Joint Problems and Injuries

(The following section was adapted from a series of articles by the author in conjunction with Dr. Sal A. Arria for Muscle & Fitness magazine.)

Most athletes are no strangers to joint problems, and martial artists are no exception. The following section deals with the most common joint problems and injuries, and offers a range of preventive suggestions and solutions. Remember that with any medical problem, the most prudent first step is to consult with a competent sports medicine physician, chiropractor, or other health care specialist.

The Elbow

Considering the incredible and constant strain the elbow experiences, it is a very sturdy joint! The elbow is a ginglymus, or hinge-type joint, formed by the humerus bone of the upper arm and the radius and ulna bones of the lower arm. Although only flexion and extension occur around the elbow itself, the joint also permits rotation of the radius around the ulna.

The elbow is encased within an extensive synovial membrane, which synthesizes synovial fluid for the purpose of lubricating the joint. The elbow is quite stable, owing to the numerous tendons and ligaments that contribute to its integrity. In fact, over a dozen muscles cross the elbow joint, not just the biceps and triceps!

Causes and Pre-conditions for Elbow Problems. Acute traumatic elbow injuries are fortunately rare. Those that do occur are almost always the result of extreme stress in power and explosion events such as judo, wrestling, boxing, and various forms of full contact combat. Traumatic injuries of any type must receive immediate medical attention by a qualified sports medicine physician. Chronic injuries in the elbow are usually a result of overuse. Fighters often suffer from such conditions. Most athletes fail to consider the cumulative impact of all stressful events on the elbow, limiting their attention only to training-related stress. Some of the occupations that present certain risks to the elbow include mechanics (constant work with wrenches, screwdrivers, etc.), secretaries and office workers (constant typing, and writing), and health professionals (massage, physiotherapy, and other forms of physical manipulations).

These types of people are at risk for repetitive overuse syndrome (R.O.S.) to the elbow, due to constant and excessive contracture of the gripping muscles (all of which cross the elbow joint). Most R.O.S. of the elbow is seen in the dominant side, so "handedness" becomes an additional factor to consider in these types of injuries.

In grappling disciplines, clenching the gi repetitively during throws often tightens the flexor tendons of the hand wrist and/or arm, resulting in a possible overuse tendinitis of those flexors at the medial epicondyle and/or restrictions due to myofascial adhesions throughout the forearm.

Intense sparring involving choke holds is highly abusive to the biceps, brachialis, and brachioradialis tendons just above the elbow or at their attachments on and near the lateral epicondyle of the forearm. The tendon of the long head of the biceps at the shoulder could also experience overuse from too many hours spent choking an opponent without considering recovery methods.

The vulnerability of the elbow is apparent in the tiny size of the tendinous attachment sites, of which there are many. These sites can become progressively weakened by both impact and the dynamic forces of leverage. This leverage means that ten pounds in the hand equals approximately 45 pounds at the shoulder joint, for a person with average arm length.

Another way to view this phenomenon is to compare the force achieved by turning a bolt with a long-handled wrench, as opposed to a short-handled wrench. Using this analogy, its easy to see how a boxer throwing a wide hook can impart high leverages to the elbow, as compared to a tightly thrown hook.

The impact of repetitively hitting an opponent or a heavy bag can result in high levered forces, causing cumulative microtrauma to the tendinous attachment sites at the elbow. Over time, if not treated, these tendons actually begin to fray, much like a nylon rope would if stretched beyond its tensile strength. Eventually, the tendon can detach from its attachment site at the elbow, requiring surgical repair.

Its important to note that tendons and musculotendinous areas in muscles fatigue first in sport and are the places most commonly prone to overuse type injuries. One way to prevent this is to ensure that the areas which are highly stressed in one's discipline are strengthened adequately to withstand the loads placed on them.

Stretching the forearms after exercise is helpful to keep the fascia within muscles and tendons flexible and unadhered. An individual who feels the possibility of a trauma or tear to a muscle or tendon should apply ice immediately to induce recovery before the inflammation involves surrounding tissues as well. This will often resolve the problem before it becomes a bigger one. If ice is not readily available, use the nearest soda can. Even five minutes of cold applied immediately is far more effective at eliminating a potential problem than doing nothing at all.

Treatment Options: From Conservative to Radical

1) Rest. The most effective yet overlooked aspect of post-injury recovery is simply to become more aware of and markedly limit activities that cause pain and swelling to the affected area! In light of the elbows ubiquitous role in almost all human activity, this is no easy task!

2) Massage. Carefully applied massage techniques can be of great assistance in mitigating the adhesions which result from micro- or macro-trauma out of the connective tissue. Find a physical therapist who works with athletes or a sports massage therapist who knows how to effectively apply cross-fiber friction massage, sometimes called Deep Transverse Friction (DTF), developed by an orthopedist, James Cyriax, for these kinds of injuries.

Active Release Technique (ART) is also very effective at ungluing the adhered and restricted muscles, connective tissue and tendons. Some forms of deep tissue work like Rolfing can be applied effectively to hypertonic or adhered tissues depending on the skill of the practitioner. Look for someone who has background working with sports applications and specific training for athletes. Personal recommendations from other athletes who have experienced the practitioners skills are often the best referrals.

3) Forearm Strap. This is used by tennis players, golfers, and other athletes with elbow problems. The strap acts like a "shunt," absorbing impact and vibrational forces before they reach the tendinous attachment at the elbow. One of the best straps is the Interceptor (ordering information is in the resources section).

4) Aspirin Therapy. Aspirin reduces an edema (swelling). Recovery simply does not begin until an edema has subsided.

5) Diathermy. This is a high frequency form of heat which can penetrate as deep as two and one-half inches into injured tissues. Administered by a chiropractor or physical therapist, diathermy promotes circulation to the injury site, accelerating the healing process. Diathermy should precede cryo-therapy treatments.

6) Electrostimulation: Moderate to intense amounts of intermittent electrostimulation are applied directly to the injured tendinous area or ten to fifteen minutes per session. This form of electrostimulation is most effective when it follows diathermy and is followed up with cryo-therapy.

7) Cryo- Therapy: After diathermy or deep massage, construct an ice pack by placing crushed ice in a "zip-lock" bag, or keep a package of frozen peas in the freezer, marked "do not eat," and use them. These frozen packages are cheap and mold well around the joints. Alternatively, "blue ice" is very inexpensive now, retains its soft gel like texture when cold, and sometimes comes with a neoprene wrap which can be Velcroed around a wounded area for icing several times a day without having to stop other activities to do it. Cryo-therapy is very beneficial in reducing edema, reducing pain, and pumping muscular tissues free of accumulated training-induced waste products. Spend at least five minutes, but no longer than twenty minutes on the ice.

Upon initial discovery of an injury, ice it as much as five times the first day or two depending on the extent of the trauma, with at least an hour between each icing. After removing the inflammation and edema, ice also causes reflexive dilation of the capillaries, thus ensuring increased blood flow to the area, bringing in the nutrients and proteins required for cellular repair. It is a very simple but possibly most effective tool for quick recovery from the minor glitches which often come with sport training.

8) Cortico-Steroids. Administered by injection to the injury site, cortico-steroids help to reduce inflammation and pain. The drawback, however, is that these agents cause a breakdown of collagenous and ligamentous tissue after repeated injections.

9) Pro liferent-Injection Therapy. This describes an injection directly into the injury site, causing an "artificial injury" which then provokes the collagenous cells to begin restructuring themselves more quickly.

10) Surgery. In the most extreme cases, a torn or avulsed tendon or ligament may require surgical reattachment. This is "the final straw" when it comes to solutions for joint problems! Many methods are used, including tendon grafts, and stapling. Prevention is the key! Fortunately, most serious elbow problems can be completely prevented with good training and work habits, and immediate intervention upon the onset of trouble. Never train through elbow pain. Instead, seek the immediate guidance of a qualified sports medicine physician or chiropractor.

The Shoulder

Any athlete training for more than two or three years has probably experienced shoulder pain. More than any other joint, the shoulder seems particularly prone to injury, both chronic and acute. Once shoulder pain has set in, even routine daily tasks such as putting on a shirt overhead or shampooing in the shower become burdensome. Training seems beyond the bounds of possibilities, since nearly all movements involve the shoulder in varying degrees. Even squatting and calf raises involve and can aggravate shoulder problems.

The shoulder's role as the "black sheep" of joints stems from it's structure. First, the gleno-humeral (G/H) joint (where the head of the humerus attaches to the shoulder complex) is a ball-and-socket type joint, but unlike the hip, the G/H joint is quite shallow. In fact, the bones contribute little to the joint's stability. That role falls onto the surrounding muscles and their tenuous attachments, as well as the capsular ligaments. Always remember that the shoulder's forte is mobility, not stability.

The second structural factor leading to shoulder dysfunction is the enormous leverage that can be applied to the shallow G/H joint by the arm. Remember that for a person of average arm length, a ten-pound dumbbell in the hand equates to over forty-five pounds of force at the shoulder joint when held out at arms' length, such as in a lateral raise.

Causative Factors in Shoulder Injury. Shoulder injuries stemming from both sports and training-related events are summarized below:

Sports-Related Shoulder Injuries.

1) Falling In many combat disciplines, including wrestling, judo, aikido, sambo, and other grappling arts, falling is inevitable. During a fall, the hand instinctively reaches out to break the fall, decelerating the body's downward movement with the arm outstretched. This instinctive reaction creates a long lever which results in tremendous mechanical forces to the G/H joint-fulcrum, often leading to injuries ranging from strains and sprains of the surrounding muscles and ligaments to subluxation (less than a full dislocation) or in the worst-case scenarios, dislocation of the joint.

2) Striking/punching. Any hitting or swinging movement is essentially an attempt to separate the G/H joint, in biomechanical terms. Toward the extreme range of movement in any punching skill, the rotator cuff muscle group is responsible for decelerating the arm. Since many individuals have very weak rotator cuffs and posterior deltoids as compared to the anterior shoulder muscles, the deceleration aspect of the punch often results in strains and sprains of the shoulder's soft tissues, especially those of the rotator cuff.

3) Impact. Nearly all combat sports involve direct and often violent impact to the shoulder and arm. Direct blows to the upper arm in particular can "pry" the G/H joint apart, creating injuries ranging from microtraumatic soft tissue injuries to shoulder separations. Additionally, multiple shoulder injuries stemming from years of athletic participation often result in adhesions, loss of range of motion, calcium deposits, and degenerative changes to the joint itself. With each new injury, the shoulder becomes both more prone to, as well as less capable of withstanding, further injuries.

Training-Related Shoulder Injuries.

1) Bench Pressing. Arguably the most popular current-day gym exercise, this great builder of pectorals also results in legions of shoulder wrecks. Besides contributing to the imbalance between the anterior and posterior muscles of the shoulders, the bench press has an almost mystical allure for many trainees, making it more of a demonstration event than a training exercise for many.

The bench is the vehicle for more forced repetitions, heavy negatives, missed attempts, and bad training form than any other exercise. Over 90% of all shoulder injuries from bench pressing occur during the transition or amortization phase between the negative and positive portions of the movement.

Specifically, a rapid lowering of the bar prior to pressing upward results in large linear momentum forces which must then be quickly reversed by the shoulder musculature before the bar can be raised. When these forces exceed the strength of the joint mechanism, the shoulder may not be capable of reversing the accumulated momentum, which means that the lifter will miss the lift, suffer a muscle tear, or both. For this reason, always lower the bar with complete control. This does not mean a full "coffee break" pause, however! With the exception of a competitive powerlifter, a controlled "touch-and-go" movement is best.

2) Muscle Imbalance. As noted earlier, most trainees neglect the posterior shoulder musculature in training. Most popular gym exercises such as bench-presses, seated-presses, lat pulldowns, and so on involve internal rotation of the humerus at the shoulder joint. The movements that work the external rotators, infraspinatus, part of the rotator cuff group which reinforce the capsule of the shoulder joint (bent laterals, etc.) have little are no cosmetic value, so few trainees do them. That is, until they suffer a shoulder injury. Eventually, the weaker muscles in the rotator cuff become virtually useless in performing their intended role in stabilizing the shoulder.

3) Overtraining. Not in the traditional sense (i.e., performing deltoid exercises too frequently), but in the sense that whenever a bar or dumbbell is in hand, there is stress on the shoulder joint. From this perspective, even exercises for the back, biceps, or triceps can significantly aggravate existing chronic shoulder symptoms. Avoiding this type of overuse demands a purposeful, conscious approach to nearly every movement, both in and out of the gym! Some of the most common movements, such as getting up off of the floor after doing crunches, opening a car door, or putting on a sweater can add stress to a malfunctioning shoulder.

The Knee

The prevalence of knee problems among martial artists can be attributed in part to the fact that the knee is an anatomical vortex of sorts, where the body's largest and strongest muscle groups converge upon a tiny, though sturdy kneecap (in most cases). When this structure suffers from improper kicking technique, exercise form, and/or unsuitable training gear, the prescription for disaster becomes compounded exponentially.

Common Knee Problems and Solutions.

1) Chondromalacia. Defined as an abnormal softening of cartilage which roughens the underside of the patella. Causes may include obesity, improper footwear, inadequate quadriceps flexibility, repetitive overuse, or genu valgum (knock knees). Chondromalacia causes pain when rising out of a seated position or ascending stairs. When chondromalacia is suspected, discuss the problem with a doctor. Prescriptions include cold and/or heat packs, anti-inflammatories or exercises to correct possible underlying causes from muscle strength imbalances between vastus medialis and lateralis.

2) Instability. This is indicated by a tendency for the knee to suddenly "give out," usually caused by lax ligaments from old injuries. Any individual who experiences a knee suddenly giving out should immediately see a doctor. If torn structures are ruled out, the doctor may prescribe leg extensions with toes pointed inward to strengthen the medial quadriceps.

3) Locked Knee. This is usually caused by a torn meniscus cartilage or a loose body within the joint cavity. A locked knee should receive prompt medical attention. Arthroscopic surgery is often warranted, with good results. If left unattended this could deteriorate into an arthritic knee, a much bigger problem.

4) Swelling/Tightness. Almost without exception, this indicates an internal injury. Stop training and seek competent medical assistance immediately. Do not try to force a knee which is swollen and unable to fully straighten or flex into full ROM. Otherwise, this could turn the temporary swelling into a permanently injured or arthritic knee. Not a good plan.

5) Crepitus. Defined as "noisy" knees that snap, crackle, and pop. If the crepitus is not painful, don't worry. But if pain and / or swelling accompany the noise, see a doctor.

6) Arthritis. Osteoarthritis is the "normal" wear and tear of the joint. It often occurs with age and overuse. Rheumatoid arthritis is the more severe and disabling form of joint inflammation (and sometimes destruction). If a doctor confirms arthritis, avoid high impact leg movements, lose excess weight (if applicable), and perform exercises with the doctor's approval. Arthroscopic surgery may help in some cases.

Weight Training Tips for Healthier Knees.

For squats, hack squats, and leg presses, foot position is an important variable in determining training results and safety of the knees. Although each athlete must determine his or her own best stance for each exercise, (based on the person's distinct anatomical peculiarities such as height and leg length), every athlete should consider the following notes about proper stance.

1) The quadriceps muscles can push more efficiently when the feet are pointing slightly outward as opposed to straight ahead. Athletes who squat with a very wide stance recruit the adductors to assist the quadriceps. This can result in undue stress to the medial collateral ligament, abnormal cartilage loading, and improper patellar tracking.

2) In any leg training movement, make sure the knees are tracking directly over the feet, not to the inside or outside. Many athletes turn their knees inward when rising up from a heavy squat, and they usually aren't aware of it. Get feedback from a coach, training partner, or videotape of a training session to preclude this mistake. Athletes who discover they are turning their knees in should reduce their training load until proper technique is achieved and the legs become strong enough to perform the movement correctly.

3) When rising out of a squat, always push from the heels. This not only keeps the shins more vertical, but also allows the hamstrings to contribute to the movement with maximum efficiency. Balance improves as well, adding an extra margin of safety.

4) Although many athletes use a very close stance (feet together) for the purpose of isolating the quads when squatting, remember that anything that isolates the quads also intensifies the shearing forces to the patellar tendon and ligament. Some have knees that can take this kind of abuse, but others don't.

5) When squatting, try to be efficient in the exit from the rack, and while establishing stance. After lifting the weight from the rack, take just one step backward and assume the squatting stance immediately. This takes time to master, but the reward is to get right into the stance without lots of minute adjustments. Once set in the stance, keep the feet "nailed down" for the duration of the set. Many people fidget with their feet and toes between repetitions which can cause a variety of problems, ranging from a break in concentration to a loss of balance.

Training Shoe Selection and Knee Health.

Athletic footwear is the foundation of leg training. Wearing broken-down fitness shoes (or so-called "kicking shoes" that are recently popular) for heavy squatting or leg pressing is like putting old, worn-out tires on a race car!

Why? Because most general purpose fitness shoes simply lack adequate stability, and have little or no arch support for heavy lifting. During squats, many athletes pronate, or "cave in" their feet. When this happens, the knees are also forced inward, leading to a constant strain on the medial collateral ligament, excessive shear force on the meniscus, and improper patellar tracking, all of which lead to chondromalacia. Those whom pronate anyway, or are knock-kneed, have an even greater need for good training shoes.

Specialized shoes provide a deep and solid heel cup, which prevents the feet from rocking and rolling laterally (to the outside) when they're compressed under heavy loads.

It's also worthwhile to know the difference between a worn-out shoe and one that's broken down. Even if a pair of shoes look fine, they still may offer no arch or heel support at all either because they never had any to start with or because after a handful of heavy leg sessions the supports have compressed to the point where they no longer function as they were intended.

Think about it: A tennis shoe is meant to support a 160-pound tennis player, not a 600-pound leg press! Loads like these cause the shoe to break down without visual signs of wearing out. Choose a heavy duty training shoe for use in weight training only. Use a stable running shoe or cross-trainer for other training activities.

Therapeutic Options.

1) Cryotherapy. The "gold standard" of therapy for minor knee pain or swelling, the application of ice reduces edema, promotes circulation, and deadens pain. Crushed ice in a "zip-lock" bag makes the most effective ice pack. The effectiveness of cryotherapy is perhaps doubled when applied with the leg elevated. With the ailing leg in a vertical or nearly vertical position, (lie down on the floor and put a heel on the wall), use an Ace bandage to secure an ice pack to the injured knee. This procedure reverses the hydrostatic or columnar pressure which accumulates during a long day of standing.

When experiencing any trauma to the tendons or ligaments of the knee, employ ice massage immediately to help speed up the healing. Wrap the back one-third of an ice cube with a paper towel to make a handle. Or, freeze a dixie cup of water and peel away the top one-fourth of the paper and use the edge of the ice as a tool. Many athletes prefer the square shape because the corner is a more precise tool to place exactly on the site of the lesion. Rub the ice back and forth across the site of the lesion (the exact spot where the pain is) moving the skin and underlying tissue as one.

Repeat this cross-fiber ice massage for thirty seconds to two minutes for each spot which is painful, then follow it with five to fifteen minutes of regular ice therapy to enhance the chances of removing an adhesion out of a tendon or ligament before it becomes a worse strain or sprain. This treatment protocol should be applied every other day as long as it continues to improve and for as long as there is still some small sign of pain in the area. Tendons and ligaments can be worked effectively this way immediately after injury. Muscle bellies should not be worked deeply immediately after an injury.

2) Aspirin Therapy. As noted previously, most athletes simply don't realize the effectiveness of aspirin for relieving pain, reducing edema, and improving circulation. Many individuals find that minimal dosages work as well for them as larger doses. Check with a doctor about any medication, however. Caffeine is thought to be a catalyst for aspirin, improving it's effectiveness. Those who tolerate caffeine well should consider this enhancement.

3) Diathermy. A professional therapeutic modality, diathermy is a high-frequency form of heat that penetrates injured tissues deeper than any other available heat modality. Diathermy increases vasodilation (blood supply) needed to carry nutrients to injured tissues. Any form of heat therapy should be followed by cryotherapy for best results.

4) Electrostimulation. Typical use involves electrodes that create a contraction of the surrounding musculature, pumping edema out of the affected tissue. An atypical application, pioneered by former Eastern Bloc sports medicine specialists,72 involves placing electrodes not on the muscles, but directly on the joint. Moderate to intense amounts of intermittent stimulation are applied for ten to fifteen minutes per session. This type of trans-articular electrostimulation is most effective when implemented immediately after diathermy, followed by cryotherapy and elevation.

5) Extremity Adjusting. At times, the relationship between the three bony components of the knee can become slightly askew. By using extremity adjusting, a good chiropractor can easily restore normal alignment.

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