Sports Medicine

The Achilles Tendon

Achilles Tendon Injuries

The Achilles tendon is the largest tendon in your body. It connects the muscles in the back of your lower leg to your heel bone (the calcaneus) and must withstand large forces during sporting exercises and pivoting. There are two main types of injuries that affect the Achilles tendon: 1) overuse and inflammation, called Achilles Tendonitis, and 2) a tear of the tendon.

Achilles Tendonitis

Achilles tendonitis often occurs when you rapidly increase the intensity of training or start new types of training when your body is not fully conditioned, e.g., adding uphill running to your training schedule or restarting training after a period of inactivity. You may experience mild pain after exercise that gradually worsens. Mild swelling, morning tenderness, and stiffness may also occur, but may improve with use. Severe episodes of pain along the length of the tendon several hours after exercise may also be experienced.

Because other symptoms may be present, it is best to see your doctor for full evaluation of an Achilles injury. Treatment depends on severity and typically involves rest and nonsteroidal anti-inflammatory medications (NSAIDs) to relieve pain and inflammation. An orthosis (a brace) may be needed to relieve the stress on your tendon and support your ankle, or bandages may be applied to restrict joint movement.

Surgery is sometimes an option to repair any tears and remove any inflamed or fibrous (toughened) tissues. Recovery in general includes rehabilitation to avoid future weakness in your ankle.

Achilles Tear

Your Achilles tendon may tear if it is overstretched, usually while playing sports. The tear may be partial or complete and most commonly occurs just above the calcaneus (your heel bone). A snap or crack sound may be heard at the time of injury. Pain and swelling near your heel and an inability to bend your foot downward or walk normally are signs that you may have ruptured your Achilles tendon.

Surgery is typically needed for a complete rupture. After surgery, your ankle will be kept stable in a cast or walking boot for up to 12 weeks. A torn ligament may also be managed nonsurgically with a below-knee cast, which would allow the ends of the torn tendon to heal on their own. This nonsurgical approach may take longer to heal, and there is a higher chance that the tendon could re-rupture. Surgery offers a better chance of full recovery and is often the treatment of choice for active people who wish to resume sports.

If you suspect that you have signs or symptoms of an Achilles tendon injury, please see your doctor for further evaluation and discussion of treatment options.

ACL Tear

Ligaments are tough, nonstretchable fibers that hold your bones together. A tear to the anterior cruciate ligament (ACL) of your knee joint is among the most common sport-related injuries. The ACL connects the thighbone (the femur) to the shinbone (the tibia) and acts to prevent your thighbone from moving too far forward over the knee joint. This ligament also helps stabilize the shinbone from rotating out of the knee joint.

The ACL can tear when it’s stretched beyond its normal range. This typically happens by sudden twisting movements, slowing down from running, or landing from a jump. You may hear a popping sound at the time of injury. Your knee may give way and begin to swell and hurt.

Because the ACL is not capable of healing itself (ligaments, unlike muscles, do not have their own blood supply), it can only be reconstructed (that is, replaced) surgically — it cannot simply be repaired.

Less active people may choose to treat a torn ligament nonsurgically with a rehabilitation program focusing on muscle strengthening and lifestyle changes. Surgical reconstruction, however, may help many people recover full function after an ACL tear. Your doctor can discuss these different options with you and help choose what is right for you.

After ACL reconstruction, performing rehabilitative exercises may gradually return full flexibility and stability to your knee. Building strength in your thigh and calf muscles to support the reconstructed knee is a primary goal of rehabilitation. You may also need to use a knee brace for a short time, and it is important not to return to full activity too soon to prevent reinjury.

Bursitis of the Hip

A bursa is a fluid-filled space that acts as a cushion between tendons, bone, and skin which helps your joints move with ease. There are over 150 bursae in your body, and several are found around the outer area of the hip, near the portion of your thighbone (the femur) called the greater trochanter. Bursitis occurs when a bursa becomes inflamed, and it is a common cause of pain to your hip.

Inflammation of a bursa is caused by repetitive-use injuries, prolonged pressure, lumbar spine diseases, rheumatoid arthritis, and sometimes infection. It can affect anyone at any age, but is most common in women and the middle-aged. The main symptom is aching pain over the part of the outer hip. The pain worsens with movement or pressure and may travel down the outside of the thigh toward the knee. Pain caused by pressure at night can make sleeping very difficult.

Your doctor will be able to diagnose bursitis when he or she physically examines the specific area causing pain and tenderness. However, an X-ray may be taken to rule out other causes.

Initial treatment of bursitis involves resting, immobilizing the area, and nonsteroidal anti-inflammatory medications (NSAIDs) to reduce inflammation and relieve pain, a regimen that is often effective. Exercise and physical therapy, especially for the hip and lower back, can be helpful to strengthen the surrounding muscles and help prevent further episodes. If these measures don’t relieve your pain, a doctor may recommend an injection of corticosteroids around the bursa, which usually brings rapid pain relief. Surgery to remove the damaged bursa may be an option in severe cases.

To help prevent bursitis, try:

  • Stretching your hip muscles before activity
  • Practicing good posture
  • Avoiding repetitive hip movements that cause the pain
  • Cushioning your joints (cushion chairs when sitting, and use extra hip support when sleeping)

If you suspect that you have signs or symptoms of hip bursitis, please see your doctor for evaluation and further discussion of treatment options.

Low Back Pain

The lower back is made up of five lumbar bones (vertebrae), all of which are separated by spinal discs composed of a gel-like substance and covered with cartilage. These discs act as shock absorbers and help your entire spinal column to move. The vertebrae themselves can be felt when you touch your back, and all the muscles that stabilize the spine attach to these bony points. The spinal canal, which holds the spinal cord and the nerves that branch off, runs the length of the spinal column. Because your lower back supports the majority of your body’s weight, it is very common to experience pain that comes from the muscles, the nerves, or the spine itself.

In fact, low back pain is the second most common reason people visit their doctor (cold and flu are number one).* There are many causes of back pain, and there is no single explanation for each person, although most people experience pain because of injury or trauma. The most common causes of back pain include:

  • Injury to a muscle (strain) or ligament (sprain)
  • Disc herniation
  • Degenerative disc disease
  • A pinched nerve (sciatica)
  • Hip joint inflammation (sacroiliitis)

Strains and sprains can occur for many reasons, and may not be caused by any single event. Using improper lifting techniques, being overweight, and having poor posture can cause enough strain on the structures of the lower back to cause injury. You are particularly at risk if you have a job that requires heavy lifting, don’t exercise, or have a history of osteoporosis or arthritis.

Most people find that low back pain improves with simple, at-home measures that include rest (limited to two days) and nonsteroidal anti-inflammatory medications (NSAIDs) or acetaminophen to relieve pain. Sometimes, stronger muscle relaxants and narcotics are used for a short period. Prolonged bedrest (longer than two or three days) is not recommended and may actually worsen the problem.

It is important to gradually resume activity after the first couple of days. Other methods of care include applying heat or cold packs, massage therapy, ultrasound, electrical stimulation, and traction and reduction (physically maneuvering the bones). Injection with local anesthetics or corticosteroids is also an option for short-term pain relief. With all causes of low back pain, one of the most important ways to improve your condition is with back strengthening and conditioning. This is done with specific exercises, as well as general aerobic conditioning.

Surgery for low back pain is an option when nonsurgical options have been unsuccessful. The most commonly performed back operation is spinal fusion, which limits movement of the most painful part of your back. Surgery is considered successful when pain is reduced; however, recovery can take longer than a year. Furthermore, it is rare for people to have complete recovery from pain. Surgery is not the right answer for everyone, and your doctor can best discuss the benefits and limitations of surgery for your particular condition.

How to prevent low back pain:

  • Use correct lifting techniques.
  • Exercise regularly to strengthen back muscles.
  • Maintain good posture.
  • Maintain a healthy body weight.

Home care for low back pain:

  • Stop normal activity and apply ice for first few days.
  • Apply heat to lower back.
  • Gradually increase activity to normal.
  • Take over-the-counter pain relief (ibuprofen or acetaminophen).

Back pain with a loss of bowel or bladder control, leg weakness, weight loss, or fever may suggest a more serious condition. If you experience these symptoms, please seek emergency care for further evaluation.

Meniscal Tear

A meniscal tear is a common injury of the knee. The meniscus is a wedge-like, shock-absorbing piece of cartilage found within your knee joint. It is shaped like a C and curves inside and outside the joint to stabilize your knee. It also allows your thigh (the femur) and your shin (the tibia) bones to glide and twist over each other with movement, as well as provide cushioning support for the weight-bearing job of your legs.

Injury to the meniscus often happens during sport activity, when a sudden twisting of the knee, pivoting, or deceleration causes a tear in your cartilage. A meniscal tear can also occur simultaneously with injury to other ligaments of the knee (in particular, the anterior cruciate ligament which helps to connect the upper and lower leg bones).

You may hear a popping sound at the time of injury to the meniscus, and you may still be able to bear weight and walk on the injured knee. Pain, swelling, and redness of the joint then develop over the next 12 to 24 hours. In some cases, a piece of cartilage can interfere with knee movement, and you may notice that your knee will “lock” or “pop” with attempted movement. Your doctor may choose to evaluate a possible tear with an MRI scan, a form of imaging that uses a large magnet to view changes in tissue.

Initial treatment of a meniscal tear follows basic home care management  “RICE,” which stands for Rest, Ice, Compression, and Elevation. Nonsteroidal anti-inflammatory medications (NSAIDs) are helpful to relieve pain and inflammation. This may be all that is needed for minor tears that have occurred in the outer edges of the meniscus.

Surgery may be recommended for tears that are central, cause locking or instability of your knee, or for injuries that don’t heal on their own. Surgery may involve using a small, pen-sized camera (called an arthroscope) to trim torn flaps in the cartilage and repair any other damaged ligaments. Often, a brace or cast is needed after surgery, and physical therapy is an important part of recovery to relieve pain and strengthen and stabilize the muscles around your knee.

If you suspect that you have signs or symptoms of a meniscal tear, please see your doctor for further evaluation and treatment options.

Muscle Cramps

A muscle cramp  the sudden involuntary contraction of one or more muscle groups  usually results in intense pain. The exact cause of muscle cramps is unknown. However, overuse, heat, dehydration, and salt and mineral depletion are considered triggers. In general, overuse, injury, and exercise in hot weather often lead to cramps. Occasionally, muscle cramps can signal other serious medical conditions, such as narrowing of the arteries to the legs (atherosclerosis), nerve compression because of lumbar spine narrowing (spinal stenosis), or potassium depletion.

Just about everyone experiences muscle cramps in their lifetime. They often occur when you’re exercising, although they can happen while you’re sitting or sleeping. They are very common in endurance athletes and other people who perform strenuous activities.

Athletes most often experience muscle cramps in the preseason of their sport, when their bodies are not yet conditioned. The most commonly affected muscles are the lower leg (calf) and the thigh (hamstring and quadriceps).

Muscle cramps usually go away on their own and don’t require medical treatment. There are a few things you can do to help relieve the pain and even prevent the cramps. The most important home-care management technique is to stay hydrated with salt-replenishing fluids. Other methods you can use to get rid of your cramps include:

  • Gentle stretching and massaging of the cramping muscle
  • Holding the muscle in a stretched position until the cramp stops
  • Applying heat to tense or tight muscles or cold to sore or tender muscles

Regular flexibility exercises can also help you prevent cramps from starting. Flexibility exercises are best done before and after you work out to stretch muscle groups that are prone to cramping.

Please see your doctor if your muscle cramps are severe, occur often, respond poorly to treatment, or have no obvious cause. Your doctor may choose to evaluate for possible problems with circulation, nerves, medications, or nutrition.

“Runner’s Knee” (Patellofemoral Pain)

“Runner’s knee” is a blanket term to describe a number of conditions that cause pain at the front of the knee (patellofemoral pain). A common complaint of athletes, it is often the result of irritation in the soft tissues around the front of the knee. For some people, it is the result of their kneecap being out of alignment, which results in the wear and tear of the kneecap cartilage. This chronic wear and tear can eventually cause the cartilage to soften and break down, a condition identified as chondromalacia. As a result, the underlying bone and knee joint become irritated.

You may experience dull, aching pain around the front of the kneecap (the patella) where it connects to the lower end of the thighbone (the femur). The pain may worsen when going up or down stairs, squatting, or kneeling.

Treatment of patellofemoral pain depends on the underlying cause. The most important way to improve your condition is rest and rehabilitation. In some cases, surgery can correct the underlying condition and improve support to the knee. Arthroscopy, which involves the use of a small, pencil-sized camera, can be used to remove small fragments of kneecap cartilage. Realigning the kneecap is also an alternative, and this is done by opening the knee and reducing the abnormal pressures on the cartilage.

What causes “runner’s knee”?

  • The kneecap being out of alignment
  • Overuse
  • Previous injury
  • Weak thigh muscles

At home, general care involves “RICE”:

  • Rest
  • Ice
  • Compression
  • Elevation

Shinsplints

The term “shinsplints” refers to the pain that develops along the inside of your shin (the tibia bone). Also known as medial tibial stress syndrome (MTSS), it commonly affects runners, aerobic dancers, and people in military boot camp because it is an exercise-related overuse injury. In such injuries, your repeated movements during exercise cause muscle fatigue. This fatigue leads to additional forces applied to the tissue (called the fascia) that attaches muscles to the bone. The muscles that attach to the tibia, which include the soleus muscle (ankle flexor) and the flexor digitorum longus (toe flexors), are what actually hurt during MTSS (injury to the bone itself does not cause pain).

Early in the condition, pain is experienced at the beginning of a training session and disappears as the exercising continues. As your injury progresses, the episodes of pain lengthen.

With repeated stress-related injuries, the bone itself can be affected and may eventually develop multiple microfractures — what is referred to as a stress fracture. The pain associated with a stress fracture will be sharp and focused on a very small area of your bone. Stress fractures are more serious and typically require you to restrict your activities to ensure proper healing.

Treatment of MTSS involves rest and often requires you to completely stop training for a period of time. It’s important to follow your doctor’s guidance and begin with lengthened rest time scheduled between training sessions. Your doctor may recommend that you take anti-inflammatory medications or use cold packs and mild compression to relieve the pain. For severe conditions that do not respond to the usual treatment, surgery may be an option. However, a full return to sports is not always achieved following surgery.

You may be more likely to develop MTSS if you:

  • Have flatfeet or abnormally rigid arches
  • Have “knock-knees” or “bowlegs”
  • Are a frequent runner
  • Are an aerobic dancer

If you suspect that you have signs or symptoms of MTSS, the pain is prolonged, or if there is no improvement with rest, see your doctor for further evaluation and treatment.

Stress Fracture

Stress fractures are tiny cracks in a bone caused by the overuse and the repetition of movements during exercise. When your muscles are fatigued, they become unable to absorb additional shock during exercise and transfer the overload of stress to the bone. This constant process causes tiny “microcracks” in the bone.

Stress fractures are most common in the weight-bearing bones of your lower legs. They result from increasing the amount and intensity of activity or from an impact on unfamiliar surfaces. For example, a tennis player who changes from a soft to hard court may experience a stress fracture. Athletes participating in tennis, basketball, track and field, and gymnastics are most susceptible to stress fractures, especially if they are not resting enough between training sessions.

Studies have shown that women are more at risk for stress fractures than are men. This appears to be related to nutritional deficiencies and a woman’s propensity for decreased bone mass density.

The most common signs and symptoms include swelling and pain that decrease with rest, and increase with activity. Also, there may be a spot that feels tender or painful when pressure is applied. A stress fracture is sometimes mistaken for a shinsplint (an inflammation of the tibia or shinbone that commonly affects runners). However, stress fractures are more serious.

The most important factor in managing your pain and healing the fracture is rest, which may be needed for 4 to 12 weeks. You may also have to modify other daily activities during these weeks. The next step, rehabilitation, includes a program of muscle strengthening and generalized conditioning. If pain persists, careful use of nonsteroidal anti-inflammatory medications (NSAIDs) may be helpful. However, these medications may limit bone repair and are therefore should be used cautiously. In most cases, stress fractures can be managed with these conservative measures. However, more severe fractures may require surgery to fix and prevent further injury to the bone, as well as to ensure proper healing. Recovery from this kind of surgery is approximately six months.

You may be at risk for a stress fracture if you:

  • Participate in high-impact sports
  • Have been told you have low bone density
  • Suddenly begin an intense training schedule
  • You are an adolescent (bones are not fully mature)

If you suspect that you have signs or symptoms of a stress fracture, if the pain is prolonged, or if there is no improvement with rest, please see your doctor for further evaluation and treatment.

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