Chest Muscle Injuries: Strains and Tears of the Pectoralis Major

Once rare, injuries to the chest muscles, particularly the pectoralis major muscle, are becoming more common. In fact, a recent study noted that of the 365 cases of pectoralis major ruptures reported in the medical literature from 1822 to 2010, 76% occurred over the past 20 years.1 Pectoralis major injuries can range from contusions (bruises) and inflammation to complete tears and frequently result in pain, weakness, deformity in the contour of the chest, and, ultimately, a decline in overall shoulder function. These injuries most often occur in active individuals who participate in sports or perform heavy labor and can be the result of either an acute traumatic event or chronic overuse. Pectoralis major tears are common in younger males who lift weights2 and in older athletes who do not warm-up adequately; however, these kinds of tears have even been reported in the elderly.3 When pectoralis major injuries occur, they can be disabling, especially to athletes.

The chest muscles

The 2 pectoralis muscles, the pectoralis major and the pectoralis minor (the larger and smaller muscles of the chest) connect the Humerus front of the chest wall with the humerus (upper arm bone) and shoulder (Fig). The pectoralis major is a thick, fan-shaped muscle consisting of 2 heads or portions, the clavicular and the sternal. The clavicular head originates from the anterior border of the medial half of the clavicle (collar bone) while the sternal head arises from the sternum (breast bone) and first through sixth ribs. The 2 portions of the muscle then converge on the outer side of the chest with the subclavius muscle (the small, triangular muscle between the clavicle and first rib) to form the axilla or armpit. The multiple origins and insertions of the pectoralis major muscle allow it to initiate a wide range of actions on the arm, enabling it to adduct (draw toward the body), flex (bend), extend (straighten), and internally rotate (turn toward the body).

 

 

Causes

Over time, repetitive or prolonged activity may cause the tendons of the pectoralis major muscle to degenerate, resulting in a strain. Chronic muscle imbalances, weaknesses, tightness, and abnormal biomechanics, especially when combined with excessive training, can also contribute to the development of a pectoral strain. By contrast, acute strains or tears to the pectoralis muscle happen when a force goes through the muscle and tendon that is greater than they can withstand. This can occur while weight training, especially when performing a bench press, chest press, or pectoral fly, and is more likely to happen when using free weights than machines. For example, if too great an external force is applied when the muscle is at its maximal stretch point, as during the downward movement of a bench press, it will rupture at the tendon juncture. When this occurs patients typically report a sharp pain with a pop.

Classification

Tears to the pectoralis major muscle may be small and partial or may constitute a complete rupture. Additionally, they can be classified as 1 of 3 grades, based on the number of muscle fibers torn and how much function has been lost, with grade 3 representing the most extensive damage. The majority of tears are grade 2.

Symptoms

Following a pectoralis major tear, the patient may have bruising, swelling, and deformity of the chest and upper arm. In addition, he or she may report pain and loss of strength when pushing with the extremity. The pain is localized to the chest and front of the shoulder or armpit, but may radiate into the upper arm or neck and may increase from an ache to a sharper pain with activity.

Diagnosis and assessment

In the acute phase of injury, a physical exam may be difficult to perform because swelling from the injury can distort the shoulder and pain can affect strength and motion testing. Once the swelling has resolved, the contour of the chest and shoulder may appear abnormal. The strength of the muscle can be tested by having the patient adduct while internally rotating (moving toward the body) the arm and adding resistance (pulling away from the body). The results can then be compared with results from the opposite arm.

Imaging is used to differentiate a pectoralis injury from other types of disorders and to determine its extent. X-rays should be taken to look for a possible bone fragment on the tendon or other associated fracture or dislocation. CT (computed tomography) can be used to evaluate fractures identified on x-rays for surgical fixation. Ultrasound is an inexpensive modality that can be used to assess the presence of a tear or retraction of the tendon while an MRI (magnetic resonance imaging) can be performed to determine the site and extent of the injury.

Treatment

The treatment for a pectoralis major injury depends upon the severity of the injury, the extent of muscle function, and the patient’s health and general activity level. Nonsurgical treatment must be considered in patients who have low demand, are elderly, or have either partial tears or tears in the muscle belly. Initial management with immobilization, rest, and cold therapy followed by strengthening and stretching can offer a satisfactory to excellent functional result. Shoulder motion returns and patients can resume daily activities.4 In those patients who either need to return to full strength and function or are concerned with cosmetic appearance, surgical repair is recommended. In a recent study, patients were highly satisfied with surgical repair of the pectoralis major, reporting a return of strength, structure, and overall function.5 The need for rehabilitation after surgery varies depending on how the muscle was repaired. In general, patients can return to normal activities 4 to 6 months after their procedure.

Outcomes

The management of pectoralis major injuries is patient specific. In sedentary or low-demand individuals with partial or complete tears, nonsurgical management can provide acceptable to excellent results. In those who demand function and form, surgical treatment may be the best option. While complications such as failure of repair, infection, and stiffness can occur, they are fairly rare. Generally, full return to activity and improved appearance can be expected following surgical repair and rehabilitation.

Author: Dan Morris, DO Columbus, GA

Reprinted with permission from the Hughston Health Alert, Volume 29, Number 2, Spring 2017.

I Have Scoliosis, Which Sports Can I Play?

If your spine curves toward the side and is shaped like a “C” or an “S,” (Fig) you may have scoliosis. Scoliosis is defined as a curvature of the spine of more than 10 degrees combined with a rotation of the vertebrae, the small bones that form the spine and through which the spinal cord passes. The 2 most common locations for this abnormal curvature are the thoracic (upper to mid) and lumbar (lower) spine. The thoracic portion of the spine is made up of 12 vertebrae and the lumbar portion of 5. The signs and symptoms of scoliosis include uneven hips, musculature that is uneven from one side of the body to the other, a rotating spine, back pains, and possibly chest pain. If as an athlete you have scoliosis, you may be wondering which sports you can play without experiencing discomfort or worsening your condition.

How do I know whether I’m at risk?

Most forms of scoliosis (about 65%) are idiopathic, meaning that the cause is unknown, and current research reports that the disease is most likely caused by several factors. While anyone can have idiopathic scoliosis, it is most often seen in children between the ages of 10 and 13; in fact, it is the most common spinal disorder in pre- and early teens. Additionally, studies have shown that females are more susceptible to the condition than males, though no definitive reasons have been found to explain this greater risk. A popular theory is that altered sensitivity to leptin, a hormone involved in the regulation of bone and energy metabolism in children and the initiation of puberty in girls, may result in increased sympathetic nervous system activity and a consequent disorder in skeletal growth, such as asymmetry of the spine. Apart from gender, the most significant factor contributing to scoliosis is genetics. Therefore, if someone in your immediate family, such as parent or sibling, has the condition, you should get checked regularly.

Can I be diagnosed as an adult?

Adults are often diagnosed with either idiopathic or degenerative scoliosis. If you are diagnosed with idiopathic scoliosis as an adult, chances are that the condition began in your adolescent to teenage years. If, on the other hand, as an adult you suffer from degenerative scoliosis, then a degenerating vertebral disc (the cushioning fibrocartilaginous pad between vertebrae) is the cause of the problem. As this disc degenerates, gravity can place too much pressure on one side of it, causing your spine to bend and curve. Your symptoms will depend on the degree of curvature, and may include back pain, shortness of breath with activity, lumbar stenosis (compression of the spinal nerve roots in the lower back), or poor posture.

How will my scoliosis be treated?

Through regular checkups with doctors, a treatment plan can be established for you as a scoliosis sufferer. The type of treatment depends on several factors such as your age or pubertal status, the degree and location of the curvature, gender, and associated symptoms. Once the doctor has assessed all the factors in your case, he or she can determine the best course of treatment. This could consist of getting fitted for a brace and attending physical therapy or could mean having a surgical procedure. A combination of bracing and spinal casting may be prescribed as a way to avoid surgery.

Progressively worsening scoliosis may require surgical intervention. As a very young patient, your options may include the implantation of growing rods as a way to straighten the spine without damaging growing tissues. Using hooks or screws, these rods are attached to the spine, or sometimes to the ribs, both above and below the spinal curvature. For children with early onset scoliosis there are also magnetic growing rods which, once surgically implanted, can be controlled and lengthened remotely as the child grows.

If you are an older teenager or adult, your condition may warrant spinal fusion. This is a surgical procedure to correct problems with the vertebrae and prevent any deformity from worsening. It may also improve the appearance of the spine. The procedure fuses together the painful vertebrae so they heal into a single, solid bone. This usually involves the placement of screws, hooks, and rods. The majority of patients are able to resume their normal activities, including athletics, a few months after spinal surgery.

Which sports can I play?

When you hear that you have a disease of the spine, you may be worried that playing a sport is out of the question. This is not true. Having scoliosis does not dictate whether you can play sports, though it may limit which sports you can play. Sports such as gymnastics, football, and heavy weight lifting that put a great deal of stress on the bones in the lower back are discouraged for athletes with scoliosis. On the other hand, sports which are low-impact, such as swimming and certain types of cycling, are encouraged. Moreover, these sports rely on a strong core. Your core includes not only your abdominal muscles, but also the muscles in your lower back and hips. When these muscles are conditioned and equal in strength, they work together to align and stabilize your spine, creating an anatomical brace. If, however, these core muscles are weak and imbalanced, they cannot support your spine and the result is poor posture. Your physician or physical therapist may prescribe an appropriate stretching and strengthening routine that targets your core to help with your condition. You may also benefit from structured activities such as yoga.

Carrying on with scoliosis

Scoliosis is a curvature of the spine that calls for regular monitoring visits with a spinal specialist or an orthopaedist with spinal expertise. While anyone can have scoliosis, statistics show that it is more prevalent in young females. How your scoliosis is treated and which sports you can participate in will ultimately depend on the severity of your condition. With the proper oversight, care, and attitude, you can carry on an active lifestyle and play a variety of sports despite having scoliosis.

Author: Chelsea Adams, LAT, ATC, and Morgan Carr, MS, LAT, ATC

Reprinted with permission from the Hughston Health Alert, Volume 29, Number 2, Spring 2017.

The Verdict on Vaping

Electronic cigarettes have been marketed as “healthier” alternatives to traditional cigarettes and as a good way to quit smoking. Only recently have people begun to look into the science behind these devices and ask the right questions. What exactly are electronic cigarettes? How do they work? Are they safer than tobacco cigarettes? Can they help me quit smoking? Unfortunately, the answers research is providing to some of these questions, especially when it comes to teens and young adults, are not what most people hope to hear.

The e-cigarette

Electronic cigarettes were invented in 2003 by Hon Lik, a Chinese pharmacist who was trying to quit smoking, and as of 2015, most were still made in China. Also known as electronic nicotine delivery systems (ENDS) and personal vaporizers, electronic or e-cigarettes are handheld, electrical devices designed to deliver nicotine to users in the form of vapor instead of smoke. They come in a variety of shapes, sizes, and styles, including cigars, pipes, and cigarette or pen look-a-likes. Most e-cigarettes have 3 main components. First, is the power source, which is usually a battery. Next, is the heating device, called an atomizer or vaporizer, which turns the liquid into an aerosol or vapor. Lastly is a cartridge or tank which holds the e-liquid and has a mouthpiece on one end. Sometimes the atomizer and cartridge are combined into a single unit called a cartomizer. As the user breathes into the mouthpiece, the heating device activates, and he or she then inhales or “vapes.”

The e-liquid

The liquid in an e-cigarette cartridge contains 4 main ingredients: nicotine, flavoring, propylene glycol, and glycerin. While the amount of nicotine in e-cigarettes varies greatly, a low level generally corresponds to 6 to 12 mg of nicotine, a medium level to 18 mg, a high to 24 mg, and very high to 36 mg. E-cigarettes taste like conventional cigarettes, but also come in a variety of flavorings from menthol to mocha dream. Currently, there are as many as 7,700 flavors on the market.2 Sweet flavors appeal particularly to young people.
Until August of 2016, the US Food and Drug Administration (FDA) did not regulate e-cigarettes, so there were no requirements for ingredient disclosure, warning labels, or youth access restriction. Partly as a consequence of FDA involvement, scientific research into the components of e-cigarette liquid as well as the health effects of e-cigarette use and exposure has increased. The findings reveal that the e-liquid usually contains not only nicotine, a highly addictive substance, but also benzene (which is found in car exhaust) and heavy metals, such as nickel, tin, and lead. Even an ingredient used in anti-freeze, diethylene glycol, has been identified in the e-liquid.3 Moreover, 75% of flavorings contain a chemical called diacetyl, which, when inhaled, has been linked to bronchiolitis obliterans, or permanent scarring of the airways in the lungs, and severe respiratory disease (Fig).1-3

The e-vapor

The real danger of vaping, however, may derive from the process that turns the liquid into a vapor. At a temperature of about 100 to 250°C (212 to 482°F), the chemical compounds inside the fluid break down and are converted into other chemicals. Scientists have examined the resulting mix and found both formaldehyde (a carcinogen or cancer-causing substance) and formaldehyde-releasing agents.1 Therefore, although traditional cigarettes contain over 4,000 chemicals— including 43 known cancer-causing compounds and 400 other toxins like arsenic, acetone (the active ingredient of nail polish remover), carbon monoxide, ammonia, and methanol (found in rocket fuel)—the risk of developing cancer from electronic cigarettes may be 15 times higher than from tobacco cigarettes, according to a report by Agence France-Presse. Moreover, like smoking, vaping can expose others to dangerous second-hand emissions (Fig).

Can e-cigarettes help me quit smoking?

It has been well established that cigarette smoking is harmful to nearly every system of the body and can cause a host of serious illnesses from emphysema and lung cancer to heart attack and stroke (Fig). Smoking is also a notoriously difficult habit to break: approximately 80% of would-be quitters will relapse within the first month. E-cigarettes have not only been promoted as safer than traditional cigarettes, but also as a means for smokers to quit. As there has been no evidence until recently that the devices can help traditional cigarette smokers stop smoking or even cut back, the FDA has been trying to evaluate and regulate this claim. E-cigarettes that contain nicotine levels lower than the 1mg of nicotine in tobacco cigarettes have been marketed with the idea that vaping small amounts of nicotine might help smokers quit. However, as consumers typically refill e-cigarette cartridges, they may offset any benefit from the reduced nicotine, exposing themselves to greater quantities than recommended.1 On the other hand, in 2014, the first Cochrane review—an independent, non-profit collaboration of researchers from more than 130 countries who work to produce credible and accessible health information without commercial sponsorship and other conflicts of interests—reported that, based on 2 randomized, controlled trials of more than 660 individuals conducted in England, e-cigarettes could increase the chance of smokers quitting: 9% of those using such devices stopped smoking for at least 6 months, compared with only 4% of those using e-cigarettes without nicotine. In a larger survey, University College London Professor of Health Psychology Robert West estimated that for every 10,000 people who use e-cigarettes to help them quit smoking, approximately 580 will quit. In 2015 alone, e-cigarettes may have helped about 18,000 smokers quit who might not have otherwise. Other studies, however, have revealed more modest results, cautioning that only 1 out of every 5 of those who attempt to quit smoking permanently by substituting vaping succeed.3 Furthermore, debates about whether e-cigarettes are more effective or safer than nicotine patches or other aids to quit smoking continue. Unlike pills and patches, the devices offer the advantage of mimicking the behavioral and psychological aspects of smoking; they provide a substitute for hand-to-mouth action and a coping mechanism for conditioned smokers.

Smoking trends

According to both the US Centers for Disease Control and Prevention and the FDA, electronic cigarette use now exceeds that of conventional cigarettes.3 Everyday usage is common, and many vapers are middle-aged males who also smoke. Among teens, e-cigarettes, and even marijuana, are more popular than tobacco cigarettes. A survey performed by the CDC found that while the total number of teen cigarette smokers has declined over the past 2 decades to 1.6 million, 1.3 million youth have taken up vaping.1 In fact, according to a recent FDA News Release on new tobacco regulation, between 2011 and 2015, e-cigarette use among high school students jumped from 1.5 to 16%, an increase of about 900%. This is a disturbing trend as e-cigarettes have not been proven to be healthier than regular cigarettes. Additionally, vaping can be a gateway to tobacco use for the younger generation. A study conducted by the National Center for Chronic Disease Prevention and Health Promotion revealed that US teens and young adults who have never smoked but have used e-cigarettes were 8.3 times more likely to begin smoking after just 1 year than those who have never vaped.3

Nicotine is not for teens

While nicotine is not a known carcinogen, it is a highly addictive substance that is lethal in high doses. In 2015, the American Association of Poison Control Centers reported 3,073 calls involving issues with e-cigarette devices and liquid nicotine. Moreover, nicotine can have long-term effects on brain development. This is largely because the brain’s prefrontal cortex (PFC), which is responsible for executive functions and attention performance, is one of the last areas to mature, continuing to develop until age 25. Consequently, when young people smoke, they increase the risk of developing impaired judgment, cognitive dysfunction, and attention deficits, as well as psychiatric and mood disorders. Smoking can also reduce impulse control in youths and alter the way they will make decisions as adults. Furthermore, nicotine use can lead to an increased risk of cardiovascular, respiratory, and gastrointestinal disorders as well as a decrease in immune response, which can negatively impact reproductive health (Fig).

The verdict

On December 8, 2016, the Surgeon General’s Office released “E-Cigarette Use Among Youth and Young Adults: A Report of the Surgeon General,” which comprehensively reviewed the public health issue of e-cigarettes, particularly their impact on US teens and young adults. Surgeon General Vivek H. Murthy has dubbed the devices “a public health threat to America’s youth” that is putting a whole new generation at risk for nicotine addiction. Fortunately, however, the upward trend in e-cigarette use among high school seniors has recently begun to reverse with just 12% saying they have used e-cigarettes compared with 16% in 2015.3 E-cigarettes may help some people quit smoking, and due to variable nicotine and chemical contents of the e-liquid, some controversy remains about whether they can be less harmful than tobacco cigarettes. Still the verdict on vaping, especially for teens, is simple: if you haven’t started, don’t; if you have, quit.

Author: BreAnna Hankins, MS, LAT, ATC and McKenzie Wakefield, LAT, ATC

Reprinted with permission from the Hughston Health Alert, Volume 29, Number 2, Spring 2017.

MD or DO: What’s the difference?

Most of us are quite accustomed to using academic titles such as “Doctor” or “Professor” when addressing someone with a doctoral degree. It is quite natural when referring to someone as “Doctor” to assume that this individual has a degree in the medical arts, but this title also applies to those with doctoral degrees in the fine arts, dentistry, veterinarian science, or law. In the US there are 2 types of doctors licensed to practice the medical arts; allopathic (MD) and osteopathic (DO). A frequently asked question is: what are the differences between a Doctor of Medicine (MD), and a Doctor of Osteopathic Medicine (DO)?

In years past, there were some significant differences between the 2 professions, but today there are many more similarities. Both are capable of practicing the full scope of medicine and specialize in fields like orthopaedics, neurosurgery, cardiology, internal medicine, and family practice. Both attend 4 years of medical school with similar curricula, and complete accredited residency training programs. Overall the training is very similar. There are some subtle differences in the approach to medical care, but the most noticeable difference is the hands on approach to patient care.

Osteopathic medicine was founded in 1892 by Andrew Taylor Still, MD. Dr. Still was a practicing allopathic physician who lost his wife and children to meningitis. After their deaths, he grew dissatisfied with the medical practices of the day, which were frequently ineffective and often caused more harm than good. The common medical practices during that time period included the use of arsenic, opium, castor oil, and whiskey. Dr. Still’s distrust in the medical practices of his day, prompted him to develop a new theory of medicine that would promote the body’s innate ability to heal itself.

Osteopathic medicine was founded on 3 key principals: 1) the body is a unit and health is related to the mind, body, and spirit of the individual; 2) the human body has an inherent ability to heal itself given the optimal conditions; and 3) that structure influences function and proper alignment of the musculoskeletal system is key to proper function.

The first 2 principals are not novel concepts; they date back to Hippocrates who said, “It is far more important to know what person the disease has than what disease the person has.” DOs are trained to use a holistic approach to patient care, which means they see each person as more than just a collection of organ systems, body parts, or disease. Today most physicians, MD and DO, have adopted this holistic approach to patient care.

The most notable difference between an MD and DO, however, is the hands on aspect. A key concept in osteopathic medicine is that structure influences function. Thus, if there is a problem in the body’s structure, function in that area, and possibly other areas, can be affected. Osteopathic physicians use this knowledge to aid in making diagnosis and in some instances to treat. This concept is generally applied through osteopathic manipulative medicine (OMM). A DO receives about 200 extra hours in OMM training during medical school. OMM is most often used by a DO in primary care fields such as family medicine, sports medicine, pediatrics, and internal medicine. It can be used to diagnose and treat a variety of medical conditions, including, but not limited to: low back pain, joint pain, neck pain, headaches, gastrointestinal conditions, and respiratory problems.

Currently there are about 141 medical and 33 osteopathic schools in the US. Each year around 80% of medical students enter MD programs and 20% enter DO programs. The prerequisites for acceptance into either program are the same, as well as the pathway for board certification and maintaining continuing medical education (CME). There are currently over 100,000 practicing DOs that make up about 7% of the medical physicians in the US.

In all 50 states, licensing agencies, hospitals, and residency programs recognize MD and DO degrees as equivalent. Recent studies comparing both disciplines have revealed that there are few remaining differences. While the pathways to becoming either an MD or DO are becoming indistinguishable, a blend of both the allopathic and osteopathic approaches to treating patients may offer patients the most comprehensive form of treatment.

Author: M. Canaan Prater, DO, and David Coffey, DO, FAAO, FCA

Reprinted with permission from the Hughston Health Alert, Volume 29, Number 3, Summer 2017.

2018 Art Gala Exhibition and Awards

The Hughston Foundation collaborated with Harris County High School Work Based Learning program to offer the 2018 Art Gala Competition and Exhibition. High school and middle school students throughout West-Central Georgia counties submitted ninety-six biologically or medically inspired entries under drawing, painting, photography, 3D, or mixed media categories to the competition. The submission deadline was November 1, and the exhibition was held November 9.

The art gala began at 7pm with the introduction of special guests and the presentation of awards and scholarships. There were 2 STEAM Awards worth $250 each, sponsored by Georgia Healthcare Science Technology Education Foundation. One was presented to the top scoring middle school aged student, 6th – 8th grades, and the second was presented to the highest rated high school aged student, 9th – 12th grades. Artists, Cameron Pearce received the high school award for “Biological Asymmetry,” and Lila Vasquez received the middle school award for “Beauty.”

Lexi Sirard received the Champ Baker Best Anatomical Award and $250 cash for “L’interieur de la Main.” Additionally, a $500 Columbus State University scholarship was awarded to Cameron Pearce. The Columbus State University scholarship went to the high school junior or senior who was selected as a winner. The award will be divided over the first two semesters of full-time enrollment. The student must qualify for admission to CSU, remain in good academic standing, and must enroll at CSU with a major or minor in Art, Biology, Kinesiology, or Health Sciences.

Other high school level winners include: 2nd Place Ribbon, Sunil Francis for “Insecurities” and 3rd Place Ribbon to Noah Hehman for “Ink Stipling.” Additional middle school winners included 2nd Place Ribbon to Janiyah Bryant for “What I See, I Feel” and 3rd Place Ribbon to Charlotte Young for “Brain Processing.”

The Hughston Foundation Art Gala for the Biologically Inclined is perfect for art students who have yet to unmask the exciting world of art and science. This biological and medically inspired art competition encouraged students to create artwork while integrating the principle areas of the national STEAM initiative (Science, Technology, Engineering, the Arts, and Mathematics). This was the inaugural year and the goal is to continue to provide annual competitions that will offer awards and scholarships to students. For more details regarding this event, please visit: https://www.hughston.com/2018-art-gala-competition-exhibition/.

Reducing the Spread of Herpes in the Locker Room

Herpes is a viral infection that has multiple strains (genetic variants or subtypes) (Fig. 1). All strains are transmitted by direct contact with the virus through either a skin lesion or infected bodily fluids. While the virus stays with a person for life, it can remain dormant within the body; however, symptoms can flare up at any point in time, but especially during events such as stress, fatigue, trauma, or other illnesses that weaken the immune system.

A common form of herpes among the athletic population is herpes gladiatorum, a skin infection caused by HSV1. Because it is particularly prevalent in the wrestling community where it can be easily transmitted through the skin to skin contact that takes place on the wrestling mat, it is often called “mat herpes.” An HSV1 lesion can appear in various sites on the body, but they are typically found on the head, face, neck, or upper extremities and present as clustered, rigid vesicles on a red base. Cold sores commonly found around the mouth are an example of a HSV1 viral infection.

Signs and symptoms

Symptoms usually present around 8 days following exposure to the virus, but some people exhibit no signs or symptoms at all. Those infected may develop flu-like symptoms, fever, swollen lymph nodes, burning and tingling sensations in the affected area, or cluster formations that may or may not become painful. Cluster formations are multiple skin lesions, also known as vesicles, within the affected area, which are generally surrounded by a reddened area that often produces a clear fluid (Fig. 2).

Once the fluid-filled vesicles dry up, a crust, or scab-like cover forms and acts as the body’s own barrier to prevent spreading the virus. If fluid is present in the vesicles, then the virus is highly contagious. These skin lesions generally heal within 7 to 10 days. Transmission rates are high if a person has no symptoms or if the vesicles have not crusted over. Because of their weaker immune systems, younger athletes are at greater risk of contracting the virus. While signs and symptoms can be used to try to find a cause, a definitive diagnosis of herpes can only be made by performing a viral culture from vesicle scrapings.

Treatment

There is no cure for herpes; however, there are some treatment options, such as the antiviral medication Acyclovir (brand names Zovirax® and Valtrex®) that reduces the outbreak of sores and blisters. If taken in the daily recommended doses, these medications can help reduce the transmission and recurrence of outbreaks. It should also be noted that once the lesions are fully formed, ruptured, and crusted over, antiviral medications are no longer effective. If an athlete does become infected with HSV1 and exhibits signs and symptoms, such as vesicles, he or she should be prohibited from practice and play until symptom free for 72 hours with no new or moist vesicles. To deal with recurrent flare ups, a physician should be consulted and a preventative treatment, such as an antiviral medication may be prescribed.

Prevention in the locker room

Since the virus is highly contagious and easily transmitted through skin contact with lesions, prevention is crucial. The locker room contains a multitude of shared personal items from soap to drinks, any one of which can be a vehicle for virus transmission. For example, if a cell phone is pressed against a lesion when talking on the phone and then handed off to a fellow athlete for use, it could potentially transmit the virus. Technically, any object that is exposed to a lesion can become a means of transmission. Basic prevention begins with not sharing personal items and includes proper hygiene. According to the 2008 NCAA guideline, “Skin Infections in Athletics,” some other ways to reduce exposure in the locker room are:

While prevention begins with athletes practicing good hygiene, a comprehensive prevention program should also involve athletic trainers, coaches, and building maintenance staff. Each plays a role in ensuring a sanitary environment for athletes by using a germicide to clean and disinfect common areas such as showers, benches, practice clothing, treatment tables, water bottles, mats, and equipment. Any shared object should be cleaned daily to prevent the spread of infectious disease. If an athlete has a suspicious skin rash, he or she should consult medical staff prior to practicing in order to prevent the transmission to fellow teammates.

Practicing proper hygiene and frequently cleaning communal areas and shared practice items is the best way to prevent transmission. When a skin rash appears, it is important to have it checked by medical staff prior to participating in sporting activities, especially contact sports, to ensure it is not contagious. If a contagious skin rash is present, such as HSV1, report it to the staff immediately so effective precautions can be taken to prevent any potential spread to teammates, coaches, or staff. The key is prevention and everyone has a role.

Author: Marissa Turturro, MS, ATC, NSCA-CPT and Joanna Sunnes

Reprinted with permission from the Hughston Health Alert, Volume 29, Number 3, Summer 2017.

Traumatic Patellar Dislocation

During a traumatic event, such as a fall, auto accident, or sports injury, the patella (kneecap) can completely or partially dislocate. A patellar dislocation occurs when the patella “jumps” out of the trochlear groove (a groove that holds the patella in line) and usually moves toward the outside of the knee. With patellar dislocations, often the most recognized damage is to the medial patellofemoral ligament (MPFL). A MPFL tear allows the patella to move out of place; and then, when it returns to its normal position, the patella damages the trochlea, causing bone bruising or fractures. Three bones form the knee joint—the tibia (shinbone), the femur (thighbone), and the patella, and these bones are held in place by a group of ligaments (tissues connecting bone to bone) and tendon (connects muscle to bone). These include the patellar ligament, medial and lateral patellotibial ligaments, medial patellofemoral ligament, and quadriceps tendon. As you move your leg, the patella glides up and down on top of the femur inside the trochlea (Fig.1).

Symptoms

Patellar dislocations occur most commonly in young athletes and can be a result of a direct blow to the knee or patella. After a kneecap dislocation, a patient often experiences pain, swelling, and hemarthrosis (a collection of blood) in the joint. The kneecap usually is displaced toward the outside, but the appearance of the knee may lead the untrained eye to think the patella moved toward the inside because the shape of the large medial femoral condyle, the bony projection at the end of the femur (Fig.2). It may be painful to walk or to bear weight and the range of motion of the knee may be limited. The patella may need to be reduced, or put back in place, or it may spontaneously reduce (return on its own). The doctor can perform the reduction by gently straightening the knee and placing a side-directed force to the patella. After reduction, an immobilizer or hinged knee brace is worn to keep the knee in full extension (straight) to protect it from dislocating again while it heals. This injury can have long-term consequences, such as instability of the patella, pain, recurrent dislocation, and patellofemoral osteoarthritis.

Diagnosing the injury

An orthopaedist should examine your knee after a patellar dislocation. During the doctor’s visit, the physician will take a medical history and perform a physical exam, which helps evaluate the nature of your injury. Your physician will order x-rays and may elect to order a magnetic resonance imaging (MRI, a scan that shows the bones, muscles, tendons, and ligaments). Not all first-time patellar dislocations require an MRI, but based on the severity of your injury and the results of your physical exam the test can help determine the extent of other damaged structures within your knee. During the visit, the orthopaedist will likely ask questions to help determine the course of treatment. For example, is this the first time you have injured your knee or have you had other problems with your knee before. The information can help determine if the injury is due to trauma, if it is the result of malalignment of the patella, or if you have a history of patellar instability.

Nonsurgical treatment

Your orthopaedist will decide on a course of treatment based on information ascertained about your knee and the history of your injury. Initially, your physician may elect to have you wear a brace that allows minimal weight-bearing, control pain with medications, and have you transition to a physical therapy program. During physical therapy, range of motion will be the focus for the first 4 weeks. Then, strengthening exercises start around 4 to 6 weeks and sports-specific training between 6 and 10 weeks. Often, you can return to sport at 10 to 12 weeks as long as there are no other dislocations.

Surgical treatment

After a course of therapy, if your patella continues to dislocate or feels unstable your surgeon may offer surgical intervention. Surgery would include knee arthroscopy, to look at the inside of the knee for damage, and an open procedure to stabilize the patella. This can be done with a procedure called proximal extensor mechanism realignment. This procedure takes tissue available in the knee and tightens the stretched-out structures. It also loosens tighter structures to balance the forces of the patella, and the trochlea groove it slides in. After the arthroscopic portion of the procedure, a 3 to 4 cm vertical incision is made over the upper portion of the patella to gain access to the vastus medialis oblique (VMO) and vastus lateralis (VL) tendons. While the knee is bent at 30 degrees the VMO attachment is removed from the upper inside pole of the patella. It is then advanced (pulled) over the superior medial body of the patella, essentially tightening it, and reestablishing stability as this is the loose side. With the knee still bent, the VL is also released in a similar fashion; however, it is reattached to the center of the patellar ligament; thereby loosening the more contracted side. This surgery is usually an outpatient procedure or a short 23-hour hospital stay. Risks include infections, blood clots in legs, problems with anesthesia, stiffness of the knee, and damage to nerves, arteries or veins.

Returning to your sport

After surgery, rehabilitation is similar to early conservative treatments, such as physical therapy that first concentrates on range of motion, then strength training, followed by sports-specific training. Your physician will not recommend returning to your sport until you have reached the strength and agility levels you had before injury. You should not be surprised if it takes you a little more than 3 to 6 months to return to your pre-injury level.

Author: George B. Sutherland, MD

Reprinted with permission from the Hughston Health Alert, Volume 30, Number 2, Spring 2018.

Why Tape My Ankle?

Ankle taping is commonly used in athletics, but why is it done? Initially, an athletic trainer may tape your ankle to help reduce the swelling that often occurs right after an injury. Later, taping the ankle provides the external stabilization that your stretched ligaments (tissues connecting bone to bone) need while they heal. Additionally, after you have completed rehabilitation and are ready to return to play, the athletic trainer may tape your ankle for extra support to avoid another injury.

The method used to tape your ankle depends on the type of injury you incurred. The most common type of ankle injury is an inversion (turning inward) ankle sprain (stretching or tearing a ligament). This occurs when the athlete’s ankle turns “in” or “under,” forcing the 5th digit (small toe) towards the ground. When this injury occurs, ligaments are stretched leaving the ankle unstable in the process. Once you have sprained your ankle, it will be more susceptible to sprains in the future because the stretched ligaments are weaker. This is where taping helps.

When the stirrup strips are done, they should form a fan shape to cover the malleoli (the bony projections at the ankle). The horseshoe strips provide the basic support needed at the sides of the ankle joint. Next, the trainer applies 2 heel-locks that keep the heel in place, slightly limiting motion and providing support for the ankle. Then the trainer places strips in the shape of a figure 8. Once these strips are in place, the athletic trainer finishes with multiple strips of tape placed in a circular motion similar to the anchor strips, ensuring that the taping application stays and does not unravel.

Be proactive to prevent injury

Once you have an ankle injury, strengthening exercises and balancing drills can help you be proactive in preventing further harm. You should perform several repetitions of each exercise 2 to 3 times a day. The 4-way ankle strengthening exercise is performed by placing a resistance band on the ball of the foot, and then moving the ankle joint in an up and down, and side-to-side “t” pattern. Additionally, perform towel slides by placing a towel flat on a smooth surface, and then placing the foot at the end of the towel. Then use your foot to pull the towel to the left and then right (Fig. 2).

Similarly, restoring proper balance is important to reduce risk of injury as well by placing more outside forces on the ankle to help strengthen it. Balancing drills such as single-leg stands with increasing difficulty levels, adding ball tosses and unstable surfaces can help you regain confidence in your ankle and ability to balance (Fig. 3). When performing these exercises correctly, they enhance the ankle’s overall strength and decrease the likelihood of another injury.

Taping after an inversion ankle sprain

The athletic trainer will first apply adhesive spray to hold heel and lace pads and a prewrap in place. The pads and prewrap protect the skin by reducing friction, which results in fewer blisters, and makes removing the tape easier and less painful. Next, a base layer of 1 to 3 pieces of tape, called anchor strips, are placed at the base of the calf muscle, half on the prewrap and half on the skin. The anchor strips do just what they imply; they anchor the tape by providing a base for the other tape pieces to stick. Then, the athletic trainer adds a series of alternating stirrup and horseshoe strips, forming a weave (Fig. 1).

A stabilizing effect

Ankle sprains are a common injury among athletes of all ages and level of participation. As a result, athletic trainers look for the best ankle stabilizer that will reduce injuries while minimizing the effect it may have on your performance. The ideal ankle taping method should be restrictive and comfortable while functional and protective. It should provide the extra support you need to feel confident in your return to play. Once you have completed all the necessary rehabilitation and regained confidence in your ankle, then taping may cease.

Author: Cassandra Bryant, MS, LAT, ATC, and Danielle Gunnin, MS, LAT, ATC, ITAT

Reprinted with permission from the Hughston Health Alert, Volume 30, Number 2, Spring 2018.

Swimmer’s Shoulder

The shoulders produce 90% of the driving force that propels the body through water, which explains why the most common musculoskeletal complaint in swimmers is shoulder pain. The term “swimmer’s shoulder” includes a number of painful overuse injuries that often correlates with a sudden increase in training or using poor swimming techniques. Because there are various parts of your shoulder in action during the swimming stroke, you may injure and experience pain at any single or multiple sites about the shoulder. Pain can be the result of 1 or more conditions, such as reduced shoulder stability, muscle or tendon (tissue connecting muscle to bone) strains, nerve irritation, or sprains from stretching or tearing ligaments (tissues connecting bones).

Anatomy

The glenohumeral joint, or shoulder, is a ball-and-socket joint formed by the head (ball) of the humerus, or upper arm bone, with the glenoid cavity (socket) of the scapula (shoulder blade). The shoulder cavity is shallow, which reduces the amount of contact between the bones. This provides increased freedom of motion at the expense of stability. However, the glenoid labrum, a ring of cartilaginous fiber that lines its circumference, deepens the cavity by about 50%, allowing for more surface contact, a better fit, and added stability. In addition, the joint capsule and its ligaments (tissues that connect bone to bone) provide some added stability. The glenohumeral joint is also known as a muscle-dependent joint. It is primarily stabilized by the biceps brachii, or muscle on the anterior (front) side of the upper arm, and the tendons of what are called the rotator cuff muscles. The rotator cuff is made up of 4 muscles, which work together, to help keep your shoulder centered in the socket during motion. These include the subscapularis, supraspinatus, infraspinatus, and teres minor muscles. Each of these muscles originates from the scapula and has a tendon that attaches to the head of the humerus (Fig).

Diagnosis

Identifying the source of pain in swimmer’s shoulder is crucial to obtaining the correct diagnosis and best treatment. Your physician will look for the characteristics of your discomfort, such as the location, radiation, timing, and position of pain, as well as the type of swimming stroke used and if you have had any changes in training. Additionally, a thorough health history is essential when identifying the source of shoulder pain. Your physician may order x-rays to rule out any abnormal anatomy and magnetic resonance imaging (MRI scan) to evaluate the shoulder’s muscles, tendons, and ligaments. If your physician suspects neuropathy (nerve damage), an electromyography (EMG) test that measures the muscle response to a nerve’s stimulation may be ordered as well.

Treatment

In general, nonoperative treatment is the primary approach to swimmer’s shoulder. Rest and icing the injury and taking nonsteroidal anti-inflammatory medications, such as aspirin or ibuprofen are the initial recommended management techniques. You should rest your shoulder and stop the movement or activity that caused or reproduces your shoulder pain. Apply ice for 20 to 30 minutes every 2 to 4 hours to help reduce the swelling. It may be difficult for you to lift your arm or to sleep; therefore, you may need to wear a sling or have your shoulder taped for support and you may need to sleep in an upright position or use a pillow for added support. Once you have passed the acute phase of inflammation, you should consider modifying your training regime so that it does not aggravate the injury and cause additional pain.

Depending on the severity of your injury, your physician may recommend a corticosteroid injection into the shoulder that helps to reduce swelling and leads to pain relief. Each patient reacts differently, however the injection can relieve the pain and swelling for weeks or months or alleviate the problem altogether.

Another nonsurgical option is a physical therapy program that focuses on both stretching and strengthening exercises to neutralize any uneven muscle strength. During swim training, a muscle strength imbalance and muscle shortening can occur in the shoulder. Strengthening exercises are used to re-establish a muscular strength balance allowing a more synchronized movement of the shoulder. When performing stretches, the athlete must be mindful to include both anterior (front) and posterior (back) aspect of the shoulder as to not create an imbalance that may exacerbate some injuries. Once you have improved motion and muscle coordination, you can begin a gradual return to training.

When nonoperative treatment fails or if your physician has identified a structural problem, you may need surgical treatment. The type of structural problem present will direct surgery. Common injuries that require surgery in swimmers are multidirectional instability, impingement syndrome, and labral tears. For multidirectional instability, the surgeon tightens the soft tissue structures to increase stability of the joint. However, this procedure can decrease motion in the shoulder and may affect athletic performance afterwards. For athletes that fail therapy or injections for subacromial impingement, surgical treatment with removal of inflamed bursal tissue is an option. The recovery is relatively quick as there is no down time for healing of tissue. In those with a labral tear that have failed conservative treatment either labral repair or debridement can be performed. Returning to swimming after surgery varies according to the procedure preformed. The goals and expectations of the athlete should be examined and considered in relation to expectations after surgery.

Dive in

Of all the joints in the body, the anatomy of the shoulder allows for the greatest range of motion. The demands you place on your shoulders during swimming, coupled with the anatomy can lead to a wide range of injuries. If you experience shoulder pain, stop what you are doing and evaluate your technique and posture. Once you give the shoulder a short rest, restart your training slowly so you do not reinjure the joint. If the pain returns, it may be time for you to have the injury evaluated by a physician. After taking a detailed history and physical exam, your doctor can make an accurate diagnosis and start you on a treatment plan. The correct diagnosis will help guide appropriate treatment and ultimately a successful return to sport.

Author: Daniel J. Morris, DO

Reprinted with permission from the Hughston Health Alert, Volume 30, Number 3, Summer 2018.

Rhabdomyolysis

Physicians first described rhabdomyolysis in the medical literature during ancient times; however, in our modern era, a notable number of cases were reported during World War I and II in soldiers who sustained crush injuries from bombings and trench collapses. Rhabdomyolysis is a condition that results when damaged muscles release toxic muscular contents (fluids) into the bloodstream. In healthy skeletal muscle, each muscle fiber is enclosed in a thin membrane that controls a number of pumps that regulate and maintain the electrolyte concentration inside and outside the cell. Electrolytes are minerals—the 4 basic are magnesium, calcium, sodium, and potassium—in your blood and other body fluids that carry an electric charge. The proper balance of electrolytes and other nutrients provided by normal blood flow allow muscles to contract and relax in response to nerve stimulation. Any direct or indirect injury to the membrane can cause damage and the breakdown of muscle cells, resulting in toxic muscular contents to leak into the body’s circulation (Fig).

What causes rhabdomyolysis to occur?

You can develop rhabdomyolysis from muscle damage in a number of ways, but the most common causes are trauma that leads to muscle compression and crush-type injuries, muscle overexertion from excessive exercise, and the abuse or overuse of drugs, alcohol, and certain medications (Table). Regardless of the cause, the results of a muscle injury can cause a cascade of events that leads to the release of toxic muscle byproducts into the bloodstream that not only affects your muscles, but also your organs and the rest of the body. In a crush injury—for example when a patient is trapped in a car or collapsed building—muscle dies when the blood flow is cutoff. When the compression is relieved, fluids from the damaged muscle are released into the bloodstream.

Additionally, excessive or intense exercise beyond the extent of a person’s physical limits can cause exercise-induced rhabdomyolysis. The primary factors that tend to worsen this condition include the level of physical fitness, the intensity, and types of exercise. Exercise-induced rhabdomyolysis tends to occur in individuals who are poorly conditioned, during long durations of exercise, in high humidity and temperatures, and during excessive exercise while taking drugs or drinking alcohol. Physicians have treated exercise-induced rhabdomyolysis in military recruits, and participants of marathons, triathlons, soccer, crossfit, weight lifting, and numerous other sports.

Another cause occurs during prolonged immobilization from anesthesia, coma, or drug- or alcohol-induced unconsciousness when unrelieved pressure on a gravity-dependent body part is present. There are multiple reports of a person developing rhabdomyolysis from drug or alcohol induced comas in which their arm or leg was compressed against a firm object or another body part which decreased blood flow to the extremity for multiple hours causing muscle damage.

Symptoms

Symptoms of rhabdomyolysis can vary depending on the extent of your muscle damage; however, the classic symptoms are severe muscle pain with weakness to the point you will have trouble moving your arms or legs, and you may experience dark red or brown urine or decreased urination. Additionally, local symptoms around the injured area can include muscle pain, weakness, swelling, extreme soreness, stiffness, cramping, bruising, and tenderness. You can also experience an overall sickly feeling with fever, abdominal pain, nausea, and vomiting. Occasionally changes in mental status, such as confusion or loss of consciousness can occur.

Diagnosis

Physicians use laboratory tests that detect excess muscle proteins and enzymes in the blood and urine to diagnose rhabdomyolysis. A careful history and physical exam may reveal the underlying cause or at least aid in the selection of the most appropriate diagnostic workup.

Complications

Complications from rhabdomyolysis can be numerous and severe. As the toxic fluids pour into the bloodstream from damaged muscle tissue it can affect not only local tissue but also organs throughout the body. More locally, compartment syndrome can occur when increased pressure builds up within a muscle compartment resulting in decreased oxygenation to the local tissues. Irregular heartbeats and even cardiac arrest can occur from electrolyte dysfunction as well. For example, a patient may experience high levels of potassium in the blood, which can cause an irregular heartbeat. Muscle byproducts can also cause liver dysfunction, which occurs in approximately 25% of rhabdomyolysis cases. Other complications include increased blood clotting, low blood pressure, and shock. Kidney failure is also one of the most serious complications in the days following the initial presentation of rhabdomyolysis.

Permanent kidney injury and even death can occur as a result in very severe cases.

Treatment

After muscle damage has occurred, the main treatment of rhabdomyolysis includes aggressive fluid resuscitation (IV fluids) to avoid kidney injuries. Once in a hospital setting, aggressive fluid resuscitation will continue along with a careful history and physical exam to identify and manage any complications. Management of complications can include cardiac monitoring, medications to correct electrolyte imbalances and irregular heartbeats, surgery to alleviate elevated pressures in an extremity, physical therapy, close monitoring of kidney function, and use of dialysis in severe cases of kidney injury.

Recovery

Recovery from rhabdomyolysis varies and depends on the degree of muscle damage and the specific complications that occurred. If the condition is recognized and treated early, you can avoid most major complications and expect a full recovery. Recovery from exercise-induced rhabdomyolysis, with no major complications, can take several weeks to months for the patient to return to exercise without recurrence of symptoms. More severe complications, such as those often seen in compartment syndrome, can result in multiple operations, months of rehabilitation, and permanent disability. Additionally, the kidney dysfunction that results from rhabdomyolysis often resolves, however, if you experience severe kidney injury it can result in permanent damage and a need for long-term treatments, perhaps even dialysis.

Prevention

Prevention is geared toward avoiding what causes rhabdomyolysis; but you can only avoid what you have control over. You cannot always prevent an accident or injury; however, you do have control over exercise-induced rhabdomyolysis. Exercise-induced rhabdomyolysis can be prevented by initiating a gradual training program with sufficient recovery time included, avoiding extreme exercises, preserving fluid balance, and not exercising in high heat and humidity.

A rare condition

Luckily, rhabdomyolysis is a rare condition, especially since it can have serious and long-lasting complications. While you cannot always avoid an injury, patients can steer clear of the complications by minimizing the risk factors that they can control. If a crush injury occurs or if you experience the symptoms of rhabdomyolysis, the best results will come if a physician promptly identifies and treats the condition.

Author: David Barnes, DO

Reprinted with permission from the Hughston Health Alert, Volume 30, Number 3, Summer 2018.