As a kid, my friends and I always got together to play tackle football.  None of us weighed over 100 pounds and, as such, we threw our bodies at one another like Adam Sandler in The Waterboy. We didn’t think twice about going head first into someone on the opposing team.  Little did we know, throwing our bodies around like this could potentially be extremely damaging.  This general disregard could have caused a plethora of injuries, the most common of which (caused by Goldberg-esque spear shots) being neck injuries.  Neck injuries are a serious concern in the NFL.  Millions of dollars are poured into research looking at the long-term effects of head injuries, specifically concussions.  This past week, Indianapolis Colts’ quarterback and Saturday Night Live star, Peyton Manning, underwent neck surgery to relieve symptoms of a pinched nerve that he has been suffering from for the past four years.  Despite the enormous media coverage his surgery received, the exact type of surgery he underwent was not disclosed…luckily we have a pretty good idea of what went down (one of the few perks of medical training).  This article will dive head first into the injury, from the anatomy of the nerves (called spinal nerves… ingenious!) to symptoms associated with a pinched nerve and the surgeries and physical therapy commonly used treat them.

Stat Fact: As of February 1^st, 2010 more than 250 current and former athletes have volunteered to donate their brains to research the effects of repeated head trauma.

Spinal Nerve Anatomy

The cervical spine has seven bones called vertebrae.  Each vertebra contains a vertebral disc that acts as the “air bag” or cushion between adjacent vertebra.  Each of these vertebrae is associated with a spinal nerve root that exits the spine between the vertebrae.  Once the nerve exists, it travels a distinct path relaying sensation and providing motor control to specific regions of the body.  The nerves are the electrical system of the body.  One of their functions involves sending information to muscles causing activation and contraction.  The nerves in the cervical spine provide information to various areas of the neck and arms.  Pinched nerves are caused by a variety of anatomical adaptations to stress.  With the majority of pinched nerves, the gel-like disc between the vertebrae loses it’s elasticity and is compressed, decreasing the amount of space between vertebrae and subsequently causing compression of the nerve.  Another common cause of pinched nerves is from a bulged disc; in this pathology the gel-like center of the intervertebral disc bulges through the tough outer layer.  This bulging region then presses on the nerve root decreasing conductance of the nerves and causing excruciating pain.

Stat Fact: Vertebral discs begin to lose their size and absorption capacity by the third decade of life.

Signs and Symptoms

Pinched nerves present in a variety of ways, most of which involve pain and discomfort…not a good thing for any athlete, let alone a 10-time pro bowl quarterback.  Despite the fact that the “pinching” of the nerve occurs just outside the spinal cord, most signs and symptoms occur in the area that the nerve innervates (i.e. the region of the body to which the nerve supplies electrical connections).  As stated, most of the nerves in the cervical region of the spinal cord distribute sensation to the arms and neck.  Common symptoms of a pinched nerve include:

• Numbness and decreased sensation in the area supplied by the nerve

• Sharp or burning pain radiating over the region supplied by the nerve

• Symptoms become more severe with coughing or sneezing

• Muscle weakness or twitching in the affected area

• Feeling that the area involved has “fallen asleep”

These symptoms can be felt on one or both sides of the body.  Medical doctors or physical therapist can confirm these symptoms with a variety of tests:

• Reflexes: Reflexes are typically decreased in patients with a pinched nerve

• Nerve Conduction Study: This involves the application of an electrode to the farthest point of a potentially compressed nerve followed by a mild electrical pulse (don’t worry…not Frankenstein style) to a point higher up the nerve.  The study is testing the speed with which that impulse is carried down the nerve.  Slowed conduction speeds can indicate that the nerve is being compressed at some point along the path.

• Electromyography: This test measures the electrical activity produced by a muscle.  This test is performed by placing a needle (which sounds scarier than it really is…think acupuncture needle not horse tranquilizer) into the muscle and record the electrical discharge made by the muscle during movement.

• Magnetic Resonance Imaging: This technique uses a magnetic field and radio waves to produce an image of the affected area and look for a region of nerve compression.

These tests, as well as the patient’s symptoms, will provide the doctor (either a physical therapist or an MD) with a better idea of the severity of the injury and the ideal treatment course.  The more we know, the more we can help you…thus all the tests (they really aren’t as fun for as to perform as you think).

Stat Fact: 70% of cervical radiculopathies (a.k.a. the pain and loss of function caused by pinched nerve) occur at the 7^th cervical vertebrae (indicated by the white arrow in the x-ray shown). This nerve innervates the triceps (We don’t play football anymore but we’re pretty sure the triceps are important…yes, our sources have just confirmed they are).

Treatment Options

Surgery

Most surgeries for a pinched nerve are part of the “otomy” family: foraminotomy, laminotomy, hip-hopotomy (OK, one of those is fake.  Any guesses?) The suffix “-otomy” is Latin for “partial removal” and “-ectomy” is total removal (for example, a cholecystectomy is the removal of the gall bladder). If I had to guess, I would say Mr. Manning had an “-otomy”, considering that the press releases proclaim it was minor surgery.  Nowadays, these types of surgeries are minimally invasive endoscopic surgeries (meaning that they are performed through small incisions with a video camera and tiny instruments). In Peyton Manning’s case, we do not know which form of surgery he received but it is most likely a foraminotomy or laminotomy:

• Foraminotomy:  This outpatient surgical procedure is used to widen the foramen (the round opening that exists between the two vertebra) by removing small pieces of the vertebrae to relieve the pressure being placed on the nerve.

• Laminotomy: This surgery can be performed in the outpatient setting as well and is used to clear space on the spinal cord.  This surgery relieves pressure placed on the nerve by removing part of the lamina of the vertebra (the portion of the vertebra seen in the picture above and below the intervertebral foramen) creating more space for the nerve to pass through.

Another typical surgery to relieve pressure is a discectomy.  A discetomy is performed when a bulging disc is the cause of the nerve compression.  The procedure involves the removal of the intervertebral disc that is putting pressure on the spinal nerves (you can see in the picture to the left that the inner gel-like part of the disc has ruptured through the tough outer ring of the disc and is now pressing on the nerve root…and a pinched nerve is born).  Total removal of an intervertebral disc increases the likelihood of degeneration since it takes away the cushion between the vertebrae at that level.  Newer minimally invasive procedures have been developed to decompress the bulging disc without removing the whole disc itself (easier to do AND you may be able to salvage your intervertebral disc).

Physical Therapy

In therapy, enhancing the strength of the muscles that hold the head upright is essential.  Most pinched nerves and bulging intervertebral discs are caused by poor posture for extended periods of time.  Hunched behind the center, the quarterback keeps their neck extended (to keep their eyes on the defense rather than the center’s robust butt) decreasing the space between the vertebrae.  Repeated bouts of poor posture may have lead to Manning’s pinched nerve…that or repeated bone-crushing blows from 300 pound linebackers moving at lightening fast speeds.  Our guess: The latter.  Since Manning was able to play with the injury for 4 years, it is likely that it was not an acute injury (enter the mental image of Manning being speared by Goldberg), but rather a progressive injury.  With these types of injuries, consistent neutral neck posture is mandatory (Good luck staring at the center’s booty, Peyton).  Increasing strength and flexibility will alleviate pain and prevent reoccurrence of the injury.  The goal of strengthening exercises is to increase strength in the front and back of the neck.  Recommended neck-strengthening exercises can be seen in our previous article, Pain in the Neck.

Conclusion:

Even though you’re not a 6′5”, 230 pound, 10-time Pro Bowl quarterback, you may still end up with the same neck problems if you do not address them now.  Proper posture, strength and flexibility of the neck and shoulders are key to preventing pinched nerves.  Keep this in mind next time you spend 8 hours sitting at a desk in front of a computer…nobody wants to end up as another Office Space neck pain statistic.  Help us help you.

Questions? E-mail John: mullen@myhousecallmd.com

Almost every woman has, at one time, experienced that “Ummm… something’s not quite right down there…” sensation. Today we’ll be discussing three cases of vaginas gone wrong – Bacterial Vaginosis, Candida Vulvovaginitis, and Trichomoniasis. Not the sexiest part of womanhood, but often an unavoidable aspect of it. All three have simple treatments and sound much more sinister than they actually are.

Firstly, let’s just say that, contrary to what some people (even some male doctors) believe, not all vaginal discharge is abnormal. Happy, well-adjusted vaginas can regularly release a small amount of milky, whitish, or clear fluid daily.  This fluid is made up of sloughed off cells from the vaginal lining (vaginal cells slough off just like your other skin cells). The color and consistency of the fluid can change with your menstrual cycle. Yes, it’s true – the vagina is a self-cleaning organ. And even though it may be slightly unpleasant to think about, normal vaginas are full of bacteria (just like many other places in the body…your nose, for instance, is packed full of bacteria). Every woman’s “vaginal flora,” as we medical folk call it, is made up of a personalized balance of different species of bacteria, kind of like how every forest has a slightly different mix of foliage. Most vaginas are in a peaceful symbiosis with Lactobacillus acidophilus and Staphylococcus epidermidis.

Things go wrong when this delicate vaginal balance is disrupted. Here are some ways this could happen:

• Douching: We thought that people stopped doing this in the seventies, but it turns out that it is still popular in some social circles. A word from the wise: Don’t do it! It’s never a good idea – you are flooding your personal space with a bunch of annoying, irritating chemicals that will make your vagina unhappy and make it easier for that delicate balance to be disrupted. Also, if you have a STI, (and you might not even know it if you do) douching can push the evil bacteria into your uterus and fallopian tubes in an ugly, infectious tidal wave, making the problem much, much worse. The best way to clean down there is with some gentle soap and water on the outside. Also falling into the “no no” category would be other irritants such as hygiene sprays, bubble baths, and perfumed detergents. Your vagina does not have to smell like flowers!

• Antibiotics: Remember the idyllic forest analogy? Taking antibiotics can kill the healthy bacteria your vagina likes and needs, making room for other bacteria or yeast that your vagina hates. But of course, this isn’t a reason for not taking antibiotics if you really need them. An imbalanced vagina is easier to treat than Scarlet Fever.

• Contraception: Oral contraceptive pills, IUD’s, condoms, and spermicide (especially nonoxynol-9) have been associated with increased yeast infections. Once again, this is not a good reason to stop using contraception – yeast infections, though annoying, are much less annoying than unwanted babies and incurable STD’s.

• Health conditions: Diabetes, pregnancy, or infections can mess with your vaginal flora.

• Sluttiness: Just kidding, we don’t judge – but having unprotected sex can put you at high risk for a lot of bad things, including Trichomoniasis.

• Who knows? Women can get BV or yeast infections out of nowhere, for no identifiable reason whatsoever.  It sucks, but there’s a lot that we doctors just don’t know.

Bacterial Vaginosis (BV)

BV is a very common cause of vaginal annoyance – a third of women who visit their doctor complaining of a vaginal issue end up being diagnosed with BV. Although almost half of women with BV have no symptoms at all, most complain of a fishy-smelling discharge that can be yellow, creamy white, green, or gray (have we ruined your appetite yet?  Our sincere apologies). They can also have some minor itching. No one knows the exact cause of BV, but we know that somehow there is an overgrowth of new, annoying bacteria in the vagina, usually Gardnerella vaginalis, Mobiluncus, or Mycoplasma hominis (the can be seen in the picture to the right…the little dark spots mixed in with the large healthy cells are the unwanted intruders). BV can be more likely to rear its ugly head when a woman has been involved with a new sexual partner, and studies have shown a concordance of BV between lesbian partners; however, there is no clear evidence that it is sexually transmitted.

Candida Vulvovaginitis (a fancy term for a yeast infection)

Candida is a yeast – yes, similar to the yeast that makes your bread and beer delicious – that is present on many people’s skin, but can make vaginas exceptionally angry. This is the type of yeast that many women self-treat with over-the-counter creams but it is, in fact, less common than BV, accounting for about a quarter of the women who come to the doctor with vaginal symptoms. Women with yeast infections often have a thick, curd-like white discharge that kind of smells, well, yeasty. Unlike BV, yeast infections can make your vagina and vulva notably painful, itchy, and red. As we said before, many women will try over-the-counter creams but, if for some reason the symptoms persist or come back, it is important to see a doctor and make sure there isn’t something more serious going on. Studies have shown that most women aren’t very good at diagnosing yeast infections on their own so don’t hesitate to go in for a check-up if you’re unsure.

Trichomoniasis

Trichomoniasis is caused by a little protozoan with a tail (named Trichomonas) that swims around in seminal or vaginal fluid, causing mischief. Trichomonas, although cute, is without a doubt an STI, and can be easily prevented by wearing condoms with every sexual encounter. Trichomonas can live on objects like sex toys and towels and can also be found in urine. Women with Trichomoniasis usually have a significant amount of thin, discolored, foamy discharge, as well as a strange odor and itching. When the infection gets really bad, it can cause fever and lower abdominal pain (but these can be symptoms of other serious infections as well). Trichomonas also likes company – a third of women who have it will have another STI at the same time.

Your Take Home Message

Vaginas can be rather finicky and complicated. Happy, healthy vaginas have their own natural balance of bacteria and anything that disrupts that delicate balance can cause itching, discharge, or odor. If you think that your vagina’s balance is off, it’s a good idea to see a doctor. With a quick swab of your vagina (you don’t usually need a speculum for this) and examination via microscope or laboratory, he or she can diagnose the problem and treat it accordingly. All three conditions can be cured quite easily so there’s no reason to try and fight it off alone. We’re here for you… might as well let us help!

Questions?  E-mail Sarah: sarah@myhousecallmd.com

We, at House Call, MD, are big fans of the “snuggle.”  There are few people on this planet who will not benefit in some way from a hug, massage or simple back rub.  A recent New York Times article suggests that we may be on to something (1).  While outright snuggling may create interesting and awkward scenes in the workplace, recent studies are showing that positive interactions involving touch may increase in human performance.

Before we dive into the details of the research on this topic and the science behind them, let’s start with some simple logic: If touch makes us “feel better” and “feeling better” makes us work harder, then it follows that positive or cooperative touch can improve performance.  Seems fairly reasonable to us.  Now on to the science behind the theory.

First, we must show that touching someone is a means of communicating—right?   Some of the most compelling studies regarding the role of touch in communicating emotion are currently being performed at UC Berkeley.  The most recent study sought to show that a wide array of emotions could be conveyed between two complete strangers using only touch.  What is interesting to us is how they conducted their study…

Imagine you are a freshman in college taking a Psychology course and, as part of your grade, you are required to participate in a study currently taking place on campus.  As part of the study you are taken to a small room and blindfolded (and yes, this does sound like the opening scene of a cheesy horror film, but stick with us).  After a minute, an individual enters the room, slaps your wrist, and walks out.  You are then given a list of emotions and asked to identify the emotion the other person was trying to convey to you.  You circle your answer (What would you answer, by the way?), re-blindfold yourself and wait for the next assault.  An individual walks in for the second time, hugs you, and leaves.  You are given the same list of emotions to choose from…etc.

The experiment showed that touch, independent of words, sounds or facial expressions, functions as a distinct means of communicating emotion.  The emotions that were successfully communicated in this study include: anger, fear, disgust, love, gratitude, sympathy, happiness and sadness.  Pretty impressive, right?

You may still be thinking “OK, so how is snuggling supposed to make me perform better?”  This is where the fun comes in.  Michael Kraus of UC Berkeley conducted a study examining the role of “tactile communication” (a.k.a. touching) and its effects on the performance of NBA players (2).  The study hypothesized that players who touched fellow teammates more often throughout a game would be more successful on the court.  They believed that the same would be true for entire teams as well (i.e. the more high-fives and butt pats, the better the team would play).  They watched each individual player in the NBA for an early season game and tallied the number of times the player touched a teammate. “These celebratory touches included fist bumps, high fives, chest bumps, leaping shoulder bumps, chest punches, head slaps, head grabs, low fives, high tens, full hugs, half hugs, and team huddles.”  Can you imagine a bunch of scientists sitting around a television tallying “chest bumps”?  Welcome to the wacky world of UC Berkeley.  After assigning each player a score based on the number of touches throughout the game, the researchers quantified each player’s performance throughout the season in terms of points scored, rebounds gained, successful passes completed, and a number of other parameters that make a player valuable.  The researchers found that the more a player touched his teammates in that early season game, the more successful the player was that season. Teams that had the highest number of positive touches between players were also the most successful teams in the NBA!

According to the study, the Boston Celtics and the Los Angeles Lakers were at the top of the list of the touchiest teams, while the Sacramento Kings and Charlotte Bobcats were the least touchy teams in the league (1).  And the league’s most touchy-feely player?  Kevin Garnett of the Celtics (see photo of picture-worthy hug at left).  While the study showed a correlation between touching and performance, they did not prove that touching causes improved performance.

This observation has been studied in other settings as well.  Tiffany Field, one of the more prolific touch researchers, studied women with prenatal depression.  In the study, they compared participants whose partners gave them a regular massage to a control group in which the subjects got didily-squat (isn’t that sad?).  Guess what they found? Yep, those receiving regular rub-downs reported both a decrease in pain as well as improved relationships with their partners (3).  The same group of researchers studied autistic children and showed that touch therapy (which consisted of 15 minutes of physical contact two times per week for four weeks) was associated with less touch aversion, off-task behavior and stereotypic behavior and improved attention, behavior regulation, social behavior and initiating behavior (4).  Put simply, autistic kids were able to more easily control their behavior (this is one of the biggest challenges of the disease).

What is the science behind these observations?

Lets look at two hormones the body produces in relation to touch: oxytocin and cortisol.

Oxytocin

Oxytocin is the ultimate snuggle hormone.  It is best known for its action in pregnant women and is particularly responsible for milk “let-down” (a.k.a. allowing the milk made in the mammary glands of the breast to move to a “holding chamber” so that when the baby sucks on the nipple, milk is actually released).  Interestingly enough, the very act of suckling causes an increase in release of oxytocin by the pituitary gland (we have no political position regarding that statement.  Use this newfound knowledge at your own risk).  It is a self-perpetuating cycle to make sure babies get the food they need!  In terms of pregnancy, oxytocin also prepares the cervix for the birthing process (“Pitocin”, as oxytocin is called in this setting, is used as a topical gel to move things along and get the baby out faster).

Oxytocin is not only found in pregnant women…no need to feel left out, gentlemen.  Both men and women release oxytocin in relation to touch.  Studies have even found an increase in its release with warm contact on the skin.   Increases in oxytocin levels have been correlated with an increase in trusting behavior and decrease in fear.  It has also shown to be associated with generosity, empathy and even sexual arousal.   All of these emotions contribute to the formation of a bond between individuals.

Cortisol

On the opposite end of the spectrum, cortisol is commonly referred to as the “stress hormone.”  It raises blood pressure, spikes your blood sugar and suppresses the immune system among other things.   The body naturally increases its levels of this hormone in times of stress and anxiety (Remember “fight or flight” from high school biology?  This is a related chemical reaction).  Interestingly, one of the actions of oxytocin is the inhibition of cortisol.  One would think that a peak in cortisol levels in situations like an NBA game would help with performance.   The research, however, shows that it may actually be beneficial to have some level of suppression of cortisol in this scenario.

Therefore, when an NBA player high-fives his fellow teammate, he is triggering a biochemical signal in his teammate’s mind and body that says, “You can trust me.”  Perhaps it is this sense of security that allows players to push themselves physically and out-perform their rivals.  So next time you are on the spot, whether it be before shooting the game-winning free throw or as you sit down to take that final exam, giving the person next to you a motivating high-five will make a lot more sense.  It may be the “secret-weapon” you have been looking for.

Questions? E-mail Kelly: erickson@myhousecallmd.com

References:

1. Carey, B. Evidence That Little Touches Do Mean So Much.  The New York Times.  February 22, 2010.

2. Kraus, M, Huang, C,  and Keltner, D. Running Head: Touch, Cooperation and Performance.

3. Field T, Figueiredo B, Hernandez-Reif M, Diego M, Deeds O, Ascencio A.  Massage therapy reduces pain in pregnant women, alleviates prenatal depression in both parents and improves their relationships. J Bodyw Mov Ther. 2008 Apr;12(2):146-50. Epub 2007 Oct 2.

4. Field, T., Lasko, D., Mundy, P., Henteleff, T., Kabat, S., Talpins, S., Dowling, M. Brief Report: Autistic Children’s Attentiveness and Responsivity Improve After Touch Therapy. Journal of Autism and Developmental Disorders.   Volume 27(3), June 1997, pp 333-338

You’re fiancé is sick. His nose is running, he’s sneezing every two seconds while concurrently coughing up a lung.  In between all these bodily functions, he still manages to complain about how sick he is.  On your side of the bed, you’re struggling to get a good night’s sleep because you have work early the next morning. You drag yourself out of bed and head to the local 24-hour pharmacy hoping to find something (really anything) to help his symptoms and your chance of getting some sleep.  Instead of finding the remedy to soothe his symptoms, you develop a symptom of your own: a headache.  As you look around the never-ending aisles of drugs, you realize you have no idea where to start.  They all promise to alleviate every symptom under the sun.  What’s the difference between them all?  Your head begins to pound.

Let’s back up the story to the point at which he caught the cold. It’s called the common cold because, well, it’s common.  It’s all around us.  It turns out that there are over 200 viruses that can cause the “common cold.”  So yes, you’re surrounded and outnumbered.  People usually get the common cold by touching the virus (i.e. touching something someone with a cold sneezed on) and then touching their eyes or nose (yes, you can get sick from touching your eyes with infected hands).  We hate to admit it but we are the ones giving the virus a free ride into our bodies.  Another way to catch the virus is by inhaling or swallowing a droplet that someone expelled via sneeze or cough.  Droplets from a sneeze can travel up to 30ft away (impressive and terrifying at the same time) and infect someone on the opposite side of the room. Now you see why your mother always told you to cover your mouth and wash your hands after you sneeze?

So let’s say your fiancé is a teacher and caught the virus from one of his students at school whose mother never taught him to cover his mouth when he sneezes (not a rare scenario since 75% of viral infections are transmitted by children).  About 1-2 days after catching the virus, he started to complain of a sore and scratchy throat. Day 2 started off with a symphony of sneezing and sniffling.  Then there’s the predictable transition in your nose: clear discharge slowly becoming hazy and booger filled later on as the infection progresses.  Day 2 -3 is when things heat up (i.e. you develop a fever).  Children and older adults are more likely to develop a fever while everyone else usually just gets that general feeling we medical professionals call “yuck + aches.”  Days 4 and 5 bring coughing.   Early on, nothing came out when he coughed (called a “dry cough”) but as the cold progressed he started coughing up sticky mucous clumps (predictably called a “wet cough”).  This is the general scheme of how the common cold progresses.  At the same time, every individual is different and every virus is different.  The common cold is also different from the flu which has similar but more severe symptoms that last longer.  The common cold usually last 5-12 days while the flu can last anywhere from 2-3 weeks.

Now lets go through each symptom and outline the medications of choice to minimize the suffering.  Remember, there is no cure for the common cold for many reasons, one of which being the fact that so many different viruses can cause it.  All the recommendations below help reduce symptoms so you can go on with your life (and stop his complaining) while his body fights off the cold but they are not “cures” for the cold.  Your body will take care of that on its own.  When shopping for medications, be sure to look at the Active Ingredients.  This is what you are paying for.  Active ingredients are the components of the medication that work to improve your symptoms.  As you browse, you may begin to notice that many of the medications contain similar ingredients…not a coincidence.  What matters when shopping for the right treatment is the active ingredient, not the fancy name and logo on the front of the box.

Symptom 1: Sore/Scratchy Throat

Complaint: “It hurts to talk. It hurts to swallow. It even hurts to breathe.”

A sore throat can make it hard to drink and eat, both of which are very important in helping your body fight off a cold.  Common components of medications that help soothe a sore throat are Benzocaine, Menthol, Phenols, and Dyclonine. Benzocaine and Dyclonine are painkillers and stop your nerves from feeling the sore throat. Menthols are extracted from peppermint or other mint oils and, similar to phenols, produce a cooling sensation in the throat.  They’re all equally effective and come in two different forms (pick whichever better suits your fancy).

• Lozenges: Hard candies you can suck on which release the medication into your mouth and help relieve the pain.  Some common brands include Halls, Cepacol, or Cholraseptic. You can take one lozenge every 2 hours to relieve the soreness.

• Liquids: Usually sprayed, swished, or gargled then spit out. You can use them up to four times a day.

Whichever formulations you choose, remember to try not to eat or drink for an hour after using the medication since doing so will wash away the medication.

Symptom 2: Runny Nose (or “Sniffles” for the under 10 crowd)

Complaint: “My nose has turned into Niagara Falls and I’ve gone through enough Kleenex to fill a landfill!”

You can either blow your nose or do what you did in second grade (remember taking a big sniff and swallowing your spoils…yum).   You can also try something that will stop the flow (the more socially acceptable approach).  The class of medications usually used to relieve the sniffles is called decongestants.  Decongestants cause your blood vessels to contract so that less fluid is allowed to leak out of the capillaries in your nose and, viola, the sniffles go away.  One problem with decongestants is what is called “reflexive vasodilation.”  When the medication wears off, the blood vessels in your nose dilate causing the return of Niagara Falls.  An unfortunate side effect of temporary relief.  Decongestants come in two forms: topical and oral.

Topical decongestants come in little spray bottles that you insert in your nostril, delivering the medication directly to your nasal capillaries.  Some common topical decongestants are:

• Short-Acting (will relieve runny nose for 4-6 hours)

  • Ephedrine

  • Epinephrine

  • Naphazoline

  • Phenylephrine

  • Tetrahydraoline

• Medium-Acting (8-10 hours)

  • Xylometazoline

• Long-Acting (12 hours)

  • Oxymetazoline (Afrin)

When shopping for your decongestant, take into account how long you want the medication to work.  They are included in many different brand name decongestants so be sure to turn the bottle around and read the back where it tells you the “active ingredients.”  Oxymetazoline is a popular one since it works the longest and can be found as the brand name “Afrin.”  An important note about topical decongestants is that using them longer than 3-5 days will actually cause a condition called rhinitis medicamentosa (fancy word for your runny nose will get WORSE…a much more severe form of reflexive vasodilation).  Take Home Message: don’t over these medications and start to wean yourself off of it after 3 days.

Oral decongestants come in tabs and take longer to work since you don’t apply them directly to your nose.  The two most common ones are Phenylephrine and Pseudoephedrine.  Phenylephrine is shorter acting (about 3 hours) while pseudoephedrine can work for up to 12 hours with one dose.  All pseudoephedrine-containing medications (brand name is usually Sudafed) are stored behind the counter at the pharmacy.  You have to show your ID to prove you’re over 18 and sign a document in order to purchase it.  Why?  It turns out that people have figured out a dangerous way of making an illegal drug using pseudoephedrine and the government would like to discourage such activities.  If you have high blood pressure or are pregnant/breastfeeding, avoid using this product since it causes blood vessels to constrict which is unfavorable in any of those conditions. Also, oral decongestants can cause you to become more alert and energized so avoid taking them close to bedtime…unless you want to pull an all-nighter when you’re sick.  We wouldn’t recommend it.

Symptom 3: Sneezing

Complaint: “AAACHOOOOOO! If I sneeze one more time my head may explode.”

Sometimes a sneeze feels great.   When you’re sick, it just hurts. So what can you do to make them stop?  Antihistamines are typically used for allergies but they also decrease mucous production throughout your body.  Take an antihistamine and you can say goodbye to sneezing, runny nose, itchy throat, and runny eyes. Yes, antihistamines are amazing. The downside is they can be very sedating.

• Most sedation: Diphenhydramine (Benadryl), Clemastine fumarate (Tavist)

• Intermediate sedation: Pyrilamine maleate (Theracof), Pheniramine, Brompheniramine (Dimetapp), Chlorpheniramine (Chlor-Trimeton), and Tripolidine (Actifed)

• Least sedating: Loratadine (Claritin) and Cetirizine (Zyrtec)

If you’re about to go to bed, taking Diphenhydramine may not be such a bad idea since it’ll help you fall and stay asleep.  If you’re about to go to work, Loratadine is the better choice.  It’s all a matter of what you need at that time.

Symptom 4: Fever

Complaint: “I’m hot then I’m cold. I feel like Katy Perry.”

Treating a fever is tricky because a fever can be an indication of a more severe illness than your garden-variety common cold. If you have a fever for more than 24 hours you need to see your doctor.  If you have a fever and you’re taking medications to help reduce it but the fever continues to get worse even after three days of treatment, definitely go see your doctor.  The best medications to take for a fever are Acetaminophen (Tylenol) or Ibuprofen (Motrin, Advil).  They both work equally well to lower a fever.  They both come in many forms including tablets, capsules, liquid capsules, liquids, and suppositories so pick whichever you’re most comfortable with.

Tylenol overdoses are more common than we would hope and are very dangerous (Tylenol can wreak havoc on your liver).   Be sure you are not taking too much and follow the directions on the bottle carefully. The maximum amount you can take is 4000mg (4 Grams) per day. Ibuprofen is safer but it’s recommended that you take no more than 1200 mg a day.

If you have a child with a fever, just go see your doctor.  Fever-reducers are much more complicated and dangerous in children so working with a pro is recommended here.

Symptom 5: Cough

Complaint: “Between sneezing and coughing I have no time left for breathing…which I can’t do anyway since my nose is so stuffed up!”

There are two types of cough (as we previously mentioned): nonproductive and productive. Nonproductive coughs are dry hacking coughs during which time nothing comes out (i.e. nonproductive).  Productive coughs are the ones where you get a nice surprise in your mouth at the end (yup, a gooey ball of mucous). These two types of coughs are treated differently.

For nonproductive coughs, try Dextromethorphan (Robitussin) or Diphenhydramine (Benadryl).  We don’t know how Dextromethorphan works and some doctors claim that it really doesn’t.  It’s one of those medications that has been around for such a long time and used so frequently that nobody bothered to study it.  Diphenhydramine (yes, our friend the antihistamine is back) is actually one of the best treatments for a cough caused by the common cold.  It’s great at bedtime if you want to fall asleep and will prevent you from waking up coughing. No cough and a good night’s sleep sounds pretty awesome to us.

For productive coughs, Guaifenesin (also called Robitussin) is the way to go. Guaifenesin won’t stop your cough but it will make it easier to cough up the mucus in your airway so that you will eventually stop coughing.  Out is better than in.  It’s important to drink lots of water when taking this medication (and when your sick in general).  Drinking water helps the drug loosen up the mucous, making it easier to cough out.  Getting rid of all this mucous will help eliminate the infection as opposed to stopping the cough and keeping the virus-infected mucous in your throat and lungs.

You now know the basic components of just about every cold and flu medication on the market.  There are tons of combination products that mix and match ingredients to suit the limitless permutations of symptoms.  Next time the common cold strikes, turn the bottle around read the ingredients.  You know how to treat each of your symptoms in a much more strategic fashion.  If you forget, you can always ask your friendly and knowledgeable pharmacist (or just print out this article and take it with you to the drug store).

We’ve gone over the most accepted treatments of common cold symptoms.   What about all that other stuff you find in the aisle?

The “Other Stuff”

Airborne

When Airborne hit the market in 1999, who wasn’t swearing that it could cure the common cold?  Nine years later, Airborne Health, Inc. found itself waist-deep in class action law suits for making claims about therapeutic efficacy that it couldn’t support with medical research.  All the lawsuits were settled out of court and Airborne Health, Inc. paid truckloads of money to make the lawsuits go away.  The main problem was that Airborne claimed it could “prevent or reduce the risk of colds, sickness, or infection; protect against or help fight germs; reduce the severity or duration of a cold; and protect against colds, sickness, or infection in crowded places such as airplanes, offices, or schools.”  Not a single clinical trial was done to prove that any part of that statement was correct.  If you’ve checked out their website or commercials, you know that a lot has changed.  Now they only claim that, “The Airborne health formula helps to support your immune system through its blend of vitamins and minerals.”

The verdict?  Their new advertising campaign is much more accurate.  Airborne is simply a combination of vitamins and minerals that your body will generally be getting from a well-balanced diet.  It never hurts to take a multivitamin to compensate for any dietary deficiencies but that’s all Airborne is.  It has higher amounts of specific vitamins, like vitamin C, than your average multivitamin.  The adult tablets have 1000mg (1gram) of vitamin C.  If you took the tablets the way they recommend you do (every 3 hours while awake) you would be consuming up to 5 grams of Vitamin C per day.  Doses that high aren’t necessarily bad for the average person but they can cause kidney stones in certain individuals.  In addition, there is no benefit to taking that much vitamin C (unless you enjoy a good dose of diarrhea which doses that high can cause).  Doses of 2-3 grams per day have been shown to help reduce the duration of cold symptoms but do nothing for the severity of the cold.  Also, Vitamin C does not work as a preventative measure.

The Final Verdict: Sure, go ahead and take airborne as long as you realize you are taking an overpriced yet tasty (yum, pink grapefruit) multivitamin.  Oh, and it’s not a miracle cure.  Did we mention that?

Zicam

Zicam brand makes every form of medication you could ask for.  From nasal swabs to lozenges, they are working hard to please the full spectrum of consumers.  Their line of products called “Symptom Relief” contain the spectrum of medications we discussed earlier (from menthol to Tylenol) so make sure you read the back before you buy any of them.   You may be just able to buy a bottle of Tylenol and a decongestant for less money.  The Zicam uniqueness is found in their line of “Cold Remedy” products.  The active ingredients in this line of products are Zincum Aceticum and Zincum Gluconicum (different forms of Zinc). One line of zinc-containing products (Zicam Cold Remedy Nasal Gel, Zicam Cold Remedy Nasal Swabs, and Zicam Cold Remedy Swabs, Kids Size) was completely removed from the market because they caused people to lose their sense of smell (definitely not a good thing).  These were zinc-containing products that were applied directly to the inside of the nose.  NOTE: If you have any at home, throw it away!  The company is currently considering the FDA’s request to discontinue the product…until the controversy settles, don’t use them.

Back to the other zinc-containing products: The makers of Zicam believe that zinc prevents the rhinovirus (one of the viruses that causes a cold) from invading human cells.  Some studies have found that zinc-containing products can shorten the length of time cold symptoms last and minimize the severity of the common cold if they are taken within 24 hours of symptom onset.  Other studies claim that these initial studies were poorly designed and that zinc does little to help with the common cold.  Who should we believe?   Let’s think about this logically.  If Zicam prevents the rhinovirus from invading human cells but there are over 200 different viruses that cause the common cold, the odds of Zicam helping your particular cold seem slim.  On the other hand, rhinoviruses are the most common cause of the common cold so the odds go up a bit.

The Final Verdict: It really depends the particular virus you have.  If you take Zicam as soon as you develop cold symptoms and you don’t get better, you probably don’t have a rhinovirus.  At this point, refer to all of the medications outlined above that have been proven effective for your cornucopia of symptoms.

You are now officially an informed consumer!  Next time you’re in the pharmacy shopping for treatments for your cold symptoms, flip the box around and strategically target your symptoms of choice with the correct active ingredient.  No need to suffer any longer!  We wish you a sneeze-less, cough-less, and complaint-less night.  Go get some shut eye.

Questions?  E-mail Tania: houspian@myhousecallmd.com

Fantasy baseball drafts and spring training are in the air…you can almost smell the finely cut grass, taste the $10 hot dogs and feel the $20 beer in your hand.  At the same time, the beginning of the season comes with big question marks hanging over the heads of players with injuries: Tommy John surgery, alcohol related rehabilitation, and hamstring strains (aka “pulling a hammie”) to name a few.  Most regular folk have experienced a hamstring strain and know it does not get better without a fight and a bottle of Georgia Moon (maybe not the later for everyone).   Before we get into treatment lets hit the basics of the hamstring.

Stat Fact: One-third of hamstring strains will recur with the highest risk of recurrence occurring 2 weeks after the initial injury.

Getting to Know Your Hammies

The hamstring is the predominant muscle in the back of your thigh.  The hamstring is composed of three muscles (biceps femoris, semimembranosus, semitendinosis…in case you were wondering) and their primary collective action is to flex the knee.  The most common cause of a hamstring strain is from the “eccentric use of the hamstring” while running. The eccentric use of the hamstring is highest when your leg is extending, off the ground, and swinging forward prior to hitting the ground for your next step.  This stage is termed the “terminal swing” (and yes, we realize this sounds more like a carnival ride than a leg movement).  The eccentric load is highest due to the amount of stretch it places on the hamstring muscles (this is similar to the strain you feel in a straight leg raise).

How do you know if you’ve hurt your hamstring?

Hamstring injury usually presents with a pop, pain in the back of the leg and decreased strength and range of motion.  The strain can occur in any of the three hamstring muscles at any point in the muscle, but the most common site for a strain is either behind the knee or near the butt.  Hamstring strains are classified by the amount of pain, weakness and loss of range of motion associated with the injury.  They are commonly graded on a 1-3 scale with I being mild, II is moderate and III is severe.  The duration of the injury depends on the site and size of the injury.  If you have a large tear near your butt, you’re what we physical therapists call “pretty screwed.”

Stat Fact: The attachment of the biceps femoris is at the outside of the knee (where the complete tear is identified in the picture above).  This particular region is the most commonly strained part of the hamstring muscles because it undergoes the highest amount of stretch amongst the hamstring posse.

Hamstring Hangover

The goal of rehabilitation is to return the athlete to their prior level of performance while minimizing the risk of injury recurrence.  Multiple factors contribute to a high re-injury risk of the hamstring: (1) persistent weakness in the injured muscle, (2) reduced flexibility due to scar tissue, (3) impaired movement/biomechanics due to injury.  Strengthening the hamstring is a fundamental component of rehabilitation and needs to include eccentric (muscle lengthening) and concentric (muscle shortening) exercises.  In addition to strengthening your hamstrings, the muscles attached to the pelvis are often weak and require assessment and strengthening. Rehabilitation of grade I and II hamstring strains can be broken into three distinct phases:

Phase I:

The goal of the Phase I is to decrease swelling, pain and scar tissue formation. You should avoid excessive stretching of the hamstring in this phase since over stretching can increase scar tissue formation. To avoid over stretching, limit your knee flexion range of motion by taking shorter strides while walking or using of crutches.  Ice should be used 2-3 times per day for 15-20 minutes with an ice pack to decrease swelling and pain (no more than 15 minutes at a time as longer amounts of time may increase swelling).  Exercises in Phase I should not stress the injury site. The most common exercises prescribed during this phase are single leg balance (seen in the picture to the left), isometric abdominal exercises, and lateral stepping drills (grapevine/karaoke).  Advancement from the first stage of rehabilitation includes normal walking and stride length without pain, light jogging without pain, and a lack of pain while resistance is applied with the knee bent to 90 degrees (lay on your stomach with your knees bent to 90 degrees and have someone gently pull your ankle down to the floor…pain = no good). Phase I is typically 5 days long but as doctors love to specify that “it depends.”  It always depends.

Phase II:

The goal of Phase II is to increase intensity of exercises, increase range of motion and to begin eccentric exercises. Ice is typically used after training to decrease pain and inflammation associated with exercises.   In Phase II exercises, we increase speed and intensity of agility drills.  Side to side agility drills should be utilized to decrease the risk of overstretching the muscle.  At the end of Phase II, you can progress agility and strengthening drills to include forward and backward movements (supine bent knee bridge walk-outs…Google it).  Eccentric strengthening is initiated and incorporated as functional movements (light jogging, moderate high knees) instead of isolation exercises.  To progress to Phase III, the participant must be able to 1) pull with the full strength of your hamstring against resistance with your knee bent to 90 degrees and 2) forward and backward jogging at 50% of maximum speed without pain. Phase II typically last 1-2 weeks.

Stat Fact: Mobilization (lengthening) of skeletal muscle 5-7 days after injury can enhance fiber regeneration.

Phase III:

Phase III involves sport specific movements with no range of motion restrictions but sprinting and high accelerations should be avoided until return-to sport-criteria are met.  Ice should be used as needed after rehabilitation exercises.  Exercises in Phase III involve sport-specific exercises emphasizing quick direction changes and proper technique.  Trunk stabilization should be improved with movements in multiple planes of motion. Single leg bridges and single limb windmills (see picture) are examples of high intensity exercises.  In order to be cleared to return to the sports you need full range of motion, strength and functional abilities (cutting, running, jumping). Phase III usually lasts 1-2 weeks.  The total time for hamstring recovery is typically 3-5 weeks.

Prevention:

To prevent hamstring strain, we recommend a combination of stretching and strengthening exercises. Research studies have not shown any significant benefit to stretching your hamstrings therefore static hamstring stretching is not the best prevention tip.  However, scientists believe that an improper length of the quadriceps and hip flexors are a risk factor for hamstring strains.  Therefore, increasing flexibility of these muscles is mandatory to prevent hamstring strains.  Additionally, research showed that eccentric hamstring training prevents strains.  Eccentric hamstring training should be incorporated into a preseason and in-season training program for all athletes at risk for hamstring injuries.  An exercise routine for eccentric hamstring training can include Romanian dead lifts, knee fall downs and single leg Romanian dead lifts (see picture above). Lastly, exercises that incorporate the lower extremities and pelvis are associated with a decreased risk of hamstring strains.  Examples of these exercises include high knee marching, forward-falling running drills, and explosive starts.

Reiteration:

Prevention is the key here!  Make sure warm-up for 10-15 minutes (and by “warm-up” we mean activity that raises your heart rate and gets you sweating) before any work out.  Incorporating a proper warm-up, eccentric hamstring training and proper hip flexor and quadriceps muscle length will decrease your chance of the ending up with a hampering hamstring.  Everyone wins!

Questions?  E-mail G. John Mullen: mullen@myhousecallmd.com

References:

1. Heiderscheit B, Sherry M, Silder A, Chumanov E, Thelen D. Hamstring strain injuries: recommendations for diagnosis, rehabilitation, and injury prevention. J Orthop Sports Phys Ther. Feb 2010;40(2):67-81.

With record-breaking storms keeping many Americans trapped indoors this winter, it is hard to imagine that summer will ever come.  Daydreaming about your spring getaway or summer vacation to Europe may be your only respite from the cold.  But when you consider vacation, especially one that takes you multiple time zones away from home, one of the major drawbacks is coping with the even harsher reality of “jet lag”.  Whether it requires you to sleep when you arrive at your destination rather than enjoying immediate exploration or demands that you take yet another day off from work once you return home, jet lag is undeniably inconvenient.  Here we will explain the causes of jet lag and how to best prevent it from hindering your well-deserved adventures.

What is jet lag?

According to a recently published article in The New England Journal of Medicine, jet lag is a “recognized sleep disorder that results from crossing time zones too rapidly for the circadian clock to keep pace.”  It is a constellation of symptoms that can include insomnia, daytime sleepiness, fatigue, poor physical performance, cognitive impairment and gastrointestinal changes.  What the scientists meant to say was that you are going to feel lousy.   Jet lag is most commonly experienced after crossing at least 5 or 6 time zones (the East Coast-West Coast trip doesn’t apply here!).  Jet lag is most commonly confused with “travel fatigue”, which is the unfortunate result of the combination of sleep deprivation, stress caused by traveling, diet changes, etc.  While travel fatigue can be easily treated with a little rest and T.L.C., jetlag is a horse of a different color.

How does this “jet lag” nonsense happen?

The body’s circadian clock is located in the suprachiasmatic nucleus (SCN) of the hypothalamus (imagine a point directly between your eyes and two inches towards the back of your head…eureka, you’ve found it!).  It communicates with the retina, allowing it to sense light and dark.  Based upon our regularly predictable cycle of waking and sleeping, the SCN promotes alertness or sleepiness in sync with our daily routine by regulating the secretion of melatonin from the pineal gland.  The system works such that light inhibits the secretion of melatonin.  Therefore, melatonin has often been referred to as the “dark hormone”, because it is only secreted when there is no stimulation by external light (aka nighttime).  The problem with this system is that our circadian clock does not adapt quickly to changes in the cycle (i.e. flying half-way around the world in single day).  Therefore, in the same way that “motion sickness” is the result of desynchronization between visual and spatial stimuli in the setting of movement (didn’t know that, did you?), jet lag is the body’s response to the imbalance between a predicted sleep-wake cycle and a change in external light and dark stimuli.

How to Beat It:

1.  Re-sync your clock. This is accomplished with 2 strategies.

• Timing of Light Exposure: Based on what we now know about the circadian clock, we now understand how light can be used as a powerful tool to “trick” the circadian clock and therefore advance or delay it.  Although it may seem logical to think that sleep itself resets the clock, it is actually exposure to light and dark that is most effective.  What does this mean?  Studies have shown that light exposure should be used as follows after travel. Eastward travel: Upon arrival seek exposure to bright light in the morning.  This will help delay your circadian clock.  Westward travel: Seek exposure to bright light in the evening, which will help advance your circadian clock.

• Taking Melatonin:  Because light inhibits melatonin secretion, recommendations for melatonin are the opposite of those for light exposure.  When melatonin is taken in the evening, it resets the body clock to an earlier time and when taken in the morning, it causes the clock to be set to a later time.  Guidelines for melatonin use are, once again, broken down depending upon the direction of travel.  Eastward travel: Take 0.5mg-3mg at bedtime to shift your circadian clock to an earlier time and help you fall asleep.  Westward travel: Take 0.5mg during the second half of the night to shift circadian clock to later time and allow you to continue to sleep.  When traveling westward, the most common sleep disturbance is difficulty staying asleep.  Therefore, melatonin should be taken after awaking in the middle of the night in your new time zone.

2. Plan out your ZZZZZ’s. When planning a trip, you buy your airlines tickets in advance, purchase your travel books and research all of the best sites to visit.  Why not spend a few extra hours sleeping before you leave to help ease the jetlag when you arrive?  More sleep plus less jet lag sounds like a good deal to us.  In general, this means shifting the timing of your sleep 1-2 hours earlier for a few days before eastward travel and 1-2 hours later for a few days before westward travel.

3. Medication. When all else fails, manage your symptoms with some good old-fashion meds.

• Downers (aka sleeping pills):  Studies have shown that 10mg zolpidem at bedtime helps patients get a good night’s rest after long-distance travel and helps to reduce the symptoms of jet lag.  It’s best if you give the medication a test-run before you leave to ensure that you do not have any unwanted side effects while in the safety of your home country (amnesia and confusion…not so fun in a new city where you don’t speak the language).

• Uppers: Caffeine, while generally discouraged for those attempting to overcome jetlag, can be used in small doses early in the day to increase daytime alertness and decrease sleepiness.  Small doses for those of you who missed that part the first time.

The Take Home Message: Jet lag sucks (as the scientists so eloquently explained) but can be mitigated with some planning, preemptive measures before you leave home, and a little proactive management once you’re on the ground in your exotic location of choice (our advice: print out this article so you can remember all these tips when it’s go time).  There’s no reason to feel like poop during your valuable travel time.  Vacation, here we come.  Now get packing!

Questions?  E-mail the author: Kelly Erickson, MD 2010 | erickson@myhousecallmd.com

References:

1.  Sack, Robert L.  Jet Lag.  The New England Journal of Medicine 2010; 362:440-7.

2.  Herxheimer, A., Sanders, M., Mahowald, M., Sokol, H.N., Jet Lag. UpToDate, 2010.

3.  Herxheimer, A, Petrie, KJ. Melatonin for the prevention and treatment of jet lag. Cochrane Database Syst Rev 2002; :CD001520.

4.  Jamieson, AO, Zammit, GK, Rosenberg, RS, et al. Zolpidem reduces the sleep disturbance of jet lag. Sleep Med 2001; 2:423.

5.  Morris HH, 3rd, Estes, ML. Traveler’s amnesia. Transient global amnesia secondary to triazolam. JAMA 1987; 258:945.

With the Vancouver Winter Olympics in full swing, tendon injury is a hot topic on news channels across the globe.  Sports fans from every nation will be cheering on their favorite athletes and crossing their fingers for speedy recoveries from accidents incurred during the intense competition in the coming weeks.  Shoulder pain, elbow pain, ankle pain?  These joints are common sources of pain for professional athletes and law-abiding citizens alike.  Whether you have golfer’s elbow, tennis elbow, speed skater’s knee, shoulder impingement, jumper’s knee, Achilles tendon pain, you are suffering from a “tendinopathy.”  Tendons, which connect muscles to bones, are composed of collagen.  Tendinitis is the most common term associated with tendinopathy. Tendinitis is the acute injury of a tendon and is typically associated with inflammation (note that “-itis” means inflammation). Tendinosis is a term used less commonly but refers to the process in which tendinitis becomes chronic (lasting greater than 3 weeks). To understand the disease of tendinopathy, it is essential to understand the design of a tendon, common causes, treatments for the different types of tendinopathies and what you can do to prevent these disorders.

Stat Fact: The prevalence of Achilles tendinosis has been estimated to be between 11% and 24% in runners, whereas the prevalence rate for patellar tendinosis in basketball and volleyball players has been recorded as high as 32% and 45%, respectively⁴.  That’s a lot of tendon inflammation.

Tendon Architecture

As we mentioned earlier, the tendon is primarily composed of collagen, more specifically type I collagen (there are 29 different types of collagen in the body but 4 main types make up 90% of our collagen).  Tendon tissue has a poor blood supply (only 1/3 of the blood supply that muscles have) which means that it takes tendons notably longer than muscles to heal.  Following an acute injury, the tendon strained becomes inflamed (filled with cells trying to repair the tissue).  After chronic use of the tendon, type III collagen becomes predominant.  This change in collagen will make the tendon larger due to increased collagen rather than from inflammation.   Along with the increase in collagen comes an increase in water in the tendon as well.  These two changes make the tendon thicker which you notice as increased stiffness.  At the same time, the tendon becomes more compliant leading to an increased rate of tendon strain after a chronic tendon injury.  Cadaveric studies suggest after a chronic tendon injury, the strain increases causing a decrease in stiffness and strength.  Strain is “the amount of displacement with an external load placed on the object” or, in the cadaveric study, “the amount of displacement increased after injury.”  Essentially, it means the amount of laxity (“looseness”) in the tendon after injury.

Common Causes

The majority of tendinopathies are due to overuse and are caused by such activities as:

• Rapid increase in usage (New Year resolutions…)

• Not warming up properly

• Changes in footwear (for lower extremity tendinopathies)

• Weak surrounding muscles

• Improper muscle length or flexibility

Stat Fact: Achilles tendinopathy is a common overuse injury, accounting for 11% of all running injuries².

Tendinitis Treatment

Tendinitis is an acute tendon injury associated with inflammation. Tendinitis is caused by an accident that causes damage to the tendon or chronic use leading to tendon irritation.  The length of this inflammation is variable, therefore the term tendinopathy is used to classify all the tendon injuries (you know doctors don’t like to put timelines on healing!).  The majority of treatment for tendinitis consists of anti-inflammatory medication or a cortisone shot (used only in extreme situations) administered by the physician.  The list of anti-inflammatory drugs is extensive, including as Ibuprofen, Motrin, Naproxen, Celebrex, and many more.  Physical therapists can help reduce inflammation with a number of treatment modalities (electrical stimulation, low level laser therapy, ultrasound, ice) that can decrease pain and inflammation.  The last and the most important treatment for tendinitis is a temporary discontinuation of the activity that caused this inflammation.  As stated, true tendinitis is from an acute accident therefore discontinuing that activity while the tendon heals makes sense…let’s agree to agree on this one.

Tendinosis Treatment

Treatment of tendinosis is more researched than the tendinitis.  In general, injuries that present to physical therapy and primary care doctors are tendinoses.  Remember, tendinosis develops from long-standing tendinitis and is often mistaken for tendinitis due to the increase in tendon size.  However, this increase is size is due to remodelling of collagen as opposed to the inflammation we see in tendinitis.  Recent studies show that exercise is beneficial for healing tendinosis.  More specifically, eccentric overload training appears to have optimal results.  What is “eccentric overload training”, you ask?  An eccentric exercise is an exercise that lengthens a muscle.  For example, if you are performing a squat, lowering your body down is the eccentric phase of the exercise on your thighs and returning to the start position is the concentric phase for your thighs.  Overload eccentric exercise training studies suggest eccentric training increases stiffness of the tendon and help change the tendon back to type I collagen.  Increasing the tendon stiffness provides the support your muscles need to contract so that it can maintain the muscle in the position where it produces the most force.  Let’s look at another example:  Achiles tendinitis is common in runners.  Mix in a little hard headedness and a desire to keep running despite injury and you have yourself the perfect storm for the development of a tendinosis.   To treat this population of patients, a 12-week exercise program consisting of heel drops has shown excellent results.  This program uses high repetitions of the exercise: 3 sets of 15 repetitions two times a day with progressively increasing external weight (you can add weight to backpack that you wear during the exercise)¹. One key during this exercise is to only perform the eccentric phase of the heel drop with your injured leg.  To do this, slowly lower yourself down on the injured leg (the eccentric phase) and then return to your tippy toes by concentrically using the healthy leg.  This type of eccentric exercise can be used in any type of tendinosis.

Stat Fact: In the study mentioned, participants noted a decrease in pain from an average of 81/100 to 5/100 where 0 represents no pain¹.

Double Stat Fact: Studies suggest that eccentric exercise can change tendon stiffness from a 14% loss in stiffness to a 10% gain in 14 weeks³.

Preventing Tendinopathy

Many times tendinopathies can be prevented with proper warm-up and progression of exercise.  Include proper stretching and eccentric muscle training to muscles at risk for your activity and you will have created an adequate prevention program.

Examples of eccentric exercises for common tendinopathies:

Heel drop for Achilles Tendinopathy:

Begin with your foot on a surface that allows your heel to drop below the height of your foot, while holding onto a handrail, banister or child (ok, maybe not a child) lower yourself slowly on the injured leg.  Push yourself back up on your non-injured leg.

Theraband ankle inversion for Posterior Tibialis Tendinopathy:

Begin in a sitting position and put loop theraband (an thick elastic band) in which the loop is on the inside of your foot.  Move your foot down and in without resistance and then attach the theraband around the foot with high tension.  In a controlled manner, allow the foot return to the up and out position.

Wrist Extension and Flexion for Golfer’s and Tennis Elbow

Begin in a sitting position and allow your elbow to rest on your thigh.  For tennis elbow, begin with your hand facing the floor, with a weight in your hand.  Slowly lower the weight and then use the other hand to bring the weight back up to the starting position.  For golfer’s elbow, begin in the same starting position, but with your hand facing the ceiling and then lower the weight to the floor.

Rehab Recommendations:

During recovery, the following recommendations should be followed for all eccentric exercises²:

• 3 sets of 15 repetitions

• Slow, controlled movements

• Exercise should elicit a moderate amount of pain

• Passive return to starting position with assistance from the non-injured side

• Increase load when pain is minimal or absent

• Perform exercises twice a day

• Avoid aggravating activities for 4-6 weeks during eccentric rehabilitation

References:

1. Alfredson H, Pietilä T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med.26(3):360-366.

2. Chang H, Burke A, Glass R. JAMA patient page. Achilles tendinopathy. JAMA. Jan 2010;303(2):188.

3. Narici M, Maganaris C. Adaptability of elderly human muscles and tendons to increased loading. J Anat. Apr 2006;208(4):433-443.

4. Wasielewski N, Kotsko K. Does eccentric exercise reduce pain and improve strength in physically active adults with symptomatic lower extremity tendinosis? A systematic review. J Athl Train.42(3):409-421.

It is freezing cold outside, you’re stressed out about finals, and now your good old friend, Herpie (your favorite cold sore), is back.   You and Herpie have been friends for a while now.  You met him at a party in college when you didn’t think it would hurt to share drinks with the guy with the weird bump on his lip.  College is, after all, the time for bad decisions.  You live and you learn.  Now you are so paranoid that you won’t even share a cup with your own mother.  Sadly, though, it’s too late.  You and Herpie have begun an unavoidable lifelong relationship, a relationship that people all over the world are stuck with (note Paris Hilton’s sexy, lip gloss-coated cold sore).  With the medical treatments we have today, there’s nothing you can do to stop cold sores from coming back.  There are, however, a few things you can do to minimize number of cold sores you get and potentially shorten the length of time those annoying cold sores stick around.  Now let’s see if any of the current treatments are good enough to prevent a cold sore.

What causes a cold sore?

Cold sores are caused by a virus called the herpes simplex virus type 1 (HSV1). Yes, I said herpes.  When most people hear herpes they think of the sexually transmitted infection that causes sores in the nether regions (genital herpes) and they’d be right. Most cases of genital herpes are caused by herpes simplex virus type 2 (HSV2) while most cold sores are cause by HSV1 but both viruses can (although much less common) cause sores in the opposite region if the active virus comes in contact with that region (use your imagination here).

How do you “catch” a cold sore?

When you “catch” a cold sore you’re catching a virus.  Viruses are much smaller than bacteria and live inside your cells.  When someone has a cold sore it is caused by the herpes virus in the cells of their lips making a bunch of copies of themselves eventually causing the cells to burst open.  When the cell bursts, it frees the viral particles allowing them to invade more cells and repeat the cycle.  When enough of your cells are burst you get that wonderful oozing area of cells referred to as a cold sore.  Most people can see some redness, feel itchiness and pain over the area in which they are about to get a cold sore. This is caused by the death of your cells in that region.

So where did you get the initial virus?  You can get it anytime you exchange fluids with someone who is infected with the herpes virus and is actively shedding the virus.   Activities like kissing, sharing a cup, sharing utensils, toothbrush, etc.  Cold sores are most contagious when someone has an open blister present on their lips until the point where the blister has completely healed.  At the same time, note that certain people can spread the virus through their saliva even if there is no open blister present.  Maybe hold off on kissing a lot of frogs until you meet prince charming?  We’ll leave that one up to you.

Ok, so why is there no cure for herpes?

That’s like asking why there isn’t a cure for the common cold (also caused by a virus, though not a herpes virus).  Viruses are pesky like that.  Herpes, in particular, has the ability to travel deep into your body and make a home for itself in your nerve fibers.  Once the virus reaches your nerves, it temporarily goes into stealth mode, waiting for the opportune time to resurface.  During this time, the elusive little buggers hide from your immune system and medications.  This is called “Latency” (as seen in the diagram below depicting the virus moving from the epithelial on your lip to your nerve cell where it will lay dormant).  Herpes then rears its ugly head when your immune system gets weaker or is preoccupied with another infection.   It’s like guerilla warfare.  That’s why most people get another cold sore (called “reactivation” of the virus) when they get sick, are stressed out, or are just generally not taking good care of themselves.  Sun damage has also been linked to cold sore outbreaks (so if you find that’s one of your personal triggers, try using a chap stick with at least SPF 15).

Now to the fun stuff: products that may help quickly get rid of or prevent a cold sore that you can find at your local pharmacy and don’t need a prescription to get.

Abreva  (active ingredient: Docosonal)

How it works:  It changes the cell membranes of healthy, uninfected cells. These changes help prevent the cold sore virus from getting into healthy cells so the viral particles can’t spread to new cells. Think of it as dead bolt and home security system for the doors into your healthy cells.

Does it work?:  Yes!  It doesn’t prevent a cold sore but if you start using it as soon as you think you’re getting a cold sore it will shorten the amount of time you have to spend with Herpie.  On average, Abreva shortens the cold sore’s stay by 3 days (so if your cold sore usually hangs around for 7 days it’ll be gone by day 3 if you use Abreva at the first sign of it…remember that initial itching/tingling sensation?).

How to use it:  It comes in a cream and spray that you apply onto the cold sore.  You’re supposed to start applying it at the first signs of a cold (so any redness, tingling, itching, etc near your lips. If you’ve ever had a cold sore you can probably tell your going to get one soon).  If you wait until the blister is fully formed, Abreva will still help but it won’t be as effective as it is if you use it right away.

Note:  This is the only FDA approved drug to shorten the duration of cold sores and speed healing time (when you hear FDA approval you can rest assured that its been thoroughly tested for safety and efficacy before being sold to you).  The rest of the treatments that can be found in your pharmacy have some supporting research but no FDA approval just yet.

Cost:  $18 for each 2-gram tube. Each tube last from 2-3 outbreaks depending on your cold sore. If you’ve got a monster of a cold sore then it may only last through one.

Lysine

How it works: Lysine is an amino acid your body absorbs when you eat eggs, red meat, cheeses, or fish (among many other sources). By increasing the amount of lysine you eat (either through diet changes or taking lysine pills) or applying a lysine ointment directly onto the cold sore it is believed that you disrupt an important ratio of lysine to arginine (another amino acid) that the virus needs to make copies of itself

Does it work?: It’s not FDA approved for treating cold sores but there’s a lot of buzz and research into it. One trial found that 40% people treated with lysine at the first sign of outbreak were rid of their cold sore by day 3.  Pretty awesome if you ask us.

How to use it: There are creams like Lysine+™ that contain lysine as one of the main ingredients that you apply in the same way you apply Abreva at the first sign of a cold sore. There are also pill forms of lysine that you can find in the vitamin section of some pharmacies.  Most sources recommend 1000mg (1 gram) three times a day at the first sign of a cold sore. Some people have found that if they start the lysine pills early enough, they can actually prevent the blister from fully forming (sorry Herpie).

Cost: A tube of Lysine+™ usually costs about $8 for a 0.25 oz tube that will last 2-3 sores. Lysine tabs can range in price depending on the brand (usually around $10) but definitely go for a well-known brand that uses high-quality sources of lysine.

Peppermint Oil (yes, peppermint oil)

How it works: Peppermint oil is thought to have direct viricidal (i.e. virus killing) abilities. How does it do this?  We’re not sure just yet…but if the cold sore goes away, does it matter?

Does it work?: Surprisingly, the answer may be “yes.”  Not enough studies have been done on the subject but it seems like peppermint oil is capable of killing the virus particles that are outside of your cells.  Studies have yet to be conducted on humans or on the exact way to use peppermint oil (dosing, delivery mechanism, etc.) so it’s a little iffy right now.  At the moment its just test tube medicine.  Feeling adventurous?  Might be worth a shot.   People who use it have reported seeing their cold sore disappear faster.

How to use it:  There are no tried and true rules for how to use these oils at the moment but here are some guidelines:

• Use good quality peppermint oil

• Dip a cotton swab in water and then into the peppermint oil (this is to help dilute the oil a little because 100% peppermint oil can be very irritating to your skin)

• Apply on to the cold sore

• Do this a couple of times a day

• DO NOT drink the oil.  It won’t help, we promise.

Note: A lot of other natural products like tea tree oil, eucalyptus oil, and lemon balm are also being investigated as possible treatments for cold sores. If any of them interest you, use them similarly to peppermint oil.

Cost: Greatly varies but like with any natural remedy make sure its good quality and from a source you trust. On average though its pretty inexpensive.

You may have noticed that all these products ask you to start using them at the first sign of a cold sore.  This means that you have to be in tune with your body and recognize how your cold sores develop.  Look for warning signs of your next outbreak.  It’s also a good idea to keep track of the things that triggers your cold sore.  If you get a visitor on your lips every time finals come around or workload gets heavy, then start using one of these products preemptively around the start of finals.

Other products:

The products below are frequently advertised as treatments for cold sores but they don’t contain any ingredients that make them particularly active against the herpes virus.  They’re great for keeping your lips healthy and conditioned (nothing some chapstick with SPF wouldn’t do).  They can also help reduce the pain, itching, and redness caused by the cold sore because a many of them have pain-relieving ingredients.  Unfortunately, there is nothing in them that will get rid of the herpes virus and make the outbreak go away faster.

• Zilactin

• Anbesol

• Blistex Medicated

• Carmex

• Orajel

• Neosporin-LT

• Campho-Phenique

Again, this is a brief review of products that are available.  The world of cold sole- combating “medications” is filled with a ridiculous number of products but the cure has yet to be uncovered.  The Internet is full of people’s home remedies (from toothpaste to bleach) and products popping up claiming to be FDA approved.  Use common sense and a healthy dose of detective skills when considering any product (we don’t recommend using bleach on your mouth.  It seems like the kind of horrible idea that will land you a Darwin Award).  Find out what the product’s active ingredients are and see if those are chemicals you’d want in or on your body.  Activities that undoubtedly help reduce cold sores are staying healthy and dealing with stress in a healthy way.  Also, do your friends and family a favor and try not to introduce them to Herpie.  If you know you have a cold sore developing, don’t share anything that touches your mouth with them.  Until something better comes along, you and Herpie are just going to have to learn to work together…and do your part to shorten his stay!

References:

Abreva New Drug Application. 20-941. FDA Archives. Oct.29.1999

Elish D, Singh F, Weinberg JM. Therapeutic options for herpes labialis: experimental and natural therapies. Cutis. 2005 Jul;76(1):38-40.

Schuhmacher A, Reichling J, Schnitzler P. Virucidal effect of peppermint oil on the enveloped viruses herpes simplex virus type 1 and type 2 in vitro. Phytomedicine. 2003;10(6-7):504-10.

Singh BB, Udani J, Vinjamury SP, Der-Martirosian C, Gandhi S, Khorsan R, Nanjegowda D, Singh V. Safety and effectiveness of an L-lysine, zinc, and herbal-based product on the treatment of facial and circumoral herpes. Altern Med Rev. 2005 Jun;10(2):123-7.

Every January approximately half of all Americans resolve to eat better and lose weight. With increased portion sizes and the evolution of coffee drinks that have more calories than a burger and fries, more and more people are reducing their sugar consumption by choosing low calorie or calorie free sugar substitutes. There are a number of artificial and natural sweeteners on the market, including recently approved Stevia, but which one is really the best choice? We’ll explore the difference between artificial and natural sweeteners, as well as learn about the newest low calorie sweetener, Stevia.

What is the difference between Artificial Sweeteners & Natural Sweeteners?

Artificial sweeteners are chemicals or chemically altered natural compounds that provide sweetness like sugar but with fewer calories. Natural sweeteners taste like sugar but occur naturally as opposed to being synthetically manufactured like artificial sweeteners. Individuals with diabetes have been using artificial sweeteners for years; these “fake sugars” taste like sugar but the body does not utilize them like regular sugar and therefore they don’t raise your blood sugar levels.

In addition to use by diabetics, artificial sweeteners are commonly used to aid in weight loss since they’re low in calories or calorie free. While artificial sweeteners may contain little or no calories, the foods that contain these products may be high in calories, fat or carbohydrates. Let’s look at a few examples showing how artificial sweeteners may aid in weight loss or inhibit it. A regular 12 oz can of coke contains 140-150 calories but a diet coke is calorie free therefore, if we want to cut down our calorie count, the diet coke containing artificial sweeteners would be a better choice. Now another scenario: one serving of Oreos (34g) contains 160 calories. An equivalent serving of CarbWell Oreos, the sugar free version, contains 113 calories.  Murray’s Sugar Free Chocolate Sandwich Cookies contain 131 calories for the same serving. When we look at sugar free cookies vs. regular cookies the ideal choice isn’t as black and white.

Common Artificial Sweeteners

There are a variety of different artificial sweeteners available, each with different chemical properties that allow some of the products to withstand heat, while others cannot. For each sweetener we’ve included the ADI (Acceptable Daily Intake), which is the maximum quantity that is safe to be consumed per day, based on body weight in kilograms (kg) (Note: weight in lbs/2.2 = weight in kg, for example a weight of 150 lbs/2.2 = 66 kg).  As a side note, imagine the lab in which they were testing the “maximum amount of artificial sweetener that can be consumed.”  We’d love to find out what happened there.  Maybe even just see a picture of the whole operation.

Aspartame: Common products containing aspartame include Nutrasweet and Equal.  Aspartame is 200 times sweeter than sugar!  It is safe to consume 50 mg/kg a day which is equivalent to 18-19 cans of diet cola per day (based on body weight of 150 lbs).  We do not recommend trying this.  If you do, however, please let us know what happens with can #20 so we can utilize your discovery for the betterment of mankind.  Aspartame does not withstand heat and therefore cannot be used for cooking. Aspartame is not safe for people with Phenylketonuria (PKU), and an appropriate warning is required on all products containing Asprartame. Aspartame can be found in a number of products including soft drinks, sugar free cookies, chewing gum and yogurt.

Saccharin: Common products containing saccharin include Sweet ‘N Low and SugarTwin.  This sugar-alternative is 200-700 times sweeter than sugar. It is safe to consume 5 mg/kg per day which is equivalent to 9-12 packets of sweetener per day (based on body weight of 150 lbs).  Saccharin is able to withstand heat and is thus can be used for cooking.  Saccharin is most commonly used in diet sodas.

Acesulfame K: This sugar-alternative is 200 times sweeter than sugar and is found in Sunette and Sweet One. It is safe to consume 15 mg/kg a day which is equivalent to 30-32 cans of diet soda per day (based on body weight of 150 lbs). Acesulfame K is able to withstand heat and cooking. Acesulfame K is commonly found in baked goods and diet sodas.

Sucralose: Common products include Splenda and it is 600 times sweeter than sugar. It is safe to consume 5 mg/kg a day which is equivalent to 6 cans of diet cola per day (based on body weight of 150 lbs). Splenda is able to withstand heat and cooking. Sucralose is commonly found in diet sodas, protein bars and sugar free baked goods.

Common Natural Sweeteners

Stevia: The most recent natural sweetener on the market in the US is Stevia. While Stevia has been used internationally for hundreds of years, the FDA only put Stevia on the GRAS (Generally Recognized as Safe) list in late 2008, allowing its use as a sweetener. Stevia is an herb that is grown around the world, particularly in China and South America, that, when purified, is 200-300 times as sweet as sugar. Stevia is virtually calorie free and does not raise blood sugar levels, so it can be beneficial for diabetics or people looking to lose weight. While Stevia has been recognized as safe, people taking anti-hypertensive or diabetic medications should be cautious due to possible interactions with their medications (i.e. talk with your doc before jumping on the Stevia train if you’re on these meds). Some people may experience mild side effects including nausea or a feeling of fullness after eating.  A component of the Stevia leaf known as Rebaudioside A (Reb A) is used to make the sweetener. There are several brands of sweetener that use Stevia (these brands vary the components used in their sweetener but all contain Stevia):

• SweetLeaf Sweetener contains only Stevia and is a zero calorie natural sweetener.

• PureVia uses Reb A in addition to erythritol (a sugar alcohol), cellulose powder and natural flavor.  The product is 97% Reb A. PureVia can be found in 0 Calorie Sobe Lifewater as well as other Pepsi Products.

• Truvia contains rebiana (a form of stevia), erythritol (a sugar alcohol) and natural flavors. It is safe and possible to cook with Truvia. Truvia can be found in products including VitaminWater 10, Odwalla, and Sprite Green.

Sugar alcohol: Examples of sugar alcohols include sorbitol or mannitol. Sugar alcohols contain 2 calories/gram vs. 4 calories/gram found in sugar. Sugar alcohols are carbohydrates that resemble sugar and alcohol and therefore are considered “sugar free”. These substitutes are not completely absorbed and therefore can cause gas and diarrhea; any product that contains sugar alcohol will contain a warning label that states that excess consumption may have a laxative effect (i.e “diarrhea” which is scientifically classified as “not fun”).  The American Dietetic Association advises that consuming greater than 50 g/day of sorbitol or 20 g/day of mannitol may cause diarrhea. Sugar alcohols are commonly found in sugar free hard candies, sugar free baked goods and soft drinks.  In addition, sugar alcohols are found naturally in fruits and vegetables.

Honey: Honey contains disease-protecting antioxidants that may help reduce the risk of cardiovascular disease and cancer. Honey is sweeter than sugar and can cause blood sugar spikes.  As such, it should be used sparingly by diabetics.

Agave nectar: Agave nectar comes from the same Mexican plant that is used to make tequila. While it contains higher calories per teaspoon than sugar, it is a sweeter alternative and therefore less is needed to obtain the same level of sweetness. Agave is favored by vegans who are opposed to the use of honey (no bees are harmed in the making of agave nectar…party on vegans!).

So what should we choose as a sweetener?

Any of the artificial or natural sweeteners we’ve discussed, as well as sugar, are fine in moderation. According to the National Cancer Institute, there is no risk for developing cancer if you consume artificial sweeteners in moderation. If you’re a diabetic or trying to lose weight it may be beneficial to choose a low calorie sweetener instead of sugar to control blood sugar and caloric intake. At the same time, this does not means that you should only consume foods with low calorie sweeteners; a diet consisting of diet coke and sugar free cookies may be lower in calories but it is also missing some key nutrients (and sounds pretty horrible to have to eat every day). Remember that the most natural form of sugar can be found in nature’s candy: fresh fruit!

References:

Artificial Sweeteners and Cancer. 2009. Available at: http://www.cancer.gov/cancertopics/factsheet/Risk/artificial-sweeteners. Accessed Feb 10, 2010.

Mayo Clinic Staff. Artificial sweeteners: A safe alternative to sugar? Find out the benefits and portenital pitfalls of using artificial sweeteners. 2008. Available at: http://www.mayoclinic.com/health/artificial-sweeteners/MY00073. Accessed Feb 10, 2010.

PureVia: Available at: http://www.purevia.com/. Accessed Feb 11, 2010.

SweetLeaf Sweetener. Available at: http://www.sweetleaf.com/. Accessed Feb 11, 2010.

Truvia. Available at: http://www.truvia.com/. Accessed Feb 11, 2010.

With the Superbowl only days away, Colts fans across the nation are keeping their fingers crossed for Dwight Freeney’s return.  The Colts’ All-Pro defensive end said he’s been walking around barefoot and along the sandy beach outside the team’s hotel to strengthen his sprained right ankle.  The question is whether this game-changer, who recently suffered a severe ankle sprain, will be ready for the sharp cuts and quick footwork he will need on Sunday.  As simple as this sounds, hard cuts followed by the unfortunate rolling of an ankle cause ankle injuries to numerous players (pro and recreational alike) each year, injuries that may have been prevented with proper footwear, ankle strength and coordination.  Before we discuss those topics, let’s go over what an ankle sprain is as well as the main causes of ankle injury.

Stat Fact: Ankle sprains in men and women whose average age was 23 had an injury rate of 10 per 1,000 hours of sports participation.

What is an ankle sprain?

An ankle sprain, more commonly called “rolling your ankle,” is a stretch or tear in one or more ankle ligaments.  These injuries are caused by running, jumping, landing on an uneven surface or awkwardly planting your foot (or tackling a quarterback in the NLF in Freeney’s case).  The most common type of ankle sprain is of the anterior talofibular ligament (which connects the talus to the fibula) and the calcaneal fibular ligament (connecting the calcaneus to the fibula) on the lateral side (aka the outside) of your foot.  You can see this ligaments on the image to the right and imagine the type of ankle movement that would strain them.  This type of sprain is caused by rolling your ankle downward and inward (exactly what you had imagined).  There are many other ligaments in the ankle that can be stretched or torn in the sprain but the overwhelming majority of ankle sprains involve these two ligaments.  In addition, there are three different grades of an ankle sprains: Grade I is a stretch of the ligament, Grade II is a partial tear and Grade III is a full tear of the ligament.

The signs and symptoms of a sprained ankle are similar to most musculoskeletal injuries:

• Pain and swelling

• Bruising

• Difficulty walking

• Stiffness

Stat Fact: Sprains of the lateral ankle make up 85% of all ankle sprains.

Acute Ankle Sprain:

Now that you know some basic facts about the ankle, we will discuss what to do if you have just sprained your ankle playing a pick-up game of basketball or Louisville Chugger.  Most ankle sprains are Grade I (i.e. relatively benign) and will begin to feel better within a few days.  To help speed up the healing process, most physicians, physical therapist and medicine men will tell you to R.I.C.E. your ankle.

• Rest: For 24-48 hours after an injury, rest your ankle and allow it proper time to heal.  During this time sit back, relax, watch The Office and discontinue any physical activity.

• Ice: Icing can be used to decrease swelling of the injured ankle.  Ice should be used for approximately 20 minutes (about the same length as an office episode…) at a time and should be used intermittently throughout the day (about 6 times).  Make sure the injury site does not go numb when icing the injury.  When the injury becomes numb, tissue can be damaged and more harm can be done!  The type of cooling method is irrelevant, but make sure the ice pack, pack of frozen corn or cold pack covers the inflamed area. Additionally, make sure not to leave the ice on for longer than 20 minutes.  The ice is used to reduce the swelling in the area.  When ice is left on for longer than 20 minutes, the body begins to think that it is freezing and increases the amount of blood to the area to warm it up (thus increasing the swelling!).   The take home: 20 minute on, 20 minutes off!

• Compression: An ACE bandage works best, but any type of garment can be used to compress the injury site.  Wrap your ankle from your toes upward to your calf, but do not wrap too tightly or more harm than good can be done.  Make sure you can still feel a pulse in your foot (blue toes are a bad sign!).

• Elevate: This is simple, keep your ankle higher than your heart…lying down is key here (for those of you trying to maintain the kung fu position with one leg in the air) and remember to keep your ankle elevated with a pillow while you sleep.

If the ankle swelling does not subside after a few days (~7 days) or if the ankle is preventing you from everyday activites, it may be necessary to see the physician or physical therapist and it is likely you have suffered a Grade II or III sprain…our hearts go out to you.

Chronic Ankle Instability/Functional Ankle Instability

Now that you’ve sprained your ankle and the pain and inflammation has gone by the wayside, you may be interested in preventing future ankle sprains. If you are a bit of a couch potato (not recommended by physicians) it is likely the sprain was a freak accident and is unlikely to occur again.  On the other hand, if you are an active individual, the ankle is likely to be reaggrevated by future activities.   The good news is that future ankle injury can be prevented by non-surgical options including ankle braces (orthosis), strengthening and improving balance.

1. Ankle Braces: External ankle braces such as an Aircast or any semi-rigid external device is recommended during physical activity.  This device should be fitted by a trained exercise specialist to make sure the device is working and fits properly.  If properly worn the device will provide the support an individual needs to safely perform all of their sports needs (sounds like a good pitch if you ask me).

2. Balance: Balance exercises include: single leg standing, single leg squats, single leg calf raises, etc. Any of these single leg activities helps improve your balance while strengthening your ankle simultaneously. As you progress, you can perform these exercises with your eyes closed or on top of a pillow to make them more challenging.  A Dyna Disc or Bosu Ball (see pictures) can also be used to improve strength and balance of your ankles.  Squat, lunges and various other exercises can be used on these devices to increase the difficulty of the exercise.

3. Strengthening: Balance and strengthening go hand in hand as it is a critical aspect of rehabilitation for an active individual.  Strengthening is usually performed with elastic bands and on a Dyna Disc or Bosu Ball.   One exercise that can be used is called the elastic band clock and involves holding the band at 12 o’clock, 3 o’clock, 6 o’clock and 9 o’clock.  I know this sounds like nonsense but if you loop the elastic band around your foot and hold the band directly above your foot, you are in 12 o’clock, and if you hold the band in your hand on the outside of your foot you are in 9 o’clock similar to the picture on your left.   Push your foot against the resistance of the elastic band and stretch the band as far as you can without moving your shin or any other aspect of your leg (you are moving your foot at the ankle).   Movements in all these planes of direction will greatly strengthen your ankle and improve your balance.  These exercises can be done for 3 sets of 15 repetitions and should not be terribly difficult.  A little TV time makes them infinitely more enjoyable.

Stat Fact: Basketball players with a history of ankle sprains were nearly five times as likely to sustain another ankle injury.

If these non-invasive interventions do not help the ankle instability, surgery may be considered.  Ankle surgery is done only in the most severe cases of ankle instability and would have to be recommended to you by an experienced orthopedic surgeon.

Ankle instability and sprains can hamper one’s recreational football and basketball career, but implementing these three main sources of rehabilitation (bracing, balance, and strengthening) can get you back in action sooner and keep you there longer.  Rehabilitation programs vary greatly from injury to injury and if you have chronic ankle instability it is recommended to see your physician or physical therapist to implement an individualized plan to help strengthen your ankle and get you back to 100%.  Let’s hope Dwight Freeney is doing his ankle exercises (enter his long walks on the beach) and keeping that ankle elevated (for the Colts’ sake that is!).

References:

Handoll HH, Rowe BH, Quinn KM, de Bie R. Interventions for preventing ankle ligament injuries. Cochrane Database Syst Rev. 2001;(3):CD000018. Review.

Loudon JK, Santos MJ, Franks L, Liu W. The effectiveness of active exercise as an intervention for functional ankle instability: a systematic review.  Sports Med. 2008;38(7):553-63.