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SPORTS INJURIES Indiana Osteopathic Association

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1 SPORTS INJURIES Indiana Osteopathic Association
32nd Annual Winter Update December 6,2013 David C. Koronkiewicz, D.O. Iu goshen Orthopedics & Sports Medicine

2 Sports Injuries-Outline
Overview Types of injuries Prevention Specific injuries We 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 Statistics In 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 Injuries Most 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: 512,213 Bicycling: 485,669 Football: 418,260 Soccer: 174,686 Baseball: 155,898 Skateboards: 112,544 Trampolines: 108,029 Softball: 106,884 Swimming/Diving: 82,354 Horseback riding: 73,576 Weightlifting: 65,716 Volleyball: 52,091 Golf: 47,360 Roller skating: 35,003 Wrestling: 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 & fractures Overuse - series of repeated small injuries resulting in pain Sports 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 quickly Running or jumping on hard surfaces Training vigorously without adequate rest Poorly functioning equipment Improper techniques Working through pain Lack 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 play Inability to play Limp, loss of motion or swelling Visible deformity Severe pain Active, 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; or Visible 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 ligaments Strains: injuries to muscles, tendons or the junction between the two Contusions: 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 body Sprains 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 pronounces Third degree are a complete tear of the ligaments Strains 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 rules Wear appropriate protective gear Know how to use equipment Never “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 instruction Year round conditioning Not 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 Athletes Always Warm Up First!

13 Preventing Sports Injuries
WARM UP Break a sweat Marching Walk in place Jumping jacks Mimic the sport you are about to do Whether 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 stretch Should not feel pain Avoid bouncing Hold stretch 30 seconds Stretch both sides After 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 lifting Frequent site is the Back

17 Strains Signs & Symptoms Localized swelling Cramping Inflammation
Loss of function Pain General weakness Discoloration Prevention Proper warm-up Stretch Proper mechanics Proper cool-down/ stretch Proper nutrition & hydration

18 Strain First aid treatment
Rest the muscle affected while providing support Cold applications initially to reduce swelling Warm wet applications applied later because warmth relaxes the muscles Obtain 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 motion Ligaments, tendons and other issues are stretched or torn Common sites for sprains are the ankles and wrists Signs and symptoms Swelling, pain and discoloration Impaired motion at times

20 Sprain Rest and limited or no movement of the affected part
First aid for sprain Rest and limited or no movement of the affected part Ice to reduce swelling and pain Compression with elastic bandage to control swelling Elevation of the affected part Obtain medical help if swelling is severe or if there is any question of a fracture

21 Contusion Bruise Sudden traumatic blow to body (severe compression force) Usually injury to blood vessels under skin Speed of healing depends on tissue damage and internal bleeding Hematoma formation is caused by a pooling of blood and fluid in a tissue

22 Tendon Injuries Tears commonly at muscle belly, musculotendinous junction, or bony attachment Tendonitis: inflammation of tendon-muscle attachments, tendons, or both

23 Tendonitis Signs & Symptoms Treatment Prevention Pain & inflammation
Worse with movement Treatment RICE NSAIDs-Advil, Aleve Ultrasound therapy Rehabilitation Prevention Slowly increase intensity & type of exercise Don’t try to do more than ready for Proper warm-up & stretch

24 Skeletal Injuries Subluxation
Occurs when bone displaces and partially separates Dislocation Excessive 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 bone Wrist/Forearm Fractures

26 Why are Injuries on the Rise?
Increase youth participation Immature bones and muscles Insufficient rest after an injury Poor training or conditioning Specialization in just one sport Year-round participation

27 Children & Sports Youths 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.

28 Injuries in Female Athletes

29 Injuries in Female Athletes
Common injuries in women/girls include: Anterior cruciate ligament (ACL) injuries Patellofemoral pain syndrome Stress fractures

30 ACL Girls Soccer – 1 torn ACL for every 6,500 times a girl competes or practices Boys Football – 1 torn ACL for every 9,800 times a guy competes or practices Girls 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 leg Making abrupt stops If 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.

32 ACL

33 ACL Injuries 400,000 reconstructions per year in the US
Females 4 times more likely to tear ACL with non-contact injury

34 ACL Women have an increased predisposition to ACL injury
Many theories, but no one proven definitive cause

35 ACL Injuries Intrinsic factors: Intercondylar notch size
Joint laxity Hormones Limb alignment Ligament size Intercondylar notch size Extrinsic factors: Conditioning Experience Skill Strength Muscle recruitment patterns Landing techniques

36 ACL Female athletes rely more on their quads and calf muscle than their hamstrings Jumping & landing techniques in women are also different

37 MRI ACL Normal Torn-ACL

38 ACL- What to do? Prevention Learn how to fall, jump and to cut
Plyometric training Reduce landing forces and improve strength ratios (quadriceps:hamstrings) Increase hamstring activation

39 Hip Pain in Runner 18 year old female runner with 1 month of anterior groin/inguinal pain Pain worse with weight bearing Over past week she has developed night pain What are the possibilities?

40 Differential Dx. Torn adductor muscle
Avulsion of adductor or sartorius muscle Pubic ramus fracture Femoral neck fracture Femoral shaft fracture SI joint subluxation Ruptured iliopsoas bursa

41 Physical Exam Swelling noted in groin and high proximal femur
Pain with all attempts at motion, especially internal rotation Distal pulses 2+ No distal sensory deficits

42 Do You Need X-rays?

43 AP Hip X-ray

44 MRI

45 Femoral Neck Stress Fracture
Groin pain in runner or jumper- don’t ignore Female triad at increased risk as well as those with an increase in training and postmenopausal women Need to know which side the stress fracture is on (compression vs tension side) Plain films often negative Get MRI

46 Treatment If stress fracture by x-ray or further imaging
Compression side 12 weeks to heal +/- NWB Tension side Ortho consult/surgery Femoral neck fracture-surgery Cross train Proper nutrition and calories

47 Complications if Missed
Stress to complete fracture Avascular necrosis Chronic pain End of career

48 Patellofemoral Pain Syndrome
Anterior knee pain Probably more than one etiology Chondromalacia (softening of cartilage) Malalignment of patella

49 Patellofemoral Pain Syndrome

50 Patellofemoral Pain Syndrome
Clinical Features and Exam: Reports of anterior knee pain Pain with climbing stairs and/or sitting for prolonged periods of time Pressure on the kneecap during bending and straightening of the knee may elicit cracking and popping with discomfort Abnormal kneecap alignment Genetic Acquired

51 Patellofemoral Pain Syndrome
Other causes Muscle imbalances Foot type (either flat or high arched feet) Shoes Overuse Treatment includes: decreasing activity, correct alignment issues, physical therapy for strengthening, bracing or taping

52 Patellar Dislocation Planted foot with twisting of the body around the knee (similar to ACL) Kneecap off to the side Very painful

53 Patellar Dislocation MRI

54 Patellar Dislocation Loose Body – Arthroscopy Brace? Rehab
Return to play when comfortable

55 Osgood-Schlatter Disease
Jumping sports-basketball, volleyball Dull, aching pain below the knee Bump may be present Boys 10-16 Girls 9-13

56 Osgood-Schlatter Disease
Overuse injury Traction apophysitis (growth plate)

57 Osgood-Schlatter Disease
Overuse injury Traction apophysitis (growth plate)

58 Osgood-Schlatter Treatment
NSAIDS Ice Brace Relative rest Full rest Physical therapy Knee immobilizer Cast

59 Osgood-Schlatter Disease
Pain usually goes away after the growth plate closes The bump will remain

60 Meniscus Tear History of twisting injury to the knee Pain Giving way
Symptoms Pain Giving way Locking Clicking Swelling You 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
Overuse Poor muscle balance Lack of flexibility Weakness in soft tissue Biomechanical problems Malnutrition Stresses on body are greater than body can compensate Symptoms Pain Tenderness after activity No or little pain in AM, but pain returns after activity

64 Stress Fractures Chronic, overuse injury
Most common in weight bearing bones Feet, tibia, femoral neck Seen commonly in Female Athlete Triad (eating disorders, amenorrhea (lack of menstrual periods) & osteoporosis(low bone mass) Diagnosis by x-ray, bone scan or MRI Treatment is rest, address biomechanical issues---some fxs are surgical (e.g. femoral neck)

65 Return to Running Progression of functional activity
Very structured, all timed Pain & symptoms are to guide progression Can have frequent setbacks

66 Return to Running Phase I: Walking Phase II: Plyometric Routine
30 minutes, aggressive, pain free Phase II: Plyometric Routine Hopping, 470 foot contacts Phase III: Walk/Jog progression 5 minute/1 minute to 2 minute/4minute Phase IV: Timed Running Schedule Intermediate & Advanced

67 Achilles Tendon Rupture
History Acute pain in the back of the ankle with contraction, no antecedent history of calf or heal pain Average age 35 Steroids, fluorquinolones, and chronic overuse may predispose to rupture Pathology Rupture occurs 3-4 cm above the Achilles insertion in a watershed area

68 Achilles Tendon Rupture
Physical Exam Tenderness over achilles tendon Palpable defect Positive Thompson’s test Needle test- needle inserted midline 10cm proximal to the superior aspect of the calcaneous moves towards the foot when the calf is squeezed No evidence to support routine use of MRI, U/S, or Xray

69 Achilles Tendon Ruptures
Surgical repair Younger active patients Nonoperative treatment Older sedentary patients Patients with increased risk of soft tissue complications IDDM Smokers Vascular disease BMI > 30

70 Achilles Tendon Ruptures
Nonoperative treatment Weaker tendon Higher risk re-rupture Slower return to sport No surgical morbidity Lower cost

71 Indications of Non-Operative Versus Operative Treatment
Non-Operative Tx may be indicated for older patients with minimally displaced ruptures Non-Operative may be indicated for patients who are at an increased operative risk due to age or medical problems Note 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 plantarflexion Cast is brought out of equinus over 8-10 weeks Walking is allowed (in the cast) at 4-6 weeks Alternatively, consider using functional brace starting in 45 degrees of flexion Following casting, a 2 cm heel lift is worn for an additional 2-4 months Long leg cast (LLC) Initial LLC in gravity equinus for 6 weeks, followed by short leg cast for 4 weeks

73 Achilles Tendon Rupture
Non-Operative Resistance exercises started at 8 weeks Return to sports in 4 – 6 months May 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 hospitalizations No wound complications No difference in functional strength Gillies and Chalmers- 80% vs. 84.3% return of strength compared to unaffected side, non-op and operative, respectively Wills, 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

75 Achilles Tendon Ruptures
Surgical repair Superior tendon strength Lower risk re-rupture (1-3%) Quicker return to sport Surgical morbidity Infection Dehiscence Superficial nerve injury Increased cost

76 Achilles Tendon Rupture
Surgical treatment Preferred for athletes Medial incision avoids the sural nerve Percutaneous vs. Open treatments described Isolate the paratenon as a separate layer

77 Conclusion The current preferred treatment in young and other wise healthy patients is surgical repair Conservative treatment remains an acceptable alternative in older, sick or sedentary patients who have fewer physical demands with limited functional and athletic goals

78 Lisfranc Injury Lisfranc injuries may represent 1% of all orthopedic trauma, but 20% are missed on initial presentation Inability to WB, mid-foot pain, weight bearing x-rays are key

79 Do You Need X-rays?

80 X-rays

81 Treatment RICE Bulky Jones dressing or posterior splint
NWB on crutches Frequent neurovascular checks Refer to Ortho

82 Complications if Missed
Chronic pain Arthritis Inability to run or jump Acute compartment syndrome

83 Wrestling Bursitis Shoulder injuries Auricular hematomas

84 Bursitis Knee Elbow

85 Shoulder Injuries Dislocation Separation

86 Shoulder Dislocation

87 AC Separation

88 Surgical Repair Shoulder dislocation AC joint repair

89 Ear Injury Irritation of the ears can occur to the point that permanent deformity can ensue. Some of these injuries may include: Cauliflower-ear Lacerations Ruptured eardrum To 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 abrasion Head or knee Incidence reduced with headgear 16% (51% to 35%) Only 5% of coaches require headgear at practice

91 Mouth Guards In addition to protecting the teeth, mouth guard absorbs shock and helps to prevent concussions.

92 Mouth Guards Correctly fitted mouth guard prevents the majority of dental trauma. Fit should be: Tight fit Be comfortable Unrestricted breathing Should 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
Cheerleading Journal of Pediatrics 10/21/12 Academy of Pediatrics Position Paper Sport Designation Better conditioning Availability of trainers Better coaching Undergo Physicals 37,000 ER visits last year

94 Injuries

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.

96 Ankle Sprain

97 Rehabilitation ROM, strengthening, flexibility, balance
Treatment R.I.C.E. – Rest, Ice, Compression and Elevation Modify athletic activity Rehabilitation ROM, strengthening, flexibility, balance Cooperation and communication between patient, parents, coaches and physician What 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.

98 Wrist Injuries

99 Ganglion Cysts

100 Mallet Finger

101 Finger Dislocations A 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 injury Exact 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 fascia Plantar 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 curb On a step Plantar fascia stretch 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.

107 Plantar Fasciitis Massage may be helpful
Warm up well before stretching Ice heel, minutes Anti-inflammatories Night splint If 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 pain See your physician if pain persists There 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
Tendonitis Overhand sports-pitching, serving: (tennis,volleyball), swimming Weight lifting Use proper technique, good supervision Shoulders 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 Injuries Reduce Intensity Warm up before Ice afterwards Work with coaches 10% Rule Don’t Increase Activity by More Than 10% Per Week

111 Conclusion Year round conditioning Cross train Warm up/ stretch
Use proper equipment Listen to your body Seek medical care if pain continues

112 Thank you THE END

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