Thursday, September 29, 2011

Hamstring Pulls and Tears

Reef fish near the swim start of Ironman Hawaii

"Hold on to 16 as long as you can.  Changes come around real soon make us women and men"
                                                                           John Mellencamp

You're out for a run on a cold early fall day.  Not much of a warm up.  You sprint to catch up to the group when WHAM! It feels like you got shot in the back of the thigh.  Maybe you fall, maybe only limp.  But it's a big limp.  Maybe you've suffered your first hamstring tear.

The three hamstrings are among the first leg muscles one studies in medical school. They're known as biceps femoris, semi-membranosus, and semi-tendinosus originating at your "sit down" bones extending to just below the knee joint. Functionally they provide for flexion power at the knee as well as extension of the hip.

This muscle group is frequently the source of pain and injury in both the endurance athlete as well as the more explosive sprinters or football players. As can happen in any muscle, the injury pattern can be graded with relation to the degree of severity on a 1 - 3 scale. Grade one injuries are a simple "pulled muscle," grade two comprise those with an actual partial tear of the muscle substance itself, and grade three are the most serious in which the muscle tears completely and surgery to reapir it may be under consideration. These injuries occur when the muscle is stressed to a limit greater than it can handle. Folks who have relatively poor conditioning are at risk for this injury as are those are overly "tight," ones who are fatigued or have a muscle imbalance. As you'd expect, simply the choice of sports can increase ones chances of suffering this injury when considering among basketball and soccer players, dancers, etc. Also a risk group are older adolescents whose growth has yet to be completed.


Grasping the posterior thigh in pain, the hall mark of this injury, can be accompanied by swelling, decreased strength of flexion of the knee, and bruising. Occasionally this bruising can be quite extensive (a little bit of blood goes a long way) as the athlete sees purple hues on the back of the thigh, knee, calf and sometimes all the way to the ankle. There's no doubt that an injury of significance has occurred. When they get to my office with this type of story, we examine the limb for the above bruising, areas of tenderness, and once in a while the examiner can even feel a gap along the course of the muscle. This is especially true when the muscle has pulled off it's bony origin. In some instances further information can be obtained from a plain x-ray. Less frequently, an MRI may be ordered to determine the actual amount of damage.

 Treatment options are usually based around both the severity of the injury as well as particulars of the athlete involved. In most cases, a non-surgical regimen will be the order of the day. Short term crutches and cessation of the patients sport put the muscle group to rest and allow it to heal. Application of a straight leg brace furthers these efforts. Traditionally the use of cold therapy icing down the injured location a few times/day can also be beneficial and diminishes the pain to a degree. Many will use a 6" Ace Wrap around the thigh to keep further swelling and bleeding to a minimum, re-wrapping it several times/day, leaving it off at bedtime. We routinely recommend the patient, for the first 48 hours, try to spend time in a recliner elevating the limb, also with the intent of swelling reduction. Surgery is usually reserved for those who've avulsed (pulled off) the attachment of the muscle from the pelvis and those who've suffered a complete tear of the muscle belly itself.

 At some point, the services of the local physical therapist may be of benefit to help mobilize the extremity, recover strength and develop a plan which minimizes the potential for re-injury. Depending upon the degree of the tear, the level of swelling, any history or previous hamstring injury, etc., athletes can be back to slow running in a matter of weeks where those who've required surgical repair can take 6 months, or more, to be back to full strength. This is one muscle group where the owner wants to follow instructions. If they don't, and suffer a recurrent hamstring tear, it can lead to a permanently injured muscle which never provides full function again. But, fortunately this is the rare occurrance as most get back to their original sport even it if does take time.

Image 1 Bryce Groark, 2 and 3 Google Images

Thursday, September 22, 2011

Exertional Compartment Syndrome

Some things are not what they seem.

"I met her in a club down in old Soho,
Where you drink Champagne and it tastes just like cherry cola, C-O-L-A cola.
She walked up to me and she asked me to dance,
I asked her her name and it a dark brown voice she said Lola, L-O-L-A Lola.
                                                                          The Kinks

Many an athlete toils with the diagnosis of shin splints, periostitis, tibia stress fracture, compression neuropathy, tibial stress syndrome, etc. when what they really have is compartment syndrome.

Compartment syndrome is frequently manifested by pain with increased exercise as muscles swell in an unyielding sleeve of bone and fascia leading to a gradual pressure increase within this "compartment" and pain.  If you were to research the anatomy of this compartment you'd find muscles, vessels, nerves, etc. and as the pressure increases, on some occasions it can reach a level where blood flow is completely shut off and the contents of the compartment die.  The picture above is a pressure measuring device as it about to enter the anterior compartment of the lower leg, a common location for compartment syndrome.

Look down at your right leg, feel the sharp bony crest of the tibia.  The soft tissue to the right, extending around posteriorly to the fibula (feel your fibular head.  The rest of the bone is encased in muscle until you get closer to the ankle,) makes up your anterior compartment.

Lower Leg Muscles

We as triathletes will see this issue as just one of the "overuse" injuries that find themselves on a long list of potential issues to the 3 sport endurance athlete.  That said, this can be an acute problem in some that needs to be addressed, "Before the sun goes down!" While the source of this urgent scenario can accompany a fracture or severe blow to the extemity, some develop it spontaneously with no prodrome what so ever.  Others may already be in a cast or dressing which has been applied overly tight and needs to be loosened pronto.

Traditionally, the first signal that this may be occuring in the acute setting is pain out of proportion to the injury.  The compartment can feel full or tight, firm to the touch. Some will complain of accompanying numbess or a burning feeling in the leg.  However, the "chronic" picture is more one of pain in this location with exercise.  With either, after a full check of the motor and nerve function of the limb, the examiner will try to elicit pain by passively stretching the muscles.

If the diagnosis of ACUTE compartment syndrome is made, the next step is to the operating room to "decompress" the offending compartment.  The image above shows what's known as a fasciotomy, an incision (not excision) of the fascia to allow the contents of the compartment to expand.  Ultimately, they will return to near pre injury size but the athlete will not suffer the ravages of untreated disease, in some cases, an amputation.

When CHRONIC compartment syndrome, exertional compartment syndrome, is considered in the diagnosis, the examiner will use the pressure measuring device in image 1 in the office, have you run for a pre determined interval, and again measure the pressure.  Remember, this is frequently what's called a diagnosis of exclusion where one tries to rule out the other more common causes of pain in this area with plain xrays, etc. If conservative measures fail in the chronic case, the compartment may need to be released on an elective basis.  But, you'd save surgery till last in most instances.

Images 1, 2, 3 Google images, #3 Elsevier

Monday, September 19, 2011


Although small, the sesamoid bones in your feet can lead to big problems!

His shirt says: It's just safer to sssume I know Karate
This is "Herbert" of  If you're not familiar with him because you spend no time on Slowtwitch, that's a mistake. Give it a look when you have a free moment.

"Give me three steps, gimme three steps mister..." Lynyrd Skynyrd

To the right is a pair of legs. "Old legs," you might quickly say.  Yes, but old legs standing on the pier in Kona that have qualified for the race.  Hmm, lookin' better all the time!

I field questions al the time from athletes with foot problems and a possible sesamoid fracture.  Do I need a bone scan?  Do I need surgery? Etc. It occurred to me that most folks didn't know they had sesamoid bones, or if they did, where they were.

The simplest definition of a sesamoid bone is one that's surrounded by tendon or intra-tendinous. The most obvious example would be the knee cap. This blog will be devoted to the pair of sesamoid bones underneath the ball joint of the big toe. They are about the size of a lima bean, normally glide front and back with each stride and rarely give us much cause for concern.

But as with any bone in the foot, they can be broken or subject to a stress fracture. A true fracture takes a pretty significant injury such as a fall from a height where we in the endurance sport world are more likely to see a stress fracture from the usual causes. The athlete with a true fracture is going to be immobilized between 4 and 8 weeks, will be made non-weight bearing on crutches, and likely be doing all of his/her training in the pool for a while. Treating the stress fracture is much less aggressive, but here, too, your running shoes will see no action for longer than you'd like.  Note: like so many things displayed here, it is so much better to get this fixed right the first time and not be bullheaded while trying to train through it.  You'll be so glad you did.

Often times, sesamoid problems present as sesamoiditis, an inflammation of the area caused by the usual culprits of too much too fast, especially speed work or hills. One starts with the gradual onset of pain under the big toe, initially present during only the hardest portion of the workout and increasing to any running, even walking. There doesn't seem to be much redness or bruising. They can be slightly swollen but frequently it's not easy to see.

So what do you do? Back off for a while. Maybe do a percentage of your weekly run volume in the pool. (It can be fun.) Then, if you can unload the area of distress by using a metatarsal pad or other device to very slightly overload the non-injured portion of the foot being certain to ice down the area once the run is over. Don't be so aggressive that you risk frostbite but 15-20 minutes ought to do it.

Lastly, trying to go through your log book examining each week, each run, for clues as to the cause and how to never have it again is always beneficial. And if you're successful, your "three steps" will be crossing the finish line without pain!

Image 3 Google images

Sunday, September 11, 2011

Separated Shoulders

"People say believe half of what you see, and none of what your hear." Marvin Gaye, I Heard It Through The Grape Vine

I'm not sure that's Marvin's always right.  In this case, I'd believe all of what I see.

Difference Between Soreness and Injury

It’s normal to experience some degree of pain while exercising and in the early recovery period.  Usually we’re talking muscle soreness from a good work out effort.  In fact, the US Navy SEALs are fond of saying that, "If you complain of muscle soreness around our house, you’re just bragging!”  However, if the athlete begins to have more specific pain in a joint or a muscle group it’s probably time to back off a bit.  Time to reduce the load for a few days. (Better to take a pass on a full work out or two than to risk placing oneself in potential peril.)  If resolution of the pain is not seen, it may be time to seek help. 

But, athlete after athlete ignores this recommended behavior.  They are so driven, that it's more important to get the workout and feeding of the log book you know...than to exercise simple, adult-like common sense, and an injury situation that could put them out of commission for and extended  period time is risked.  Please don't let this be you. 

Separated Shoulders
     The most commonly broken bone in the body is the clavicle.  Before the development of a series of plates which conform to the natural contours of the bone, phrases like, "If both ends of the bone are in the same room it'll heal" were common place.  This is close to the truth but not in every case.  We as an Orthopedic community frequently settled for less than optimal appearance and function.  The result was a shoulder with a shortened clavicle with a big, not terribly cosmetic, bump over it.  The newer plates eliminate that, but then an operation is required to get them in and reduce the fracture.  The plate generally stays in forever, and in most instances, will not set off the TSA alarm at the airport.  Recent recipients of such a plate are Lance Armstrong and Frank Schleck.  If I had a clavicle fracture I would give serious thought to using this device and recommend it be part of your treatment discussion should you unfortunately have the same.

Similar advances have been made in treatment of the separated shoulder.  Simply speaking, these injuries occur after a significant fall striking the shoulder.  The ligaments at the far end of the clavicle are torn to a degree, some worse than others, and in the more severe injuries, the end of the clavicle becomes quite prominent.  There's a big bump over the end of the shoulder.  Should this be the case, one of the recommended possibilities will likely be arthroscopic reconstruction of the joint, possibly using surgical hardware and/or tissue from the tissue and bone bank.

       This is  an important concept to understand as an occasional bad actor in the tissue harvesting arena gives the whole business a bad rep.  As you know, we put all kinds of things in our bodies that used to belong to someone else.  A good example is blood.  I'm on a first name basis with the folks at the local blood bank as I donated my 100th unit of blood last year.  Blood products are used in so many ways be it to help resussitate trauma patients to those with hemophilia.  The same is true of other body parts needed for ACL reconstruction, eye surgery, total joint replacement, and in this case a reconstruction of the acromio-clavicular joint.

In the not too distant past, a number of large screws, braces, Gortex straps, etc. were designed to hold the joint in place and none worked very well.  Currently, the use of small threaded screws, buttons and "allograft" (from another human) tendon tissue work quite nicely to restore the relationships of the A/C joint.  After a period of early rehab, patients are returned to weight training about 3 months after the operation and sports requiring contact like lacrosse or football by 6 months.  It's a good operation which seems to solve the problem and one that I feel will stand the test of time.

Right acromioclavicular separation

4 weeks until Kona - good luck to all participating.  Don't forget that warm weather acclimation is one of the big keys in this race.

Images 2, 3 Google Images