How to stretch and strengthen calf muscles [pdf]
By Dr. John Aronen

By Dr. John Aronen

Older men would be wise to get an annual PSA. A colonoscopy also is a good idea after turning 50.

 
I’ve been writing for Handball magazine since 1984. I always write about musculoskeletal injuries, the area of medicine in which I have extensive training, experience and expertise.

While I was team physician at the Naval Academy, people used to ask my wife what I did for a living. She would reply that I was a vulture: I would cover athletic events waiting for someone to get hurt. That statement is only partly true, for my love is taking care of athletic injuries, and to do that you must be where the action is.

Fortunately, most patients with athletic injuries return to an active lifestyle.

Unfortunately, over the years of my involvement with the USHA, life-threatening medical conditions have occurred not only to myself and my family but also to the members who I have grown to know and love. So let’s discuss medical conditions each of us is prone to develop but often can be prevented. Five conditions come to mind. We can significantly lower the possibility that we will develop them or, if we do, increase the chance of catching them in the early stages, when the prognosis for successful treatment is high.

Colorectal cancer

The good news is that this is a very slow-growing cancer. If detected in its early stage before it has metastasized to organs outside the colon, the chance of successful management is very high.

The bad news is twofold:

• The patient does not experience any symptoms as the cancer grows in the colon or spreads to other organs.
• The chance of successful management decreases significantly once the cancer has spread outside the colon.

Colorectal cancer most frequently occurs in men and women older than 50, but it does occur in patients between 40 and 50.

Since there are no symptoms, what can one do to ensure early detection? The answer is to have a colonoscopy performed when you turn 50, or sooner if recommended by your physician.

A colonoscopy should not be confused with a flexible sigmoidoscopy. Only a colonoscopy, which is performed on an outpatient basis at a hospital, allows the physician to view the entire colon. If the physician notes any questionable lesions or polyps, a biopsy can be easily taken.

Because this cancer is slow-growing, if your first colonoscopy is negative, you will not need another for seven to 10 years.

Alternatively, a virtual colonoscopy can be done. This involves no foreign objects being inserted into your colon. Instead multiple views of your colon are taken with a scanning device. The downside is that if any suspicious lesion or polyp is noted, a regular colonoscopy must then be done to perform biopsies.

The main things to remember are:

• Colorectal cancer, if detected before it metastasizes outside the colon, has a high probability of successful management.
• There are no symptoms.
• The only reliable tests are the colono-scopy and the virtual colonoscopy.

Prostate cancer

About 20 years ago, males had their prostate evaluated in an enjoyable exam by a urologist–typically one with large hands and knuckles! The exam allowed the physician to determine the size and firmness of the prostate, but in reality this was inadequate for cancer screening.

Now a simple blood test, called the PSA, can be done yearly to detect increased activity of the prostate gland that may be compatible with cancer. PSA tests are recommended yearly from 50 on, along with the examination.

As with colorectal cancer, there are no symptoms when this cancer is isolated to the prostate. It typically metastasizes to bone in the lower back, resulting in low back pain. Thus, evaluation of low back pain in males older than 50 should always include a check for prostate cancer. Be sure to have your PSA level checked annually.

Cardiovascular disease

Thought of as a disease of males, cardiovascular disease–coronary artery disease, heart attacks and strokes–is unfortunately just as prominent in women.

Though breast cancer gets the majority of notoriety, a significantly larger number of women die from cardiovascular disease than from breast cancer.

Factors that contribute to the onset of cardiovascular disease are smoking, diabetes, high blood pressure, elevated cholesterol and being overweight. Genetics plays a significant role in the onset of cardiovascular disease, and though nothing can be done to treat genetics, it does alert your physician of your higher risk.

Looking at these factors, it appears that each can be easily addressed:

• Stop or, more wisely, never start smoking.
• Work with your physician to keep your diabetes under control.
• Work with your physician to keep your blood pressure under control.
• Have your cholesterol checked and work with your physician to keep your cholesterol at the limits desired with a diet and exercise regimen.

If your cholesterol level cannot be controlled with diet and exercise alone, the addition of cholesterol-lowering drugs called statins may be necessary. A recent report found that most people with elevated bad cholesterol (LDL) chose to continue inappropriate dietary habits and avoid exercise since they were able to lower their bad cholesterol simply with a pill. How sadly this speaks for our society.

Cardiovascular disease typically provides warning signs. But one reason people die unnecessarily from heart attacks and strokes is denial of the symptoms.

Heart attacks can present a variety of symptoms, but in all cases patients usually
feel that something is wrong. Common symptoms are just not feeling good, a feeling of indigestion, tightness in the chest, pain or discomfort in the jaw or left arm, and sweating. It is not uncommon for women to experience tightness or discomfort in their upper back.

One of my friends experienced tightness in the chest, became scared and drove himself to the parking lot of the emergency room, only to have the tightness slowly subside. He then decided it was nothing–denial–and started to drive home, only to have the tightness in his chest return. But this time he also started sweating profusely.

Now really scared, he drove back to the emergency room and was rushed to the operating room. He had two stents inserted into the main arteries of his heart that night.

The moral of the story is having a heart attack isn’t necessarily the end of the world with the new treatment methods available. But denying that you may be having a heart attack can result in the end of your world.

Common symptoms of strokes, which occur and cause death more frequently in women than men, are numbness or weakness in one side of the face, an arm or a leg; impaired vision in one eye or double vision; confusion; trouble speaking or swallowing, and severe headache.

The vast majority of strokes result from a clot in one of the arteries in the brain. If treated with clot-destroying drugs within three hours, chances of a successful recovery are high.

Delayed treatment due to denial, which significantly reduces the chances of favorable results, is too common.

Breast cancer

Genetics plays an important role. Women with family members diagnosed younger than 50 are more prone to develop it.

Thanks to all the research, cases caught in the early stages before metastasizing have a high cure rate. All women should learn how to perform self-examinations and have routine evaluations as recommended by their physician.

Malignant melanoma

The USHA’s Matt Krueger is wise to keep the sun off his face as he works in Toledo.

There are three types of skin cancer: squamous cell carcinoma, basal cell carcinoma and malignant melanoma.

Having spent my life destroying my skin with the sun, I have had my share of squamous and basal cell carcinoma lesions removed. In comparison, my wife, who hails from Montana and avoids the sun, has had two malignant melanomas removed.

The doctors think she developed them when she suffered a number of severe sunburns as an adolescent. It appears that severe sunburns during our adolescent years predispose us to malignant melanomas in later life.

Whereas squamous cell and basal cell carcinomas can typically be treated with local excision using a procedure that ensures all the cancerous cells have been removed, malignant melanomas are different. Malignant melanomas, which typically develop from a pre-existing mole or skin lesion, result in subtle changes in their color and configuration: They usually become darker, and the borders become uneven. Additionally, malignant melanomas invade the deeper skin tissues.

Thus, what determines your prognosis is the depth the melanoma has spread into your skin tissues. Caught at an early stage, as my wife’s were, the prognosis is very good. But once the melanoma reaches a certain depth in the skin, the prognosis is poor, for it spreads throughout the body via the blood vessels. My wife has a “total body geographical examination” by a dermatologist every six months.

Any lesion that changes color or config-uration or bleeds should be evaluated by a dermatologist immediately. Other lesions that occur in areas frequently exposed to sunlight should be examined to determine if a referral to dermatology is warranted.

There are too many diseases–such as brain tumors, pancreatic cancer and leukemia–that we can do nothing to avoid. And there are too few handball players in the world. So help keep the number of handball players as high as possible by practicing preventive medicine.

Shoulder, back problems a result of compensation?

By Dr. John Aronen

Dr. John Aronen dispenses advice at the nationals. He developed non-reversible changes to his left shoulder and low back due to his attempt to compensate for the pain and loss of motion he experienced from his arthritic right hip.

The Houston nationals marked the 22nd year of existence of the USHA Sports Medicine Team. For myself, Ray Chronister and Kevin Regan, it has been a most rewarding and memorable relationship.

Over these years, the vast majority of the players–in fact, 100 percent!–seem to have aged somewhat, with many of them suffering ailments common to aging athletes.

As with a car or a dog, as we get older parts start to wear out. The knee is the joint most likely to give players problems, followed by the hip and shoulder.

With some players, the wear and tear simply comes on as a result of the stresses placed on their joints by playing handball–a weight-bearing activity that requires upper-extremity involvement.

Many players participated in other athletic activities like football and basketball in high school or college before becoming involved in handball. Many brought a previous injury, most frequently to one or both of their knees, into the court. In this group, the combination of a previous knee injury followed by an active career in handball simply hastens the wear and tear on the knee.

Routinely at the nationals or in phone calls, players ask me if I still play handball, which I don’t because of an arthritic back and left shoulder. Though I never had a significant injury to my back or shoulder, I did have an interruption of the blood supply to my right hip at the age of 7 that resulted in non-reversible changes in the hip. Thus, at 7, I had to face the reality that my hip would only worsen in time, especially with weight-bearing activities.

I was already a seasoned swimmer at that age, so swimming, a non-weight-bearing sport, remained my primary sport through grade school, high school and college.

It was in high school when my future father-in-law introduced me to handball, a sport that was not only fun to play but also good for conditioning. Though I was aware that if I continued to participate in handball my hip would worsen more quickly than if I restricted my activities solely to swimming, the lure of the court and the camaraderie associated with handball was much more appealing than watching the bottom of the pool.

As I continued to play, the pain in my right hip gradually increased as the motion gradually decreased. Soon it got to a point where I would attempt to find ways to shoot that would result in the least discomfort in my hip.

I was compensating for my hip, and in doing so I used my lower back incorrectly and shot with my left shoulder incorrectly. I realized at the time that if I continued to compensate for my hip, I might develop non-reversible changes in my low back and left shoulder.

Rather than do the smart thing–stick to swimming only–I kept trying to play handball until I could play only right-side doubles once a week and required narcotics to sleep that evening. At 35, my low back and left shoulder bothered me as much as my hip.

Unfortunately, simply stopping handball did not alleviate the pain, for I had developed the non-reversible changes to these three areas to a significant degree.

Five years after I quit handball, I had a total right hip replacement. Though the operation resulted in a pain-free hip with full motion, I was unable to return to handball because of my chronic low back and left shoulder pain.

Handball is similar to tennis. The proper method of playing is to use the entire body–first get to the ball to properly position yourself to shoot, and then shoot with the entire body in one smooth motion, resulting in minimal stress on the shoulder and back. Players run into problems one of two ways.

The vast majority of handball players would rather play handball than spend the valuable time they could be on the court running or riding a bicycle to condition their legs. The ones who pay the price for this lack of adequate conditioning of their legs typically note the onset of sore shoulders or low back pain with tournament play, where they play harder and longer.

Years ago, Fred Lewis said, “When your legs go, your game goes.”

Thus, in many of these cases, the shoulder and low back problems are avoidable. These players end up shooting incorrectly simply due to lack of adequate conditioning of their legs.

Try staying up with Alan Sherrill, who rides his bicycle about 60 miles a week or more, in the court for a two-hour match. He and Jim Smith don’t outshoot their opponents at the national three-wall tournament each year. They outlast them by returning everything due to their superb conditioning, especially of their legs.

The moral of the story for these players is to get your legs and yourself in shape for the rigors of tournament play. You must get to the ball and properly position yourself to shoot with your entire body to avoid shoulder or low back problems.

Players who bring an old knee injury into the court or develop wear-and-tear changes to their knees or hips from the stress of handball will eventually be forced to compensate due to the discomfort experienced. Their altered style of play repeatedly places abnormal stresses on their shoulders and low back.

These are the individuals who are difficult to deal with medically, for even if their shoulder or low back problem can be managed successfully, as soon as they return to the court they will once again abuse their bodies with forced compensation. So the cause of the problem–the arthritic knee or hip–has not been addressed.

Obviously, the lucky players are the ones who have healthy wheels that are not adequately conditioned and shoulders and low back free from non-reversible problems, for all they need to do is get their legs in shape, strengthen their shoulder muscles, incorporate low back strengthening and stretching exercises into their daily routine and, in many cases, lose some of the excess baggage they’re carrying around the court. I don’t have to name the players who are, shall we say, a bit overweight, for you know who you are.

The players with arthritic (worn out or getting there) knees or hips need to realize that their bad knees or hips are the cause of their shoulder or low back problem. Thus, they will continue to have shoulder or low back problems until the cause of the problem–the worn-out knee or hip–is medically addressed.

Hopefully they will get a total knee or hip replacement before they develop non-reversible changes to their shoulders or lower back so they can return to the court without recurrent problems. While you are rehabilitating your new knee or hip, your reversible shoulder or lower back problem can be treated by your physical therapist and physician.

Why are players who are candidates for a knee or hip replacement reluctant to have the surgery? I don’t know. An excuse I routinely hear is, “I’m only 50, and the knee or hip replacement is only good for about 15 years, so I’ll need to have another replacement when I’m 65.” My answer: “If you have a slip of paper that guarantees that you’re going to live to be 65, let me know where you got it because I’d like to have that guarantee also.”

If you fall into this category and are considering a knee or hip replacement, why wait? All that can be done for you–such as medications, injections or having the knee surgically cleaned out–will only make you a little better for a short period of time.

Players who do get knee or hip replacements before developing non-reversible problems with their shoulders or low back are able to return to the court pain-free with no need to compensate. Don’t wait until you develop such severe problems. Remember, it is always best to do as I say and not as I do or did.

I encourage all players with knee or hip problems that are forcing them to compensate on the court to call me. We can discuss your future in handball, placing emphasis on your being able to continue to play The Perfect Game.

You can call me at 858-485-9488. Please don’t call before 9 a.m. Pacific time. If I’m not here, leave a short message stating your phone number clearly and slowly, and I’ll return your call.

Most important knee exercise helps stop pain, gets you back on court

by Dr. John Aronen

The right knee and thigh muscles are well defined. The vastus medialis obliquus, the most important muscle of the knee, is just above and to the inside of the kneecap.

Basically, a joint is a junction of two bones designed to allow motion of one bone on the other. The knee consists of two joints:

asically, a joint is a junction of two bones designed to allow motion of one bone on the other. The knee consists of two joints:

• The “hinge joint,” with which everyone is familiar.
• The “kneecap joint,” with which not many people are familiar.

  The hinge joint consists of the thigh bone (femur) and the shin bone (tibia) and medically is called the tibiofemoral joint.

  The kneecap joint consists of the kneecap (patella) and the thigh bone (femur) and medically is called the patellofemoral joint.

  Each bone of these two joints has specific sites on it that are designed to be the points of contact of the bones during motion of the knee.

  To ensure that these specific sites are continuously lined up to be in contact with each other during knee motion requires stabilization of the bones.

  This stabilization is provided primarily by the thigh muscles, with the quadriceps muscles being the most important contributors. Knowing this, one can understand why regaining or maintaining sufficient strength of the quadriceps muscles is necessary to prevent and treat knee injuries.

  Fortunately, there is a simple exercise you can do to regain and maintain sufficient strength of your quadriceps.

  There are four quadricep muscles. Of these four, one, the vastus medialis obli-quus, or VMO, is the key. This is true for two reasons.

  First, the VMO is the key muscle for the stabilization of the two joints of the knee, especially the kneecap or patellofemoral joint.

  Second, the VMO is the key muscle to use as your evaluator to determine:

The “hinge joint,” with which everyone is familiar.

• The “kneecap joint,” with which not many people are familiar.

  The hinge joint consists of the thigh bone (femur) and the shin bone (tibia) and medically is called the tibiofemoral joint.

  The kneecap joint consists of the kneecap (patella) and the thigh bone (femur) and medically is called the patellofemoral joint.

  Each bone of these two joints has specific sites on it that are designed to be the points of contact of the bones during motion of the knee.

  To ensure that these specific sites are continuously lined up to be in contact with each other during knee motion requires stabilization of the bones.

  This stabilization is provided primarily by the thigh muscles, with the quadriceps muscles being the most important contributors. Knowing this, one can understand why regaining or maintaining sufficient strength of the quadriceps muscles is necessary to prevent and treat knee injuries.

  Fortunately, there is a simple exercise you can do to regain and maintain sufficient strength of your quadriceps.

  There are four quadricep muscles. Of these four, one, the vastus medialis obli-quus, or VMO, is the key. This is true for two reasons.

  First, the VMO is the key muscle for the stabilization of the two joints of the knee, especially the kneecap or patellofemoral joint.

  Second, the VMO is the key muscle to use as your evaluator to determine:

The hinge joint consists of the thigh bone (femur) and the shin bone (tibia) and medically is called the tibiofemoral joint.

The kneecap joint consists of the kneecap (patella) and the thigh bone (femur) and medically is called the patellofemoral joint.

Each bone of these two joints has specific sites on it that are designed to be the points of contact of the bones during motion of the knee.

To ensure that these specific sites are continuously lined up to be in contact with each other during knee motion requires stabilization of the bones.

This stabilization is provided primarily by the thigh muscles, with the quadriceps muscles being the most important contributors. Knowing this, one can understand why regaining or maintaining sufficient strength of the quadriceps muscles is necessary to prevent and treat knee injuries.

Fortunately, there is a simple exercise you can do to regain and maintain sufficient strength of your quadriceps.

There are four quadricep muscles. Of these four, one, the vastus medialis obli-quus, or VMO, is the key. This is true for two reasons.

First, the VMO is the key muscle for the stabilization of the two joints of the knee, especially the kneecap or patellofemoral joint.

Second, the VMO is the key muscle to use as your evaluator to determine:

• If you have sufficient strength of your quadriceps, and if not …
• If you are doing the exercises correctly to regain sufficient strength of your quadriceps, and …
• When you have regained sufficient strength of your quadriceps.

  The VMO is the muscle located just above and to the inside of your kneecap and can be seen when you tighten your thigh muscles, as shown above.

  Determining if you have sufficient strength of your quadriceps is simple—the size and tone (firmness) of the VMO of the thigh of your bad knee should be equal to the size and tone of the VMO of the thigh of your good knee.

  To be able to compare the size and tone of your VMOs, you must use a method of tightening your thigh muscles that results in a firm contraction or tightening of the VMO.

  One method is to sit on the edge of a chair with your knees straight and your heels on the floor and tighten your thigh muscles as if you were trying to push the back of your knees toward the floor.

  To compare one VMO to the other, tighten your right and left thigh muscles at the same time and, while holding them tight:

If you have sufficient strength of your quadriceps, and if not …

• If you are doing the exercises correctly to regain sufficient strength of your quadriceps, and …
• When you have regained sufficient strength of your quadriceps.

  The VMO is the muscle located just above and to the inside of your kneecap and can be seen when you tighten your thigh muscles, as shown above.

  Determining if you have sufficient strength of your quadriceps is simple—the size and tone (firmness) of the VMO of the thigh of your bad knee should be equal to the size and tone of the VMO of the thigh of your good knee.

  To be able to compare the size and tone of your VMOs, you must use a method of tightening your thigh muscles that results in a firm contraction or tightening of the VMO.

  One method is to sit on the edge of a chair with your knees straight and your heels on the floor and tighten your thigh muscles as if you were trying to push the back of your knees toward the floor.

  To compare one VMO to the other, tighten your right and left thigh muscles at the same time and, while holding them tight:

The VMO is the muscle located just above and to the inside of your kneecap and can be seen when you tighten your thigh muscles, as shown above.

Determining if you have sufficient strength of your quadriceps is simple—the size and tone (firmness) of the VMO of the thigh of your bad knee should be equal to the size and tone of the VMO of the thigh of your good knee.

To be able to compare the size and tone of your VMOs, you must use a method of tightening your thigh muscles that results in a firm contraction or tightening of the VMO.

One method is to sit on the edge of a chair with your knees straight and your heels on the floor and tighten your thigh muscles as if you were trying to push the back of your knees toward the floor.

To compare one VMO to the other, tighten your right and left thigh muscles at the same time and, while holding them tight:

• Compare the size of the VMO of your bad knee against the size of the VMO of your good knee with observation.
• Compare the firmness of the VMO of your bad knee against the firmness of the VMO of your good knee by pressing on the VMOs with your index fingers at the same time.

  If the VMO of your bad knee is smaller in size and/or not as firm as the VMO of your good knee, then you lack sufficient strength of your quadriceps and need to perform the following exercise.

  Sit on the edge of a chair with your knee straight and your heel on the floor. Then tighten your thigh muscles as if you were trying to push the back of your knee toward the floor. Once your thigh muscles are tightened and you can see and feel your VMO, hold them tight for six seconds, and then relax your thigh muscles for two seconds.

  One set consists of six to eight tightening episodes of six seconds followed by two seconds of rest.

  Ideally, you will perform sets of this exercise numerous times during the day. Your goal is to regain and maintain sufficient strength of your quadriceps—in other words, retain and maintain the size and tone of the VMO of your bad knee equal to the VMO of your good knee.

Compare the size of the VMO of your bad knee against the size of the VMO of your good knee with observation.

• Compare the firmness of the VMO of your bad knee against the firmness of the VMO of your good knee by pressing on the VMOs with your index fingers at the same time.

  If the VMO of your bad knee is smaller in size and/or not as firm as the VMO of your good knee, then you lack sufficient strength of your quadriceps and need to perform the following exercise.

  Sit on the edge of a chair with your knee straight and your heel on the floor. Then tighten your thigh muscles as if you were trying to push the back of your knee toward the floor. Once your thigh muscles are tightened and you can see and feel your VMO, hold them tight for six seconds, and then relax your thigh muscles for two seconds.

  One set consists of six to eight tightening episodes of six seconds followed by two seconds of rest.

  Ideally, you will perform sets of this exercise numerous times during the day. Your goal is to regain and maintain sufficient strength of your quadriceps—in other words, retain and maintain the size and tone of the VMO of your bad knee equal to the VMO of your good knee.

If the VMO of your bad knee is smaller in size and/or not as firm as the VMO of your good knee, then you lack sufficient strength of your quadriceps and need to perform the following exercise.

Sit on the edge of a chair with your knee straight and your heel on the floor. Then tighten your thigh muscles as if you were trying to push the back of your knee toward the floor. Once your thigh muscles are tightened and you can see and feel your VMO, hold them tight for six seconds, and then relax your thigh muscles for two seconds.

One set consists of six to eight tightening episodes of six seconds followed by two seconds of rest.

Ideally, you will perform sets of this exercise numerous times during the day. Your goal is to regain and maintain sufficient strength of your quadriceps—in other words, retain and maintain the size and tone of the VMO of your bad knee equal to the VMO of your good knee.

Ligaments, muscles team to bolster joints

By Dr. John Aronen

Well-defined thigh and leg muscles indicate good stability in the joint.

As noted in Part I, joints were designed to allow bones to move on one another, with some joints being designed more for mobility than stability and some more for stability than mobility.

Thus, the new obstacles would be designing anatomical structures that could:

• Create motion of a joint.
• Allow mobility but provide stability.
• Maintain the alignment of the sites of articulate cartilage that are designed to articulate on each other.

  The answer? The creation of muscles and ligaments.

  It is only after one looks at the difference in the inherent makeup of muscles and ligaments that the significant difference in their contribution to overcoming these three obstacles becomes apparent.

  Ligaments are fibrous bands of fixed length that limit the extremes of distraction between bones. Because ligaments cannot actively contract, they serve as a passive stabilizer, playing the role of a check-rein.

  Muscles, because they can actively contract, serve as an active stabilizer. The motion of a joint results from active contractions by muscles.

  Ligaments are unable to contribute to motion because they cannot actively contract.

  Joints allow us mobility, but joints must have structures that provide stability. This necessitates structures that limit the degree of distraction between the bones of the joint.

  Muscles and ligaments are the primary stabilizers of every joint. Because ligaments cannot contract, they serve as a passive stabilizer. But muscles can actively contract, so they serve as an active stabilizer.

  In this role, muscles can actively limit the degrees of distraction between bones, whereas ligaments are relegated to limiting the extremes of distraction between bones. In recognizing this, one can understand why muscles are referred to as the first line of defense against instability episodes.

  Muscles protect the ligaments from forces that may challenge the stability of a joint. If the force challenging the stability of a joint is sufficient to overpower the muscles, the passive line of defense–ligaments–can be subjected to stress.

  In either instance, the stress placed on the muscles can result in a strain of the muscles, with the end result of the strain being residual weakness of the muscles. Thus becomes apparent the rationale for emphasizing regaining and maintaining the normal strength of the involved muscles in all episodes of joint instability.

  Adequate and appropriate treatment of instability in joints includes regaining and maintaining the normal strength of the involved muscles.

  Joints were designed such that specific sites of articular cartilage would be in apposition with each other during motion of a joint.

  Maintaining the alignment or tracking of these specific sites designed to be in apposition relies primarily on anatomical structures that can actively contract during motion of a joint.

  Thus, again, muscles contribute significantly to maintaining the alignment of the specific sites of articulation because they can actively contract. But ligaments contribute very little to maintaining the alignment of the sites of articulation because they cannot actively contract.

  For the muscles to maintain the designed alignment, they must have full or normal strength. Thus becomes apparent the rationale for emphasizing regaining and maintaining the normal strength of the muscles tasked with maintaining the designed alignment of joints.

  Adequate and appropriate treatment of alignment or tracking problems in joints includes regaining and maintaining the normal strength of the involved muscles.  

   

Human joints: Their function and problems
By Dr. John Aronen 

Articular cartilage is essential in a joint.

There are many statements in life that we do not like to hear. One of these is being told that we have become a candidate for a total joint replacement.

To understand how this can apply to seemingly healthy handball players, one first has to understand the structural make-up of a healthy joint.

Our bodies were designed with joints to allow bones to move or articulate on one another. Some joints, such as the shoulder, are designed for mobility more than stability. Others, such as the hip, are designed for stability more than mobility. Either way, joints allow us the motion we enjoy.

Ideally, a joint would be pain-free, provide and maintain a set level of a healthy fluid to function as a lubricant, have an extremely low coefficient of friction to minimize wear-and-tear changes, and be problem-free and pain-free throughout our lives.

Even at rest, forces are constantly placed on joints by the muscles that move them. Weight-bearing joints, such as the hip, knee and ankle, experience significantly greater forces than non-weight-bearing joints.

Bone has an abundance of pain fibers. Thus, if joints consisted solely of bone on bone, every joint would be a source of constant pain. That’s why the parts of bones that move on each other are covered with articular cartilage.

Whereas bone has an abundance of pain fibers, articular cartilage has no pain fibers. (Articular cartilage also is referred to as chondral, so the bone under the articular cartilage is called subchondral bone.)

In covering the subchondral bone, articular cartilage can effectively serve as an intermediary between the subchondral bone and the forces placed on a joint. This cartilage absorbs the forces placed on a joint so the underlying bone does not have to.

If the subchondral bone, which has an abundance of pain fibers, does not experience any of the forces placed on the joint, the joint will be pain-free.

Every joint has a capsule that encloses it, making the joint a confined space. The capsule is lined with synovial cells.

There are two types of synovial cells. The first, Type A cells, are secretory. These cells produce and secrete the synovial fluid that functions as an extremely effective lubricant for the joint. Synovial fluid is much more effective than any lubricant produced by man.

We also have a second type of cells, called Type B cells, added to the lining of the capsule. The Type B cells are phagocytic, meaning they remove the broken-down lubricant from the joint.

So we produce our own healthy lubricant with the Type A cells and remove the broken-down lubricant with the Type B cells. Through the combined actions of the Type A and B cells, our joints maintain a set level of healthy synovial fluid.

When articular cartilage is in pristine condition, it is super smooth. Besides having no pain fibers, articular cartilage also has no blood supply, which means:

• Articular cartilage lacks a source of nourishment.
• Articular cartilage cannot heal or regenerate.

   

  The first problem is solved because the surface of the articular cartilage is filled with microscopic holes. These tiny holes allow the synovial fluid to enter the cartilage and provide nourishment. The synovial fluid also coats the surface of the articular cartilage. The combination of the super-smooth surface of articular cartilage coated by the synovial fluid results in a coefficient of friction of almost zero between the articulating surfaces of the joint.

  The second problem, that articular cartilage cannot regenerate, will be addressed in a subsequent article.

   

Program for treatment of the No. 1 injury in competitive sports: Sprained ankles

By Dr. John Aronen

With the ankle being the No. 1 injury in sports, here is a treatment program for sprained ankles.

Goals

>>Eliminate the soft-tissue swelling of your injured ankle so it looks like your other ankle. Do this with compression (Ace wrap), elevation and pain-free motion exercises.

>>Eliminate the soft-tissue swelling of your injured ankle so it looks like your other ankle. Do this with compression (Ace wrap), elevation and pain-free motion exercises.

>>Regain full pain-free motion of your ankle equal to that of your other ankle. Do this with pain-free motion exercises.

>>Restrengthen the muscles responsible for preventing recurrent ankle sprains. Do this with the strengthening exercises to prevent recurrent ankle sprains.

How does elevating my ankle help, and how frequently do I elevate it?

Elevation of your ankle expedites elimination of the swelling. Although the maximum benefits result from the ankle being elevated higher than your heart, any elevation during the day is better than none. At night, the most effective way to maintain your injured ankle elevated higher than your heart is to place a large pillow or other object at the end of your bed between your mattress and spring so you “permanently” elevate the end of your bed. You can greatly enhance the benefits you gain from elevating your sprained ankle by performing the motion exercises whenever you have your ankle elevated. Start the strengthening exercises to prevent recurrent ankle sprains as soon as you have enough motion to do them.

Why do I need to perform the motion exercises, and when do I start doing them?

The motion exercises contribute to the treatment of your ankle sprain in two ways:

The motion exercises contribute to the treatment of your ankle sprain in two ways:

>>The motion of the ankle helps “pump” the swelling from the ankle, especially when the ankle is elevated.

>>The motion exercises enable you to regain the amount of ankle motion you had before spraining your ankle. The sooner you start the exercises, the sooner you will regain full pain-free motion of your ankle. Each time you perform the exercises, use pain as your guideline–perform only the amount of motion that you can do pain-free. The more times you perform the exercises, with or without elevation, the sooner you will regain full pain-free motion.

Figures 1A and 1B show the first of the three motion exercises. The first exercise is the same as repeatedly pushing your foot down on a gas pedal of a car as far as you can and pulling it back up as far as you can.

Figures 1C and 1D show the second motion exercise. With this exercise, you keep your heel still and move your forefoot with the motion as that of a windshield wiper of a car. Keep your heel still and repeatedly move your forefoot in and up as far as you can and then out and up as far as you can.

Figure 1A	Figure 1B
Figure 1C	Figure 1D

Once you have achieved an increase in your pain-free motion, you can add a third motion exercise. The third exercise combines the actions of the first two exercises and thus enhances your gains. To perform this exercise, keep your heel still and, using your big toe as a pen, write the letters of the alphabet in capital letters with your big toe while you keep your heel still. Continue to perform the motion exercises until you are capable of writing the alphabet in capital letters as large in size as you can with your other ankle—”proof” you have regained full motion.

Figure 2A	Figure 2B

 Strengthening exercise to prevent recurrent sprains

The typical ankle sprain occurs when you come down on the outside of your foot and your ankle rolls under. When you land on the outside of your foot, the muscles that turn your foot up and out are trying to stop your ankle from rolling under. Sometimes these muscles have sufficient strength to stop your ankle from rolling under, but if they don’t, your ankle rolls under and you end up with a sprained ankle.

Along with spraining your ankle, you also overstress the muscles that attempted to prevent the ankle from rolling under. This overstress leaves these muscles with weakness. If you don’t restrengthen these mus-cles, the next time you come down on the outside of your foot your ankle will roll under more easily, for these muscles will have less than normal strength to prevent your ankle from rolling under.

To perform the strengthening exercise for the muscles that turn your foot up and out, sit on the front edge of a chair and put both feet into the loop of a stretchable material, as shown in Figure 2A. (A 12-inch bicycle inner tube is available from departments stores for about $3.) The amount of resistance you will feel is determined by the tension of the loop, which varies with the distance between your feet. The initial amount of resistance to feel is that which allows you to perform the exercise correctly.

It is important that all of the motion against the stretchable material is performed at the ankle. To ensure this, the knee and leg of the injured ankle must be kept stationary. Locking your knees straight forward with your hands as shown in Figure 2A limits all the motion to the ankle.

Start position is with the foot of the injured ankle on the floor (Figure 2A). While keeping the heel of your injured ankle on the floor, raise the ball of your foot up off the floor and then rotate your foot out and up against the resistance of the stretchable material as shown in Figure 2B.

For maximum benefit, slowly return your foot to the start position, resisting the pull of the stretchable material as you return your foot to the start position. Each repetition should always begin and end with the foot in the start position–with the foot on the floor (Figure 2A). Perform repetitions of this exercise until you feel a burning on the outside of your leg. This burning represents fatigue of the muscles you desire to strengthen.

As you feel the strength of the muscles increase and do more and more repetitions, spread your feet farther apart to increase the tension of the stretchable material and gain more strength. Continue the exercises until you achieve the goal, which is the capability of balancing on the ball of the foot of your injured ankle for the same length of time you can on the ball of your other foot, usually five to 10 seconds.

Risks of high salt intake outweigh benefits

By Dr. John Aronen

An article in the December 2002 issue of Handball magazine caught my attention, for it discussed muscle cramps and proper steps to take to prevent them.

I have always wondered about muscle cramps, for in my 25-plus years of dealing with athletes I have never been able to come to any conclusion other than the onset of cramps is typically associated with extreme overstress or fatigue of one or more muscle groups.

There are a plethora of theories as to why muscle cramps occur, such as low potassium. But none of these theories have scientific data to back them up.

Most recent studies have shown that muscle make-up–the type of muscle fibers with which you are genetically gifted–is the primary determinant as to whether you will be capable of enduring extensive bouts of strenuous activity without incurring muscle cramps.

Adequate hydration before participation has been shown to be beneficial in reducing the incidence of muscle cramps in endurance events. The rule to follow is that you are adequately hydrated when your urine is colorless.

Additionally, alcohol and caffeine, which are diuretics and result in an increased loss of fluids through urination, inhibit adequate hydration. Thus, drinking beer the night before a match and coffee in the morning the day of a match hinder your chances of being adequately hydrated. Of course, drinking beer the night before a match is relatively uncommon in handball players!

Which leads me to comment on the article, which discussed the possible relationship between muscle cramps and large losses of sodium and fluid.

The author stated that “since sodium is an important mineral in initiating signals from nerves and actions that lead to movement in the muscles, a deficit of this element” could cause cramps. Part of the recommendation to solve this problem was to add sodium to meals.

The only reason I am commenting on the article is because of my concern that handball players may follow the recommendations regarding the “addition of salt to their diet.”

Hypertension, or high blood pressure, is a major health problem worldwide. Hypertension has been identified as a major contributor to many serious health problems, such as heart attacks, kidney failure and strokes.

The incidence of hypertension increases with age, with about 50 percent of people in their 50s having elevated blood pressure. Of the people with hypertension, about 95 percent-plus fall into the category of having essential hypertension–in other words, you have it, but the exact reason you have it cannot be determined.

What can be determined are factors that contribute to your hypertension and measures that should be taken to address these factors. The most common factors include excessive daily intake of salt, being overweight and stress.

The Food and Drug Administration recommends no more than 2,400 milligrams (mg) of sodium daily. Each day people consume more sodium from the salt in their normal diet than the amount that has been determined as safe by the FDA.

There is salt in almost every food we eat and beverage we drink. For instance, one slice of bread has 120 mg of sodium and one tablespoon of catsup has 190 mg of sodium. This is why a low-sodium diet is recommended for anyone with high blood pressure.

In recognizing that the majority of handball players are close to or over 50 and, should I say, a “well-documented” percentage are overweight, the addition of salt to meals does not strike me as a good idea for most people.

The moral of the story is to have your blood pressure checked regularly and, if you are diagnosed with hypertension, take your medications on a regular basis, adhere to a low-sodium diet, keep your weight under control instead of under your shirt, avoid episodes of typically self-induced stress, hydrate yourself adequately with water before playing a match and rehydrate with water between matches.

And watch that salt intake.