Sunday, April 27, 2014

Swimmers Shoulder - Bicep tendinitis

Athletes frequently complain of shoulder difficulties.  As noted in many places the most common reason is "too much too soon." This blog will help you understand the anatomy of the shoulder and the etiology of the problem.

Tendonitis of the Long Head of the Biceps
Long head of biceps tendonitis is an inflammation or irritation of the upper biceps tendon. This strong, cord-like structure connects the upper end of the biceps muscle to the bones in the shoulder.
Pain in the front of the shoulder and weakness are common symptoms of biceps tendonitis. They can often be relieved with rest and medication. In some cases, surgery is necessary to repair the tendon.

The biceps tendons attach the biceps muscle to the shoulder.
Your shoulder is a ball-and-socket joint made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).
The head of your upper arm bone fits into a rounded socket in your shoulder blade. This socket is called the glenoid. A combination of muscles and tendons keeps your arm centered in your shoulder socket. These tissues are called the rotator cuff. They cover the head of your upper arm bone and attach it to your shoulder blade.
The biceps muscle is in the front of your upper arm. It helps you bend your elbow and rotate your arm. It also helps keep your shoulder stable.
The biceps muscle has two tendons that attach it to bones in the shoulder. The long head attaches to the top of the shoulder socket (glenoid). The glenoid is lined with soft cartilage called the labrum. This tissue helps the head of the upper arm fit into the shoulder socket.
The short head of the biceps tendon attaches to a bump on the shoulder blade called the coracoid process.
Biceps tendonitis is inflammation of the long head of the biceps tendon.
Biceps tendonitis usually occurs along with other shoulder problems. In most cases, there is also damage to the rotator cuff tendon. Other problems that often accompany biceps tendonitis include:
  • Arthritis of the shoulder joint
  • Tears in the glenoid labrum
  • Chronic shoulder instability
  • Shoulder impingement
  • Other diseases that cause inflammation of the shoulder joint lining
In the early stages of biceps tendonitis, the tendon becomes red and swollen. As tendonitis develops, the tendon sheath (covering) can thicken. The tendon itself often thickens or grows larger.
The tendon in these late stages is often dark red in color due to the inflammation. Occasionally, the damage to the tendon can result in a tendon tear, and then deformity of the arm (a "Popeye" bulge in the upper arm).

Normal shoulder anatomy.

Biceps tendonitis causes the tendon to become red and swollen.
In most cases, damage to the biceps tendon is due to a lifetime of overhead activities. As we age, our tendons slowly weaken with everyday wear and tear. This degeneration can be worsened by overuse — repeating the same shoulder motions again and again.
Swimming, tennis, and baseball are some sports examples of repetitive overhead activities. Many jobs and routine chores can cause overuse damage as well.
Repetitive overhead motion plays a part in other shoulder problems that occur with biceps tendonitis. Rotator cuff tears, osteoarthritis, and chronic shoulder instability are often caused by overuse.
  • Pain or tenderness in the front of the shoulder, which worsens with overhead lifting or activity
  • Pain or achiness that moves down the upper arm bone
  • An occasional snapping sound or sensation in the shoulder
Doctor Examination
After discussing your symptoms and medical history, your doctor will examine your shoulder.
During the examination, your doctor will assess your shoulder for range of motion, strength, and signs of shoulder instability. In addition, he or she will perform specific physical examination tests to check the function of your biceps.
Investigations, Tests
Other tests that may help your doctor confirm your diagnosis include:
X-rays. Although they only visualize bones, x-rays may show other problems in your shoulder joint.
Magnetic resonance imaging (MRI) and ultrasound. These studies can create better images of soft tissues like the biceps tendon.
Your orthopedic surgeon will work carefully to identify any other problems in your shoulder and treat them with your tendonitis.

Nonsurgical Treatment

Biceps tendonitis is typically first treated with simple methods.
Rest. The first step toward recovery is to avoid overhead activity.
Ice. Apply cold packs for 20 minutes at a time, several times a day, to keep swelling down. Do not apply ice directly to the skin.
Nonsteroidal anti-inflammatory medicines. Drugs like ibuprofen and naproxen reduce pain and swelling.
Steroid injections. Steroids, like cortisone, are very effective anti-inflammatory medicines. Injecting steroids into the tendon can relieve pain. Your doctor will use these cautiously. In rare circumstances, steroid injections can further weaken the already injured tendon, causing it to tear.
Physical therapy. Specific stretching and strengthening exercises will restore range of motion and strengthen your shoulder.

Surgical Treatment

If your condition does not improve with nonsurgical treatment, your doctor may suggest surgery. Surgery may also be necessary if you have other shoulder problems.
Surgery for biceps tendonitis is usually performed arthroscopically. During arthroscopy, your doctor makes small incisions around your shoulder. He or she then inserts a small camera and miniature instruments through the incisions. This allows your doctor to assess the condition of the biceps tendon as well as other structures in the shoulder.
Repair. In many cases, the biceps tendon can be repaired and strengthened where it attaches to the shoulder socket (glenoid).
Biceps tenodesis. In some cases, the damaged section of the biceps is removed, and the remaining tendon is reattached to the upper arm bone (humerus). This procedure is called a biceps tenodesis. Removing the painful part of the biceps usually resolves symptoms and restores normal function.
Depending on your situation, your surgeon may choose to do this procedure arthroscopically or through an open incision.
Tenotomy. In severe cases, the long head of the biceps tendon may be so damaged that it is not possible to repair or tenodese it. Your surgeon may simply elect to release the damaged biceps tendon from its attachment. This is called a biceps tenotomy. This option is the least invasive, but may result in a Popeye bulge in the arm.
Surgical complications. Complications are rare with these types of arthroscopic procedures. Infection, bleeding, stiffness and other problems are much less common than open surgical procedures.
Overall, complication rates are low, and complications are usually simple to correct.
Rehabilitation. After surgery, your doctor will prescribe a rehabilitation plan based on the procedures performed. You may wear a sling for a few weeks to protect the tendon repair.
You should have immediate use of your hand for daily activities — writing, using a computer, eating, or washing. Your doctor may restrict certain activities to allow the repaired tendon to heal. It is important to follow your doctor's directions after surgery to avoid damage to your repaired biceps.
Your doctor will soon start you on therapeutic exercises. Flexibility exercises will improve range of motion in your shoulder. Exercises to strengthen your shoulder will gradually be added to your rehabilitation plan.
Surgical outcome. Most patients have good results. They typically regain full range of motion and are able to move their arms without pain. People who play very high-demand overhead sports occasionally need to limit these activities after surgery.

Sunday, April 13, 2014

Tobacco Related Events in the US, 1900-2014

                                                                                                      Mark Twain

Hard to believe but there are those among us that train by day and smoke by night.  Like anything that's an addiction, once started, even though the desire to race quickly is strong, the grip of the addiction often wins.  Like many of you, I started smoking in HS.  By the time I was a Marine Helicopter instructor in Pensacola, FL smoking was part of my nature at 2-3 packs a day.  
However, after getting rejected by 9 medical schools the first year I applied, I made a deal with myself that if I got accepted second time around I'd pay a significant price - stop smoking.  From the instant I opened the acceptance letter to the University of Miami School of Medicine so many years ago, I haven't had a cigarette since.
Maybe we just need the right motivation.  It's human nature. 

Smoking sucks! The one thing I would say to my kid is, 'It's not just that it's bad for you. Do you want to spend the rest of your life fighting a stupid addiction to a stupid thing that doesn't even really give you a good buzz?'
                                    Katherine Heigl

Tuesday, April 8, 2014

Flying After Racing? Watch Out For Blood Clots

"I think it is just terrible and disgusting how everyone has treated Lance Armstrong, especially after what he achieved, winning seven Tour de France races while on drugs.  When I was on drugs, I couldn't even find my bike."  
                                                                       Willie Nelson

Many of us fly some distance to an event, race, smile, get a finishers medal or better, pack up and head to the airport.  This can be a dangerous strategy.  Despite being in peak condition, we may be little dehydrated (or a lot dehydrated in some cases - ring any bells here?) and this puts us at risk for developing deep vein thrombosis (DVT), or blood clots in the deeper veins in our legs.  Although these may cause us mild pain or leg warmth, occasionally there's calf swelling, but in many cases little to no symptoms. According to WebMD, When you have a deep-vein thrombosis (DVT), you need to treat it to avoid a life-threatening complication: a pulmonary embolism. A pulmonary embolism (PE) usually happens when a blood clot in the leg breaks away, travels to the lungs, and blocks a lung artery. It can damage the lung and other organs and lead to low oxygen levels in the blood. It can even be fatal!

In short, DVT can be a big deal, and like the other medical issues you had no knowledge of prior to starting this sport, like hyponatremia, understanding how to avoid DVT and it's related problems is the winning way.

First, start that re hydration in earnest before leaving the race course and continue until you are urinating again and it's light yellow.  Experienced competitors already know that depending on the conditions this make take some effort.  In an earlier blog I mentioned talking with one finisher after the race at Splasher's Restaurant located at the finish line in Kona (Thanks for the beer, Inde) who said he'd had several glasses of fluid post-race, more to drink in the condo, and two beers at Splasher's - not one, two - before we started chatting. So after what amounts to nearly 100 ounces of fluid replacement, he still had no urge to pee.

If you have some of those knee high compression hose, put them with your post-race clothing so you know to wear them on the jet home. And even though you may prefer that window seat to rest your head against the bulkhead and nap, grab an aisle seat this time so you can get up and move around frequently.  It keeps the muscles in your calves contacting and the blood flowing throughout your legs.

Note right calf appears larger than left calf from behind.

Although the development of a DVT and subsequent PE is fairly rare, I've seen it in my patients enough time to have great respect for the process.  One only needs to check Slowtwitch or other tri forum and the number of athletes who've suffered a DVT is surprising!

Those who are obese, have a blood clotting disorder, take birth control pills, are pregnant or smoke are at greater risk. If you can remember a few of the symptoms you'll be half way.  As noted above, these can be non symptomatic but then again you may notice a little calf swelling, perhaps more on one side than the other.  Or, an unexpected leg cramp. Similarly, a pulmonary embolism can be asymptomatic but frequently there's chest pain, shortness of breath, coughing up blood and a feeling of rapid heart beat or sudden sense of doom.  If this description ever fits, it's an emergency and you need get immediate medical attention.

Excellent Resource:

Saturday, April 5, 2014

How to Breathe on Both Sides/Unbridled Enthusiasm for Triathlon

"...she's bright as a button and kisses like a nymphomaniac on death row."
                                                                      Notting Hill

Although this comment was addressed to Hugh Grant about an upcoming date, are you this enthusiastic about your sport? I hope so.  Triathlon can yield significant health benefits, a sense of  well-being and perhaps even a little weight loss in motivated athletes.  USAT has over half a million registered triathletes all smiling just like you as winter turns into summer and racing is here!

Lynne Cox in action.

If you can't breathe easily on both sides, you're simply a Stone Age triathlete.  The reasons to master this skill are many.  Safety for one. If you look both right and left while you're in open water, you'll be aware of other swimmers, maybe a boat or two and have a powerful, balanced, faster stroke. How can you make your best racing turn around a buoy on your left if you only know how to breathe on the right?  I doubt you can.

Often you'll encounter a little chop or some small waves crossing your swim course.  You can keep the back of your head, and your open mouth seeking air but sucking air and water, to the wind and waves if you know how to breathe either to one side or the other.  Most successful racers do.

Lynne Cox, author of the Open Water Swimming Manual, and a swim career that includes twice setting the record for fastest crossing of the English Channel, has a few easy paragraphs that may make it a little easier for the self-coached athlete.  If it's still a challenge in your local pool, a couple sessions with the swim coach may be all you need to get over this hump and never look back.  But to look to the right and left, though.

One note of caution.  When attempting something new, it's very easy to try it for two minutes, mess it up, and say "Oh well," returning to ones previous flawed technique.  This will prove a challenge to you, one I learned 20 years ago at one of the Total Immersion Swimming weekends.*  So give it some time, maybe just a few minutes on day 1, but keep at it.  The rewards greatly exceed the awkwardness of learning something new.

Bilateral Breathing Drill from Lynne Cox

-In the pool, lie on your right side, as if you are going to swim side stroke, with your right arm extended above your head and the other arm resting on your side.
-Put your face in the water and blow bubbles.  Take a breath when needed.
-Kick six to eight times on your side.
-Take a stroke with your left arm and use the core of your body to roll all the way over to the other side of your body.  Make sure you are using your core to roll over.
-With your left arm extended, let your right arm rest on your side as you kick on your left side six to eight times with your face in the water.
-You want to maintain a straight line in the water.  Usually, swimmers are more balanced on one side than the other.  Sometimes it takes a little more concentration and work on balance to kick on one side as opposed to the other.  But this exercise will help you balance your stroke and also swim in a straighter line.  It is easy to see which swimmers in the open water have a balanced stroke.  Those who are not balanced will swim in the direction of their dominant side, off to the right or left, and not maintain a straight line.
-This drill will also help you maintain a horizontal position and enable you to move efficiently through the water.  You will be rotating from one side of your body to the other reinforcing that your arm stroke is done in conjunction with the rotation of your body, so that you are pulling with your core as well as your arms.  If you do not use your core with your arm strokes, you will not swim efficiently.  You will be swimming flat on the water, and if you are using only your arms, the muscles in your arms will fatigue more rapidly and you will tire sooner.
-This drill will also help you increase your power, speed and endurance while you are swimming.