Hip stiffness in athletes is associated with later development of chronic groin injury and as such may be a risk factor for this condition. "Sports hernia," pubic bone edema, and entrapment neuropathies-are potential causes of chronic groin pain in assessing athletes. 

Groin injury is among the most common cited injuries in the sports of ice hockey, soccer, Australian Rules football, calisthenics and cricket. There are very few prospective studies examining risk factors for groin strain injury in sport. There is support for an association of previous injury and greater abductor to adductor strength ratios as well as sport specificity of training and pre-season sport-specific training, as individual risk factors in groin strain injury in athletes. Core muscle weakness or delayed onset of transversus abdominal muscle recruitment may increase the risk of groin strain injury. Debate exists in the literature regarding the role of adductor strength and length as well as age and/or sport experience as risk factors for groin injury. There is no strong evidence to support a causal association for any of these risk factors and groin injury.  (Maffey L. Emery C. What are the risk factors for groin strain injury in sport? A systematic review of the literature. Sports Medicine. 37(10):881-94, 2007). 

MR imaging studies in 141 patients (134 male patients, seven female patients; mean age, 30.1 years; range, 17-71 years) who had been referred to a subspecialist because of groin pain showed MR imaging to have more sensitive and specific for rectus abdominis tendon injury and for adductor tendon injury. Injury in each of these structures was significantly more common in the patient group than in the control group. Only two patients had hernias at surgery. (Zoga AC. Kavanagh EC. Omar IM. Morrison WB. Koulouris G. Lopez H. Chaabra A. Domesek J. Meyers WC. Athletic pubalgia and the "sports hernia": MR imaging findings. Radiology. 247(3):797-807, 2008). 

Adductor dysfunction is a condition that can cause groin pain in competitive athletes. A single pubic cleft injection of local anesthetic and steroid into the adductor enthesis (tendon thickening) had been used.  This single injection gave at least one year of relief of adductor-related groin pain in a competitive athlete with normal findings on a magnetic resonance imaging scan; however, it should be employed only as a diagnostic test or short-term treatment for a competitive athlete with evidence of adductor longus tendon thickening (enthesopathy) on magnetic resonance imaging.  (Schilders E. Bismil Q. Robinson P. O'Connor PJ. Gibbon WW. Talbot JC. Adductor-related groin pain in competitive athletes. Role of adductor enthesis, magnetic resonance imaging, and entheseal pubic cleft injections. Journal of Bone & Joint Surgery - American Volume. 89(10):2173-8, 2007). 

eToims has been useful in the treatment of groin pain related to adductor dysfunction since it can be used repeatedly and regularly without side-effects.  Treatments have to be directed to all hip muscles supplied by multiple nerve roots as well as to muscles segments supplied by spinal nerve roots  above and below the hip joint.

www.stopmusclepain.com Chronic Pain| Groin Muscles

Increased knee-laxity measures may contribute to increased risk of anterior cruciate ligament  injury.

 
Strength training as a single intervention method may not be sufficient to reduce the risk of noncontact anterior cruciate ligament injury in female recreational athletes.

Female soccer and basketball players had an anterior cruciate ligament injury rate seven times that of male players.

The integrative effects of fatigue and decision making may represent a worst case scenario in terms of anterior cruciate ligament injury risk during dynamic single leg landings.

Females display knee moments and kinematics that may place them at greater risk for ACL injury during a stop-cut task. Females should be coached to perform stop cuts with more knee flexion and a more neutral knee rotation angle upon foot contact in an effort to reduce moments that may place the ACL at risk (Wallace BJ. Kernozek TW. Bothwell EC. Lower extremity kinematics and kinetics of Division III collegiate baseball and softball players while performing a modified pro-agility task. Journal of Sports Medicine & Physical Fitness. 47(4):377-84, 2007).

Women with anterior cruciate ligament reconstruction have neuromuscular strategies that allow them to land from a jump similar to healthy women, but they exhibit joint moments that could predispose them to future injury if they participate in sports that require jumping and landing. (Ortiz A. Olson S. Libby CL. Trudelle-Jackson E. Kwon YH. Etnyre B. Bartlett W. Landing mechanics between noninjured women and women with anterior cruciate ligament reconstruction during 2 jump tasks. American Journal of Sports Medicine. 36(1):149-57, 2008.

Altered equilibrium position of the tibiofemoral joint associated with reduced patellar ligament insertion angle and adaptations of gait patterns following anterior cruciate ligament injury may be associated with degenerative changes in the articular cartilage (Shin CS. Chaudhari AM. Dyrby CO. Andriacchi TP. The patella ligament insertion angle influences quadriceps usage during walking of anterior cruciate ligament deficient patients. Journal of Orthopaedic Research. 25(12):1643-50, 2007 Dec.

Revision anterior cruciate ligament surgery allowed approximately 60% of patients to go back to sports, most of them at lower levels than their prerevision function. Instrumented laxity of <3 mm was associated with a better result. Radiographic arthritis was associated with duration of instability symptoms after primary failure. Patients who undergo revision anterior cruciate ligament surgery should be counseled as to the expected outcome and cautioned that this procedure probably represents a salvage situation and may not allow them to return to their desired levels of function.  Battaglia MJ 2nd. Cordasco FA. Hannafin JA. Rodeo SA. O'Brien SJ. Altchek DW. Cavanaugh J. Wickiewicz TL. Warren RF. Results of revision anterior cruciate ligament surgery. American Journal of Sports Medicine. 35(12):2057-66, 2007

www.stopmusclepain.com Knee pain| Anterior cruciate ligament injury

Stress fracture is a common musculoskeletal problem affecting athletes and soldiers. Repetitive high bone strains and strain rates are considered to be its etiology. The strain level necessary to cause fatigue failure of bone ex vivo is higher than the strains recorded in humans during vigorous physical activity.

A study was performed to prove that during fatiguing exercises, bone strains may increase and reach levels exceeding those measured in the non-fatigued state. To test this hypothesis, this study was performed in 4 subjects to measure tibial strains, the maximum gastrocnemius isokinetic torque and ground reaction forces before and after two fatiguing levels of exercise: a 2km run and a 30km desert march. Strains were measured using strain-gauged staples inserted percutaneously in the medial aspect of their mid-tibial diaphysis. There was a significant decrease in the peak gastrocnemius isokinetic torque of all four subjects' post-march as compared to pre-run  indicating the presence of gastrocnemius muscle fatigue. Tension strains increased 26% post-run and 29% post-march  as compared to the pre-run phase. Tension strain rates increased 13% post-run and 11% post-march and the compression strain rates increased 9% post-run and 17% post-march. The fatigue state increases bone strains well above those recorded in rested individuals and may be a major factor in the stress fracture etiology. (Milgrom C. Radeva-Petrova DR. Finestone A. Nyska M. Mendelson S. Benjuya N. Simkin A. Burr D. The effect of muscle fatigue on in vivo tibial strains. Journal of Biomechanics. 40(4):845-50, 2007.

Consider stress fracture as a diagnosis in adolescent athletes complaining of worsening vague pain without a clear mechanism of injury. Remember that initial radiographs may be normal, especially early in the clinical course. If the fracture is of low risk for delayed or non-union, conservative management is indicated, with repeat radiographs 2 weeks after initiation of treatment. If a high-risk fracture is suspected, early diagnosis with MRI, bone scan, and, in some cases, CT is important for surgical decision making. (Logan K. Stress fractures in the adolescent athlete. Pediatric Annals. 36(11):738-9, 742, 744-5, 2007) 

www.stopmusclepain.com Muscle fatigue| Stressfractures

A recent report in the Lancet medical journal reports that in a survey of 3,982 Americans, 29% of men and 27% women reported feeling some pain.  Those who have higher levels of pain are usually those with lower income and less education working in manual labor and other blue-collar jobs.  About $60 billion in productivity is lost each year because of workers experiencing pain and about $13.8 billion was spent on prescription medicines in 2004.  

Pain can start as early as the teen years and increases to the mid-40s and then plateau to increase again after age 75.  The degenerative changes seen in autopsies confirm the reason for these pain symptoms (see below).   

The intervertebral discs lies between the vertebral bodies, linking them together. The components of the disc are nucleus pulposus, annulus fibrosus and cartilagenous end-plates. The blood supply to the disc is only to the cartilagenous end-plates. The nerve supply is basically through the sinovertebral nerve. The important components of the disc are collagen fibers, elastin fibers and aggrecan. As the disc ages, degeneration occurs, the nucleus dries up, and the disc flattens. During these changes, pain producing nuclear material tracks and leaks through the outer rim of the annulus. This is the main source of disc related pain. While this is occurring, the degenerative disc, having lost its height, effects the structures close by, such as ligamentum flavum, facet joints, and the shape of the neural foramina. This is the main cause of spinal stenosis and radicular pain due to the disc degeneration in the aged populations. (Raj PP. Intervertebral disc: anatomy-physiology-pathophysiology-treatment. Pain Practice. 8(1):18-44, 2008).  

In a study of 248 sections of lumbar disc and vertebral bodies from 41 routine autopsies (range, 7 months to 88 years), these degenerative changes were noted:  fibrous transformation starts in the nucleus, then annular disorganization, endplate, and vertebral body alterations progress.  These changes occur predominantly in the first 2 decades and in the 5^th to 7^th decades. In the 3^rd and 4^th decades, little progression occurs. Nuclear clefts and annular tears appear later, mostly starting in the 2^nd decade, with clefts preceding formation of tears. Radial and concentric tears develop similarly over time, whereas rim lesions mostly develop after the sixth decade. Significant differences are observed between upper and lower lumbar spine.  Haefeli M. Kalberer F. Saegesser D. Nerlich AG. Boos N. Paesold G. The course of macroscopic degeneration in the human lumbar intervertebral disc. [Journal Article. Research Support, Non-U.S. Gov't] Spine. 31(14):1522-31, 2006.

www.stopmusclepain.com Pain| Disc Degeneration

In a study to investigate the co-morbidity of chronic refractory headache with obstructive sleep apnoea syndrome, seventy-two patients (51 women and 21 men) with chronic and refractory headaches, whose headache occurred during sleep or whose sleep was accompanied by snoring, were submitted to polysomnography.  

Patients diagnosed with obstructive sleep apnoea syndrome began continuous positive airway pressure (C-PAP) treatment and were followed up for >or= 6 months.  Twenty-one cases of obstructive sleep apnoea syndrome were identified (29.2% of the total investigated). 

Headaches were classified into several headache disorders, medication overuse headache and cluster headache being the most prevalent. Multivariate regression analysis revealed that age, male gender and body mass index were associated with obstructive sleep apnoea syndrome. C-PAP treatment improved both sleep apnoea and headache in only a third of the cases.

Patients suffering from chronic refractory headache associated with sleep or snoring, in particular those who are also middle-aged, overweight men, should be considered for polysomnography. C-PAP treatment alone does not seem to improve headache, but further investigation is needed. (Mitsikostas DD. Vikelis M. Viskos A. Refractory chronic headache associated with obstructive sleep apnoea syndrome. Cephalalgia. 28(2):139-43, 2008).

In another study, it was found that headache and neck pain were more likely among patients admitted for polysomnography compared with the general population (n = 41 340). This association was mainly restricted to those with frequent complaints (> or =7 days per month).

Chronic headache (headache > or = 15 days per month) was seven times more common among individuals with and without confirmed obstructive sleep apnoea syndrome than in the general population. There was no linear dose-response relationship between headache and neck pain and severity of apnoea or oxygen desaturation. Thus, hypoxia per se is less likely to explain the high headache prevalence among patients admitted for polysomnography. (Sand T. Hagen K. Schrader H. Sleep apnoea and chronic headache. Cephalalgia. 23(2):90-5, 2003 Mar)    

It is essential to have chronic pain patients especially those on long-term narcotics complaining of sleep difficulties examined for sleep apnoea.  There is a dose-dependent relationship between chronic opioid use and the development of a peculiar pattern of respiration consisting of central sleep apneas and ataxic breathing. (Walker JM. Farney RJ. Rhondeau SM. Boyle KM. Valentine K. Cloward TV. Shilling KC. Chronic opioid use is a risk factor for the development of central sleep apnea and ataxic breathing.[erratum appears in J Clin Sleep Med. 2007 Oct 15;3(6). Journal of Clinical Sleep Medicine. 3(5):455-61, 2007)

www.stopmusclepain.com Headaches | Sleep Apnoea

An online survey to investigate predictors of high physical function in 2,580 people with fibromyalgia (FM) showed that  significant explanatory variables of high physical function were: men, greater education, younger age, lower intensity fatigue, spasticity, and balance problems, not using prescription pain medications, using aerobic or strength training exercise, and not using relaxation methods. 

Conclusions were that people with FM suffer from multiple symptoms and use many modalities to control symptoms to remain functional.  The authors had questions pertaining to developing strategies to promote better functioning, prospective trials to track the natural course of study variables, measuring their effect on function, and to test effects of interventions to maximize function. (Rutledge, Dana N.; Jones, Kim; Jones, C. Jessie Predicting High Physical Function in People With Fibromyalgia. Journal of Nursing Scholarship. 39(4):319-324, December 2007). 

Important to note is that the study variables can be seen in earlier and milder cases of fibromyalgia which relates to better function levels in these types of individuals.   

Self-care education is very important in patients with fibromyalgia to maintain physical function. Repetitive motion activities (even if aerobic) are to be avoided as much as possible with frequent rest periods if exposed to such tasks. 

Strength training activities are not encouraged. Weightlifting should be curtailed and anything lifted should be less than 2 pounds (maximum less than 5 pounds) at a time and lifting must be with using both arms.  There should be no reaching forward or lifting with arms outstretched or performing overhead activities.  Any lifting should be done with the elbow at the side of the body.  This pertains also to any activities that involve pushing or pulling.  Unsuspecting injuries occur with opening or closing heavy-duty doors and drawers. 

Any activities done should have equal duration of rest for the duration of activity performed.  There is tendency for patients to continue exercises either by number of repetitions or by a set time session for the exercise.  The best way is to titrate the activities by the level of feelings of discomfort, soreness, pain, achiness, tightness, stiffness, and fatigue.  The activities must be stopped immediately and the patient must rest as soon as the symptoms increase so that the pain symptoms do not escalate.   

Pain and discomfort symptoms in nerve related muscle pain is from ischemia and anoxia to nerve and muscle tissue when the muscles shorten and tighten.  Pushing through pain will just make to ischemia and anoxia worse leading to escalating pain through ireversible nerve damage. 

Chronic pain and fibromyalgia are lifelong diseases and patients must learn how to preserve their physical functions for as long as possible by knowing about self-care techniques. 

Treatments to decrease the level of pain is essential for maintaining or increasing function with improvement in quality of life.  eToims reverses the ischemia and anoxia that causes nerve damage allowing nerves and muscles to heal.   Please visit the main site of www.stopmusclepain.com to learn about the role of eToims in relieving acute and chronic nerve related muscle pain such as that experienced by patients with fibromyalgia. 

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