Diagnosing, Treating and PREVENTING a Hamstring Strain

The hamstrings are a group of three muscles located in the back of the thigh. They are referred to as two-joint muscles, and they connect the hip and knee. The hamstring muscles bend the knee and extend the hip as well as contribute to numerous other motions of the body’s lower extremity. Anyone who has injured their hamstrings has quickly discovered the important role they play and the importance of making them pain-free.

Because of their multiple actions and their need for extension, the hamstring muscles are frequently vulnerable to strain. In fact, research indicates muscle strains occur most often in those like the hamstrings that cross two joints.

Diagnosing Hamstring Strains

Muscle strains are classified according to their severity:

1. A mild or first-degree strain is a tear of a few muscle fibers. Symptoms include minor swelling and discomfort with minimal or no loss of strength and function.
2. A moderate or second-degree strain involves greater damage of muscle with some loss of strength and function. Usually second-degree strains result in bleeding within the muscle secondary due to rupture of intramuscular blood vessels.
3. A severe or third-degree strain is a tear in the muscle extending across the whole muscle belly, resulting in total loss of muscle strength and function.


The good news is that most of the athletes I treat experience a first- or second-degree strain of the hamstrings. The not-so-good news, and research verifies this, is that athletes with a hamstring strain usually experience significant, from four to six weeks, recovery time and are more susceptible to recurrent hamstring injury for about six months to one year. So how do we get, treat hamstring strains, and more importantly, how can we prevent them?

Treating Hamstring Strains

Treating a hamstring injury after the initial strain is the same as other soft tissue injuries. In the acute phase (2–4 days after the injury) you should control inflammation with ice, compression and elevation. This initial phase also involves early motion of the lower leg such as stationary bicycle and pool exercises involving kicking and walking in the water.

The subacute phase (5–10 days after the injury) treatment consists of early motion on a stationary bicycle, isolated hamstring resistive exercises and pain-free stretching. The remodeling phase (11–21 days out) involves continued resistive exercises isolating the hamstrings, stretching and lengthening muscle exercises called eccentrics. An example of this type of exercise is to lie on your stomach and slowly lower your leg from a flexed position.

The final phase, the functional phase, (22-90 days) includes continued strengthening and stretching as well as jogging, sprinting and sports-specific drills. This treatment regimen is usually successful in returning athletes to their specific sport within several weeks. However, to reduce the recurrence of the injury requires preventive strategies.

Preventing Hamstring Strains

Ever day in our clinic, we treat muscle imbalances. Muscles work in groups: some muscles move bones while others hold onto them. In this group work, where muscles are referred to as synergists, one muscle is the agonist and another is the antagonist. The dominant use of the hamstring muscle (the agonist) and the under-utilization of the hip extensor muscle or gluteus maximus (the antagonist) can be a major contributor to the hamstring’s susceptibility to injury. In a 2004 study published in the Journal Orthopedic and Sports Physical Therapy, titled “A Comparison of Two Rehabilitation Programs in the Treatment of Acute Hamstring Strain,” M. Sherry and T. Best revealed a more effective rehabilitation and conditioning program for hamstring strains. They found that a program consisting of progressive agility and trunk stabilization exercises was more effective than a program emphasizing isolated hamstring stretching and strengthening in returning athletes to their specific sport and preventing injury recurrence.

In our clinic we also have discovered that strengthening the hip and trunk are critical in treating hamstring strains. I refer to this approach as muscle balancing and it comprises three phases:

1. Identify, through a detailed evaluation, the weak muscles within the trunk, hips and pelvis.
2. Design a specific strengthening program for the weak muscles.
3. Perform sports-specific activities designed to challenge the muscles’ ability to work in a group without over-working or under-utilizing an individual muscle.

Keep your muscles balanced and you just may never experience the pain of a strain

What is Jogger’s Foot (Medial Plantar Neuropraxia)?

Jogger’s foot, otherwise known as medial plantar neuropraxia, is a chronic entrapment syndrome of the medial plantar nerve in the foot. It is an unusual cause of heel pain in long distance runners.

Who get’s Jogger’s Foot?
Jogger’s foot is seen in athlete’s that participate in running endurance sports such as marathons, ultramarathons and Iron Man competitions as well as any athlete that is repetitively training with long distance running. A runner with flat feet is more predisposed to this injury than someone with a more pronounced longitudinal arch of their foot. Medial plantar nerve entrapment has also been seen in an unusual presentation in ballet dancers.

What is the relevant anatomy of this region?
The medial plantar nerve is a small nerve that supplies sensation to part of the bottom of the foot. It branches off of the much larger posterior tibial nerve above and behind the ankle on the medial (or inside) aspect of the ankle. The medial plantar nerve travels beyond the ankle and curves under the medial border of the foot. It enters a tunnel behind a bony prominence, known as the navicular. This tunnel is also bordered by a small muscle known as the abductor hallucis muscle which originates from the heel and inserts on the great toe. Repetitive trauma and inflammation caused by long distance running leads to swelling and compression of the medial plantar nerve in this tunnel. This effect is exacerbated by a flat arch and foot (known as pes planovalgus). With a poor arch, more pressure and stretch is placed on this nerve since the foot contacts the ground with higher force.

How is the diagnosis of Jogger's foot made?
Making this very rare diagnosis requires a high index of suspicion for this injury and awareness on the part of the treating sports medicine or foot and ankle physician specialist. In the many of cases, symptoms may be present for more than a year prior to determining the correct diagnosis. The runner describes chronic pain on the inside of the mid portion of the foot. This pain is often described as an ache in the arch region of the foot. There may or may not have been a specific injury that occurred in the past to cause the onset of pain. They may also describe a “giving-away” sensation while running. There may also relate a burning sensation in the medial aspect of the heel. This is from the irritated nerve causing chemical excitation of other nearby branches to the heel from the same posterior tibial nerve. On physical exam of the injured foot, there will be tenderness with palpation over the area of nerve entrapment just behind the navicular bone on the medial side of the foot along the arch. Tapping this area, otherwise known as a Tinel’s test, will recreate the athlete’s symptoms as the nerve is irritated. It is important that the alignment of the foot and heel are evaluated for the longitudinal arch.

How is Jogger's foot treated?
Once the diagnosis of jogger's foot (medial plantar neuropraxia) is made, initial treatment involves changing the mechanical forces at play that lead to the nerve irritation in the first place. A period of relative rest for the foot may be necessary to allow the irritated nerve to calm down. This can include the involvement of various non-impact cross-training exercises so that the athlete may maintain their cardiovascular fitness. The runner’s shoe wear must be evaluated for medial arch support as well as overall quality. Custom arch support inserts may be useful, however in some cases they may exacerbate the symptoms by placing further pressure on the irritated nerve. A running evaluation by a specialized sports chiropractor, physiotherapist, or practitioner knowledgeable in running mechanics is necessary to alter the runner’s gait in a fashion to relieve pressure on the medial aspect of the foot. Regular anti-inflammatory use is important to decrease the body’s inflammatory response and swelling at the entrapment site. Other medications that specifically target nerve pain may be useful as well. An injection of cortisone can be considered in the region of entrapment, however the proximity of the plantar fascia, and the possibility of it’s rupture, is always a consideration in endurance runners.

In the rare circumstance that a runner’s symptoms are not able to be alleviate with non-operative management as detailed above, then surgical treatment may be considered. This would include an incision along the medial border of the foot and the site of nerve entrapment is exposed. Part of the ligament (“naviculocalcaneal”) is released, such that the medial plantar nerve has more space surrounding it and less of a chance of further compression. Following surgery, there will be a period of relative immobilization of the foot and restriction on weight-bearing.

What is the long term prognosis of Jogger’s Foot?
The majority of runner’s with entrapment of the medial plantar nerve improve without the need for surgery. This usually requires months of non-operative treatment to alter the pressure over the area as well as retraining the athlete in their running technique. Due to the very rare nature of this injury, there are no large series of runner’s reported in the sports medicine research literature to give a specific timetable or determine the probability for full recovery.

When should heat be used to facilitate healing in an injury?

I am always surprised by the number of patients I see, who use heat on an acute injury. I feel that there is a great deal of confusion surrounding when to use heat and when to use ice on an injury, so I felt it important to address the issue.

It is important to understand a little bit about how the body heals to understand how and when heat should be used to treat injuries. There are three recognized phases to the healing process.

The first phase is known as the inflammatory phase. The goal during this phase is to protect the injured area from further injury while the body debrieds and contains the damaged tissue. When an injury initially occurs, there is damage to the soft tissue structures (ligament, muscle, and tendon) but also damage to the blood vessels immediately in the area.

The damage to the blood vessels causes fluids to build up in the injured area causing the swelling that is typically seen in a new injury. To help reduce the flow of fluid into the area and thereby reduce swelling, cryotherapy (cold applications) is the best modality to use right after an injury. Cold modalities can help slow down and decrease the circulation to the area thereby reducing swelling.

Heat applied during this phase is contraindicated because heat increases blood flow into the injured area significantly increasing the amount of swelling. Increased swelling prolongs the rehabilitation process because it takes time to reverse the process and remove the extracellular fluid.

This first phase of the healing process can last for several days depending on the amount of tissue damage. For most injuries, two days is the most common time frame for phase one and is when ice should ONLY be applied to injuries.

The second phase of the healing process is known as the proliferation phase and is characterized by the laying down of new tissue and the formation of scar tissue. Again, depending on the amount of damage to the injured area, this phase can begin on post-injury day three and last for several weeks.

IT IS DURING THIS SECOND PHASE OF HEALING THAT HEAT CAN BE APPLIED TO THE INJURIED AREA TO FACILITATE THE HEALING PROCESS. The athlete can determine if he/she has entered phase two of healing when the initial swelling and pain of the injury starts to decrease.

Heat therapies can also be used during the third and final phase of the healing process known as the remodeling phase. During this phase the new tissue laid down during phase two matures. This phase can last up to one full year depending on the type of tissue that was injured.


What are the physiological effects of using heat?
When heat is applied during the second phase of healing, a number of physiological effects occur including:

• Increase in circulation to help remove debris and waste products
• Increase in cellular metabolism
• Increase in capillary permeability
• Provide an analgesic effect
• Reduce muscle spasms
• Increase in oxygen and nutrients into the area to promote healing
• Increase in extensibility of muscle and connective tissue to help facilitate stretch and elongate tissue

Many of these effects apply to modalities that create heat deep within soft tissue (ultrasound). Superficial heat therapies only heat tissue within several centimeters of the body and can be beneficial for superficial injuries. However, joint and muscle injuries (depending on their location) may not receive the same benefits if they are located deeper within the body.

To heat deep tissue (up to 1 ½ inches deep), the modality most commonly utilized in the therapeutic setting is ultrasound. Although ultrasound has different settings and can be used for different purposes, continuous ultrasound can effectively heat deep tissue.

Ultrasound works on the principle of sound waves. The sound waves enter the tissue and are transferred into heat energy under the surface. Ultrasound is a very effective modality for increasing the tissue temperature of localized injuries to facilitate the heating process (see above list).

Injuries that are commonly treated with ultrasound include rotator cuff strains, quadriceps strains, hamstring strains, and all types of sprains. The deep heat created by the ultrasound facilitates healing in tissues that cannot be reached by superficial heat modalities.


What types of injuries can be treated by heat?
One of the most common injuries treated by heat is muscle spasms in the back area associated with muscular back strains. Because the back muscles have the unique ability to “splint” themselves to protect the injured area, initial treatment needs to focus on reducing the muscle spasms.

Heat has been found to be effective at reducing the pain associated with muscle spasms by providing an analgesic effect and relaxation effect for tight muscles. For small muscle spasms, moist or dry heat packs can be effective. Larger areas can be treated by full-body immersion in a hot whirlpool.

Heat therapy is also effective in increasing the range of motion of joints after injury. Once the swelling from the original injury begins to subside, the injured area can be heated using a warm whirlpool or hot pack for 10 -15 minutes.

Because tissue becomes more extensible after it has been warmed up, range of motion exercises can be performed after heating to improve joint motions. The goal is to gradually increase the range of motion of the joint and restore it to pre-injury levels. However, care must be taken to not push a joint through pain as this can actually reinjure the tissue.

Joint injuries that can benefit from superficial heating to increase joint movement after injury include sprained ankles, turf toe, knee sprains, elbow and wrist sprains, and thumb and finger sprains.

Superficial muscle strains can also benefit from superficial heating techniques based on the same principle as above. When muscle tissue is heated, it becomes more extensible and better able to stretch. Heat modalities should be used prior to stretching for 10 – 15 minutes. After heating, a gradual and progressive pain-free stretch can be applied to the area.

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Back Strain

This morning I woke up with some slight stiffness in my back, likely due to the 2 hour bike ride that my husband and I took yesterday. Since we are heading out to golf this morning, I thought that an appropriate topic for todays post would be Back Strains. These are so common, and can often be prevented by improving flexibility, especially following strenuous activity.

What is a back strain?
Most athletes will have a minor back problem at one time or another. Muscle strains are the most common causes of low back pain. A low back strain occurs when the muscle fibers are abnormally stretched or torn. For example, back muscle strains can occur during sports, recreational activities and after sudden movements. They can also occur while lifting heavy objects and even normal household items.

Why are back muscles subject to strain?
The muscles that move the spine are not large muscles grouped together, but rather a large contingency of very small, individual muscles layered and aligned to produce contractions of varying intensities. Because they are small, they are more at risk for injury.


Who gets a back strain?
A back strain is common in athletes and the general population with a great deal of research being spent on how to better understand the mechanics of lifting for the purpose of preventing these injuries.
The back muscles are placed at risk for strain when an individual starts in any combined positions of flexion, lateral flexion, and rotation and then extends and rotates the spine back into a neutral position. Sports that involve repetitive hyperextension, jumping (compressive loading from the landing), and twisting can place athletes at risk for back strain. These sports include gymnastics, basketball, wrestling, tennis, golf and rowing.

Symptoms
What are the classifications of muscle strains?
Classifications of muscle strains are divided into three categories including minor (first degree), moderate (second degree), and severe (third degree).
First degree muscle strains are the most common and involve either overstretching or minor tearing of one or more muscle fibers. Because the injury is mild, the individual is typically functional (can move the spine) but with some discomfort. Increased movement exacerbates the pain and may lead to localized muscle spasm. There may also be some weakness in the muscle that has been strained.
Second degree muscle strains involve a partial tear of one or more muscles. Because the tear is greater in a second degree, the symptoms of the injury are more pronounced. The individual may be guarded in all back movements due to muscle spasm. All movements are affected and may be limited in all directions. The pain is significantly greater both because of the torn tissue and the associated muscle spasms. With a back strain, the individual may have significant difficulty standing, sitting, and lying down. Because the muscles responsible for spine extension are used any time the body is in movement, all movements may be guarded and painful.
A third degree muscle strain involves a complete tear of one or more muscles. The tear may either be in the muscle or at the musculotendinous junction (common location for a rupture). Significant muscle tears may have a palpable indentation or gap. Swelling and discoloration maybe present. As in the second degree strain, muscle spasm will be present and may cause increased pain during any attempted movement.

How is a back strain diagnosed?
The best and most common tool for diagnosing a back strain is a comprehensive medical history with specific attention to the mechanism and signs and symptoms of injury. The sports medicine professional will initially rule out more serious injuries that may involve the spine, nerve roots, intervertebral discs, and/or ligaments. The location of the pain (either to the right or left of the spine), absence of neurological symptoms (numbness, tingling, radiating pain down the legs), functional movement, and manual muscle tests can all be used to diagnose a muscle strain.
If a second or third degree strain is suspected, an MRI may be ordered. The MRI can clearly distinguish a tear in soft tissue injury.

Causes
Individuals whose back muscles are tight and weak are at risk for muscle strains. Muscles that are flexible can be stretched farther (during a quick movement) before tearing as compared to muscles that are rigid and tight.
Weak back extensor muscles are also at risk for injury. Weak muscles tend to atrophy and become smaller and less able to handle the demands placed on them. A common mechanism for a back strain is a quick, unanticipated movement (extension or rotation) or a sustained muscle contraction that places the muscles in a position of risk (extension, rotation).

Prevention
The focus on preventing a back strain needs to be on stretching and strengthening the muscles in and around the spinal column as well as an awareness of good body mechanics for lifting.

Flexibility - Keeping the muscles of the back flexible is one way to prevent a back strain. Static stretching performed over time will gradually elongate muscles allowing them to be stretched farther before an injury to the muscle occurs.
Static stretching – Static stretching is a type of stretch that is done actively by the individual. The individual gradually stretches the muscle to be stretched to a point of discomfort and then backs off slightly. This position is then held for 30 seconds and repeated two more times. The individual should not move into a position of pain as pain is an indicator of injury to the body.
Strengthening – Strengthening the muscles in and around the spine will also reduce the risk of injury. Exercises that strengthen the core muscles of the trunk (rectus abdominis, internal and external obliques, and erector spinae) should be the focus. This can be achieved through a variety of exercises that focus on sustaining either an isometric or concentric contraction for the muscles most involved in flexion, extension, and rotation of the spine. Exercises can be accomplished through using the individual’s own body weight as resistance, using external weights, or by using a piece of exercise equipment such as a therapy ball.
Utilize Large Muscles - One of the most important ways to prevent a back strain is utilizing the large muscles of the lower extremity to lift heavy objects rather than bending and using the small erector spinae muscles of the spine. The key is to carry the heavy object close to the spine, keep the spine straight throughout the lift, and lift with the legs. By keeping the spine straight and bending at the hips and knees, the small muscles of the spine are protected while the large muscles of the pelvis and thigh are actively engaged in the lift.

Treatment
The healing of muscle and soft tissue proceeds systematically through a three phase process. The phases include the inflammatory phase, the proliferation phase, and the maturation phase.
The initial treatment should focus on relieving the muscle spasm, decreasing pain, and minimizing swelling. As the muscle spasm decreases, treatment should focus on engaging the injured muscles in light isometric contractions so that the new collagen fibers being laid down in the torn muscle area can be aligned in the direction of tension.
If early treatment is too aggressive, reinjury can easily occur. As the pain decreases, range of motion exercises can begin and concentric muscle contraction exercises can be added. Once the individual has full range of motion and full strength without pain, then sport specific functional exercises can be added to prepare the individual for return to sport.

Initial Treatment (Inflammatory Phase – 1-3 days)
The treatment focus initially is on reducing muscle spasm, controlling the swelling (if present), and decreasing pain. The most important treatment during this phase is to rest the area which means placing the individual on relative rest. The individual should not engage in any strenuous activity, and in some cases, should try to remain in a comfortable position with knees bent (pillow under the knees to take stress off of the low back).
If an acute injury has occurred and muscle tissue is torn, an ice pack needs to be placed over the injured area to control the swelling. The ice pack should be in place for twenty minutes at a time and repeated every two hours while the individual is awake for the first 48 hours.
Because the muscles in and around the injured tissue may spasm when the muscles are contracted, all movement of the individual should be limited during this phase.


Early Exercises (Proliferation Phase – 3 -7 days)
The purpose of the proliferation phase is for new collagen tissue to be laid down to bridge the gap in the muscle left by the tear. This tissue needs to be carefully realigned from its original position to that of aligning in the direction of the muscle fibers. This is accomplished by gradually adding isometric muscle contractions (contractions without movement).
Heat can be added during this phase to increase circulation to the injured area and to relax the muscle tissue. A hot pad or moist heat (if available) can be used for 10 -15 minutes prior to beginning exercises. Heat is a good modality during this phase as heat allows the muscle tissue to become more extensible and thus better able to stretch.

After the muscle tissue has been heated, gentle stretching exercises can be added. The stretches need to be gentle so as not to tear any of the new fiber tissue that is being laid down. Static stretches that gradually stretch the extensors can be performed with care not to take the stretch into pain. Good examples of back extensor stretches include figure four, sit and reach, and cat stretch.
Once the muscles have been gently stretched, isometric back extension exercises can be performed. These are exercises that contract the extensor muscles of the back without allowing any movement of the spine. Isometric contractions can be held for up to 10 seconds and then released. These can be repeated throughout the day.
The "posterior pelvic tilt" isometric exercise is a good beginning exercise for this phase. The individual lies down on their back with their hips and knees bent and their feet on the floor. The individual presses their lower back to the floor and holds the contraction against the floor for 10 seconds and then relaxes. This can be repeated every hour up to the patient’s tolerance.


Intermediate Exercises (Proliferation Phase – 7 – 14 days)
Once isometric contractions can be sustained pain free and the individual has gained some mobility through the initial stretching exercises, the individual is ready to begin adding additional stretching exercises (rotation and lateral bends) and concentric exercises (strength exercises with movement).
Care needs to be taken to ensure that all stretching exercises are performed through pain free ranges of motion. In this phase, trunk rotation exercises can begin. One rotation exercise is to have the individual lie on his/her back. While keeping the shoulder blades on the floor, the individual can rotate the right leg over the left leg providing a stretch to the back. This same stretch can be performed in the opposite direction.
Lateral bends can also be performed during this phase. The individual starts in a standing position with arms straight down. The individual then slides one hand down the side of his/her leg until a stretch is felt. The same stretch can be performed on the opposite side. Other stretches for the back include lumbar rock, spinal twist, knees-to-chest, and lateral trunk stretch (Houglum, P. Therapeutic Exercise for Athletic Injuries, 200).
Concentric exercises can be performed for all of the muscles located in and around the spine including the rectus abdominis, internal and external obliques, and erector spinae. Although the individual strained only his/her back muscles, strengthening the muscles all around the spine are important for a full recovery.
Exercises that strengthen the abdominal muscles include abdominal crunches and abdominal crunches with a twist (elicit contractions from the obliques). Back extensor muscles can be targeted through prone supermans, and alternating arm and leg extensions while on knees and hands.
A number of exercises to strengthen the core muscles can also be performed utilizing a therapy ball including bridges, supine leg lift, hip rotation, back extension in prone position, and ball lifts (Houglum, P. Therapeutic Exercise for Athletic Injuries, 200)

Advanced Exercises (Maturation Phase)
The last phase of rehabilitation is to add power exercises to the protocol. Power exercises are specifically designed to add a “speed” component to the strength component that has already been regained. Any strength exercise can become a “power” exercise if the exercise is done explosively through either the addition of speed through the range of motion, maximum height (vertical jump), and/or distance (medicine ball work).
Plyometric exercises are classified as power exercises, but care must be taken to ensure that the athlete is strong enough and fit enough to perform them safely. When am I ready to return to play?
The purpose of return to play criteria is twofold. The first is to ensure that the injured muscle has recovered sufficiently and that the muscle is ready to respond to the demands of the sport. Second, and just as important, is for the athlete to test the muscle under controlled circumstances for the purpose of regaining confidence in his/her body’s ability to handle the demands of his/her sport.
An athlete is ready to return to play when he/she has full pain free range of motion of the trunk in all three planes (flexion/extension, rotation, and lateral flexion left and right) with full strength in all of the muscles in and around the spine. Once this is achieved, the athlete is ready to perform sport specific functional activities to ensure that his/her body is ready for the dynamic demands of sport.
Designing a sport-specific functional progression begins by analyzing the skills and demands of the sport. Specific basic skills are selected and the athlete is asked to perform those skills beginning at 50% of maximum intensity. If the athlete can perform all of the basic skills at 50% intensity, then the athlete can gradually increase the intensity to 65%, 75%, 85%, and then maximum intensity. When sport-specific activities can be performed pain-free at full speed, the athlete is then ready to return to play.

Strength and Flexibility Key to Golf Swing and Strong Back

Every year at this time we start seeing an increase in golf-related injuries. A large percentage of these injuries are characterized by a complaint of back pain.

The golf swing, because of its essential repetitiveness and consistent strain, can be a major source of back pain for golfers. There are two major schools of swings. Look at footage of Ben Hogan, and you can see his legs powering through the swing to drive the ball in the “classic” golf swing. Contrast that with today’s professional golfers using the “modern” golf swing, such as Tiger Woods, and you will notice that the lower half of the body remains relatively still as they rotate the core to power through the swing. Although the modern swing may add extra yards to a shot, it may also increase the risk for back pain and other related injuries.

The design of the spine naturally allows for a wide variety of movement. But the sometimes unnatural twisting of the modern swing can irritate the discs that rest between the vertebrae. Repeated irritation of the discs can result in the disc leaking fluid into surrounding tissue or a slipped disc and possibly pinched nerves.

Regardless of the chosen swing, says there are several ways to prevent back pain caused by the golf swing. The best regimen combines strength training and flexibility, focusing on the core—the stomach, back, and hips.

Golfers obviously benefit from a well-rounded strength training program. The more developed the muscles, the more powerful the swing. Mention strength training to golfers, and they may think of lifting weights to develop arm and leg muscles. But it is also important to focus on strengthening the core. Building the muscles in the back, stomach, and hips can provide vital support to the spine and may inhibit back injuries. Isometric planks or the use of a stability ball are ways to strengthen the core.

Increasing flexibility is also advantageous for golfers. There are many ways to increase flexibility, including activities such as yoga and Pilates. A simple at-home exercise is to practice your golf swing daily, holding position at the top of the swing for 10 seconds and holding the follow through for 10 to 20 seconds. Whether you join an organized class or perform exercises at home, flexibility exercises can help increase the range of motion in the golf swing, add power to the swing, and at the same time, help prevent back injuries.

Golfers Elbow (Medial Epicondylitis)

"Golfer's Elbow" sometimes also called throwers elbow) and known in medical terms as medial epicondylitis, is an inflammatory condition on the inner side of your elbow, where the tendons of your forearm muscles attach to the bony bump on the inside of your elbow. The pain may spread into your forearm and wrist.
And it's not limited to golfers. Tennis players and others who repeatedly use their wrists or clench their fingers also can develop golfer's elbow.The anterior forearm contains several muscles that are involved with flexing the fingers and thumb, and flexing and pronating the wrist. The tendons of these muscles come together in a common tendinous sheath which is inserted into the medial epicondyle of the humerus at the elbow joint. In response to minor injury, or sometimes for no obvious reason at all, this point of insertion becomes inflamed and can cause pain and discomfort.

Can I have golfer's elbow even if I don’t play golf?
This condition is named golfer’s elbow because this area is stressed when making a golf swing; however, the majority of the people who suffer from this condition do not play golf. Many athletes who participate in overhead athletics (baseball, javelin, tennis) can develop this condition. Many people who suffer from this condition are not involved in athletics at all.

How do I know if I have golfer’s elbow?
Focal pain located on the inside of the elbow near the medial epicondyle that is usually worse with activity. Pain with resisted forearm flexion is also consistent with golfer’s elbow.

How can I prevent this?
Unfortunately there not much anyone can do to prevent golfer's elbow. It is usually associated with minor trauma or overuse. Athletes that participate in overhead sports should focus on stretching and strengthening their forearm musculature.

What is the treatment?
Initially, a period of ice, over the counter anti-inflammatory medication, and avoidance of provocative activities can often alleviate the majority of symptoms. Persistent pain can be treated with an injection into and around the inflamed and tender area with a long-acting steroid agent. Initially the injection can cause an exacerbation of symptoms for a period of 24-48 hours; however, most patients experience a significant reduction in pain over the ensuing weeks.

Physical therapy can play role in treating golfer's elbow by focusing on local pain control and eliminating any swelling. A sports chiropractor or physical therapist may use ultrasound, electroacupuncture, Active Release Technique or other modalities to help heal the damage of an injury. Additionally, they may prescribe flexibility and strengthening exercises to allow you to return to the activity. However, over strengthening will often exacerbate symptoms. Therefore, a period of rest is usually the best initial treatment.

How many injections can I have?
Some patients experience a return of symptoms after a long period of pain relief after the steroid injection. Multiple injections in a short period of time can be very detrimental and can actually worsen injury to the tendons. Therefore, more than 2 injections in a given year should be avoided.

Do I need surgery to fix the problem?
In a very small number of cases, patients can experience persistent pain and discomfort despite rest, medication and injections. In such cases, a small surgery can be performed to remove the damaged portion of the tendon and repair the remaining tendon back to the bone. The procedure takes about 30 minutes and patients can go home the same day. After a few weeks of therapy, most patients return to full activity in approximately 6 -8 weeks.

If you suspect that you have golfer's elbow (medial epicondylitis), it is critical to seek the consultation of a local sports injuries doctor for appropriate care.

ITB Syndrome

What is iliotibial band syndrome?

The iliotibial band (IT band) is a long flat fibrous band that runs all the way down the outside of the thigh connecting the tensor fasciae latae muscle (originates in the pelvis) to the anterior tibia just below the knee. Most muscle/tendon units are made up primarily of muscle with smaller tendon attachments. However, the tensor fasciae latae/IT band is an unusual musculotendinous pair because the muscle is very small as compared to the long length of the IT band.

It is specifically this anomaly that creates the friction problem down in the knee area. If the IT band is tight, the IT band can rub and snap across the lateral femoral epicondyle when the knee moves from a flexed position into an extended position. This is exacerbated when the athlete is weightbearing as in the activities of running, cycling, and jumping.

Who gets iliotibial band syndrome?

Athletes who use a lot of flexion and extension in their sport are most at risk for iliotibial band syndrome. These would include athletes in the sports of long distance running, cycling, volleyball, basketball, and weight lifting.

Symptoms

What are the classifications of iliotibial band syndrome?

Iliotibial band syndrome can be classified as either mild, moderate, or severe depending on the intensity and duration of the symptoms. The pain is usually localized over the lateral condyle of the femur just above the lateral joint line of the knee. The pain may also radiate either up the IT band to the hip or down the IT band to its insertion on the tibia.

Athletes who experience pain towards the end of their activity and in which they are still able to continue would be classified as having a mild iliotibial band syndrome. The pain may be more noticeable during the phase of heal strike through mid-stance when the IT band is in its tightest position between the greater trochanter of the femur and the lateral femoral epicondyle.

As the condition worsens, the athlete may feel pain earlier and earlier during his/her activity. The pain will eventually affect the athlete’s ability to continue. The athlete may also begin to feel pain during weight-bearing activities such as walking down a flight of stairs. This would be classified as a moderate iliotibial band syndrome.

The condition is classified as severe when the pain restricts all running and becomes constant throughout all activities during the day.

Causes

What causes iliotibial band syndrome?

As an athlete uses his/her legs in repetitive motions, the IT band can become tight. Athletes often focus on stretching the muscles of the hip and thigh, but stretching the IT band is not often included in an athlete’s general warm-up protocol. This structure can become tight without the athlete realizing the problem until the pain hits.

A number of factors can predispose an athlete to iliotibial band syndrome including the following:

• Excessive pronation of the feet
• Leg-length discrepancy
• Prominent greater trochanter of the femur
• Training errors such as excessive distance in a single run, increasing mileage too quickly, inadequate warm-up, and running on the same side of a crowned road

Excessive pronation of the feet means that the athlete’s foot or feet roll inward towards each other when he/she walks or runs which translates upwards into the knee. This places additional strain on the IT band to control this excessive internal rotation and accompanying adduction with each foot step.This can easily be determined by watching the individual walk a short distance from behind the athlete. If the medial ankle bones roll downwards and towards each other, then the athlete is a pronator. This problem of over-pronation can be easily corrected. If it is only a minor problem it can normally be corrected by visiting a specialist sports shop where they should be able to advise you on a pair of running shoes with built in support to alter your foot position. If the pronation is more marked you may need to invest in a good pair of orthotics which are placed into the shoes and trainers to correct the foot position.

Leg-length discrepancy and a prominent greater trochanter are innate to the individual. A sports medical professional can measure an athlete for leg-length discrepancy. If the athlete does have one leg shorter than the other, the athlete can be referred for corrective shoes. Unfortunately, there is nothing that can be done for a prominent greater trochanter.

Training errors can also be easily corrected. The athlete needs to ensure that he/she includes a sufficient and gradual warm-up prior to intense activities. If the athlete is a runner, the athlete should pay specific attention to the level of the surfaces upon which he/she runs. Those who run on the edge of the road where one foot is then lower are also vulnerable to the condition. This is because the foot hitting the lower part of the road has to travel a further distance each time it hits the ground. This is the same effect as having a leg length difference.

Prevention

What can I do to prevent iliotibial band syndrome?

One of the most effective ways to prevent iliotibial band syndrome is to keep the IT band stretched and loose. Although this can be done manually by a sports medicine professional, it can also be accomplished through the use of a foam roll.

The foam roll should be placed on a carpeted surface perpendicular to the athlete. The body weight of the athlete provides the force to stretch the IT band. The athlete lies down on the side of the injured leg placing the foam roll at the level of the knee. The athlete then slowly pushes his/her body weight across the foam roll until the roll is at the level of his/her hip. Then the athlete reverses directions and slowly rolls back across the foam roll until the foam roll is back at the knee.

The athlete should know that this can be an uncomfortable exercise because of the pain experienced when the tight IT band rolls on the foam roll. If it is too uncomfortable, then the athlete can take off some of his/her body weight off of the roll by moving the top leg back or by lifting the upper body up a bit with the arms thereby reducing the amount of weight on the foam roll.

Treatment

What can I do to treat iliotibial band syndrome?

The athlete needs to understand that continuing to compete and exercise with iliotibial band syndrome will make the condition worse. Because iliotibial band syndrome is a repetitive overuse-type of injury, the first thing the athlete needs to do is rest the knee. Rest will allow the inflammatory process to run its course eliminating the inflammation and swelling in the area.

If complete rest is not an option, then the athlete’s activities should be modified to reduce the amount of weightbearing flexion/extension of the knee. For runners, this might include resting from running, but getting a cardiovascular workout by swimming or using a bike. For volleyball or basketball players, this might include reducing the number of jumping/landing drills during a practice.

At the clinic, I treat ITB syndrome with a combination of active release technique, assisted stretching, and occasionally the use of modalities. Active Release Technique and Graston Techniques are effective treatment options to decrease tension in the TFL and associated IT band. In addition, I recommend ice massage. An ice cup can easily be made at home by freezing water in a Styrofoam cup. When the water has frozen, remove the ice cup from the freezer, peel off the top inch of the Styrofoam cup, and then rub away the sharp top edges by melting the edges against the athlete’s hand.

After placing a towel under the knee, the athlete can massage the tender area by gently applying pressure beginning at the knee and slowly moving the ice cup towards the hip through the painful area. This can be done for 10 minutes both before and after exercise/practice.

Stretching the IT band with the foam roller is the key to eventually reducing the pain. Stretching the IT band daily will gradually loosen the tight tissue.

When can I return to sports?

Ideally, the athlete should have pain-free weight-bearing range of motion of the knee before returning to sports. Continuing to play or compete through pain will only elongate the healing process.

If you suspect that you have iliotibial band syndrome, it is critical to seek the urgent consultation of a local sports injuries doctor for appropriate care.

Common Overuse Injuries and Muscle Imbalances

Sports overuse injuries are very common. Pain in the front of the knee, patellofemoral pain syndrome, hamstring strains, hip strains and rotator cuff strains are conditions I treat on regular bases in my population of athletes. An overuse injury is difficult to diagnosis because of their gradual onset and intermittent pain. The most common cause of an overuse injury in athletes is muscle dysfunction.

Muscle is the best force attenuator in the body. It initiates movements, slows down movements, and controls movements of bones. In other words muscles are our best shock absorbers. Our joints are surrounded by muscle to accomplish the above functions. In order to accomplish the functions described above, muscles must work in groups referred to as agonist and antagonist. One muscle group initiates movement and the other muscle group controls movement.

If some muscles fatigue because of prolonged activities such as tennis, the muscle is no longer an effective shock absorber. As a result of fatigue the muscle can become damaged, resulting in weakness, poor flexibility, and inadequate endurance. Muscle imbalance results from weakness, poor flexibility and inadequate endurance in either the agonist or the antagonist. For example, Elliot B and Achland, (Biomechanical effects of fatigue on 10,000 meter running techniques. Research Quarterly Exercise and Sports 52:160-165, 1981), used high- speed cinematography to study the effect of fatigue on the mechanical characteristics in highly skilled long distance runners. They found that, toward the end of the race, the runners exhibited less efficient positioning of the foot at foot strike as well as decreased stride length and stride rate. All of which is placing the runner at risk of developing an injury.

The knee is very susceptible to an overuse injury because of muscle imbalance. Weakness of the hamstring muscle group can cause increase strain to the anterior cruciate ligament (ACL). Hamstring muscle tightness in the presence of rectus femoris muscle (front thigh muscle) weakness has been associated with anterior knee pain. The tightness of the hamstrings increases the compressive forces to the patella femoral joint (Knee Cap). Rectus femoris muscle weakness, especially in the vastus medialis, (the inside of the thigh muscle group); can result in lateral patella tracking during knee flexion and extension. The patella (knee cap) should follow a grove on the end of the long bone of the thigh (femur). Muscle imbalance can change the patella’s ability to track effectively.

In addition to the muscle imbalance between the quadriceps and hamstring muscle groups, muscle imbalances with the hip can also cause patella femoral tracking problems. We have observed that weakness of several key hip stabilizers such as the hip abductors (on the side of the hip) and hip external rotators (muscle that move the foot toward the opposite leg) have a devastating effect on the patella-femoral joint. A recent study demonstrated a significant correlation between weakness of the above hip muscles and injury to the lower leg in athletes. (Leetun, Lloyd-Ireland et al. Core stability measures as risk factors for lower extremity in athletes. Vol 36: 926-934, 2004). The athlete must possess sufficient strength in hip and trunk muscles that provide stability in all planes of motion.

Prevention of Muscle Imbalace and Overuse Injuries
Strength training is the best way to prevent muscle imbalance and overuse injuries. I like to incorporate the use of free weights and machine weights in hip and trunk exercises. Rotational exercises are not commonly seen in many exercise programs. However, strengthening the hip rotators is very important to the athlete. Your hip is your center of gravity, and a weak hip can have disastrous effects—particularly on your lower limbs because the hip is where all motion in the lower leg starts. Hip muscles and ligaments are among the strongest in the body and they can affect gait, quickness, agility, and explosive power.

For athletes, balancing the hip muscles can be the difference between winning versus losing and between an injury-free season versus disabling muscle strains. I have observed numerous cases in which pain and muscle dysfunction were caused by major deficits in the hip muscles. I also have seen significant changes in athletes’ performances as a result of strengthening their hip muscles.

By keeping your muscles strong, you will prevent an overuse injury. You know the proverb: “An ounce of prevention is worth a pound of cure.” If you suspect that you have a muscle imbalance or an overuse injury, it is critical to seek the urgent consultation of a local sports doctor for appropriate care.