Compartment Syndrome

Compartment syndrome is a painful condition that occurs when pressure within the muscles builds to dangerous levels. This pressure can decrease blood flow, which prevents nourishment and oxygen from reaching nerve and muscle cells.

Compartment syndrome can be either acute or chronic.

Acute compartment syndrome is a medical emergency. It is usually caused by a severe injury. Without treatment, it can lead to permanent muscle damage.

Chronic compartment syndrome, also known as exertional compartment syndrome, is usually not a medical emergency. It is most often caused by athletic exertion.

Anatomy

Compartments are groupings of muscles, nerves, and blood vessels in your arms and legs. Covering these tissues is a tough membrane called a fascia. The role of the fascia is to keep the tissues in place, and, therefore, the fascia does not stretch or expand easily.

Description

Compartment syndrome develops when swelling or bleeding occurs within a compartment. Because the fascia does not stretch, this can cause increased pressure on the capillaries, nerves, and muscles in the compartment. Blood flow to muscle and nerve cells is disrupted. Without a steady supply of oxygen and nutrients, nerve and muscle cells can be damaged.

In acute compartment syndrome, unless the pressure is relieved quickly, permanent disability and tissue death may result. This does not usually happen in chronic (exertional) compartment syndrome.

Compartment syndrome most often occurs in the anterior (front) compartment of the lower leg (calf). It can also occur in other compartments in the leg, as well as in the arms, hands, feet, and buttocks.

Cause

Acute Compartment Syndrome

Acute compartment syndrome usually develops after a severe injury, such as a car accident or a broken bone. Rarely, it develops after a relatively minor injury.

Conditions that may bring on acute compartment syndrome include:

• A fracture.
• A badly bruised muscle. This type of injury can occur when a motorcycle falls on the leg of the rider, or a football player is hit in the leg with another player's helmet.
• Reestablished blood flow after blocked circulation. This may occur after a surgeon repairs a damaged blood vessel that has been blocked for several hours. A blood vessel can also be blocked during sleep. Lying for too long in a position that blocks a blood vessel, then moving or waking up can cause this condition. Most healthy people will naturally move when blood flow to a limb is blocked during sleep. The development of compartment syndrome in this manner usually occurs in people who are neurologically compromised. This can happen after severe intoxication with alcohol or other drugs.
• Crush injuries.
• Anabolic steroid use. Taking steroids is a possible factor in compartment syndrome.
• Constricting bandages. Casts and tight bandages may lead to compartment syndrome. If symptoms of compartment syndrome develop, remove or loosen any constricting bandages. If you have a cast, contact your doctor immediately.

Chronic (Exertional) Compartment Syndrome

The pain and swelling of chronic compartment syndrome is caused by exercise. Athletes who participate in activities with repetitive motions, such as running, biking, or swimming, are more likely to develop chronic compartment syndrome. This is usually relieved by discontinuing the exercise, and is usually not dangerous.

Symptoms

Acute Compartment Syndrome

The classic sign of acute compartment syndrome is pain, especially when the muscle within the compartment is stretched.

The pain is more intense than what would be expected from the injury itself. Using or stretching the involved muscles increases the pain.

• There may also be tingling or burning sensations (paresthesias) in the skin.
• The muscle may feel tight or full.
• Numbness or paralysis are late signs of compartment syndrome. They usually indicate permanent tissue injury.

Chronic (Exertional) Compartment Syndrome

Chronic compartment syndrome causes pain or cramping during exercise. This pain subsides when activity stops. It most often occurs in the leg.

Symptoms may also include:

• Numbness
• Difficulty moving the foot
• Visible muscle bulging

Fractures (Broken Bones)

A fracture is a broken bone, the same as a crack or a break. A bone may be completely fractured or partially fractured in any number of ways (crosswise, lengthwise, in multiple pieces).

Types of Fractures

Althouh bones are rigid,  they do bend, or give, somewhat when an outside force is applied. However, if the force is too great, bones will break, just as a plastic ruler breaks when it is bent too far.

The severity of a fracture usually depends on the force that caused the break. If the bone's breaking point has been exceeded only slightly, the bone may crack rather than break all the way through. If the force is extreme, such as that caused by an automobile crash or gunshot, the bone may shatter.

If the bone breaks in such a way that bone fragments stick out through the skin, or a wound penetrates down to the broken bone, the fracture is called an open fracture. This type of fracture is particularly serious because once the skin is broken, infection in both the wound and the bone can occur.

Common types of fractures include:

• Stable fracture. The broken ends of the bone line up and are barely out of place.
• Open (compound) fracture. The skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture. The bone may or may not be visible in the wound.
• Transverse fracture. This type of fracture has a horizontal fracture line.
• Oblique fracture. This type of fracture has an angled pattern.
• Comminuted fracture. In this type of fracture, the bone shatters into three or more pieces.

Cause

The most common causes of fractures are:

• Trauma. A fall, motor vehicle accident, or tackle during a football game can all result in fractures.
• Osteoporosis. This disorder weakens bones and makes them more likely to break.
• Overuse. Repetitive motion can tire muscles and place more force on bone. This can result in stress fractures. Stress fractures are more common in athletes.

Symptoms

Many fractures are very painful and may prevent you from moving the injured area. Other common symptoms include:

• Swelling and tenderness around the injury
• Bruising
• Deformity — a limb may look out of place, or a part of the bone may puncture through the skin

Heat Injury and Heat Exhaustion

There are many types of heat injury, ranging from mild heat cramps to life-threatening heat stroke. A growing number of children and young adults are playing sports during late summer and early fall.

According to the Centers for Disease Control and Prevention, heat illness during practice or competition is a leading cause of deathx and disability among U.S. high school athletes. As more people exercise in warm conditions, it's essential to take proper precautions.

Heat-related illnesses are preventable. Prevention begins with understanding the causes of heat illness, and making sure to stay cool and hydrated during hot weather. In addition, knowing the signs of heat injury and being able to treat it immediately will reduce the number of severe cases.

Cause

When we exercise, our bodies cool off by sweating. As we perspire, we lose necessary body fluids. If we do not replace these fluids, we become dehydrated. This makes it difficult to sweat and cool down, which can result in a heat injury.

During regular exercise, 70 to 90% of the energy our bodies produce is released by heat. Many factors can hinder heat release and perspiration. These include:

• Environment. Air temperature, combined with humidity, wind speed, and sun affect how well our bodies cool themselves. Humidity influences how easily sweat can evaporate. High humidity (greater than 60%) makes sweat evaporation very difficult.
• Clothing. Dark clothing absorbs heat. This can dramatically increase the chance of heat stress. Full body clothing, heavy pads, and helmets make cooling more difficult.
• Sun exposure. Direct exposure to the sun with no available shade can increase your core body temperature.
• Fitness level/acclimatization. Before exercising in the heat, athletes must be in good physical condition. They also need to give their bodies time to adjust to warmer temperatures.
• Age. Children adjust to heat more slowly than adults. Their bodies are less effective at regulating body heat.
• Dehydration. Even mild levels of dehydration (3 to 5% of body weight) can hurt athletic performance. If you have not had enough fluids, your body will not be able to effectively cool itself through sweat and evaporation. 
• Pre-activity hydration status. Athletes who start activities in an already dehydrated state are at greater risk for heat injury. Factors that can affect your pre-activity hydration status include inadequate rehydration after a previous exercise session, excessive caffeine or alcohol consumption, rapid weight loss regimes (i.e. wrestling), and fever, vomiting, or diarrhea.
• High body fat. Athletes with high body fat have greater difficulty cooling themselves.
• Fever. Anyone with a current or recent fever may be at increased risk.
• Medications. Diuretics and stimulants may increase risk.
• Sickle cell trait. Sickle cell trait or disease increases the risk for heat illness. This is especially true if good hydration and electrolytes are not maintained.

Mild Heat Injury

Heat Cramps

Heat cramps are painful cramps in the stomach, arm, and leg muscles. These cramps are caused by not replacing salt and fluids during intense, prolonged exercise in the heat.

Treatment for Heat Cramps

• Stop exercise activity
• Gently stretch affected muscles
• Drink cool water or an electrolyte solution (low in sugar)
• For severe symptoms, treat as heat exhaustion (see below)

Moderate Heat Injury

Heat Syncope

Weakness, fatigue, and fainting are the chief symptoms of heat syncope. They are typically brought on by exercising hard in the heat. Too much salt and water are lost through perspiration and are not replaced.

Heat syncope often occurs during the first 5 days of adjusting to a new activity. It also can occur in people taking diuretic medicines or those with pre-existing heat illness. Young athletes returning to play after time off for injury are also at greater risk for heat syncope. Without treatment, heat syncope can put you at risk for heat stroke.

Heat Exhaustion (Water Depletion)

Heat exhaustion is brought on by heavy sweating and results in extreme weight loss. As heat exhaustion sets in, perspiration decreases, and skin and body temperatures rise. Core body temperature typically rises to 104° F.

Additional signs of heat exhaustion include excessive thirst, weakness, headache, and sometimes loss of consciousness.

Heat Exhaustion (Salt Depletion)

Common signs of heat exhaustion due to salt depletion are nausea and vomiting, frequent muscle cramps, and dizziness. Core body temperature is typically up to 104° F.

You are at risk for this type of heat exhaustion when you do not sufficiently replace normal body salts and minerals. This can sometimes happen during prolonged exercise if water alone is used to replenish fluids. Body minerals, such as those found in sports drinks, must also be replaced.

• Electrolyte fluid drinks are an effective way to prevent this type of heat exhaustion.
• Treatment for Heat Syncope and Heat Exhaustion
• Move the person to a cool, shaded area
• Remove tight clothing
• Give fluids, if the athlete is conscious
• Apply active cooling measures, such as a fan or ice towels, if the athlete's core temperature is elevated
• Refer to a physician to assess the needs of fluid/electrolyte replacement and further medical attention, especially if the athlete is nauseated and/or vomiting

Severe Heat Injury

Heat Stroke

Heat stroke is the most severe form of heat injury. When suffering from heat stroke, your body cannot cool itself. This is an acute medical emergency.

Heat stroke is medically defined as core body temperature greater than 104° F. Organ system failure can result from this high of a body temperature.

• Nausea, seizures, and confusion or disorientation often occur with heat stroke. Unconsciousness and coma are possible.
• Heat stroke may occur with no preceding signs of heat injury. It can also occur as a progression from heat syncope and heat exhaustion. Again, this is a medical emergency.

Treatment of Heat Stroke

• Call 911 immediately for emergency services
• Monitor core body temperature and lower it as quickly as possible
• Decrease core body temperature through immersion in an ice bath
• Remove as much clothing as possible
• Apply ice packs to the armpits, groin, and neck
• Continue cooling efforts until an emergency crew arrives

Prevention

There are many ways to reduce your risk for heat injury.

General Guidelines

See a doctor before starting a new exercise activity. Discuss recent illnesses or medications that could cause dehydration. Cardiac or pulmonary conditions can also contribute to heat injury.

Take time to adapt to a new activity or climate. Coaches should plan pre-season conditioning programs. These should be held during weather conditions similar to a typical practice.

Increase the intensity and duration of your exercise program gradually. If you participate in sports that require protective equipment, avoid wearing it at the start of training.

Recommendations

• Allow frequent periods of rest and hydration during activity. Fluid replacement is essential to preventing heat injury.
• Make sure you are well hydrated before, during, and after exercise. Replace your fluids, whether you feel thirsty or not.
• Allow frequent breaks for rest and hydration during activity.
• A general recommendation is to drink 24 ounces of non-caffeinated fluid 2 hours before exercise. Drinking an additional 8 ounces of water or sports drink right before exercise is also helpful. While you are exercising, break for an 8 oz. cup of water every 20 minutes.
• Monitor the color of your urine. The darker your urine, the less hydrated you are and the greater your risk for heat injury. Drink enough fluids to keep your urine a very light color.
• Weigh yourself before and after activity to monitor water loss. Make sure you have replaced fluids before your next exercise session.
• Gradually increase activity in the heat over a period of 7 to 10 days to allow adequate acclimatization.
• Wear lightweight and light-colored clothing.
• Protect against sun exposure with sunscreen.
• Schedule outdoor exercise at the coolest time of day, either early morning or after sunset.
• Routinely monitor changing weather conditions. Pay close attention to temperature and humidity on playing surfaces (indoor/outdoor).
• Strongly consider postponing or cancelling your activity when there are extreme heat and humidity conditions.

Muscle Contusion (Bruise)

Athletes in contact sports have many opportunities to get a muscle contusion (bruise). Contusions are second only to strains as a leading cause of sports injuries.

Most contusions are minor and heal quickly, without taking the athlete away from the game. Severe contusions, however, can cause deep tissue damage and lead to complications that may prevent an athlete from being able to play sports for months.

Cause

Contusions occur when a direct blow or repeated blows by a blunt object strike part of the body, crushing underlying muscle fibers and connective tissue without breaking the skin. A contusion can result from falling or jamming the body against a hard surface.

A contusion may result from a direct blow to a muscle when players collide during sports.

Symptoms

Contusions cause swelling and pain and can limit joint range of motion near the injury. Torn blood vessels may cause bluish discoloration. The injured muscle may feel weak and stiff.

Sometimes a pool of blood collects within damaged tissue, forming a lump over the injury (hematoma). If tissue damage is extensive, you may also have a broken bone, dislocated joint, sprain, torn muscle, or other injuries.

Contusions to the abdomen may damage internal organs.

Muscle Cramps

A muscle cramp is an involuntary contraction of a muscle that occurs suddenly and does not relax. If you have ever experienced a charley horse, you probably still remember the sudden, tight and intense pain caused by a muscle locked in spasm.

Cramps can affect any muscle under your voluntary control (skeletal muscle). They can involve part or all of a muscle, or several muscles in a group.

The most commonly affected muscle groups are:

• Back of lower leg/calf (gastrocnemius)
• Back of thigh (hamstrings)
• Front of thigh (quadriceps)
• Cramps in the feet, hands, arms, abdomen, and along the rib cage are also very common.

Cause

Although the exact cause of muscle cramps is unknown (idiopathic), some researchers believe inadequate stretching and muscle fatigue leads to abnormalities in the mechanisms that control muscle contraction. Other factors may also be involved, including poor conditioning, exercising or working in intense heat, dehydration and depletion of salt and minerals (electrolytes).

Inadequate Stretching and Muscle Fatigue

Muscles are bundles of fibers that contract and expand to produce movement. A regular program of stretching lengthens muscle fibers so they can contract and tighten more vigorously when you exercise. When your body is poorly conditioned, you are more likely to experience muscle fatigue, which can alter spinal neural reflex activity. Overexertion depletes a muscle's oxygen supply, leading to build up of waste product and spasm. When a cramp begins, the spinal cord stimulates the muscle to keep contracting.

Heat, Dehydration, and Electrolyte Depletion

Muscle cramps are more likely when you exercise in hot weather because sweat drains your body's fluids, salt and minerals (i.e., potassium, magnesium and calcium). Loss of these nutrients may also cause a muscle to spasm.

Risk Factors

Some people are predisposed to muscle cramps and get them regularly with any physical exertion.

Those at greatest risk for cramps and other ailments related to excess heat include infants and young children, and people over age 65. Other factors that put people at greater risk for muscle cramp include:

• Being ill or overweight
• Overexerting during work or exercise
• Taking certain medications

Muscle cramps are very common among endurance athletes, such as marathon runners and triathletes, and older people who perform strenuous physical activities.

• Athletes are more likely to get cramps in the preseason when the body is not conditioned and therefore more subject to fatigue. Cramps often develop near the end of intense or prolonged exercise, or 4 to 6 hours later.
• Older people are more susceptible to muscle cramps due to normal muscle loss (atrophy) that begins in the mid-40s and accelerates with inactivity. As you age, your muscles cannot work as hard or as quickly as they used to. The body also loses some of its sense of thirst and its ability to sense and respond to changes in temperature.

Symptoms

Muscle cramps range in intensity from a slight tic to agonizing pain. A cramping muscle may feel hard to the touch and/or appear visibly distorted or twitch beneath the skin. A cramp can last a few seconds to 15 minutes or longer. It might recur multiple times before it goes away.

Home Remedies

Cramps usually go away on their own without seeing a doctor.

• Stop doing whatever activity triggered the cramp.
• Gently stretch and massage the cramping muscle, holding it in stretched position until the cramp stops.
• Apply heat to tense/tight muscles, or cold to sore/tender muscles.

Prevention

To avoid future cramps, work toward better overall fitness. Do regular flexibility exercises before and after you work out to stretch muscle groups most prone to cramping.

Warm Up

Always warm up before stretching. Good examples of warm-up activities are slowly running in place or walking briskly for a few minutes.

Calf Muscle Stretch

Lean forward against a wall with one leg in front of the other. Straighten your back leg and press your heel into the floor. Your front knee is bent. Hold for 15 to 30 seconds.

Do: Keep both heels flat on the floor. Point the toes of your back foot toward the heel of your front foot.

Hamstring Muscle Stretch

Sit up tall with both legs extended straight in front of you. Your feet are neutral — not pointed or flexed. Place your palms on the floor and slide your hands toward your ankles. Hold for 30 seconds.

Do: Keep your chest open and back long. Reach from your hips. Stop sliding your palms forward when you feel the stretch.

Do not: Round your back or try to bring your nose to your knees. Do not lock your knees.

Hamstring muscle stretch. You should feel this stretch at the back of your thighs and behind your knees.

Quadriceps Muscle Stretch

Hold on to a wall or the back of a chair for balance. Lift one foot and bring your heel up toward your buttocks. Grasp your ankle with your hand and pull your heel closer to your body. Hold the stretch for 30 seconds.

Do: Keep your knees close together. Stop bringing your heel closer when you feel the stretch.

Do not: Arch or twist your back.

Hold each stretch briefly, then release. Never stretch to the point of pain.

When To See Your Doctor

Although most muscle cramps are benign, sometimes they can indicate a serious medical condition.

See your doctor if cramps are severe, happen frequently, respond poorly to simple treatments, or are not related to obvious causes like strenuous exercise. You could have problems with circulation, nerves, metabolism, hormones, medications, or nutrition.

Muscle cramps may be a part of many conditions that range from minor to severe, such as Lou Gehrig's disease (amyotrophic lateral sclerosis), spinal nerve irritation or compression (radiculopathy), hardening of the arteries, narrowing of the spinal canal (stenosis), thyroid disease, chronic infections, and cirrhosis of the liver.

Shin Splints

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

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

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

Description

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

Cause

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

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

Other factors that contribute to shin splints include:

• Having flat feet or abnormally rigid arches
• Exercising with improper or worn-out footwear
• Runners are at highest risk for developing shin splints. Dancers and military recruits are two other groups frequently diagnosed with the condition.
• Flat feet can increase stress on lower leg muscles during exercise.

Symptoms

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

Shin splint pain may:

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

Sprains, Strains and Other Soft-Tissue Injuries

The most common soft tissues injured are muscles, tendons, and ligaments. These injuries often occur during sports and exercise activities, but sometimes simple everyday activities can cause an injury.

Sprains, strains, and contusions, as well as tendinitis and bursitis, are common soft-tissue injuries. Even with appropriate treatment, these injuries may require a prolonged amount of time to heal.

Cause

Soft-tissue injuries fall into two basic categories: acute injuries and overuse injuries.

Acute injuries are caused by a sudden trauma, such as a fall, twist, or blow to the body. Examples include sprains, strains, and contusions.

Overuse injuries occur gradually over time when an athletic or other activity is repeated so often that areas of the body do not have enough time to heal between occurrences. Tendinitis and bursitis are common soft-tissue overuse injuries.

Common Acute Soft-Tissue Injuries

Acute soft-tissue injuries vary in type and severity. When an acute injury occurs, initial treatment with the RICE protocol is usually very effective. RICE stands for Rest, Ice, Compression, and Elevation.

Rest. Take a break from the activity that caused the injury. If the injury is to your leg, your doctor may also recommend that you use crutches to avoid bearing weight.

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, elevate the injury higher than your heart while resting.

Sprains

A sprain is a stretch and/or tear of a ligament, a strong band of connective tissue that connects the end of one bone with another. Ligaments stabilize and support the body's joints. For example, ligaments in the knee connect your thighbone (femur) with your shinbone (tibia), enabling you to walk.

The areas of the body that are most vulnerable to sprains are the ankles, knees, and wrists. A sprained ankle can occur when your foot turns inward, placing extreme tension on the ligaments of your outer ankle. A sprained knee can result from a sudden twist, and a wrist sprain can occur if you fall onto an outstretched hand.

Sprains are classified by severity:

• Grade 1 sprain (mild):  Slight stretching and some damage to the fibers of the ligament.
• Grade 2 sprain (moderate):  Partial tearing of the ligament. There is abnormal looseness (laxity) in the joint when it is moved in certain ways.
• Grade 3 sprain (severe):  Complete tear of the ligament. This may cause significant instability.

While the intensity varies, pain, bruising, swelling, and inflammation are common to all three categories of sprains. Treatment for sprains begins with the RICE protocol and physical therapy. Moderate sprains often require a period of bracing (for example, a CAM walking boot can be worn to help support and immobilize a sprained ankle). The most severe sprains may require surgery to repair torn ligaments.

Strains

A strain is an injury to a muscle and/or tendon. Tendons are fibrous cords of tissue that attach muscles to bone. Strains often occur in the back or leg (typically, the hamstring).

Similar to a sprain, a strain may be a simple stretch of your muscle or tendon, or it may involve a partial or complete tear of the muscle and tendon.  Symptoms of a strain may include pain, muscle spasm, muscle weakness, swelling, inflammation, and cramping.

Soccer, football, hockey, boxing, wrestling and other contact sports put athletes at risk for hamstring strains, as do sports that feature quick starts, such as hurdling, long jumping, and running races. Gymnastics, tennis, rowing, golf and other sports that require extensive gripping have a high incidence of hand sprains. Elbow strains frequently occur in racquet, throwing, and contact sports.

The recommended treatment for a strain is the same as for a sprain: rest, ice, compression and elevation. This should be followed by simple exercises to relieve pain and restore mobility. Surgery may be required for a more severe tear.

Contusions (Bruises)

Contusions occur when a direct blow (or repeated blows) by a blunt object strikes part of the body, crushing underlying muscle fibers and connective tissue without breaking the skin.  A contusion can result from falling or jamming the body against a hard surface. Discoloration of the skin is caused by blood pooling around the injury.

Most contusions are mild and respond well to the RICE protocol. If symptoms persist, medical care should be sought to prevent permanent damage to the soft tissues.

Common Overuse Soft-Tissue Injuries

Tendinitis

Tendinitis is an inflammation or irritation of a tendon or the covering of a tendon (called a sheath). It is caused by a series of small stresses that repeatedly aggravate the tendon. Symptoms typically include swelling and pain that worsens with activity.

Tiny tears in the Achilles tendon cause it to swell and thicken.

Professional baseball players, swimmers, tennis players, and golfers are susceptible to tendinitis in their shoulders and elbows. Soccer and basketball players, runners, and aerobic dancers are prone to tendon inflammation in their knees and ankles.

Tendinitis may be treated by rest to eliminate stress, anti-inflammatory medication, steroid injections, splinting, and exercises to correct muscle imbalance and improve flexibility. Persistent inflammation may cause significant damage to the tendon, which may require surgery.

Bursitis

Bursae, are small, jelly-like sacs that are located throughout the body, including around the shoulder, elbow, hip, knee, and heel. They contain a small amount of fluid, and are positioned between bones and soft tissues, acting as cushions to help reduce friction.

Bursitis is inflammation of a bursa. Repeated small stresses and overuse can cause the bursa to swell. Many people experience bursitis in association with tendinitis.

Bursitis can usually be relieved with changes in activity and anti-inflammatory medications, such as ibuprofen. If swelling and pain do not respond to these measures, your doctor may recommend removing fluid from the bursa and injecting a corticosteroid medication. The steroid medication is an anti-inflammatory drug that is stronger than the medication that can be taken by mouth. Corticosteroid injections usually help relieve pain and swelling.

Although surgery is rarely necessary for bursitis, if the bursa becomes infected, an operation to drain the fluid from the bursa may be necessary. In addition, if the bursa remains infected or the bursitis returns after all nonsurgical treatments have been tried, your doctor may recommend removal of the bursa.

Removal (excision) of the bursa can be done using a standard incision (open procedure), or as an arthroscopic procedure with small incisions and miniature surgical instruments. Your doctor will talk with you about which procedure is appropriate for your situation.

Prevention

Injuries often occur when people suddenly increase the duration, intensity, or frequency of their activities. Many soft-tissue injuries can be prevented through proper conditioning and training. Other prevention tips include:

• Use proper equipment.  Replace your athletic shoes as they wear out. Wear comfortable, loose-fitting clothes that let you move freely and are light enough to release body heat.
• Aim for balanced fitness.  Develop a balanced fitness program that incorporates cardiovascular exercise, strength training, and flexibility. Add activities and new exercises cautiously. Whether you have been sedentary or are in good physical shape, do not try to take on too many activities at one time. It is best to add no more than one or two new activities per workout.
• Warm up.  Warm up to prepare for exercise, even before stretching. Run in place for a few minutes, breathe slowly and deeply, or gently rehearse the motions of the exercise to follow. Warming up increases your heart and blood flow rates and loosens up muscles, tendons, ligaments, and joints.
• Drink water.  Drink enough water to prevent dehydration, heat exhaustion, and heat stroke. Drink 1 pint of water 15 minutes before you start exercising and another pint after you cool down. Have a drink of water every 20 minutes or so while you exercise.
• Cool down.  Make cooling down the final phase of your exercise routine. It should take twice as long as your warm-up. Slow your motions and lessen the intensity of your movements for at least 10 minutes before you stop completely. This phase of a safe exercise program should conclude when your skin is dry and you have cooled down.
• Stretch.  Begin stretches slowly and carefully until reaching a point of muscle tension. Hold each stretch for 10 to 20 seconds, then slowly and carefully release it. Inhale before each stretch and exhale as you release. Do each stretch only once. Never stretch to the point of pain, always maintain control, and never bounce on a muscle that is fully stretched.
• Rest.  Schedule regular days off from vigorous exercise and rest when tired. Fatigue and pain are good reasons not to exercise.
• Avoid the "weekend warrior" syndrome.  Try to get at least 30 minutes of moderate physical activity every day. If you are truly pressed for time, you can break it up into 10-minute chunks.

Stress Fractures

One of the most common injuries in sports is a stress fracture. Overcoming an injury like a stress fracture can be difficult, but it can be done.

What is a stress fracture?

A stress fracture is an overuse injury. It occurs when muscles become fatigued and are unable to absorb added shock. Eventually, the fatigued muscle transfers the overload of stress to the bone causing a tiny crack called a stress fracture.

What causes a stress fracture?

Stress fractures often are the result of increasing the amount or intensity of an activity too rapidly. They also can be caused by the impact of an unfamiliar surface (a tennis player who has switched surfaces from a soft clay court to a hard court); improper equipment (a runner using worn or less flexible shoes); and increased physical stress (a basketball player who has had a substantial increase in playing time).

Where do stress fractures occur?

Most stress fractures occur in the weightbearing bones of the lower leg and the foot. More than 50 percent of all stress fractures occur in the lower leg.

What activities make athletes most susceptible to stress fractures?

Studies have shown that athletes participating in tennis, track and field, gymnastics, and basketball are very susceptible to stress fractures. In all of these sports, the repetitive stress of the foot striking the ground can cause trauma. Without sufficient rest between workouts or competitions, an athlete is at risk for developing a stress fracture.

Are women more susceptible to stress fractures than men?

Stress fractures affect people of all ages who participate in repetitive sporting activities, like running. Medical studies have shown that female athletes seem to experience more stress fractures than their male counterparts. Many orthopaedic surgeons attribute this to a condition referred to as "the female athlete triad": eating disorders (bulimia or anorexia), amenorrhea (infrequent menstrual cycle), and osteoporosis. As a female's bone mass decreases, her chances of getting a stress fracture increase.

What are the symptoms of a stress fracture?

Pain with activity is the most common complaint with a stress fracture. This pain subsides with rest.

How are stress fractures diagnosed?

It is very important that during the medical examination the doctor evaluates the patient's risk factors for stress fracture.

X-rays are commonly used to determine stress fracture. Sometimes, the stress fracture cannot be seen on regular x-rays or will not show up for several weeks after the pain starts. Occasionally, a computed topography (CT) scan or magnetic resonance imaging (MRI) will be necessary.

How are stress fractures treated?

The most important treatment is rest. Individuals need to rest from the activity that caused the stress fracture, and engage in a pain-free activity during the six to eight weeks it takes most stress fractures to heal.

If the activity that caused the stress fracture is resumed too quickly, larger, harder-to-heal stress fractures can develop. Re-injury also could lead to chronic problems where the stress fracture might never heal properly.

In addition to rest, shoe inserts or braces may be used to help these injuries heal.

Prevention

Here are some tips developed by the American Academy of Orthopaedic Surgeons to help prevent stress fractures:

• When participating in any new sports activity, set incremental goals. For example, do not immediately set out to run five miles a day; instead, gradually build up your mileage on a weekly basis.
• Cross-training -- alternating activities that accomplish the same fitness goals -- can help to prevent injuries like stress fractures. Instead of running every day to meet cardiovascular goals, run on even days and bike on odd days. Add some strength training and flexibility exercises to the mix for the most benefit.
• Maintain a healthy diet. Make sure you incorporate calcium- and Vitamin D-rich foods in your meals.
• Use the proper equipment. Do not wear old or worn running shoes.
• If pain or swelling occurs, immediately stop the activity and rest for a few days. If continued pain persists, see an orthopaedic surgeon.

It is important to remember that if you recognize the symptoms early and treat them appropriately, you can return to sports at your normal playing level.

Rotator Cuff Tears

A rotator cuff tear is a common cause of pain and disability among adults. Each year, almost 2 million people in the United States visit their doctors because of a rotator cuff problem.

A torn rotator cuff will weaken your shoulder. This means that many daily activities, like combing your hair or getting dressed, may become painful and difficult to do.

Anatomy

Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). The shoulder is a ball-and-socket joint: the ball, or head, of your upper arm bone fits into a shallow socket in your shoulder blade.

Your arm is kept in your shoulder socket by your rotator cuff. The rotator cuff is a group of four muscles that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate your arm.

There is a lubricating sac called a bursa between the rotator cuff and the bone on top of your shoulder (acromion). The bursa allows the rotator cuff tendons to glide freely when you move your arm. When the rotator cuff tendons are injured or damaged, this bursa can also become inflamed and painful.

Description

When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus.

Most tears occur in the supraspinatus tendon, but other parts of the rotator cuff may also be involved.

In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes with lifting a heavy object.

There are different types of tears.

• Partial tear. This type of tear is also called an incomplete tear. It damages the tendon, but does not completely sever it.
• Full-thickness tear. This type of tear is also called a complete tear. It separates all of the tendon from the bone. With a full-thickness tear, there is basically a hole in the tendon.

Cause

There are two main causes of rotator cuff tears: injury and degeneration.

Acute Tear

If you fall down on your outstretched arm or lift something too heavy with a jerking motion, you can tear your rotator cuff. This type of tear can occur with other shoulder injuries, such as a broken collarbone or dislocated shoulder.

Degenerative Tear

Most tears are the result of a wearing down of the tendon that occurs slowly over time. This degeneration naturally occurs as we age. Rotator cuff tears are more common in the dominant arm. If you have a degenerative tear in one shoulder, there is a greater likelihood of a rotator cuff tear in the opposite shoulder -- even if you have no pain in that shoulder.

Several factors contribute to degenerative, or chronic, rotator cuff tears.

• Repetitive stress. Repeating the same shoulder motions again and again can stress your rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse tears, as well.
• Lack of blood supply. As we get older, the blood supply in our rotator cuff tendons lessens. Without a good blood supply, the body's natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.
• Bone spurs. As we age, bone spurs (bone overgrowth) often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the rotator cuff tendon. This condition is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.

Risk Factors

Because most rotator cuff tears are largely caused by the normal wear and tear that goes along with aging, people over 40 are at greater risk.

People who do repetitive lifting or overhead activities are also at risk for rotator cuff tears. Athletes are especially vulnerable to overuse tears, particularly tennis players and baseball pitchers. Painters, carpenters, and others who do overhead work also have a greater chance for tears.

Although overuse tears caused by sports activity or overhead work also occur in younger people, most tears in young adults are caused by a traumatic injury, like a fall.

Symptoms

The most common symptoms of a rotator cuff tear include:

• Pain at rest and at night, particularly if lying on the affected shoulder
• Pain when lifting and lowering your arm or with specific movements
• Weakness when lifting or rotating your arm
• Crepitus or crackling sensation when moving your shoulder in certain positions

Tears that happen suddenly, such as from a fall, usually cause intense pain. There may be a snapping sensation and immediate weakness in your upper arm.

Tears that develop slowly due to overuse also cause pain and arm weakness. You may have pain in the shoulder when you lift your arm, or pain that moves down your arm. At first, the pain may be mild and only present when lifting your arm over your head, such as reaching into a cupboard. Over-the-counter medication, such as aspirin or ibuprofen, may relieve the pain at first.

Over time, the pain may become more noticeable at rest, and no longer goes away with medications. You may have pain when you lie on the painful side at night. The pain and weakness in the shoulder may make routine activities such as combing your hair or reaching behind your back more difficult.

It should be noted that some rotator cuff tears are not painful. These tears, however, may still result in arm weakness and other symptoms.