What is An Overuse Injury?
What is the AC Joint?
What Kinds of Problems Occur at the AC Joint?
How Do You Treat Arthritis of the AC Joint?
What Can Be Done if Those Treatments Do Not Work?
What is an AC Separation?
What is the Treatment for AC Separation?
When is Surgery Indicated?
What Is An Ankle Sprain?
What Are The Symptoms Of An Ankle Sprain?
What Should I Do If I Sprain My Ankle?
How Should I Rehabilitate My Ankle?
When Can I Return To Sports?
Should I Use A Brace When I Play Sports?
What is Articular Cartilage?
How is Articular Cartilage Injured?
What are the Signs of an Articular Cartilage Defect (Injury)?
How is an Articular Cartilage Defect (Injury) Diagnosed?
When is Surgery Necessary (Articular Cartilage Defect)?
Why Is Exercise Important for Bone Health?
What Exercises Are Best for Good Bone Health?
What Else Is Necessary to Maintain Good Bone Health?
What Is Estrogen’s Role In Bone Formation?
Is Too Much Exercise Harmful?
Tips For Beginning An Exercise Program!
What Is Weight Training?
Why Weight Train?
What Equipment Is Needed To Weight Train?
How Do I Start A Weight Training Program?
Limitations weight training program
Precautions weight training program
How Common is Low Back Pain?
What are the Structures of the Back?
What Structures of the Back Can Cause Pain?
How is the Lower Back Injured?
What Tests can be Done to Diagnose the Cause of Back Pain?
What are the Common Injuries Suffered by the Lower Back?
What is the Meniscus?
How is the Meniscus Torn or Injured?
How Is A Meniscal Tear Diagnosed?
How Is A Meniscal Tear Treated?
What is Patellofemoral Pain?
Treatment of Patellofemoral Pain
Controlling or Preventing Patellofemoral Pain
What is Shoulder Impingement?
How Does Shoulder Impingement Occur?
How is Shoulder Impingement Diagnosed?
How is Shoulder Impingement Treated?
Is Surgery Necessary (shoulder impingement)?
Why Do Overuse Injuries Occur?
What Factors Are Usually Responsible For Overuse Injuries?
How Are Overuse Injuries Usually Diagnosed?
What Is The Treatment?
Can Overuse Injuries Be Prevented?

What is An Overuse Injury?

There are basically two types of injuries: acute injuries and overuse injuries. Acute injuries are usu¬ally the result of a single, traumatic event (macro-trauma). Common examples include wrist fractures, ankle sprains, shoulder dislocations, and hamstring muscle strain.
Overuse injuries are more subtle and usually occur over time. They are the result of repetitive micro¬trauma to the tendons, bones and joints. Common examples include tennis elbow (lateral epicondyli¬tis), swimmer’s shoulder (rotator cuff tendinitis and impingement), Little League elbow, runner’s knee, jumper’s knee (infrapatellar tendinitis), Achilles ten¬dinitis and shin splints.
In most sports and activities, overuse injuries are the most common and the most challenging to diagnose and treat.

What is the AC Joint?

The AC (acromioclavicular) joint is a joint in the shoulder where the collarbone (clavicle) meets the shoulder blade (scapula). The specific part of the scapula, adjacent to the clavicle is called the acromion, hence the name AC joint. This is in contrast to the glenohumeral joint, the main “ball and socket” shoulder joint.

What Kinds of Problems Occur at the AC Joint?

The most common problems that occur at the AC joint are arthritis, fractures and “separations.” Arthritis is a condi¬tion characterized by loss of cartilage in the joint. Like arthritis at other joints in the body, it is characterized by pain and swelling, especially with activity. Over time, the joint can wear out, leading to swelling and formation of spurs around the joint. These spurs are a symptom of the arthritis and not the primary cause of the pain. Motions which aggravate arthritis at the AC joint include reaching across the body toward the other arm. AC joint arthritis is common in weight lifters, especially with the bench press, and to a lesser extent military press. AC joint arthritis may also be present when there are rotator cuff problems.

How Do You Treat Arthritis of the AC Joint?

There is currently no way to replace the cartilage that is damaged by arthritis. As a result, the primary way to con¬trol the symptoms of arthritis is to modify your activities so as not to aggravate the condition. Application of ice to the joint helps decrease pain and inflammation. Medication including aspirin, acetaminophen, and non-steroidal drugs anti-inflammatory drugs (NSAID’s) are also used commonly.

What Can Be Done if Those Treatments Do Not Work?

If rest, ice, medication, and modifying your activity does not work, then the next step is a cortisone shot. One shot into the joint sometimes takes care of the pain and swelling permanently, although the effect is unpredictable and may be only transient. Surgery may be indicated if nonsurgical measures fail. Since the pain is due to the ends of the bones making contact with each other, the treatment is removal of a portion of the end of the clavicle. This outpa¬tient surgery can be performed through a small incision about one inch long or arthroscopically using several small incisions. Regardless of the technique utilized, the recovery and results are about the same. Most patients have full motion by six weeks and return to sports by 12 weeks.

What is an AC Separation?

When the AC joint is “separated” it means that the ligaments connecting the acromion and clavicle have been damaged, and the two structures no longer line up correctly. AC separations can be anywhere from mild to severe, and AC separations are “graded” depending upon which liga¬ments are torn and how badly they are torn.

Grade I Injury – the least damage is done, and the AC joint still lines up.

Grade II Injury – damage to the ligaments which reinforce the AC joint. In a grade II injury these liga¬ments are only stretched but not entirely torn. When stressed, the AC joint becomes painful and unstable.

Grade III Injury – AC and secondary ligaments are completely torn and the collarbone is no longer tethered to the shoulder blade, resulting in a visible deformity.

What is the Treatment for AC Separation?

These can be very painful injuries, so the initial treatment is to decrease pain. This is best accomplished by immobiliz¬ing the arm in a sling, and placing an ice pack to the shoul¬der for 20-30 minutes every two hours as needed. Acetaminophen and non-steroidal anti-inflammatory drugs can also help the pain. As the pain starts to subside, it is important to begin moving the fingers, wrist, and elbow, and eventually the shoulder in order to prevent a stiff or “frozen” shoulder. Instruction on when and how much to move the shoulder, should be provided by your physician, physical therapist, or certified athletic trainer. The length of time needed to regain full motion and function depends on the severity or grade of the injury. Recovery from a Grade I AC separation usually takes ten to 14 days, whereas a Grade III may take six to eight weeks.

When is Surgery Indicated?

Grade I and II separations very rarely require surgery. Even Grade III injuries usually allow return to full activity with few restrictions. In some cases a painful lump may persist, necessitating partial clavicle excision in selected individuals such as high caliber throwing athletes. Surgery can be very successful in these cases, but as always, the benefits must be weighed against the potential risks.

What Is An Ankle Sprain?

A sprain is a stretch injury of the ligaments that sup¬port the ankle. The ligaments on the outside of the ankle are most commonly injured when the foot is turned inward on an awkward step.

What Are The Symptoms Of An Ankle Sprain?

The ankle is tender and swollen on the outside, below and just in front of the ankle bone. Typically, the bone is not as tender as the area above and in front of it.

What Should I Do If I Sprain My Ankle?

Initial care is the same as for all other acute injuries: RICE. Or Rest, Ice, Compression and Elevation. Use ice for 20 to 30 minutes each hour. Do not put the ice directly on the skin because it can cause frost¬bite. Wrap the ice in a wet towel or cloth to protect the skin.

How Should I Rehabilitate My Ankle?

Rehabilitation can begin a few days after the injury, when the swelling starts to go down. There are three goals to aim for in rehabilitation.

1. Restore motion and flexibility. Gently move the ankle up and down. After 5 to 7 days, start restoring motion to the hindfoot by turning the heel in and out. You should also begin to restore flexibility to the calf muscles. One way to do this is to face a wall with one foot in front of the other and lean forward with your hands on the wall, bend the front leg while keeping the back leg straight and both heels on the floor. Lean for¬ward until you feel a gentle stretch, and hold for ten seconds. Switch legs and repeat.
2. Restore strength. After 60 to 70% of the ankle’s normal motion has returned, you can begin strengthening exercises using a rubber tube for resistance. Fix one end of the tube to an immovable object like a table leg, and loop the other end around the forefoot. Sit with your knees bent and heels on the floor. Pull your foot inward against the tubing, moving your knee as little as possible. Return slowly to the starting position. Repeat with the other foot. You can also sit on the floor with your knees bent and the tube looped around both feet. Slowly pull outward against the tube, moving your knee as little as possible. Return slowly to the starting position. Repeat with the other foot.
3. Restore balance. As strength returns, balance is restored by standing on the injured leg, hands out to the sides. You may want to warm the ankle before doing these exercises by soaking it in warm water. Warmed tissue is more flexible and less prone to injury. Use ice when finished with the exer¬cises to minimize any irritation to the tissue caused by the exercise.

When Can I Return To Sports?

Return to sports only after you have met these goals:

• You have full range of motion in all directions (up and down, side to side, and in and out).
• You have good strength in all muscles around the ankle.
• You have good balance.
• You have no pain or swelling with exercise or activity.

Should I Use A Brace When I Play Sports?

Taping the ankle or using a brace for support can help prevent re-injury. There are many different types of braces, some made of neoprene, some made of elastic material, and some have extra straps or ties for support. Select a brace that feels like it give: you the best support for the activity you want to do Braces with straps or ties generally provide greater support. Never use a brace that is too tight.
Remember, a brace helps support strong muscles but should never be used as a substitute for a strength-ening program. Continue to do strengthening exer-cises as you return to sports.

What is Articular Cartilage?

Articular cartilage can sometimes be confusing, because there are three different types of cartilage found in the body: Articular or hyaline cartilage (covers joint surfaces), fibrocartilage (knee meniscus, vertebral disk), and elastic cartilage (outer ear). These different cartilages are distin¬guished by their structure, elasticity, and strength. In some joints, such as the knee, both articular cartilage and fibro¬cartilage are found functioning side-by-side, as distinctly different structures with different functions. When the menis¬cus is injured, it is sometimes referred to as “torn cartilage” or “torn meniscus.” This is different than joint surface articular cartilage problems discussed here.

Articular cartilage is a complex, living tissue that lines the bony surface of joints. Its function is to provide a low fric¬tion surface enabling the joint to withstand weight bearing through the range of motion needed to perform activities of daily living as well as athletic endeavors. Those daily activities include walking, stair climbing, and work-related activities. In other words, articular cartilage is a very thin shock absorber. It is organized into five distinct layers, with each layer having structural and biochemical differences.

How is Articular Cartilage Injured?

Articular cartilage injuries can occur as a result of either traumatic mechanical destruction, or progressive mechanical degeneration (wear & tear). With mechanical destruc¬tion, a direct blow or other trauma can injure the articular cartilage. Depending on the extent of the damage, and the location of the injury, it is sometimes possible for the artic¬ular cartilage cells to heal. Articular cartilage has no direct blood supply, thus it has little or no capacity to repair itself. If the injury penetrates the bone beneath the cartilage, the underlying bone provides some blood to the area, improving the chance of healing.

Occasionally an articular cartilage fragment completely breaks loose from the underlying bone. This chip, called a loose body, may float in the joint interfering with normal joint motion.

Mechanical degeneration (wear and tear) of articular cartilage occurs with the progressive loss of the normal cartilage structure and function. This initial loss begins with cartilage softening then processes to fragmentation. As the loss of the articular cartilage lining continues, the underlying bone has no protection from the normal wear and tear of daily living and begins to breakdown, leading to osteoarthritis.

Also known as degenerative joint disease, osteoarthritis is characterized by three processes:

1. a progressive loss of cartilage
2. the body’s attempted to repair the cartilage
3. destruction of the bone underneath the articular cartilage

The cause of osteoarthritis is poorly understood, but life¬long moderate use of normal joints does not increase the risk. Factors such as high impact twisting injuries, abnor¬mal joint anatomy, joint instability, inadequate muscle strength or endurance, and medical or genetic factors can contribute to osteoarthritis.

What are the Signs of an Articular Cartilage Defect (Injury)?

In many cases, a patient will experience knee swelling and vague pain. At this point continued activity may not be possible. If a loose body is present, words such as “lock¬ing” or “catching” might be used to describe the problem. With mechanical degeneration (wear and tear), the patient often experiences stiffness, decreased range of motion, joint pain, and/or swelling.

How is an Articular Cartilage Defect (Injury) Diagnosed?

The physician examines the knee, looking for decreased range of motion, pain along the joint line, swelling, fluid on the knee, abnormal ailment of the bones making-up the joint, and ligament or meniscal injury. Injuries to the artic¬ular cartilage are difficult to diagnose, and evaluation with MRI (magnetic resonance imaging) or arthroscopy may be necessary. Plane x-rays are not usually good in diagnosing articular cartilage problems, but are usually taken to rule out other abnormalities.

When is Surgery Necessary (Articular Cartilage Defect)?

When a joint is injured, the body releases enzymes that may further breakdown the already damaged articular cartilage. Injuries to the cartilage that do not extend to the bone will generally not heal on their own. Injuries that penetrate to the bone may heal, but the type of cartilage that is laid down is structurally unorganized and does not function as well as the original articular cartilage. Defects smaller than 2cm have the best prognosis and treatment options. Those options include arthroscopic surgery using techniques to remove damaged cartilage, and increase blood flow from the underlying bone (e.g. drilling, pick procedure). For smaller articular cartilage defects which are asymptomatic, surgery may not be required. For larger defects, it may be necessary to transplant cartilage from other areas of the knee (joint). Consult your specialist for further information on the decision to have surgery.
For patients with osteoarthritis, non-surgical treatment con¬sists of physical therapy, lifestyle modification (e.g. reduc¬ing activity), bracing, supportive devices, oral and injection drugs (i.e. non-steroidal anti-inflammatory drugs, cartilage protective drugs), and medical management. Surgical options are very specific to osteoarthritis severity and can provide a reduction in symptoms that are generally only short lived. Tibial or femoral osteotomies (cutting the bone to rebalance joint wear) may reduce symptoms, help to maintain an active lifestyle, and delay the need for total joint replacement. Total joint replacement can provide relief for the symptom of advanced osteoarthritis, but generally requires a change in a patient’s lifestyle and/or activity level.

Why Is Exercise Important for Bone Health?

Bone health follows the old adage “Use it or lose it”. Stressing bone through activity and exercise encour¬ages it to increase its calcium content and grow stronger and more dense. A sedentary lifestyle has the opposite effect on bones. Inactivity causes the bone to lose calcium and get weaker.

What Exercises Are Best for Good Bone Health?

Any exercise is good because all exercise causes the muscles to contract against the bones, which stress¬es, or stimulates, them. So-called weightbearing exercises are the best for bone because both muscles and gravity stress the bones. A few good examples of weightbearing exercises include walking or hiking, running or jogging, aer¬obics, household chores and yard work, racquet sports, basketball, baseball, cross country and down¬hill skiing or a ski machine, skating, and weight training.

What Else Is Necessary to Maintain Good Bone Health?

To be strong, bones also need calcium. Increased calcium produces increased bone density which increases strength. Adults need 1,000 to 1,500 mil¬ligrams of calcium daily. Sources of calcium include dairy products (the best source), green, leafy vegeta¬bles, shellfish, sardines, oysters, hazelnuts, almonds and tofu. Many foods like orange juice, bread and cereal are fortified with calcium. Calcium may also be added in pills or liquid supplements.

What Is Estrogen’s Role In Bone Formation?

In women, estrogen helps calcium become absorbed into the bones. After menopause, as estrogen levels lower, calcium losses can increase dra¬matically and supplements may be considered.

Is Too Much Exercise Harmful?

Yes. Young, highly competitive athletes are most commonly guilty of overexercising by doing too much too fast and not giving their bones enough time to rest. It is important to start to exercise gradually and slowly increase the time and intensity of the workout.

Tips For Beginning An Exercise Program!

Before starting an exercise program:

• Check with your doctor to make sure that there are no medical problems that may place restrictions on your exercise program.
• Check with your orthopaedist to make sure that there are no musculoskeletal problems that may place restrictions on your exercise program.
• Select an activity that you like. Experiment with different equipment and activities until you find one you like and that’s suitable to your lifestyle. Most people stick with an exercise program that they find enjoyable.

For cardiovascular, or aerobic activities, like walking, biking or swimming

• Warm up for five minutes before activity.
• Start the activity slowly for the first five minutes.
• Increase your workout gradually from 5 to 20 minutes.
• Slowly increase your intensity so that your heart rate increases to 60 to 70% of your maximum heart rate (maximum heart rate equals 220 minus your age).
• Gradually try to maintain this level of intensity for the entire 20 minute workout at least three days a week. For strength or resistance training using free weights, machines or elastic tubing.
• Begin each exercise with very low weights and minimal repetitions.
• Slowly increase weight, never adding more than 10% in a given workout.
• Do these exercises two to three times a week. Allow for one day between each workout for your bones to rest and restore themselves.
• Gradually increase the number of repetitions to several sets of 8 to 10 repetitions with a rest period of 30 to 60 seconds between sets.

If you feel tired or ache the day after exercising, you did too much. Decrease the intensity or decrease the duration of your exercise, or both. By slowly build¬ing up your exercise program, you will be more like¬ly to stick with it and keep building stronger bones.

What Is Weight Training?

Weight training means adding resistance to the body’s natural movements in order to make those movements more difficult, and encourage the mus¬cles to become stronger.

Why Weight Train?

Weight training increases fitness by

• Increasing muscle strength and endurance
• Enhancing the cardiovascular system
• Increasing flexibility
• Maintaining the body’s fat within acceptable limits.

Weight training can be an important component of your fitness program, regardless of your age or gender.

What Equipment Is Needed To Weight Train?

Weight training programs can be done with free weights or with weight machines. Free weights are less expensive than weight machines and are more easily adapted to smaller and larger body types. Machines are safer than most free weights because the weight is more controlled.
With multiple purpose machines, like the Universal™ gym, several individuals can exercise simultaneously on the same piece of equipment within a small space. If you use free weights, select a set of barbells or dumbbells and a weight bench for the upper extremities and barbells for the lower extremities.
For all lifting, use a weight belt. Some people feel that weight gloves give them better grip strength, but they are not necessary. Good ath¬letic shoes that provide firm floor trac¬tion are a must.

How Do I Start A Weight Training Program?

First, you should establish goals for your program. Decide if you want to exercise to obtain good mus¬cular tone and cardiovascular endurance, to build muscle strength in a particular muscle group to improve sports performance or to rehabilitate an injured muscle.

If you want to improve muscle tone and cardiovas¬cular performance, design your program along the lines of a circuit program. In such a program, exer¬cises are done at least four times a week for approx¬imately 20 to 30 minutes a session, and very short rest periods (30 seconds or less) are allowed between exercises. This program would generally consist of 15 to 20 repetitions of an exercise for each major muscle group.

If you want to build strength, you should exercise the muscle group you are strengthening to fatigue. This program incorporates fewer repetitions than circuit training. For example, you would do three sets of repetitions, but only 8 to 10 repetitions per set, with a longer rest period of 60 to 90 seconds between each exercise. This may be done every other day, but not as frequently as a circuit pro¬gram because the fatigued muscles need longer to recover.

If you want to rehabilitate an injured muscle, your program would be similar to the circuit training program of higher repetitions and lower weights. However, a rehabilitation program, unlike a circuit training program, focuses on working the injured muscle group.

An exercise professional, like a certified athletic trainer, a sports physical therapist, an exercise phys¬iologist or a strength and conditioning coach, can help you design a program that’s suitable for your needs.

Limitations weight training program

It is extremely important to check with your doctor before beginning a weight training program, partic¬ularly if you are over 30 or have any physical limi¬tations. If you have musculoskeletal problems, check with an orthopaedist to make sure that the program will not aggravate those problems.

Precautions weight training program

To avoid injury when weight training, you should:

• Wear appropriate clothing
• Keep the weight training area clean and free of debris
• Stay well hydrated while lifting
• Get adequate rest
• Eat sensibly
• Stretch after warming up but before lifting
• Always use a spotter when doing when doing bench presses and squats
• Lift with a buddy, whenever possible

How Common is Low Back Pain?

Low back pain is a very common problem in industrialized countries, affecting over 70% of the working population. Back pain is also common in such sports as football, soccer, golf, rowing, and gymnastics.

What are the Structures of the Back?

The spine is composed of three regions from your neck to the lower back. The cervical region corresponds to your neck, the thoracic region is the mid-back, or back of the chest, and the lumbar area is the lower back. The lumbararea provides the most motion and works the hardest in supporting your weight, and enables you to bend, twist and lift.
Each area of the spine is composed of stacked bony verte¬bral bodies with interposed cushioning pads called discs. The vertebral bodies provide protection for the spinal cord and nerve roots that exit the spinal cord. Between each ver¬tebral body, the disc serves as a shock absorber, giving you the flexibility to move. Each disc consists of a jelly-like fluid filled center or nucleus surrounded by a stiff ligament-like outer ring, called the annulus. This hydraulic type of system enables you to perform heavy lifting and twisting tasks by moving fluid in and out of the discs. However, this hydraulic ability of the disc diminishes with time and can lead to injury.

What Structures of the Back Can Cause Pain?

Low back pain can come from all the spinal structures. The bony elements of the spine can develop stress fractures, or in the older athlete, arthritic changes, which may pinch the nerve roots. The annulus has a large number of pain fibers, and any injury to this structure, such as a sprain, bulging disc and disc herniation will result in pain. Finally, the sur¬rounding muscles and ligaments may also suffer an injury, leading to pain.

How is the Lower Back Injured?

Injuries to the lower back can be the result of improper con¬ditioning and warm-up, repetitive loading patterns, exces¬sive sudden loads, and twisting activities. Proper body mechanics and flexibility are essential for all activities. To prevent injury, it is important to learn the proper technique in any sporting activity. Improper mechanics lead to increased loads on the lower spine, making it more suscep¬tible to injury.

What Tests can be Done to Diagnose the Cause of Back Pain?

A good history and physical exam by your physician will provide the most information leading to an accurate diagno¬sis of lower back pain. Several different diagnostic tests are also helpful to aid in this assessment. X-rays reveal any abnormalities of the vertebral bodies, such as arthritis, frac¬tures, and slippage. MRI’s best identify degeneration, bulging and herniation of the discs. A stress fracture is best seen with a bone scan.

What are the Common Injuries Suffered by the Lower Back?

Mechanical low back pain is the result of an injury to the surrounding muscles of the lower back. It is most likely due to poor conditioning and body mechanics, as well as lack of adequate warm-up.

While an isolated excessive load may cause this complete herniation, it is usually the result of multiple lesser injuries that lead to the disc degeneration and final rupture.

A small tear or sprain of the annulus is usually caused by a sudden movement or lifting an excessive load. Since this structure contains a large number of pain fibers, this is quite painful. In addition to the back pain, there may also be pain along the sciatic nerve into the buttocks.

A bulging disc occurs as the disc degenerates and begins to wear out and the annulus weakens as the jelly-like fluid begins to push out, causing pain. The pain is similar to a torn annulus, but the degeneration and bulging will appear on a MRI.

With a disc herniation, the nucleus is squeezed through the annulus into the spinal canal. It may press against the nerves causing pain, numbness, tingling, and weakness.

While an isolated excessive load may cause this complete herniation, it is usually the result of multiple lesser injuries that lead to the disc degeneration and final rupture.

What is the Meniscus?

The human meniscus is a wedge shaped structure in the knee that consists of fibrocartilage, a very tough but pliable material. The medial meniscus is located on the inside of the knee (towards the middle of the body) and the lateral meniscus is located on the outside of the knee. Together, they act primarily as shock absorbers and stabilizers in the knee joint. They also help nourish the articular cartilage through their rich blood supply. This blood enhances the ability of the cartilage to repair itself.

How is the Meniscus Torn or Injured?

In young athletes, most injuries to the meniscus are the result of trauma. The menisci are especially vulnerable to injuries in which there is both compression and twisting applied across the knee. It is also common for the meniscus to be damaged in association with injuries to the anterior cruciate ligament. In older athletes, many meniscal tears are the result of triv¬ial trauma, like twisting the knee, squatting, or through repetitive activities like running, which stresses the knee joint. These tears happen because the meniscus has a ten¬dency to degenerate as part of the aging process. This degeneration often takes place in conjunction with early arthritic changes in the knee joint.

How Is A Meniscal Tear Diagnosed?

When a meniscus is torn, it will often produce pain, swelling and mechanical symptoms like catching, or locking in the knee joint. An injury to the meniscus can be diag¬nosed based upon the history that the patient provides, and a physical examination of the knee. The orthopaedic sur¬geon may also require further diagnostic studies like a MRI (Magnetic Resonance Imaging) which provides a three dimensional image of the interior of the knee joint. In some cases, surgeons may also recommend arthroscopic inspection of the knee joint, a minimally invasive surgical procedure.

How Is A Meniscal Tear Treated?

Certain patterns of injury, especially in younger patients, may call for repair of the meniscus. The decision to repair is based on many factors, including: location and pattern of the tear, age of the patient, and predictability of whether the injury will be able to heal.

Other patterns of tears, especially in older patients, are not suitable for repair. If the patient is symptomatic, and con¬servative treatment options like physical therapy are not working, surgery to remove the torn section is recommend¬ed. This surgery is called arthroscopic partial meniscecto¬my, and is usually performed on an outpatient basis, typi¬cally in one hour or less.

Most patients ask, “What is the benefit of removing the meniscus? Isn’t it an important structure in my knee?” Clearly, the meniscus does play an important role in the human knee, but once torn and unable to be repaired, many of the beneficial effects of that structure are lost. If a tear is causing pain and impaired function, removal of that tear is the treatment of choice.

What is Patellofemoral Pain?

Pain around the front of the knee is often referred to as patellofemoral pain. This pain may be caused by soft carti¬lage under the kneecap (patella), referred pain from another area such as the back or hip, or soft tissues around the front of the knee.

In athletes, soft tissue pain in the retinaculum (tendon tissue) of the anterior (front of the knee) is fairly common. This may come from strain of the tendon – which connects the kneecap to the lower leg bone (patellar tendon), upper leg bone (quadriceps tendon), or the retinaculum (whichSome patellofemoral pain is caused because the kneecap is abnormally aligned. If the patella is not correctly aligned, it may come under excessive stress, particularly with vigor¬ous activities. This can also cause excessive wear on the cartilage of the kneecap, which can result in chondromalacia (a condition in which the cartilage softens and may cause a painful sensation in the underlying bone or irritation of the synovium [joint lining]).

Treatment of Patellofemoral Pain

Treatment depends on the specific problem causing the pain. If the soft tissues (retinaculum, tendon or muscle) are the source of the pain, stretching, particularly in the prone (face down) position, can be very helpful to make the sup¬port structures more resilient and flexible. One simple stretch is to lie prone, grab the ankle of the affected leg with one hand and gently stretch the front of the knee. Hamstring stretching (rear thigh) can also be very helpful. It helps to warm up before doing these, or any other stretches.

Other treatments may involve exercises to build the quadri¬ceps muscle, taping the patella, or using a specially designed brace which provides support specific to the problem. Using ice and non-steroidal anti-inflammatory medications can also be helpful. It is often necessary to temporarily modify physical activities until the pain decreases.

In more extreme situations, a specific surgical procedure may be needed to help relieve the pain. If the cartilage under the kneecap is fragmented and causing mechanical symptoms and swelling, arthroscopic removal of the frag¬ments may be helpful. If the patella is badly aligned, how¬ever, a surgical procedure may be needed to place the kneecap back into proper alignment, thereby reducing abnormal pressures on the cartilage and supporting structures around the front of the knee.

In some people, particularly those who have had previous knee surgery, there may be a specific painful area in the soft tissue around the patella which may require resection (removal).

Controlling or Preventing Patellofemoral Pain

Good general conditioning is important. Stretching, particu¬larly in the prone position, will keep the supporting struc¬tures around the front of the knee flexible and less likely to be irritated with exercise. Proper training, without sudden increases of stress to the front of the knee will help avoid pain. Weight reduction and activity modification may be necessary in some people.

What is Shoulder Impingement?

Impingement refers to mechanical compression and/or wear of the rotator cuff tendons. The rotator cuff is actually a series of four muscles connecting the scapula (shoulder blade) to the humeral head (upper part of the shoulder joint.) The rotator cuff is important in maintaining the humeral head within the glenoid (socket) during normal shoulder function and also contributes to shoulder strength during activity. Normally, the rotator cuff glides smoothly between the undersurface of the acromion and the humeral head.

How Does Shoulder Impingement Occur?

Any process which compromises this normal gliding func¬tion may lead to mechanical impingement. Common causes include weakening and degeneration within the tendon due to aging, the formation of bone spurs and/or inflammatory tissue within the space above the rotator cuff (subacromial space), and overuse injuries. Overuse activities that can lead to impingement are most commonly seen in tennis players, pitchers and swimmers.

How is Shoulder Impingement Diagnosed?

The diagnosis of shoulder impingement can usually be made with a careful history and physical exam. Patients with impingement most commonly complain of pain in the shoulder, which is worse with overhead activity and some¬times severe enough to cause awakening in the night. Manipulation of the shoulder in a specific way by your doc¬tor will usually reproduce the symptoms and confirm the diagnosis. X-rays are also helpful in evaluating the pres¬ence of bone spurs and/or the narrowing of the subacromial space. MRI (magnetic resonance imaging), a test that allows visualization of the rotator cuff, is usually not neces¬sary in cases of shoulder impingement, but may be used to rule out more serious diagnoses.

How is Shoulder Impingement Treated?

The first step in treating shoulder impingement is eliminating any identifiable cause or contributing factor. This may mean temporarily avoiding activities like tennis, pitching or swim¬ming. A non-steroidal anti-inflammatory medication may also be recommended by your doctor. The mainstay of treatment involves exercises to restore normal flexibility and strength to the shoulder girdle, including strengthening both the rotator cuff muscles and the muscles responsible for normal movement of the shoulder blade. This program of instruction and exercise demonstration may be initiated and carried out either by the doctor, certified athletic trainer, or a skilled physical therapist. Occasionally, an injection of cortisone may be helpful in treat¬ing this condition.

Is Surgery Necessary (shoulder impingement)?

Surgery is not necessary in most cases of shoulder impingement. But if symptoms persist despite adequate non-surgical treatment, surgical intervention may be beneficial. Surgery involves debriding, or surgically removing tissue that is irritat¬ing the rotator cuff. This may be done with either open or arthroscopic techniques. Outcome is favorable in about 90% of the cases.

Why Do Overuse Injuries Occur?

The human body has a tremendous capacity to adapt to physical stresses. In fact, many positive changes occur as a result of this. With exercise and activity, bones, muscles, tendons, and ligaments get stronger and more functional. This happens because of an internal process called remodeling. The remodeling process involves both the break down and build up of tissue. There is a fine balance between the two and if break down occurs more rapidly than build up, injury occurs. This can happen when you first begin a sport or activity and try to do too much too soon. If you begin playing tennis and play for several hours in an attempt to improve rapidly you are setting your¬self up for an overuse injury. This is because you are adequate time to recover. As a beginner, you may also have poor technique which may pre¬dispose you to tennis elbow. With overuse injuries, it often takes detective-like work to understand why the injury occurred.

What Factors Are Usually Responsible For Overuse Injuries?

Training errors are the most common cause of overuse injuries. These errors involve a too rapid acceleration of the intensity, duration or frequency of your activity. A typical example is a runner who has run several miles three times a week without any problem. That runner then begins advanced training for running in a marathon, running a longer distance every day at a faster pace. Injury or break down is inevitable. Overuse injuries also hap¬pen in people who are returning to a sport or activ¬ity after injury and try to make up for lost time.

There are also technical, biomechanical and indi¬vidual factors. Proper technique is critical in avoid¬ing overuse injuries. Slight changes in form may be the culprit. For this reason, coaches, athletic trainers and teachers can play a role in preventing recurrent overuse injuries.

Some people are more prone to overuse injuries and this is usually related to anatomic or biomechanical factors. Imbalances between strength and flexibility around certain joints predispose to injury. Body alignment, like knock-knees, bow legs, unequal leg lengths and flat or high arched feet, is also impor¬tant. Many people also have weak links due to old injuries, incompletely rehabilitated injuries or other anatomic factors.

Other factors include equipment, like the type of running shoe or ballet shoe, and terrain, hard versus soft surface in aerobic dance or running.

How Are Overuse Injuries Usually Diagnosed?

The diagnosis can usually be made after a thorough history and physical examination. This is best done by a sports medicine specialist with specific interest and knowledge of your sport or activity. In some instances, X-rays are needed and occasionally additional tests like a bone scan or MRI are needed.

What Is The Treatment?

Treatment depends on the specific diagnosis. In general, for minor symptoms, cutting back the intensity, duration or frequency of the offending activity brings relief. Adopt a hard/easy workout schedule and cross train with other activities that allow you to maintain overall fitness levels while your injured part recovers. This is very important for treating the early symptoms of overuse injuries.

Working with a coach or teacher or taking lessons can assure proper training and technique. Paying particular attention to proper warm up before activity and using ice after activity may also help. Aspirin or other over the counter anti inflammatory med¬ications can also be taken to relieve symptoms.

If symptoms persist, a sports medicine specialist will be able to create a more detailed treatment plan for your specific condition. This may include a thor¬ough review of your training program and an evaluation for any predisposing anatomic or biomechanical factors. Physical therapy and athletic training services may also be helpful.

Can Overuse Injuries Be Prevented?

Most overuse injuries can be prevented with proper training and common sense. Learn to listen to your body. Remember that “no pain, no gain” does not apply here.

The 10% rule is very helpful. In general, you should not increase your training program or activity more than 10% per week. This allows your body adequate time for recovery and response. The 10% rule also applies to increasing pace or mileage for walkers and runners, as well as to the amount of weight added in strength training programs.

Seek the advice of a sports medicine specialist when beginning an exercise program or sport to prevent chronic or recurrent problems. Your program can also be modified to maintain overall fitness levels in a safe manner while you recover from your injury.