Oh My Aching Body - 5 - Lindsey Vonn

 

Does anyone else glue themselves to the TV during Olympic season?

Was anyone else super excited to watch Lindsey Vonn return to the slopes as a 41 year-old who had just become the oldest skier ever to win a World Cup?

I was.

She came out of retirement after a RIGHT knee replacement that relieved the terrible pain she had been experiencing on the slopes for so many years.

On January 30th, the week before her Olympic run, she blew out her LEFT ACL and bruised the bone and tore the meniscus in her left knee. I'll talk more about ACL injuries in a future blog post. But for now let's say it's an injury that requires reconstruction through surgery, and usually requires 6-9 months of rehabilitation before someone can do any strenuous activity. It's a ligament that gives the knee stability, and without it, the knee will buckle and "give out." Lindsey was skiing without it.

When she injured her left ACL on January 9th, Lindsey Vonn was no stranger to ACL injuries and knee instability. 

I was stunned that she was racing without an ACL in her knee only 9 days after tearing it. I was watching eagerly when she launched out of the gate. 

A few seconds later I was really bummed when she fell, as skiers often do.

But then she didn't do what most skiers do when they fall. She didn't get up with an angry or frustrated expression and glide off the run in disappointment and defeat. 

No. She just laid there on the mountain and screamed.

The rest of the mountain was silent.

...until the helicopter entered the area, and deployed an emergency team that packed her up and flew her in for emergency surgery.

At the time of her crash they didn't have a lot of information. A bit later they announced that she was in stable condition with a fractured leg. But they were still very short on details. Which leg bone? The femur would make sense, based on how she was screaming but wasn't moving at all. Femur (thigh bone) fractures are very painful, and people generally stay very still when they break a thigh bone. Maybe it was a boot-top fracture, which is common for skiers. A ski boot keeps the ankles very stable, but with skis acting as extended levers, any twisting of the leg will put all the torque above the boot. The result is commonly a fracture of the leg right at the top of the boot.

 The x-ray above shows a boot-top fracture. In this instance, both leg bones are broken like a stick.

Lindsey Vonn's leg didn't break like a stick. It broke like a vase. It didn't crack. It shattered. It didn't need a cast. It needed pins, screws, plates, and rods, over the course of a six hour bone reconstruction surgery.

That kind of bone-shattering injury is horrible enough, but that wasn't the worst of it in this case. The biggest problem Lindsey Vonn faced was the compression syndrome that nearly caused doctors to have to amputate her leg.

In the first installment of Oh My Aching Body, I talked about the benefits of compression when there's an injury. When an ankle is sprained and starts to swell, we wrap it with an elastic wrap to keep the swelling to a minimum. We wrap the injury with elastic wrap, not inelastic wrap. We don't wrap the elastic wrap too tightly, and we keep checking circulation to the toes with a quick squeeze of the toe at the toenail, to look for the quick return of color, and therefore circulation, to the toes. Compression can have benefits, but too much compression can cause tissue death.

Compression is both the result and cause of significant injury when there's damage to tissues in the leg. There are ten muscles in the lower leg, and they are grouped into four separate compartments, each surrounded by a layer of fascia. No other part of the body has this compartmentalization. If a muscle in the leg is injured and begins to swell, there's nowhere for the swelling to go because of the inelastic fascial layer surrounding the muscles. Blood collects in the compartment, squashing all the encapsulated muscles, nerves, and blood vessels. 

For Lindsey Vonn, the biggest problem she faced was not the serious damage to the bone, but the swelling within the compartments of her leg. To relieve the pressure, doctors needed to make incisions to the fascia, to open the leg compartments in what is known as a fasciotomy.

Those of us who were checking the news were hearing that Vonn had six surgeries before being flown out of Italy. The first several surgeries were just at attempt to prevent the amputation of her leg. 

It worked. The first doctors saved her leg. Then the reconstruction of the bones began. That worked, too.  She's on the road to recovery and posting Instagram reels of her physical therapy routine.

Some people have guessed that this injury happened because she's an older skier and her bones are less equipped to handle that kind of impact. 

• It didn't. 
• Lindsey Vonn was in peak physical condition, and her bone density was epic, thanks in great part to the impact her bones have sustained over the many years she has been on skis. If you read "Dem Bones, Dem Bones" in a previous blog post, I mentioned a study where third graders simply stomped their feet 100 times per day and had noticeable increases in bone density. Imagine flying through the air and landing on your feet at 40-60 miles per hour repeatedly. Lindsey's bones weren't frail.

Some people have surmised this injury happened because she had already blown out her ACL 9 days earlier. 

• It didn't.
• She explained that she was cutting the flag tight because the previous skiers had put down such amazing times, and by cutting the flag too close she ended up with her ski getting caught up in the flag pole. That kind of collision could have thrown any skier, and the torque from the twist on her left leg could have destroyed anyone's bone.

In summary, what we saw on February 9th was a once-in-a-generation bad-ass on the slopes in Cortina. Her preparation was impeccable, her comeback was incredible, her crash was terrible, the emergency response was perfect, the emergency fasciotomy surgery saved her leg, and the orthopedist reconstructed her leg beautifully. Thanks to all of those things, Lindsey Vonn will be walking and running and probably skiing again on both of her own legs someday soon.

But we probably won't get to see her in the Olympics anymore, according to her dad.

...We'll see.

Oh, My Aching Body - 4 - Back Pain

When a patient comes into a physical therapy clinic with a doctor’s prescription for physical therapy, it includes a diagnosis. It might say “Right Knee Torn Medial Meniscus” or “Left Shoulder Supraspinatus Tendinitis.” But more often than not, when someone came into the physical therapy clinic where I worked for their back, the diagnosis was “Back Pain.” 

But that’s not a diagnosis. It’s a symptom. Here’s another medical terminology tidbit:

Symptom - something that someone complains of. 

Symptoms include:

• Nausea

• Pain

• Tingling

• Numbness

• Sharp pain

• Dull ache

• Throbbing

Sign - Something that someone else can detect. 

Signs include:

• Redness

• Swelling

• Loss of range of motion

• Bleeding

• Vomiting

• Temperature increases

• Deformity

Pain isn’t a diagnosis. It’s a symptom that forces someone to see the the doctor, hoping that the doctor would provide a diagnosis and tell them what’s causing the pain.

This “pain” diagnosis is unique to back problems. We never got a “knee pain” diagnosis. It would say “Torn Meniscus”. A person presenting with foot pain would have a diagnosis that said “Plantar Fasciitis,” not “Foot Pain”. 

But not with back pain, and here’s why:

ANATOMY:

Imagine you have a cadaver in your college athletic training room supply closet. (We did.) You work on this human cadaver, making incisions in the skin to reveal all the tendons of the hand, all the muscles of the arms and legs, the tendons and muscles of the neck and shoulder, and the incomprehensible complexity of the low back. If you peel back the skin on the cadaver’s low back, then take your pinky and put it into the back musculature, your pinky won’t be as deep as the muscles along the spine. No other muscle group is as deep.

These muscles form an incredible support network for the trunk. The muscles in the front of the spine help the spine bend (flex), the muscles behind the spinal column help your spine straighten (extend). There are even tiny little muscles between the bony prominences of each vertebra. Beyond just helping you bend and straighten, they keep you upright, instead of flopping around like one of those inflatable tube men.

No core stabilization.

But that’s just the muscles! Wait until you see all the ligaments that connect the vertebrae together!

Now let’s imagine that you lunge for a backhand shot on the pickleball court and you feel a twinge in your low back. After a few minutes your back gets really stiff and it hurts every time you move. No matter which ligament or tendon you’ve injured, the signs and symptoms will be the same. It’s impossible to determine exactly which tissue is injured, but fortunately, if your disc isn’t involved (that’s a whole different ball of wax), our approach to your low back injury will be the same no matter which tissue you’ve just jacked up.

By now, if you’ve read the previous articles, you know what’s coming. The approach to virtually any muscle strain or ligament sprain is R.I.C.E.: Rest, Ice, Compression, Elevation. But there are some real complications to that approach when it comes to the low back.

REST: If someone comes to me with an ankle sprain I can provide crutches, tell them to stop using the injured side to walk, and the rest of their function will be just fine. They can go to work or school, sit in a chair with their foot on another chair, go to the store, hang out with friends, and even drive if the injury is to the left ankle. But a back strain gets worse if you just stand, because keeping you upright is the job of your spinal muscles. Sitting is even worse, because strain on the low back muscles is doubled when you go from standing to sitting. To really rest a low back injury, you’ll have to lay on your back with your knees elevated so that there’s a 90° angle at the hips and knees. 

This position is excellent for resting a low back injury, but it’s incredibly limiting! You can’t use the restroom without aggravating the injury, let alone pick up a child or grandchild. You can’t sneeze without increasing back pain, and you can’t stand at the stove and cook dinner. You can’t go up or down stairs without significant strain to the low back. The low back muscles are involved in EVERY MOTION. You can’t put a cast on it or immobilize it, so you have to just lie still and stop doing EVERYTHING (except using the restroom) for several days after a “back pain” diagnosis.

ICE: Going back to that sprained ankle, I can use ice packs or even a cold ice bucket to cool an ankle and reduce the swelling to the area. But ice packs penetrate only about ½” below your skin, …if you’re pretty lean. If you have a bit of a spare tire around your middle, the cold might not cool the muscles beneath the skin at all. With a group of muscles that are deeper than your pinky, how effective will an ice pack really be? Moist cold is more effective than dry cold, so let’s use an ice towel instead. You put crushed ice inside of a towel, then lay on it. But even with a moist towel we’re talking about ¾” in a lean person. It’s still recommended to apply ice, because even if it doesn’t penetrate to the injured muscles, it will draw heat out, reducing the surrounding temperature at least a bit.

COMPRESSION: When someone has a sprained ankle I can compress it with an ace wrap to prevent the increase in swelling to the area. With a back injury we can apply a supportive belt, but that just provides stability and won’t decrease the swelling to the area. There is no compressing a low back injury.

ELEVATION: With an ankle sprain I can tell the injured athlete to lay on a couch with the foot higher than the heart. This slows circulation to the area and reduces the amount of swelling that will go to the ankle. It’s not possible to elevate a low back above the heart when there’s a low back injury. The best we can do is lie flat.

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TREATMENT

As mentioned above, the best approach to the first few days of a low back strain or sprain include calling in to work, lay on your back with your lower legs elevated, tuck a cold pack under your low back for 20 minutes every hour or two, and have someone else bring you your favorite books, the remote control, and your meals. 

WHATEVER YOU DO, DON’T ADD HEAT!

Not for at least 3 days.

Heat packs and warm baths will penetrate twice as deep into the tissues as cold packs for some reason, and if you read the first installment of “Oh, My Aching Body,” you’ll know why you should absolutely avoid adding heat. But you know what else adds heat? Motion. Exercise. Massage. Theragun. Even just laying still without adding cold will be adding heat.

PREVENTION

The best ways to avoid a back injury is to use your legs and stabilize your core. 

Use Your Legs: If you’re picking something up off the floor, bend your knees instead of your back. If you’re on the pickleball court, the same rules apply. Try to lower your hips, keep your back straight, and move to the ball with your feet, not by reaching for the ball by bending and twisting your back.

Stabilize Your Core: The muscles of the back and abdomen work to support your torso on your pelvis. Pilates is the ultimate approach to core stabilization, but that can’t be attempted until your back injury has healed. The exercises we used in the physical therapy clinic included very simple things like pelvic tilts, where you lay on a table or bed on your back with your knees bent and feet on the table, then tighten your abdominal muscles so that the spine of your low back touches the matt, and your tailbone lifts off the table. Repeat for three sets of ten, holding each for 5 seconds. That’s it. You can’t push your heels into the table to push your tailbone upward. It all has to be done with your abdominal muscles. You’d be amazed at how many people found this very difficult. Once you can do this, you can graduate to lifting one foot a few inches off the table for five seconds. If your pelvis starts to drop when you pick up your foot, you’re not ready. Reset your pelvis and pick up the foot again. Then alternate. Eventually you’ll graduate to the “dead bug” exercise. (I didn’t name it, but I wish I did.)

Pelvic Tilt exercise. The foundation of all pelvic stabilization to protect the low back.

This is the dead bug exercise.

Next are the exercises where you’re on your hands and knees, you set your spine so that there’s no movement side to side when you lift one hand forward off the table, and hold it for 5 seconds. Then the other hand. Once that’s mastered, send one knee backward and hold the leg straight for 5 seconds, then slowly lower it. Once you can do that, you can lift one arm and the alternate leg, keeping the core stable and your body balanced on the table.

In addition to these exercises there are important muscle balance issues often involved in back problems. If the front of the hips and the back of the thighs are tight, this throws the pelvis into an arched position. Stretching the hip flexors and hamstrings is the opposite of what happens when you’re sitting, so a good thing to do is get your hips and hamstrings into the opposite position of sitting.

Here’s more exercises to protect your low back, for those who are feeling really motivated. 

If you have a back injury that nags at you regularly, it’s best to get a physical therapist to guide you through how to correct your posture, your movement, your alignment, and your muscle balance (stabilization and flexibility). It’ll make it less likely that you’ll hurt yourself again, and it will improve your pickleball, too!

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Do you have another aching-body topic you’d like to know more about? The last two articles were my response to requests from your fellow PIKL members, but now I’ve run out of requests. Please feel free to let me know what you’d like to know more about!

Oh, My Aching Body - 3 - Tennis Elbow

When I was in grade school the kids in my neighborhood used to grab some gear and head to the baseball diamond at our neighborhood park. Home plate was always there, so we’d use a frisbee for first base, a sweatshirt for second base, and maybe a pizza box from the trash for third base. We’d play whatever games we could invent with a bat, a ball, and a few baseball gloves. 

From those experiences I learned that the crack of a wooden bat on a baseball is an incredibly gratifying sound and feeling. But every now and then I might connect with the ball, only to feel the vibrations of a cracked bat. That “BZZZZZZ” feeling traveled through my hands all the way to my elbows. Or sometimes to my shoulders. And sometimes it even felt like it rattled my molars.

I’m wondering if this is a generational experience that has been lost, whether to aluminum bats, a generational shift towards soccer, a generational shift towards Pokemon Go, a reduction in outside play, or kids just avoiding neighborhood parks. But if you’re reading this and you ever struck a baseball with a cracked wooden bat, you cringed when I described what it’s like to feel those noxious vibrations up your arms. For those who can relate to that experience, it won’t surprise you to learn that those vibrations, if repeated over time, can cause long-term damage to your body.

TENNIS ELBOW

Tennis Elbow is the nickname given to a condition that is formally known as lateral epicondylitis. The reason it’s called “Tennis Elbow” is two-fold. First, “lateral epicondylitis” is hard to say without spitting food on people when you’re eating nachos. Second, it’s very common in tennis players. Recently it has been nicknamed “pickleball elbow,” to give you an idea of how things are going for the pickleball community. Tennis and pickleball players who spend hours on the court hitting a ball with a racket or paddle have micro-vibrations traveling through the racket/paddle to the elbow. The tendons that connect to the outside (lateral) prominence of the elbow (epicondyle) get inflamed (-itis).

In the first installment of “Oh, My Aching Body” I addressed acute injuries – those injuries that happen with a quick onset, and heal over a period of weeks. Unlike those conditions, Tennis (Pickleball) Elbow is a chronic condition – a condition that takes months to develop, and usually takes months to resolve. The experience and resolution of these injuries is super frustrating. 

As athletic trainers we had three acute injury seasons, and the Spring was chronic injury season. Summer, Fall, and Winter gave us football players with dislocated shoulders and broken legs, or soccer players with ruptured ACL’s. Winter gave us basketball players with sprained ankles, and wrestlers with every imaginable sprain, strain, and dislocation. The injuries happened at a specific, memorable moment. I would spend a few weeks getting the injured athlete back to activity and wouldn’t see him or her anymore. But with chronic injuries we ask, “When did this start?” and we get a vague, “Uh… I’m not sure.” Every Spring I could count on baseball and softball players suffering from rotator cuff tendinitis, track athletes suffering from shin splints, and tennis players struggling with tennis elbow. 

Chronic injuries develop slowly, and they get persistently worse until the athlete comes to the training room. When they finally come to see me they’re still not sure they should be coming in, because “it doesn’t ALWAYS hurt.” But the reality is that they should have come in weeks earlier, because we could have limited the severity if they had addressed things sooner. I’ll explain this later, when talking about the three stages of tendinitis.

TENDINITIS

Tendons are the tissues that attach muscles to bones. If you’ve ever pulled the meat off a chicken bone, it’s the white, cord-like tissue at the joints. Muscles are commonly injured with a sudden movement, but tendons get inflamed through constant, irritating activity. The suffix -itis indicates inflammation. Tonsilitis = inflamed tonsils, appendicitis = inflamed appendix, gingivitis = inflamed Gingers. 😉 If you hit a ball with a cracked bat you know how irritating those vibrations can be in an instant. Connecting with a pickleball while holding a pickleball paddle might not create the BZZZZZ vibrations that are experienced with a cracked bat on a baseball, but over time those bzzz vibrations yield chronic inflammation to the tendons in the elbow. 

Incidentally, tendonitis happens in several areas of the body. Golfers experience the same issue on the inside (medial) of the elbow. They call it “Golfer’s Elbow.” Basketball players and volleyball players experience this issue just under the knee cap in the patellar tendon. They call that “Jumper’s Knee.” The common thread is the long-term vibratory forces on a tendon, which eventually results in chronic inflammation, pain, and functional limitation.

There are three stages of tendinitis. If you have tendon pain, maybe you can identify which stage you’re in.

• Stage 1 - The tendon hurts after activity.

• Stage 2 - The tendon hurts during and after activity.

• Stage 3 - The tendon hurts all the time.

I’d usually see athletes when they were in late Stage 2, or even Stage 3. By then things are very difficult to reverse.

INFLAMMATION

Inflammation is an important and beneficial immune response to injury. With an acute injury you get redness, swelling, and an injury that feels warm to the touch, and the pain it causes forces the injured person to limit activity. Within a few weeks everything is back to normal. It’s as if you had a burst pipe in your house, so you call a plumber, he comes out to fix it, you have to see the top of his butt crack for an hour or two, but then he leaves and everything is back to normal. 

But with a chronic injury the inflammation response never goes away. Tissues are being constantly irritated through vibrations up the paddle, and the body’s response is to send inflammation to the injured tendon to heal it. For the first few weeks we aren’t really feeling much pain, so we keep playing. Over time the tendon is getting more irritated, and the inflammation response itself becomes the cause of trouble. It’s as if you have a slow leak in a pipe, so you call a plumber. He doesn’t have the replacement part, so instead of fixing the problem he just mops up the mess every few hours. He stays in your house. He yells, “Beer me!” He drinks your beer and eats your food. He hangs out in your kitchen with the top of his butt crack showing. He burps when you’re trying to watch your favorite show. He’s so annoying! You wish he’d go away, but as long as that pipe is leaking, he’s not going anywhere.

TREATMENT

So how do you get that plumber to go away? 

You turn off the water. There won’t be anything to mop up and the plumber will leave.

You know what that means in this analogy, right? That word I keep repeating in every article: 

REST.

The vibrations through your paddle are causing the problem, so you need to stop doing the activity that’s causing those vibrations.

But there are a few less-drastic answers to this problem, because there are other methods to stopping those vibrations getting to your lateral epicondyle. Tennis players have vibration-reducing devices that are inserted between the strings near the handle of the racket. If you can dampen the vibrations at the strings of the racket, you’ll reduce the vibrations getting to your elbow.

ProKennex introduced pickleball paddles with tungsten beads that ProKennex calls “kinetic mass microspheres” in the paddle body and handle. These beads absorb vibrations to prevent inflammation in the hands, elbows, and shoulders. If you’d like to try one, I’ve got two.

Sometimes you’ll see tennis or pickleball players wearing straps around their forearms near the elbow. These dampen the transmission of vibrations at the strap, to keep them from getting all the way to the elbow. 

REAL LIFE EXAMPLES

The worst case of “tennis elbow” I ever saw in my years working at a physical therapy clinic was in 1991. It was suffered by a guy who never played tennis in his life. His job was to stock grocery store shelves with bottles of wine. The top shelves were where they stocked the large glass bottles with the little finger loop on the neck of the bottle. He’d bend to the floor to the box of bottles, and with his thumb pointing toward the floor he’d loop a finger through that finger loop and lift the bottle to the top shelf an an upward backhand motion. Over and over, bottle after bottle, box after box, store after store, day after day. We couldn’t solve the problem. We’d treat him with ice and ultrasound, stretching and targeted strengthing. He’d come in during his lunch break between hours of stocking shelves. One step forward, two steps back.

That was the worst case I saw in the physical therapy clinic. The worst case I’ve ever seen ever was my own. I started developing sore forearms and elbows when I was doing deep tissue massage. After five years of doing massage I couldn’t lift the remote control, let alone do a deep tissue massage, without severe pain. 

It was time for physical therapy, which was very familiar to me, as I had spent so many years treating others, including the wine-shelf stocker previously mentioned. At first physical therapy consists of modalities to reduce inflammation. This includes ice, ultrasound, electric stimulation, and massage.

(Not my elbow.)

Once pain is reduced we can start eccentric strengthening exercises. To explain this term let’s take the knee as an example. When you’re seated, the quadriceps, on the front of the thigh, contract to straighten the knee. This shortening of a muscle is a concentric contraction. But to bend the knee you don’t have to contract the hamstrings on the back of the thigh. You need to slowly release the quadriceps in a controlled lengthening, as gravity lowers the foot to the floor. The controlled lengthening of a muscle is known as eccentric contraction. 

If your tennis elbow is in your right elbow, you support your right forearm on a counter or table while holding a weight in your right hand, which hangs off the table. You don’t lift the weight with your right hand with a concentric contraction. Instead, you lift the weight with your left hand, then slowly lower the weight with the right hand. The eccentric phase of contraction puts more load on the muscle, and less on the tendon, so it is ideal for tendinitis rehabilitation.

Irrelevant pro tip: Because the eccentric phase puts more load on a muscle than the concentric phase, it yields greater strength gains in weight training. If you’ve ever done a bench press, the concentric move is when you push the weight up. The eccentric move is the lowering of the weight to your chest, and science tells us that this is the phase where more strength is gained. Push the weight up with a 2-count, and lower it with a 4-count. 

If all of these interventions don’t improve your tendinitis, it might be time for a cortisone injection. Cortisone is an anti-inflammatory steroid which reduces pain and inflammation within a day or two. The relief lasts for months if you do nothing else, but it allows you to engage in rehabilitation activity that could prevent the pain from ever returning, so it’s a great treatment for chronic pain and limitation due to tendinitis. Regrettably, it can’t be repeated very often, because over time the cortisone will deteriorate the tendon fibers.

If steroid injections don’t last, and mine didn’t, it’s time to see an orthopedist. The orthopedist I saw ordered an MRI to see what was happening. He hoped we could avoid surgery. When he reviewed my MRI he said, “We’re going to have to do surgery, and I know exactly what I’m going to see when I get in there.”

(Not my MRI.)

TENDINOSIS

When inflammation hangs out long enough, the condition that started as tendinitis – an inflammation of the tendon – turns into tendinosis – a the deterioration of the tendon.

When surgery was over my surgeon said, “It’s exactly what I expected. It wasn’t a white cord, like you normally see in a tendon. It was like gray gristle.” During surgery he spliced the tendon open, took out the gristle, stitched the tendon back up, and then scraped the surrounding bone to cause bleeding and facilitate healing. I wouldn’t recommend it. Rehabilitation was horrible.

(These photos are my elbow, twelve days after surgery.)

I went home in a splint and wasn’t allowed to bend my elbow for a few weeks. I was grateful that it was my non-dominant arm, because not being able to bend my right elbow would have been a severe limitation.

SUMMARY

Don’t keep pushing through pain until tendinitis turns into tendinosis. When you start to feel your elbow acting up, reduce time spent on the court, get a vibration-reducing paddle, use a strap on your forearm, ice after you play, and do eccentric strengthening exercises. If things don’t improve, reduce play further and see your doctor about next steps.

Are there other aches and pains you’re dealing with that you’d like to know more about?

This is the only source of medical information where you’ll read the words “butt crack” in the synopsis. Send me a message!