscles may be to blame for lower back pain. Lack of strength, in this case, is a lesser concern compared to an inability to activate. Decrease in activation is caused by sedentary lifestyles, where the brain essentially "shuts off" the TA in response to lack of use.

When activities are added into sedentary lifestyles, like gardening or dog walking, back pain is the result because the brain-musculoskeletal relationship does not recognize the difference in activity until afterward.

This reason is essentially the same concept behind soreness. The body can complete many activities, some will just simply cause soreness because the body isn't used to being challenged in that manner. 

Add in an activity like gardening or dog walking, and the brain will not recognize the body needs the TA until even months down the road.  This is the main difference between muscle soreness and back pain related to TA activation; many muscles on the extremities are operationally responsible for specific movements - for example, the elbow is mainly bent by the biceps. The TA is not responsible for core strength - the obliques and rectus abdominus are more useful as far as actual strength goes. However, the small aspect of keeping the viscera stable and contained, as well as keeping the pelvis and spine stable, cannot be done without the TA.  This will eventually result in back pain, and the back pain will continue until the TA is retaught to fire. It is for this reason that it is just as important to train the brain in activation as much as it is in training the muscle, itself. 

DOES THIS SOUND LIKE YOU?

Talk to your doctor about chronic back pain, and make sure to mention any changes in your activity levels or daily routines.  Ask them to recommend you to Champion Performance and Physical Therapy, as that is a sub-specialty of ours. It takes diligence to train your body to activate and strengthen your TA, but with the right guidance, it is possible to continue your activities pain-free. 

2015's FOREFRONT OF ORTHOPEDIC INNOVATION

The SourceTrust custom contracting team recently traveled to Las Vegas for the 2015 Annual Meeting of the American Academy of Orthopedic Surgeons (AAOS), the nation’s leading educator in the specialty. The team met with suppliers, networked with peers and learned about the latest technologies and trends in orthopedics. Hot topics this year included:

1. 3D printing technology: Biomet released the G7 OsseoTi shell, to be used with its acetabular platform launched last year that employs color coding to reduce instrument sets and increase efficiency flow in the OR during hip arthroplasty procedures. One of the surprisingly innovative aspects of this product is the use of human CT data in combination with 3D printing technology to build a structure purported to directly mimic that of human cancellous bone. Biomet claims that this process generates a single porous architecture allowing creation of complex shapes while maintaining the consistent porosity and strength necessary to facilitate bone and tissue ingrowth and implant stability.

2. Advanced technology for total knee revision arthroplasty: One innovative technology for revision knee procedures is DJO Global’s Exprt System, which has the potential to improve patient outcomes as well as efficiencies in the operating suite. Exprt’s streamlined, compact design reduces turnaround times, minimizes waste and has proven implant design technology―all for 40 to 70 percent of the cost of comparable knee revision systems. A simple, comprehensive two-tray system replaces the traditional eight-tray setup used during complex total knee revisions, reducing prep time, eliminating unnecessary surgical steps and improving the precision skills of revision surgeons.

Lowry Barnes, M.D., chairman of Orthopaedics at University of Arkansas for Medical Sciences, comments that “the Exprt approach leads to efficient operations that save both time and money, while providing excellent early results. My operating team especially appreciates the fact that only two pans of instruments are opened. I believe that I can speak for the entire Exprt design team when I say that we have met our goals in offering a high-value, high-quality revision knee system for the accomplished surgeon.”

“In today’s value-driven healthcare environment, cost effectiveness is crucial in order to provide stakeholders with a high-quality result at a reasonable cost,” says Dr. Richard Lorio, chief of Adult Reconstructive Surgery at NYU Langone Medical Center. “Putting the patient ahead of profits, the Exprt System allows skilled surgeons to provide TKA [total knee arthroplasty] patients with a functional knee at a fraction of traditional costs.”

3. Robotics: As with AAOS 2014, robotics continues to be an area of great interest. The two main players in this arena are MAKO Surgical Corp. and Blue Belt Technologies. Limitations of the former include restricting surgeons to using only MAKO or Stryker implants, increasing disposable costs. In addition, MAKO manufactures implants for use in total hip and partial knee arthroplasty (although it anticipates launching a total knee platform later this year). Acquiring MAKO robotics is also costly. Blue Belt is more economical and provides surgeons with the option of using its STRIDE implants as well as those manufactured by Smith & Nephew, DJO Global, StelKast and DePuy Synthes. However, Blue Belt is currently approved only for partial knee procedures. Like MAKO, it expects to release a total knee implant in late 2015.

4. Patient-reported outcomes measures (PROM): These days, surgeons and hospitals can’t just say they are good at orthopedics. To gain market share, they have to prove they are clinically excellent. That means demonstrating that they are high-quality, low-cost providers of care while providing a good patient experience. The measures used to prove value are evolving from research-focused tools toward scoring instruments that are meaningful to patients. A good example is PROMIS, a means of measuring patient-reported physical, mental and social health status that is backed by the National Institutes of Health. InVivoLink demonstrated its platform for capturing PROMIS scores pre- and post-procedure to better understand clinical performance across patients, procedures and surgeons. When these PROM measures are analyzed along with implant consumption and cost data, they’re a powerful tool for driving surgical volume, surgeon engagement and cost savings. 

5. Outpatient surgery: To get ahead of this increasing market trend, Zimmer rolled out its Z-23 initiative that endeavors to limit hospital stays for hip replacement patients to no more than 23 hours. The program stresses the importance of better patient selection and creating efficiencies in the OR. More total joint procedures are moving entirely to outpatient settings thanks to better medications and anesthesia, the popularity of minimally invasive approaches, younger patients seeking such procedures, and private payer support.

6. Shoulder market: Matthew P. Willis, M.D., a fellowship-trained orthopaedic surgeon at Baptist Hospital and TriStar Centennial Medical Center in Nashville who specializes in disorders of the shoulder, discussed emerging technologies and pricing in the shoulder market at a HealthTrust-sponsored dinner during the annual meeting.

“More than hips or knees, shoulder technology continues to make significant advances,” Willis says. “This is particularly true with regards to reverse shoulder arthroplasty technology. Impending developments such as universal glenoid baseplates for total and reverse arthroplasty as well as patient specific instrumentation are on the horizon.”

Willis also addressed pricing and reimbursement. “As reimbursements for hospital systems continue to decline, competitive pricing on shoulder implants becomes more important than ever. There are no shoulder implant companies that currently offer technology to justify significantly higher pricing than [their] competitors.”

On the subject of hospital and physician alignment, Willis says the “best approach to achieving hospital and physician alignment is for the two parties to have open and transparent discussions about what is important to each. Most physicians are willing to help on cost containment if approached with reasonable alternatives and accurate data. The best case scenario is when both parties are incentivized to manage costs. If not currently, such a model may be attainable in the future. “

OBESITY LINKED TO ORTHOPEDIC CONDITIONS

The concept of obesity is a touchy one in today's social atmosphere, and being sensitive so as to not insinuate "fat-shaming" can be very tricky. As society constantly tries to ride the thin line between "fat-shaming" and educating, it is vitally important that everyone, no matter of age or sex, be aware of the risk they implement on their health. 

It is absolutely necessary for men and women, both, to be comfortable in their own skin, and be confident in who they are as a person and what their body looks like.  Finding a self-confidence-boosting activity to add to the daily regimen has not only proven to lead to an increase in dopamine (happy hormone) production, but also a decrease in cortisone (stress hormone) production. Emotional health is a vital portion of overall health status. 

Being comfortable in your own skin was meant to help people understand that their body will not always look like models or even other average individuals. We all respond differently to caloric intake, exercise, and lifestyles. For example, some people were born with incredible metabolisms - and good for them! Many of us are not, however, and we must make adjustments to our mindsets to understand that although we may never be as thin as some, we can be comfortable in our own skin. Medically speaking, however, being comfortable in your own skin is not validating obesity. 

Obesity traditionally has been defined as a weight at least 20% above the weight corresponding to the lowest death rate for individuals of a specific height, gender, and age (ideal weight). 

Twenty to forty percent over ideal weight is considered mildly obese; 40- 100% over ideal weightis considered moderately obese; and 100% over ideal weight is considered severely, or morbidly, obese. More recent guidelines for obesity use a measurement called BMI (body mass index) which is the individual's weight multiplied by 703 and then divided by twice the height in inches. BMI of 25.9- 29 is considered overweight; BMI over 30 is considered obese. Measurements and comparisons of waist and hip circumference can also provide some information regarding risk  factors associated with weight. The higher the ratio, the greater the chance forweight-associated complications. Calipers can be used to measure skin- fold thickness to determine whether tissue is muscle (lean) or adipose tissue (fat).

Much concern has been generated about the increasing incidence of obesity among Americans. Some studies have noted an increase from 12% to 18% occurring between 1991 and 1998. Other studies have actually estimated that a full 50% of all Americans are overweight. The World HealthOrganization terms obesity a worldwide epidemic, and the diseases which can occur due to obesity are becoming increasingly prevalent.

Obesity affects quality of individual patient care, the strain the healthcare system must endure to adjust, possible health insurance coverage, and nearly every organ in the body. People with obesity often have other health problems, including diabetes, heart disease, certain tumors and cancers, and psychiatric disorders. However, the role of obesity in orthopedic conditions and their treatment is less well-publicized.
 

According to orthopedic surgeon William M. Mihalko, MD, PhD, of Campbell Clinic Orthopaedics in Memphis, Tenn., “obesity can accompany a multitude of comorbidities that can have a significant impact on a patient’s outcome from elective orthopaedic surgery.” He and his co-authors of “Obesity, Orthopaedics, and Outcomes,” a study published in the November issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS), suggest that even though patients with obesity face higher surgical complication rates, orthopaedic procedures can help minimize pain and improve bone and joint function.
 
The Pains of Excess Weight
Obesity is a strong independent risk factor for pain. Adolescents with obesity were more likely to report musculoskeletal pain, including chronic regional pain, than their normal-weight peers. The disease nearly doubles the risk of chronic pain among the elderly—causing pain in soft-tissue structures such as tendons and ligaments, and worsening conditions such as fibromyalgia in individuals already living with constant pain in their muscles and joints.
 
Obesity and osteoarthritis
Osteoarthritis (OA)—a progressive “wear and tear” disease of the joints—is frequently associated with obesity. Every pound of body weight places four to six pounds of pressure on each knee joint. Research suggests that excess weight increases pressure, or the biomechanical load, on the knees and increases the likelihood of wearing away the cushioning surface of the knee joint, resulting in the development of OA and the need for total knee arthroplasty (TKA). The need for a TKA is estimated to be at least 8.5 times higher among patients with a body mass index (BMI) greater than or equal to 30, compared with patients who have a BMI within the normal range of 18.5 to 24.9.
 
Obesity and Injury
In addition to the increased likelihood of wear and tear on joints, excess weight also affects injury status. The odds of sustaining musculoskeletal injuries is 15 percent higher for persons who are overweight and 48 percent higher for people who are obese, compared to persons of normal weight.
 
Statistically, overweight and obese children also have significantly greater odds of lower extremity injuries and pain than do children of normal weight. Back and lower extremity pain, especially of the knee and foot, are more common among children with obesity.
 
Pre-surgical Considerations
“Although no upper weight limits have been established that would contra-indicate elective orthopaedic surgery, every surgeon must understand the unique risks an obese patient faces and understand how to optimize and treat each of these patients on an individual basis,” says Dr. Mihalko. The study authors recommend that patients with morbid obesity (BMI of 40 or higher) be:

• advised to lose weight before total joint arthroplasty (TJA);
• offered resources for weight loss before surgery; and,
• counseled about the possible complications and inferior results that may occur if they do not lose weight.

While patients with obesity may experience slower recovery and higher risks of surgical complications that can compromise outcomes, outweighing the functional benefits of TJA in some cases, orthopedic interventions still can provide improvements in quality of life for even for extremely obese patients.