Presentation on theme: "SPORTS INJURIES Indiana Osteopathic Association"— Presentation transcript:
1 SPORTS INJURIES Indiana Osteopathic Association 32nd Annual Winter UpdateDecember 6,2013David C. Koronkiewicz, D.O.Iu goshen Orthopedics & Sports Medicine
2 Sports Injuries-Outline OverviewTypes of injuriesPreventionSpecific injuriesWe will begin our discussion with an overview of sports injuries and some specific concerns about children and sports, when their injuries merit seeing a doctor, and some of the treatment options available for children with sports-related injuries.
3 StatisticsIn the United States, about 30 million children and teens participate in some form of organized sports, and about 3.5 million injuries occur each year.Participation in high school athletics is increasing, with more than 7.3 million high school students participating annually *High school athletes account for an estimated 2 million injuries and 500,000 doctor visits and 30,000 hospitalizations each year.***(Source: National Federation of State High School Associations)**JS Powell, KD Barber Foss, Injury patterns in selected high school sports: a review of the seasons. J Athl Train. 34:
4 InjuriesMost sports and recreational injuries are the results of: sprains (ligamentous injuries), strains (musculotendinous injuries),and contusions. Knee injuries (meniscal & ACL), bursitis, fractures, and dislocations are all commonly seen.
5 Top 15 Sports/Recreational Injuries* Basketball: 512,213Bicycling: 485,669Football: 418,260Soccer: 174,686Baseball: 155,898Skateboards: 112,544Trampolines: 108,029Softball: 106,884Swimming/Diving: 82,354Horseback riding: 73,576Weightlifting: 65,716Volleyball: 52,091Golf: 47,360Roller skating: 35,003Wrestling: 33,734*Treated in ER based on data from the US Consumer Produce Safety Commission on Injuries
6 Acute vs. Overuse Injuries Acute - sudden trauma causing sprains, strains, bruises & fracturesOveruse - series of repeated small injuries resulting in painSports injuries come in two basic types, acute and overuse. Acute injuries are those that involve sudden trauma, such as sprains, strains, bruises, and fractures. On the other hand, overuse injuries result from the cumulative result of “microtrauma,” that is, a series of repeated smaller stresses or injuries. How can you prevent these injuries? When should you see a physician? These are two very important issues we will discuss today.
7 Causes of Overuse Injuries Increasing activity too quicklyRunning or jumping on hard surfacesTraining vigorously without adequate restPoorly functioning equipmentImproper techniquesWorking through painLack of stretching/strengthening* We need to slowly progress our exercise efforts. Starting small or even using weights that seem to light is always better than overdoing it, getting hurt…………………* Running, walking or jumping should be done on a softer surface, if possible. For example, group exercise rooms have special floors with a little bit of cushion or spring to them to be easier on the feet.Our muscles actually heal and get stronger while we rest, so we need to give our bodies hours of rest before exercising that muscle group or doing a specific activity again. We certainly can do a different activity……………..Proper equipment is so crucial, especially good foot wear and clothing!Poor form is the reason for many injuries, it doesn’t hurt to work with a professional to learn proper form………. For example, lifting weight that is to heavy, use bicep and back swing.If it hurts, DON’T DO IT!Stretching is important for injury prevention, if we take a frozen steak and drop it what happens? Now a thawed steak what happens.
8 When to See the Physician Decreased ability to playInability to playLimp, loss of motion or swellingVisible deformitySevere painActive, athletic kids are likely to get bumps, bruises, and other minor injuries. There are some telltale signs that will warn you that it is time to take your young athlete to your orthopaedic surgeon:The inability to play following an acute or sudden injury;Decreased ability to play because of chronic or long-term complications following an injury;Limp, loss of motion or swelling needs to be carefully evaluated; orVisible deformity of the athlete’s arm or leg and severe pain from acute injuries that prevent the use of an arm or leg are all indicators that you should seek medical intervention.By providing prompt treatment for your child, you can often prevent a minor injury from turning into something more serious.
9 Injury Classifications Sprains: injuries to ligamentsStrains: injuries to muscles, tendons or the junction between the twoContusions: common bruises or contusions are the most frequent sports injury.Fractures & Dislocations: fractures and dislocations represent two categories of injuries involving either bones or joints of the bodySprains have 3 degrees, first, second and third.First degree is mild pain and disability occur.Second degree sprains are more sever they imply more actual damage to the ligaments involved with an increase in the amount of pain and dysfunction.Swelling more pronouncesThird degree are a complete tear of the ligamentsStrains also have 3 degrees.Contusions result from a direct blow to the body, they can happen in almost any activity, however collision and contact sports such as tackle football, basketball and baseball are more prolific in this regard.Fractures are a crack in the bone.
10 Preventing Sports Injuries Know and abide by rulesWear appropriate protective gearKnow how to use equipmentNever “play through pain”Children should always know and abide by all rules of the sport, as these rules are in part designed to keep them safe from injury. In addition, wearing the appropriate protective gear and knowing how to use the athletic equipment in a given sport are key to playing it safe. This includes helmets for skiing and snowboarding, helmets and pads for skateboarding, rollerblading, and scooter riding, and wrist guards for snowboarding, rollerblading, and skateboarding. Children should never “play through the pain.”
11 Preventing Sports Injuries Skilled sport specific instructionYear round conditioningNot surprisingly, the benefits of skilled supervision and direction and appropriate athletic equipment do not stop with young athletes. Whether you are a beginner or have been playing a sport for a long time, lessons are a worthwhile investment for younger and older athletes alike. Likewise, appropriate safety gear, including bike helmets for cyclists, can help keep your play safe. Balanced exercise programs are essential in preventing sports injuries. Balanced programs involve three key areas: aerobic or cardiovascular exercise; strength training; and flexibility or stretching. Unfortunately, most individuals will favor one or two of these over the others.
12 Preventing Sports Injuries Warming up before beginning any physical activity, especially strenuous athletic games, and being well rested and pain-free gives your child's body its best chance at optimum enjoyable and healthy athletic performance.Make Sure Your AthletesAlways Warm Up First!
13 Preventing Sports Injuries WARM UPBreak a sweatMarchingWalk in placeJumping jacksMimic the sport you are about to doWhether you are a child, a baby boomer, or a senior citizen, stretching before engaging in physical activity is one of the best things you can do to protect yourself from injury. However, the way you stretch is key to reaping its benefits.Before you stretch, warm up your muscles. Remember, warming up and stretching are not the same thing. An efficient warm-up can include marching, walking in place while swinging your arms, jumping jacks, or mimicking the sport you are about to do. The point is to get your heart rate up and your muscles warm and flexible, as cold muscles are more prone to injury. “Warming up usually involves breaking a light sweat. It prepares your body for the activity to follow. It is especially important in aging athletes and individuals who have had injuries or who have tight muscles.If you have especially tight muscles, stretching after the activity is also advised.
14 Stretching Stretching: Breathe slowly and deeply Relax into the stretchShould not feel painAvoid bouncingHold stretch 30 secondsStretch both sidesAfter warming up, your basic stretching routine should cover all of the major muscle groups. The order of the stretches is not critical, but rather stretching thoroughly should be your focus. Depending upon the sport you choose, there are also specialized stretches you will benefit from. Stretching before sports activities promotes better performance and results in fewer injuries. Investigate the best stretches for your particular sport and add them to your basic stretching routine for optimum results.
15 MOST COMMON Strains & Sprains Injuries THIS NOT THAT Strains and sprains are the most common injuries that are seen.NOT THAT
16 Strain Strain Overstretching of a muscle Caused by overexertion or by liftingFrequent site is the Back
17 Strains Signs & Symptoms Localized swelling Cramping Inflammation Loss of functionPainGeneral weaknessDiscolorationPreventionProper warm-upStretchProper mechanicsProper cool-down/ stretchProper nutrition & hydration
18 Strain First aid treatment Rest the muscle affected while providing supportCold applications initially to reduce swellingWarm wet applications applied later because warmth relaxes the musclesObtain medical help for severe strains and back injuries that don’t improve
19 Sprain Sprain Injury to the tissues surrounding a joint Usually occurs when part is forced beyond its normal range of motionLigaments, tendons and other issues are stretched or tornCommon sites for sprains are the ankles and wristsSigns and symptomsSwelling, pain and discolorationImpaired motion at times
20 Sprain Rest and limited or no movement of the affected part First aid for sprainRest and limited or no movement of the affected partIce to reduce swelling and painCompression with elastic bandage to control swellingElevation of the affected partObtain medical help if swelling is severe or if there is any question of a fracture
21 ContusionBruiseSudden traumatic blow to body (severe compression force)Usually injury to blood vessels under skinSpeed of healing depends on tissue damage and internal bleedingHematoma formation is caused by a pooling of blood and fluid in a tissue
22 Tendon InjuriesTears commonly at muscle belly, musculotendinous junction, or bony attachmentTendonitis: inflammation of tendon-muscle attachments, tendons, or both
23 Tendonitis Signs & Symptoms Treatment Prevention Pain & inflammation Worse with movementTreatmentRICENSAIDs-Advil, AleveUltrasound therapyRehabilitationPreventionSlowly increase intensity & type of exerciseDon’t try to do more than ready forProper warm-up & stretch
24 Skeletal Injuries Subluxation Occurs when bone displaces and partially separatesDislocationExcessive force that causes the ends of the bone to separate and usually remain apart requiring them to be put back together
25 Wrist/Forearm Fractures Fracture is a break or loss of structural continuity in a boneWrist/Forearm Fractures
26 Why are Injuries on the Rise? Increase youth participationImmature bones and musclesInsufficient rest after an injuryPoor training or conditioningSpecialization in just one sportYear-round participation
27 Children & SportsYouths of same age can differ tremendously in size and physical maturity.Further marking the difference between adults and children in athletics is the reality that children mature at sometimes vastly different rates. Athletic youths of the same age can differ tremendously in size and physical maturity, increasing the opportunity for injuries.
29 Injuries in Female Athletes Common injuries in women/girls include:Anterior cruciate ligament (ACL) injuriesPatellofemoral pain syndromeStress fractures
30 ACLGirls Soccer – 1 torn ACL for every 6,500 times a girl competes or practicesBoys Football – 1 torn ACL for every 9,800 times a guy competes or practicesGirls Basketball – 1 torn ACL for every 11,000 times a girl competes or practices
31 ACL Injury Direct blow to knee Non-contact injury, with foot plant Landing on straight legMaking abrupt stopsIf you play sports , there are many different structures you can injure in your knee; two of the most common are the ACL injury and the meniscus tear. Your ACL, or Anterior Cruciate Ligament, is one of the most important stabilizing ligaments in the knee. It connects the front part of your shin bone to the back part of your thigh bone and keeps your shin bone from sliding forward. The ACL is usually injured by either a direct blow to the knee or through a non-contact injury resulting from planting your foot and cutting, landing on a straight leg, or making an abrupt stop. In skiers, it frequently occurs when skiing in the “back seat,” with one’s weight too far back on one’s heels. Some signs of an ACL injury are feeling your knee give way (sometimes accompanied by an audible “pop”), moderate pain that makes it impossible to continue the activity, and over several hours swelling is present and it is difficult to walk. The swelling and pain are usually the worst during the first two days following the injury.
45 Femoral Neck Stress Fracture Groin pain in runner or jumper- don’t ignoreFemale triad at increased risk as well as those with an increase in training and postmenopausal womenNeed to know which side the stress fracture is on (compression vs tension side)Plain films often negativeGet MRI
46 Treatment If stress fracture by x-ray or further imaging Compression side12 weeks to heal +/- NWBTension sideOrtho consult/surgeryFemoral neck fracture-surgeryCross trainProper nutrition and calories
47 Complications if Missed Stress to complete fractureAvascular necrosisChronic painEnd of career
48 Patellofemoral Pain Syndrome Anterior knee painProbably more than one etiologyChondromalacia (softening of cartilage)Malalignment of patella
50 Patellofemoral Pain Syndrome Clinical Features and Exam:Reports of anterior knee painPain with climbing stairs and/or sitting for prolonged periods of timePressure on the kneecap during bending and straightening of the knee may elicit cracking and popping with discomfortAbnormal kneecap alignmentGeneticAcquired
51 Patellofemoral Pain Syndrome Other causesMuscle imbalancesFoot type (either flat or high arched feet)ShoesOveruseTreatment includes: decreasing activity, correct alignment issues, physical therapy for strengthening, bracing or taping
52 Patellar DislocationPlanted foot with twisting of the body around the knee (similar to ACL)Kneecap off to the sideVery painful
59 Osgood-Schlatter Disease Pain usually goes away after the growth plate closesThe bump will remain
60 Meniscus Tear History of twisting injury to the knee Pain Giving way SymptomsPainGiving wayLockingClickingSwellingYou might experience a “popping” sensation when your tear the meniscus. Most people can still walk on the injured knee and many athletes keep playing. Symptoms of a torn meniscus include knee pain, swelling, clicking, locking, and catching.
61 Meniscus Tear Commonly injured “Torn cartilage” The other common type of knee injury is called a meniscus tear. The meniscus is a triangular, C-shaped piece of cartilage that improves shock absorption in your joint. It helps the knee joint carry weight, glide, and turn in many directions. It also keeps your femur (or your thighbone) and tibia (shinbone) from grinding against each other. Football players and others in contact sports may tear the meniscus by twisting the knee, pivoting, cutting, or suddenly decelerating. You can also tear your meniscus with deep squatting type maneuvers as in gardening.
62 Meniscus Two C shaped cushions between the thigh and shin bone Helps knee joint carry weight, glide, and turn
63 Stress Fracture Small incomplete break in bone due to: Symptoms OverusePoor muscle balanceLack of flexibilityWeakness in soft tissueBiomechanical problemsMalnutritionStresses on body are greater than body can compensateSymptomsPainTenderness after activityNo or little pain in AM, but pain returns after activity
64 Stress Fractures Chronic, overuse injury Most common in weight bearing bonesFeet, tibia, femoral neckSeen commonly in Female Athlete Triad (eating disorders, amenorrhea (lack of menstrual periods) & osteoporosis(low bone mass)Diagnosis by x-ray, bone scan or MRITreatment is rest, address biomechanical issues---some fxs are surgical (e.g. femoral neck)
65 Return to Running Progression of functional activity Very structured, all timedPain & symptoms are to guide progressionCan have frequent setbacks
67 Achilles Tendon Rupture HistoryAcute pain in the back of the ankle with contraction, no antecedent history of calf or heal painAverage age 35Steroids, fluorquinolones, and chronic overuse may predispose to rupturePathologyRupture occurs 3-4 cm above the Achilles insertion in a watershed area
68 Achilles Tendon Rupture Physical ExamTenderness over achilles tendonPalpable defectPositive Thompson’s testNeedle test- needle inserted midline 10cm proximal to the superior aspect of the calcaneous moves towards the foot when the calf is squeezedNo evidence to support routine use of MRI, U/S, or Xray
69 Achilles Tendon Ruptures Surgical repairYounger active patientsNonoperative treatmentOlder sedentary patientsPatients with increased risk of soft tissue complicationsIDDMSmokersVascular diseaseBMI > 30
71 Indications of Non-Operative Versus Operative Treatment Non-Operative Tx may be indicated for older patients with minimally displaced rupturesNon-Operative may be indicated for patients who are at an increased operative risk due to age or medical problemsNote that younger patients w/ expectations of participating in sports such as basketball may not be good candidates for non operative Tx
72 Management of Non-Operative Tx Short leg cast strategy (SLC)SLC is applied w/ ankle in plantarflexionCast is brought out of equinus over 8-10 weeksWalking is allowed (in the cast) at 4-6 weeksAlternatively, consider using functional brace starting in 45 degrees of flexionFollowing casting, a 2 cm heel lift is worn for an additional 2-4 monthsLong leg cast (LLC)Initial LLC in gravity equinus for 6 weeks, followed by short leg cast for 4 weeks
73 Achilles Tendon Rupture Non-OperativeResistance exercises started at 8 weeksReturn to sports in 4 – 6 monthsMay take 12 months to regain maximal plantarflexion power
74 Clinical Evidence to Support Nonoperative Treatment Benefits: no wound complications, no scar, decreased patient cost.Disadvantage: up to 39% re-rupture rate, increased patient dissatisfaction, decreased power, strength and endurance.Nistor and later Gilles and Chalmers- non-operative treatment preferred because:No hospitalizationsNo wound complicationsNo difference in functional strengthGillies and Chalmers-80% vs. 84.3% return of strength compared to unaffected side, non-op and operative, respectivelyWills, 775 patients the overall complication rate of surgically treated Achilles tendon ruptures was 20%.skin necrosis, wound infection, sural neuromas, adhesions of the scar to the skin, and the usual anesthesia risks
76 Achilles Tendon Rupture Surgical treatmentPreferred for athletesMedial incision avoids the sural nervePercutaneous vs. Open treatments describedIsolate the paratenon as a separate layer
77 ConclusionThe current preferred treatment in young and other wise healthy patients is surgical repairConservative treatment remains an acceptable alternative in older, sick or sedentary patients who have fewer physical demands with limited functional and athletic goals
78 Lisfranc InjuryLisfranc injuries may represent 1% of all orthopedic trauma, but 20% are missed on initial presentationInability to WB, mid-foot pain, weight bearing x-rays are key
89 Ear InjuryIrritation of the ears can occur to the point that permanent deformity can ensue. Some of these injuries may include:Cauliflower-earLacerationsRuptured eardrumTo avoid these problems, special ear guards should be routinely worn.
90 Auricular Hematoma Cauliflower ear Wrestling 1.7-23.4% of all injuries Direct trauma or abrasionHead or kneeIncidence reduced with headgear 16% (51% to 35%)Only 5% of coaches require headgear at practice
91 Mouth GuardsIn addition to protecting the teeth, mouth guard absorbs shock and helps to prevent concussions.
92 Mouth GuardsCorrectly fitted mouth guard prevents the majority of dental trauma.Fit should be:Tight fitBe comfortableUnrestricted breathingShould not impede speech during competition.Fit is best when retained on the upper jaw and projects backward only as far as the last molar.Composed of a flexible, resilient material.
93 Availability of trainers CheerleadingJournal of Pediatrics 10/21/12Academy of Pediatrics Position PaperSport DesignationBetter conditioningAvailability of trainersBetter coachingUndergo Physicals37,000 ER visits last year
95 Ankle Sprain Ligament injury Ankle pain, tenderness, swelling In the treatment of musculoskeletal concerns, certain injuries and conditions are most commonly related to sports activities.Ankle sprains are one of the most common injuries seen in sports. They occur when the ankle suddenly twists and there is an overstretching or injury of the ligaments that support the ankle. The ligaments on the outside of the ankle are most commonly injured when the foot is turned inward on an awkward step. Ankle sprains are acute injuries. Symptoms of ankle sprain include a tender and swollen ankle on the outside below and in front of the ankle bone.
97 Rehabilitation ROM, strengthening, flexibility, balance TreatmentR.I.C.E. – Rest, Ice, Compression and ElevationModify athletic activityRehabilitation ROM, strengthening, flexibility, balanceCooperation and communication between patient, parents, coaches and physicianWhat can you expect when you go to the physician?R.I.C.E. is the most common treatment for many athletic injuries: Rest, Ice, Compression, and Elevation.If a significant injury is present, your physician will make specific recommendations that are likely to include temporary or permanent adjustments to your child’s athletic activity.Your orthopaedic surgeon may make recommendations ranging from simple observation with very minor changes to the athletic participation, up to and including the recommendation that your child no longer participate in particular athletic activities.When warranted, your orthopaedic surgeon will prescribe physical therapy, strengthening exercises, and/or bracing to help your child heal.Successful treatment for the young athlete requires cooperation and open communication among patient, parents, coaches, and physicians.
101 Finger DislocationsA dislocation occurs when the normally opposed bones of a joint are separated so that the joint congruity is lost.
102 Jammed Finger Diagnosis only by exclusion. Jamming force on extended PIP joint.Diffuse swelling with painful movement.R/O fracture, tendon injuryExact pathology is not known.
103 Jammed Finger Prolong morbidity. Up to 9 months of soreness.Permanent residual thickening about the joint.Bruising of the articular surfaces, secondary effusion and resultant edematous soft tissue swelling most likely sequence of events.
104 Plantar Fasciitis Painful heel “Heel Spur” Microtears of plantar fasciaPlantar fasciitis is pain in the bottom of the heel, usually felt on the first step out of bed in the morning or when walking again after resting from activity. If it persists, this pain can eventually be felt during all weight-bearing activity. It is not uncommon for the pain to radiate down the bottom of the foot toward the toes.The plantar fascia are dense bands of tissue deep below the skin in the foot. Plantar fasciitis is thought to be the result of the repetitive stretching that causes microtears in these dense bands of tissue as they arise from the heel. The tears build up over time, making plantar fasciitis an overuse injury, which left unchecked can easily become chronic. Sudden weight gain may be a contributing factor in some instances. Sometimes it is due to a change in shoewear. It should be noted that plantar fasciitis can result in bone spurs.
105 Plantar Fasciitis Heel cups Tape heel, arch Orthotics Surgery is rarely needed to treat plantar fasciitis. Taping the heel and arch and wearing gel inserts in a supportive shoe or sneaker are helpful. Some individuals need custom-made shoe inserts called orthotics.Regular stretching that works to increase the flexibility of the plantar fascia and calf can help. No special equipment is needed.You need two stretches to improve calf flexibility (one for the upper calf and one for the lower calf) and one additional stretch for the plantar fascia itself.For the upper calf, you can stand on a step with only the front half of your foot, then lower your heel and hold it there for 10 seconds. Repeating this stretch 10 times is recommended.For the lower calf, lean forward onto a countertop, spreading your feet apart with one foot in front of the other. Flex your knees and squat down, keeping your heels on the ground as long as possible. Your heel cords and foot arches will stretch as the heels come up in the stretch. Hold for 10 seconds, relax and straighten up. Repeat 20 times.The plantar fascia stretching exercise requires sitting with one leg crossed over the other, and stretching the arch of the foot by taking one hand and pulling the toes back toward the shin for a count of 10. The exercise must be repeated 10 times, and performed at least three times a day, including before taking the first step in the morning and before standing after a prolonged period of sitting.
106 Plantar Fasciitis Stretch (calf and plantar fascia) Against wall or curbOn a stepPlantar fascia stretchSurgery is rarely needed to treat plantar fasciitis. Taping the heel and arch and wearing gel inserts in a supportive shoe or sneaker are helpful. Some individuals need custom-made shoe inserts called orthotics.Regular stretching that works to increase the flexibility of the plantar fascia and calf can help. No special equipment is needed.You need two stretches to improve calf flexibility (one for the upper calf and one for the lower calf) and one additional stretch for the plantar fascia itself.For the upper calf, you can stand on a step with only the front half of your foot, then lower your heel and hold it there for 10 seconds. Repeating this stretch 10 times is recommended.For the lower calf, lean forward onto a countertop, spreading your feet apart with one foot in front of the other. Flex your knees and squat down, keeping your heels on the ground as long as possible. Your heel cords and foot arches will stretch as the heels come up in the stretch. Hold for 10 seconds, relax and straighten up. Repeat 20 times.The plantar fascia stretching exercise requires sitting with one leg crossed over the other, and stretching the arch of the foot by taking one hand and pulling the toes back toward the shin for a count of 10. The exercise must be repeated 10 times, and performed at least three times a day, including before taking the first step in the morning and before standing after a prolonged period of sitting.
107 Plantar Fasciitis Massage may be helpful Warm up well before stretchingIce heel, minutesAnti-inflammatoriesNight splintIf you suffer from plantar fasciitis, you should be particularly careful to warm up well before stretching and to ice your heel after stretching for minutes at the point of maximum tenderness. Arch massage can provide relief and can be done by rolling your foot and arch area over a tennis ball. Taking oral anti-inflammatory medications, trying a night splint prescribed to keep the fascia stretched while you sleep, and massaging your heel with sports cream may also be helpful.
108 Plantar Fasciitis Wear good, supporting shoes Arch support Avoid activities that cause heel painSee your physician if pain persistsThere are quite a few things you can do to avoid the painful experience of plantar fasciitis in the first place:Don’t run to lose weight after rapid weight gain—start with walking, and be sure to stretch your foot and calf thoroughly before and after.Wear good, supporting shoes for athletic activities.Keep the muscles of your feet and ankles strong to support your arch.Rest from activities that cause you pain in the heel.And as always, see your physician if your pain persists.
109 Shoulder Overuse Injuries TendonitisOverhand sports-pitching, serving: (tennis,volleyball), swimmingWeight liftingUse proper technique, good supervisionShoulders are also prone to overuse injuries, such as tendonitis. Throwing sports and weight-lifting can cause sore shoulders, so it is important to use proper technique in these sports. A supervised program can help keep participants injury-free.
110 Don’t Increase Activity Overuse InjuriesReduce IntensityWarm up beforeIce afterwardsWork with coaches10% RuleDon’t Increase Activityby More Than 10% Per Week
111 Conclusion Year round conditioning Cross train Warm up/ stretch Use proper equipmentListen to your bodySeek medical care if pain continues