Radiation injuries

Radiation injuries are caused by ionizing radiation emitted by such sources as the sun, x-ray and other diagnostic machines, tanning beds, and radioactive elements released in nuclear power plant accidents and detonation of nuclear weapons during war and as terrorist acts.

Description

Ionizing radiation is made up of unstable atoms that contain an excess amount of energy. In an attempt to stabilize, the atoms emit the excess energy into the atmosphere, creating radiation. Radiation can either be electromagnetic or particulate.

The energy of electromagnetic radiation is a direct function of its frequency. The high energy, high frequency waves that can penetrate solids to various depths cause damage by separating molecules into electrically charged pieces, a process known as ionization. X rays are a type of electromagnetic radiation. Atomic particles come from radioactive isotopes as they decay to stable elements.

Electrons are called beta particles when they radiate. Alpha particles are the nuclei of helium atoms two protons and two neutrons—without the surrounding electrons. Alpha particles are too large to penetrate a piece of paper unless they are greatly accelerated in electric and magnetic fields.

Both beta and alpha particles are types of particulate radiation. When over-exposure to ionizing radiation occurs, there is chromosomal damage in deoxyribonucleic acid (DNA). DNA is very good at repairing itself; both strands of the double helix must be broken to produce genetic damage.

Because radiation is energy, it can be measured. There are a number of units used to quantify radiation energy. Some refer to effects on air, others to effects on living tissue. The roentgen, named after Wilhelm Conrad Roentgen, who discovered x rays in 1895, measures ionizing energy in air.

A rad expresses the energy transferred to tissue. The rem measures tissue response. A roentgen generates about a rad of effect and produces about a rem of response. The gray and the sievert are international units equivalent to 100 rads and rems, respectively.

A curie, named after French physicists who experimented with radiation, is a measure of actual radioactivity given off by a radioactive element, not a measure of its effect. The average annual human exposure to natural background radiation is roughly 3 milliSieverts (mSv).

Any amount of ionizing radiation will produce some damage; however, there is radiation everywhere, from the sun (cosmic rays) and from traces of radioactive elements in the air (radon) and the ground (uranium, radium, carbon-14, potassium-40 and many others).

Earth’s atmosphere protects us from most of the sun’s radiation. Living at 5,000 feet altitude in Denver, Colorado, doubles exposure to radiation, and flight in a commercial airliner increases it 150-fold by lifting us above 80% of that atmosphere.

Because no amount of radiation is perfectly safe and because radiation is ever present, arbitrary limits have been established to provide some measure of safety for those exposed to unusual amounts. Less than 1% of them reach the current annual permissible maximum of 20 mSv.

A 2001 ruling by the Federal Court of Australia indicated that two soldiers died from cancer caused by minimal exposure to radiation while occupying Hiroshima in 1945.

The soldiers were exposed to less than 5 mSv of radiation. The international recommendation for workers is safety level of up to 20 mSv. The ruling and its support by many international agencies suggests that even extremely low doses of radiation can be potentially harmful.

Ultraviolet (UV) radiation exposure from the sun and tanning beds

UV radiation from the sun and tanning beds and lamps can cause skin damage, premature aging, and skin cancers. Malignant melanoma is the most dangerous of skin cancers and there is a definite link between type UVA exposure used in tanning beds and its occurrence. UVB type UV radiation is associated with sunburn, and while not as penetrating as UVA, it still damages the skin with over exposure.

Skin damage accumulates over time, and effects do not often manifest until individuals reach middle age. Light-skinned people who most often burn rather than tan are at a greater risk of skin damage than darker-skinned individuals that almost never burn.

The U.S. Food and Drug Administration (FDA) and the Centers for Disease Control (CDC) discourage the use of tanning beds and sun lamps and encourage the use of sunscreen with at least an SPF of 15 or greater. In addition, the rising incidence of melanoma in the United States has led the Environmental Protection Agency (EPA) to develop a sun safety education program for school-age children in order to begin changing public attitudes toward tanning.


Overexposure during medical procedures

Ionizing radiation has many uses in medicine, both in diagnosis and in treatment. X rays, CT scanners, and fluoroscopes use it to form images of the body’s insides. Nuclear medicine uses radioactive isotopes to diagnose and to treat medical conditions.

In the body, radioactive elements localize to specific tissues and give off tiny amounts of radiation. Detecting that radiation provides information on both anatomy and function. During the past 10 years, skin injuries caused by too much exposure during a medical procedure have been documented.

In 1995, the FDA issued a recommendation to physicians and medical institutions to record and monitor the dosage of radiation used during medical procedures on patients in order to minimize the amount of skin injuries. The FDA suggested doses of radiation not exceed 1 Grey (Gy). (A Grey is roughly equivalent to a sievert.)

As of 2001, the FDA was preparing further guidelines for fluoroscopy, the procedure most often associated with medical-related radiation skin injuries such as rashes and more serious burns and tissue death. Injuries occurred most often during angioplasty procedures using fluoroscopy.

CT scans of children have also been problematic. Of-tentimes the dosage of radiation used for an adult isn’t decreased for a child, leading to radiation overexposure.

Children are more sensitive to radiation; a February 2001 study indicates 1,500 out of 1.6 million children under 15 years of age receiving CT scans annually will develop cancer. Studies show that decreasing the radiation by half for CT scans of children will effectively decrease the possibility of overexposure while still providing an effective diagnostic image.

The benefits to receiving the medical treatment utilizing radiation is still greater than the risks involved; however, more stringent control over the amount of radiation used during the procedures will go far to minimize the risk of radiation injury to the patient.

Recent evidence suggests that some ethnic groups may be more vulnerable than others to radiation damage. A study done at New York University found that Jews are more likely to develop ovarian cancer as a delayed side effect of diagnostic x-rays of the abdomen than non-Jews.

These findings require confirmation by further research, but they do indicate that ethnicity and other genetic factors are involved in susceptibility to radiation damage.

Side effects from radiation therapy to treat cancer

As many as half of all cancer patients receive some form of radiation therapy as a component of treatment. The therapy can be delivered from either an external or an internal source, although the former is more common. The machines used for external radiation have become more specialized to deliver the appropriate dose to either a superficial or a deep location on the body.

Depending on the type and site of cancer being treated, internal sources of radiation can be injected, swallowed, or placed within the body in sealed containers. These are implanted into or near the tumor, either temporarily or permanently.

Some types of tumors may be eliminated by radiation therapy, if the patient is able to withstand the necessary dose. In other cases, radiation is used in conjunction with other methods of treatment.

It may be given before surgery, to shrink a tumor to an operable size, or after surgery, to try to destroy any cancerous cells that may remain. Radiation can be used to make patients with incurable disease more comfortable by decreasing the bulk of tumors to reduce pain or pressure. Treatment that is given as a comfort measure only is known as palliation, or palliative therapy.

Occupational radiation exposure

Specialists in industrial and occupational health are increasingly aware of the rising number of injuries related to on-the-job radiation exposure. One study of Swedish workers exposed to high levels of low-frequency magnetic fields found an increased incidence of kidney, liver, and pituitary gland tumors among the men, and a higher rate of leukemia and brain tumors among the women.

Sadly, the delayed effects of occupational radiation exposure have also delayed the adoption of necessary protection for workers at risk. A study of the high rate of lung cancer among Navajo Indians who worked in uranium mines during World War II did not bring about even partial protection for the miners until 1962. It was not until 1990 that Congress passed the Radiation Exposure Compensation Act to provide care for the injured miners.

The effects of cosmic radiation on human beings are also being investigated because of concern for the safety of air crew. Although findings are still inconclusive as of 2002, recent reports of an increased incidence of cancer among airline pilots and cabin crew members have led epidemiologists to study the long-term effects of cosmic radiation at the altitudes of modern aircraft flight.

Radiation exposure from nuclear accidents, weaponry, and terrorist acts

Between 1945 and 1987, there were 285 nuclear reactor accidents, injuring over 1,550 people and killing 64. The most striking example was the meltdown of the graphite core nuclear reactor at Chernobyl in 1986, which spread a cloud of radioactive particles across the entire continent of Europe.

Information about radiation effects is still being gathered from that disaster, however 31 people were killed in the immediate accident and 1,800 children have thus far been diagnosed with thyroid cancer.

In a study published in May 2001 by the British Royal Society, children born to individuals involved in the cleanup of Chernobyl and born after the accident are 600% more likely to have genetic mutations than children born before the accident. These findings indicate that exposure to low doses of radiation can cause inheritable effects.

Since the terrorist attack on the World Trade Center and the Pentagon on September 11, 2001, the possibility of terrorist-caused nuclear accidents has been a growing concern.

All 103 active nuclear power plants in the United States are on full alert, but they are still vulnerable to sabotage such as bombing or attack from the air. A nofly zone of 12 miles below 18,000 feet has been established around nuclear power plants by the Federal Aviation Administration (FAA).

There is also growing concern over the security of spent nuclear fuel—more than 40,000 tons of spent fuel is housed in buildings at closed plants around the country. Unlike the active nuclear reactors that are enclosed in concrete-reinforced buildings, the spent fuel is stored in non-reinforced buildings.

Housed in cooling pools, the spent fuel could emit dangerous levels of radioactive material if exploded or used in makeshift weaponry. Radioactive medical and industrial waste could also be used to make "dirty bombs." Since 1993, the Nuclear Regulatory Commission (NRC) has reported 376 cases of stolen radioactive materials.

One response on the part of health care workers has been stepped-up training in radiation disaster management. Emergency department personnel are being trained as of 2002 to use radiologic monitoring and other specialized equipment for treating victims of a terrorist attack involving radiation.

Causes and symptoms

Radiation can damage every tissue in the body. The particular manifestation will depend upon the amount of radiation, the time over which it is absorbed, and the susceptibility of the tissue.

The fastest growing tissues are the most vulnerable, because radiation as much as triples its effects during the growth phase. Bone marrow cells that make blood are the fastest growing cells in the body. A fetus in the womb is equally sensitive.

The germinal cells in the testes and ovaries are only slightly less sensitive. Both can be rendered useless with very small doses of radiation. More resistant are the lining cells of the body—skin and intestines. Most resistant are the brain cells, because they grow the slowest.

The length of exposure makes a big difference in what happens. Over time the accumulating damage, if not enough to kill cells outright, distorts their growth and causes scarring and/or cancers.

In addition to leukemias, cancers of the thyroid, brain, bone, breast, skin, stomach, and lung all arise after radiation. Damage depends, too, on the ability of the tissue to repair itself. Some tissues and some types of damage produce much greater consequences than others.

There are three types of radiation injuries.

• External irradiation: as with x-ray exposure, all or part of the body is exposed to radiation that either is absorbed or passes through the body.
• Contamination: as with a nuclear accident, the environment and its inhabitants are exposed to radiation. People are affected internally, externally, or with both internal and external exposure.
• Incorporation: dependent on contamination, the bodies of individuals affected incorporate the radiation chemicals within cells, organs, and tissues and the radiation is dispersed throughout the body.

Immediately after sudden irradiation, the fate of those affected depends mostly on the total dose absorbed. This information comes mostly from survivors of the atomic bomb blasts over Japan in 1945.

• Massive doses incinerate immediately and are not distinguishable from the heat of the source.
• A sudden whole-body dose over 50 Sv produces such profound neurological, heart, and circulatory damage that patients die within the first two days.
• Doses in the 10–20 Sv range affect the intestines, stripping their lining and leading to death within three months from vomiting, diarrhea, starvation, and infection.
• Victims receiving 6–10 Sv all at once usually escape an intestinal death, facing instead bone marrow failure and death within two months from loss of blood coagulation factors and the protection against infection provided by white blood cells.
• Between 2–6 Sv gives the person a fighting chance for survival if he or she is supported with blood transfusions and antibiotics.
• One or two Sv produces a brief nonlethal sickness with vomiting, loss of appetite, and generalized discomfort.

Side effects of radiation therapy

Damage caused to normal cells can show up either in the time frame shortly following radiation treatment, or as long as years after radiation has been completed. Symptoms that frequently occur soon after treatment include loss of appetite, fatigue, and skin changes. Less commonly, patients have headache, nausea, vomiting, hair loss, and weakness.

In more severe cases, dehydration, seizures, and shock-type reactions can occur. The severity and type of effects will depend on the region of the body receiving treatment, the type of radiation used during the course of treatment, and the dose. There is also individual variation in the response.

Skin rashes are common. They may take the form of redness, burn, dryness, itching, or soreness. Organs that were in the path of the beam may show changes, including scarring, functional changes (such as decrease in elasticity), and loss of cells.

Tissues that have a rapid turnover of cells may be most severely affected, including the skin and lining of the gastrointestinal tract. More severe injuries may include long-term bone marrow suppression, and occasionally even other cancers, particularly sarcomas.

People who receive radiation in the region of the head and neck are likely to experience a dry and sore mouth to some degree. The skin may become dry, and the area under the chin may droop. Sense of taste can be altered or lost. Some may experience hair loss, earaches, or difficulty swallowing due to inflammation of the esophagus.

Radiation treatments given for or around the breast, chest, or lung can also cause esophagitis and accompanying trouble swallowing. Changes in the lung tissue may lead to pneumonitis or pulmonary fibrosis. The patient may develop a cough. Breast treatments may cause pain and swelling. Blood counts can decrease.

Side effects from treatment of the stomach and abdominal area can induce nausea and diarrhea. In the pelvic region, radiation may result in difficulties with urination, and infertility in both males and females. Women may also have symptoms of dryness, itching, or burning of the vagina.

Diagnosis

The various effects of radiation on the body are well recognized. Patients who are scheduled to undergo radioactive treatments should be informed of the potential side effects they will encounter based on the area being treated and the dose of radiation being used. Advice for coping with minor injuries should be given, as well as descriptions of what symptoms should prompt a call or a visit to the treating physician.

Treatment

It is clearly important to have some idea of the dose received as early as possible, so that attention can be directed to those victims in the 2-10 Sv range that might survive with treatment. Blood transfusions, protection from infection in damaged organs, and possibly the use of newer stimulants to blood formation can save many victims in this category.

Local radiation exposures usually damage the skin and require careful wound care, removal of dead tissue, and skin grafting if the area is large. Again infection control is imperative.

One of the best-known, and perhaps even mainstream, treatments of radiation injury is the use of Aloe vera preparations on damaged areas of skin. It has demonstrated remarkable healing properties even for chronic ulcerations resulting from radiation treatment. Another topical herb that may be effective against skin inflammation following radiation therapy is chamomile cream.

Studies support the benefits of chamomile for skin inflammation and wound healing. Additional topical herbs that may be helpful are calendula and St. John’s wort. These therapies can prove very helpful since skin reaction is one of the most common side effects of radiation therapy.

Guided imagery is a method that may be used following radiation treatment, especially to help ease pain. Several nutritional supplements help with healing wounds. These include essential fatty acids (Omega 3 and 6), vitamin A, vitamin B, and magnesium/zinc.

If the tumor being treated is determined to be sensitive to radiation, there are a few herbs that are said to reduce the adverse effects of radiation exposure.

Ginseng is one that research suggests may have this benefit. Other nutrients thought to have some protective effects are coenzyme Q10, kelp, pantothenic acid, and glutathione with L-cysteine and L-methionine.

Garlic and vitamin C support immune function. Grape seed extract is a powerful antioxidant that protects against cell damage by free radicals. Any nutritional measures to support optimum health before treatment are beneficial.

Allopathic treatment

The type of treatment used depends on the area and severity of the injury. Something as serious as bone marrow suppression would require more intensive therapy, whereas more minor conditions are treated symptomatically.

Radiation-induced esophagitis may necessitate intravenous or gastrostomy feeding for a time until the injury is healed. If a perforation or a stricture develops, surgery may be necessary. Products are available to keep the eyes (drops with vitamin A) and oral mucosa moist, as the cells producing mucus and tears are often damaged.

Expected results

Tissue damage resulting from radiation exposure tends to be chronic in nature, and may even be progressive. For the lesser and more common types of problems, long-term treatment of symptoms should be anticipated.

Prevention

Part of preventing radiation injury involves doing research on the condition being treated. It is a good idea to be certain that radiation is the best available treatment for a particular cancer type before embarking on a course of therapy.

Information on preventing or minimizing damage from radiation produced by terrorist devices or other nuclear emergencies is available in a series of fact sheets that can be downloaded from the Centers for Disease Control (CDC) web site.

The fact sheets cover such topics as basic radiation facts, acute radiation sickness (ARS), dirty bombs, effects of radiation on health, possible effects of radiation on unborn children, and protective measures in the case of a nuclear event.

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Rolfing

Rolfing, also called Rolf therapy or structural inte gration, is a holistic system of bodywork that uses deep manipulation of the body’s soft tissue to realign and bal ance the body’s myofascial structure. Rolfing improve posture, relieves chronic pain, and reduces stress.

Origins

Ida Pauline Rolf (1896–1979) was a biochemist from New York who developed structural integration over the course of many years after an accident as a young woman. She was kicked by a horse’s hoof on a trip out West and developed symptoms resembling those of acute pneumonia.

She made her way to a hospital in Montana, where she was treated by a physician who called in an osteopath to assist in her treatment. After the osteopath treated her, she was able to breathe normally. After her return to New York, her mother took her to a blind osteopath for further treatment.

He taught her about the body’s structure and function, after which Rolf became dissatisfied with conventional medical treatment. Following completion of a doctorate in biochemistry from Columbia University in 1920, Rolf studied atomic physics, mathematics, and homeopathic medicine in Europe.

After 1928, when her father died and left her an inheritance that allowed her to pursue her own studies, she explored various forms of alternative treatment, including osteopathy, chiropractic medicine, tantric yoga, the Alexander technique of tension reduction through body movement, and Alfred Korzybski’s philosophy of altered states of consciousness.

By 1940, Rolf had synthesized what she had learned from these various disciplines into her own technique of body movement that she called structural integration, which later became known as Rolfing. During the Second World War, Rolf continued to study with an osteopath in California named Amy Cochran.

In the mid1960s, Gestalt therapist Fritz Perls invited Rolf to Esalen, where she began to develop a following among people involved in the human potential movement. In 1977, she published Rolfing: The Integration of Human Structures, the definitive book on structural integration bodywork.

She continued to refine the therapy until her death in 1979. Rolf’s work is carried on through her Guild for Structural Integration, now known as the Rolf Institute of Structural Integration, which she founded in 1971 in Boulder, Colorado.

Benefits

Rolfing helps to improve posture and bring the body’s natural structure into proper balance and alignment. This can bring relief from general aches and pains, improve breathing, increase energy, improve self-confidence, and relieve physical and mental stress.

Rolfing has also been used to treat such specific physical problems as chronic back, neck, shoulder, and joint pain, and repetitive stress injuries, including carpal tunnel syndrome.

Many amateur and professional athletes, including Olympic skaters and skiers, use Rolfing to keep in top condition, to prevent injuries, and to more quickly recover from injuries.

Description

Rolfing is more than just a massage of the body’s surface. It is a system that reshapes the body’s myofascial structure by applying pressure and energy, thereby freeing the body from the effects of physical and emotional traumas.

Although Rolfing is used extensively to treat sports injuries and back pain, it is not designed as a therapy for any particular condition. Rather, it is a systematic approach to overall wellness. It works by counteracting the effects of gravity, which over time pulls the body out of alignment.

This pull causes the body’s connective tissue to become harder and stiffer, and the muscles to atrophy. Signs of this stiffening and contraction include slouching or an overly erect posture.

Rolfing identifies the vertical line as the ideal that the body should approximate. The mission statement of the Guild for Structural Integration describes Rolfing as “a method and a philosophy of personal growth and integrity... The vertical line is our fundamental concept. The physical and psychological embodiment of the vertical line is a way of Being in the physical world [that] forms a basis for personal growth and integrity.”

The basic ten

Basic Rolfing treatment consists of 10 sessions, each lasting 60–90 minutes and costing about $100 each. The sessions are spaced a week or longer apart. After a period of integration, specialized or advanced treatment sessions are available.

A “tuneup” session is recommended every six months. In each session, the Rolfer uses his or her fingers, hands, knuckles, and elbows to rework the connective tissue over the entire body.

The tissues are worked until they become pliable, allowing the muscles to lengthen and return to their normal alignment. The deep tissue manipulation improves posture and agility, and increases the body’s range of movement.

Rolfers also believe that the blocked energy accumulated in the tissue from emotional tension is released through Rolfing treatment, causing the patient to feel more energetic and have a more positive frame of mind.

Clients are asked to wait for a period of six to 12 months before scheduling advanced work, known as the Post Ten/Advanced Series. This period allows the body to integrate the work done in the “Basic Ten.”

Rolfing movement integration

Rolfing movement integration, or RMI, is intended to help clients develop better awareness of their vertical alignment and customary movement patterns. They learn to release tension and discover better ways to use body movement effectively.

Rolfing rhythms

Rolfing rhythms are a series of exercises intended to remind participants of the basic principles of Rolfing: ease, length, balance, and harmony with gravity. In addition, Rolfing rhythms improve the client’s flexibility as well as muscle tone and coordination.

Preparations

No pre-procedure preparations are needed to begin Rolfing treatment. The treatment is usually done on a massage table with the patient wearing only undergarments. Prior to the first session, however, the client is asked to complete a health questionnaire, and photographs are taken to assist with evaluation of his or her progress.

Precautions

Since Rolfing involves vigorous deep tissue manipulation, it is often described as uncomfortable and sometimes painful, especially during the first several sessions.

In the past decade, however, Rolfers have developed newer techniques that cause less discomfort to participants. Since Rolfing is a bodywork treatment that requires the use of hands, it may be a problem for people who do not like or are afraid of being touched.

It is not recommended as a treatment for any disease or a chronic inflammatory condition such as arthritis, and can worsen such a condition. Anyone with a serious medical condition, including heart disease, diabetes, or respiratory problems, should consult with a medical practitioner before undergoing Rolfing.

Side effects

There are no reported serious side effects associated with Rolfing when delivered by a certified practitioner to adults and juveniles.


Research and general acceptance

There is a growing amount of mainstream scientific research documenting the effectiveness of Rolf therapy. A 1988 study published in the Journal of the American Physical Therapy Association indicated that Rolfing stimulates the parasympathetic nervous system, which can help speed the recovery of damaged tissue.

Other studies done in the 1980s concerned the effectiveness of Rolfing in treating figure skaters and children with cerebral palsy. In 1992 a presentation was made to the National Center of Medical Rehabilitation Research regarding Rolfing in the treatment of degenerative joint disease.

A 1997 article in The Journal of Orthopedic and Sports Physical Therapy reported that Rolfing can provide effective and sustained pain relief from lower back problems.

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Shin splints

Shin splints can be defined as an inflammation of the tissues in the lower leg causing pain with exercise . The disorder is also referred to as medial tibial stress syndrome.

Shin splints are an inflammation of the tendons, muscles, and periosteum most commonly seen in those who walk, jog, or run on hard, uneven surfaces. The resulting pain may indicate either anterior shin splints, with radiation down the front and lateral leg, or posterior shin splints, extending down the back and inner leg and ankle.

Depending on the body tissues involved, shin splints may indicate myositis (an inflammation of the muscle), tendinitis (inflammation of the tendons), or periostitis (an inflammation of the tissue covering the bone).

Causes and symptoms

The inflammation of shin splints is caused by an imbalance of the calf and shin muscles used to mobilize the forefoot with exercise. The associated pain in the lower leg usually worsens with exercise.

Diagnosis

The identification of shin splints is often made by the affected individual’s observation of the symptoms. X rays of the lower extremity may be requested to prevent a misdiagnosis when stress fractures are suspected.

Treatment

Exercise should not be resumed until it can be performed without pain. Switching from high-impact workouts to swimming or cycling will allow for healing to the inflamed areas. A gentle massage with lubricating oil will provide comfort and decrease swelling.

An ice massage may also facilitate healing, using a circular movement over the affected area three to four times daily for 10-15 minutes. Some find heat more comforting and beneficial, applied via a heating pad or lamp, a hot shower, or whirlpool.

A well-balanced, high-protein diet, dietary antioxidants, and essential fatty acids may also promote healing. As the patient’s activity level may be lower than usual during the initial healing phase of shin splints, adequate fluid and fiber intake is vital to promote normal bowel function.

After at least a two-week rest period, a gradual resumption of exercise is recommended. Icing the legs for 5-10 minutes before stretching and after cool-down is recommended. Crisscross taping of the anterior leg maybe be helpful for the individual with anterior shin splints, as well as raising the heel portion of the shoe approximately one-eighth of an inch.

The individual with posterior shin splints should remember to hold the body erect rather than leaning forward while running, and to avoid landing directly on the toes. An extra pair of socks for warmth while running is also recommended.

Allopathic treatment

For minor discomfort associated with shin splints, over-the-counter anti-inflammatory medications such as ibuprofen or aspirin may provide relief.

If these are found to be ineffective for pain relief, prescription-strength, non steriodal, anti-inflammatory drugs (NDAIDs) may be ordered by the physician. Physical therapy sessions and ice and/or heat application may also be helpful.

Expected results

A complete resolution of the pain associated with shin splints requires an adequate period of rest followed by a slow rehabilitation or gradual resumption of activity ranging from two weeks to two months.

Resuming activities too soon may result in a prolonged healing time and recurrence of symptoms. The change in gait and posture associated with shin splint pain may result in inflammatory or arthritic changes in the local joints, i.e. the ankle, knee, hip, or back.

Prevention

Those who exercise by running or doing high-impact aerobics should be sure to wear well-fitting shoes that offer adequate lateral and arch support with cushioning for the ball and heel of the foot. Footwear should be reevaluated for adequacy of support and cushioning about every six months.

Warming up before and cooling down after the activity is vital, and the shins should also be kept warm during exercise. Jogging on soft surfaces such as dirt or grass is preferred over hard or uneven surfaces.

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Sprains and strains

Sprain refers to damage or tearing of ligaments or a joint capsule. Strain refers to damage or tearing of a muscle.

When excessive force is applied to a joint, the ligaments that hold the bones together may be torn or damaged. This results in a sprain, and its seriousness depends on how badly the ligaments are torn. Any ligament can be sprained, but the most frequently injured ligaments are at the ankle, knee, and finger joints.

Strains are tears in the muscle. Sometimes called pulled muscles, they usually occur because a muscle lacks the flexibility, strength, or endurance to perform a certain activity. The majority of strains occur where the muscle meets the tendon, although they may occur in the middle of the muscle belly as well.

Children under age eight are less likely to have sprains than are older people. Children’s ligaments are tighter, and their bones are more apt to break before a ligament tears.

People who are active in sports suffer more strains and sprains than less active people. Repeated sprains in the same joint make the joint less stable and more prone to future sprains. Muscle strains are also more likely to occur in muscles that have been previously injured.

Causes and symptoms

There are three grades of sprains. Grade I sprains are mild injuries in which there is a stretching or mild tearing of the ligament, yet no joint function is lost. However, there may be tenderness and slight swelling.

Grade II sprains are caused by a partial tear in the ligament. These sprains are characterized by obvious swelling, localized tenderness, pain, joint laxity, difficulty bearing weight if the injury is to a lower extremity, and reduced function of the joint.

Grade III, or third degree, sprains are caused by complete tearing of the ligament. There is severe pain, loss of joint function, widespread swelling, and the inability to bear weight if in the lower extremity.

While a Grade III sprain may be very painful when it occurs, it is sometimes not painful after the injury because the ligament fibers have been completely torn and nothing is pulling on them. If this is true, the injury will be accompanied by a significant loss in joint stability.

Strains, like sprains, are also graded in three different categories. Grade I strains are considered mild. They are categorized by some localized swelling with no significant disruption of the muscle tendon unit. Stretching or contraction of the muscle may be painful.

Grade II strains indicate some disruption of the muscle tendon unit. They will often show a loss of strength and limitation in active motion, but the muscle has not been completely disrupted.

Grade III, or third degree, strains indicate a complete rupture in the muscle tendon unit. This injury is likely to be very painful and often the individual will report hearing a loud pop or snap when the injury occurred.

The site of injury is often quite visible and there will be a significant defect in the muscle that can be felt with the fingers. A Grade III muscle strain will often have very serious bruising with it as well.

Diagnosis

Grade I sprains and strains are usually self-diagnosed. Grade II and III sprains are often seen by a physician, who may x ray the area to differentiate between a sprain and other serious joint injuries. Since muscles don’t show up on x ray, Grade II and III muscle strains are usually diagnosed by physical examination.

Treatment

While the primary problem with sprains and strains is a torn or damaged ligament or muscle fiber, additional complications may develop as a result of swelling and immobilization of the injured area.

In order to prevent these complications from worsening, alternative practitioners endorse RICE: Rest, Ice for 48 hours, Compression (wrapping in an elastic bandage), and Elevation of the sprain or strain above the level of the heart.

Nutritional therapists recommend vitamin C and bioflavonoids to supplement a diet high in whole grains, fresh fruits, and vegetables. Anti-inflammatories, such as bromelain (a proteolytic enzyme from pineapples) and turmeric (Curcuma longa), may also be helpful.

The homeopathic remedy Arnica (Arnica montana) may be used initially for a few days, followed by Rhus tox (Rhus toxicodendron) for joint-related injuries or Ruta rutagraveolens for muscle-related injuries. Arnica gel or ointment, such as Traumeel, or a homeopathic combination of arnica and other remedies, has also been found effective with certain joint sprains.

Traditional Chinese medicine has been effectively used to treat soft tissue injuries like sprains and strains. Acupuncture is used to treat pain and speed the healing process in the damaged tissues by moving blocked energy from the area. The radiant heat of moxibustion may also be used to speed up the healing response in the damaged tissues.

Specialized forms of massage and soft tissue manipulation may be used by a variety of practitioners. Massage has significant effects in enhancing local circulation, promoting earlier mobility, and speeding the healing response in the damaged tissue. It will most often be used in combination with other approaches, including stretching and range of motion exercises.

Allopathic treatment

Grade I sprains and strains can be treated at home. Basic first aid for sprains consists of RICE (Rest, Ice, Compression, and Elevation). Such over-the-counter pain medication such as acetaminophen (Tylenol) or ibuprofen (Motrin) can be taken for pain.

People with grade II sprains or strains may often be referred to physical therapy. Crutches or splints may be used during the healing process to help maintain stability. Surgery may be required for Grade III sprains or strains as a greater amount of damage will often prevent adequate healing without surgery.

Expected results

Moderate sprains and strains heal within two to four weeks, but it can take months to recover from severe injuries. Until recently, tearing the ligaments of the knee meant the end of an athlete’s career.

Improved surgical and rehabilitative techniques now offer the possibility of complete recovery. However, once a ligament has been sprained, it may not be as strong as it was before. A muscle that has been strained is also more susceptible to reinjury.

Prevention

Sprains and strains can be prevented by warming up before exercising, using proper form when performing activities and conditioning, being careful not to exercise past the point of fatigue, and taping or bracing certain joints to protect them from injury.

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Tendinitis

Tendinitis is a condition caused by the tearing of tendon fibers and subsequent inflammation in the tendon. Tendons are the strong connective tissue that connect muscle to bone.

When a muscle contracts, it pulls on the tendon, which is composed of tissue that cannot stretch. The tendon then transmits that pulling force to the bone and moves the bone, producing movement.

Tendinitis usually results from excessive repeated demands placed on the tendon by the muscle. Tendinitis is not usually caused by a sudden injury; it is more commonly a result of a long period of overuse. Tendinitis occurs frequently with active individuals and those whose occupational tasks require repetitive motion.

Tendons that commonly become inflamed include:

• tendons of the hand
• tendons of the upper arm that affect the shoulder
• tendons of the forearm at the elbow
• the tendon of the quadriceps muscle group at the knee
• the Achilles tendon at the ankle

Causes and symptoms

Repeated overuse of the tendon will cause small tears to develop in the tendon fibers. As a result, the body will initiate the injury repair process in the area and lay down scar tissue. Inflammation will develop in the area as part of the injury repair process.

Inflammation increases the blood supply, bringing nutrients to the damaged tissues along with infection-fighting agents. The result is swelling, tenderness, pain, and heat. Redness may occur if the injury is close to the skin.

Since many cases of tendinitis result from chronic inflammatory conditions that develop from long periods of overuse, the inflammatory process is not as exaggerated as with an acute injury. Therefore swelling, heat, and redness are not always visible in a tendinitis complaint because the inflammation is really at a low level.

Recent research has found that tendinitis sometimes develops as a side effect of treatment with quinolones, which are a group of antibiotics frequently used to treat bacterial infections. The tendon most likely to be affected by these drugs is the Achilles tendon, and the tendinitis usually develops within the first few weeks of antibiotic treatment.

tendinitis, which affects the tendon just above the heel of the foot. While tennis elbow occurs more often in workers than in athletes (in spite of its name), tendinitis affecting the Achilles tendon is almost always related to sports. Tendinitis in the shoulder area is almost always found in workers who frequently carry heavy loads as part of their job.

Tendinitis is most often diagnosed by evaluating factors in the patient’s history that indicate muscular overuse. Tendinitis will often develop when an individual suddenly increases his or her level of activity without adequate training or conditioning. This occurs frequently in occupational and recreational settings.

In addition to evaluating factors in the patient’s history that are likely to lead to tendinitis, the clinician may use several physical examination procedures.

Most tendons are near the surface of the skin and therefore can be easily palpated (touched or pressed in order to make a diagnosis), especially by practitioners of manual therapy who have highly developed palpation skills.

Pressure placed directly on these tendons is likely to cause discomfort. In addition, the practitioner may ask the patient to contract the muscle attached to the tendon, usually against resistance, to see if this maneuver causes pain.

Treatment

Ice is often advocated for tendinitis when the tendon is in an irritated state. Ice is particularly useful for limiting inflammation in the tendon. Ice may be applied by placing a bag of ice on the skin.

It may also be applied directly to the skin using an ice cube wrapped in a paper towel or ice frozen in a paper cup with the top portion of the cup peeled away to expose the ice. An ice massage rubbing the skin and underlying tissue with ice in a slow, circular, or back-and-forth motion—will cool the injured area quickly.

If ice is applied to the skin without a barrier between the ice and the skin, the patient should be carefully monitored so that frostbite does not occur. Generally no more than about five minutes of treatment in one area is necessary with ice massage.

Compression wraps, such as elastic bandages, may be used to help provide mechanical support for the tendon during active movement. These compression wraps can be helpful, but they may also slow the healing process in the tendon if left on for long periods because they decrease blood supply in the area.

Various types of soft tissue manipulation are very effective for treating tendinitis and may be employed by a variety of practitioners, including chiropractors, massage therapists, physical therapists, and osteopaths.

One of the most common methods of soft tissue treatment for tendinitis is a vigorous friction massage to the damaged tendon. This friction massage will stimulate the healing of tissue in the area.

It is also thought to help produce a healthy and strong scar-tissue repair of the damaged tendon fibers. Practitioners of manual therapy are also likely to advocate a regular stretching program to help decrease tension in those muscles that may be pulling excessively on the tendon.

Acupuncture and traditional Chinese medicine are quite effective in treating tendinitis. Acupuncture may be used in the immediate vicinity of the tendinitis to help address muscular dysfunction.

Acupuncture treatment may also use more distant points along the energy meridians to help address pain and reduce inflammation. Acupuncture may also have significant benefits in creating an optimum environment for healing of the tendon fiber to take place.

Topical liniments and herbal preparations are often used to treat tendinitis. They have anti-inflammatory properties and will help heal the torn tendon fibers. If the condition is chronic, treatment with moxibustion (burning a small amount of mugwort near the skin) may hasten the healing process.

Some oral herbal preparations may also be used in order to create the optimal healing environment for the tendon and address any underlying problems. Practitioners of traditional Chinese medicine may also use a special form of acupressure massage called tui-na.

Allopathic treatment

Pain and anti-inflammatory medications (aspirin, naproxen, and ibuprofen) will help and are often used to treat tendinitis along with ice, compression wraps, and activity modification, as mentioned earlier.

Sometimes the inflammation lingers and requires additional treatment. Injections of anti-inflammatory medication, such as cortisone, often relieve chronic tendinitis, but they should be used with caution.

Research has indicated that cortisone may have detrimental effects on the healing of connective tissues and may, in fact, weaken them in the long run. This side effect would make the person susceptible to a greater injury in the future.

If tendinitis is persistent and unresponsive to nonsurgical treatment, the afflicted portion of the tendon can be removed through surgery. Surgery is also performed to remove the calcium buildup that comes with persistent tendinitis.

Expected results

Generally, tendinitis will heal if the activity that provokes it is stopped. Various kinds of treatments may accelerate the healing process. Some tendinitis complaints may last for a long time because they are not given adequate healing time before the individual returns to a vigorous level of activity.

Prevention

If given enough time, tendons will strengthen to meet the demands placed on them. The blood supply to tendons is poor, which means that tendons grow slowly. Therefore, adequate time is required for good conditioning. Stretching the muscles that are associated with problematic tendon will also help decrease overuse of the tendon.

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Tennis elbow

Tennis elbow is an inflammation of several structures of the elbow. These include muscles, tendons, bursa, periosteum, and epicondyle (bony projections on the outside and inside of the elbow, where muscles of the forearm attach to the bone of the upper arm).

This condition is also called epicondylitis, lateral epicondylitis, medial epicondylitis, or golfer’s elbow, where pain is present at the inside epicondyle.

Description

The classic tennis elbow is caused by repeated forceful contractions of wrist muscles located on the outer forearm. The stress, created at a common muscle origin, causes microscopic tears leading to inflammation. This is a relatively small surface area located at the outer portion of the elbow (the lateral epicondyle).

Medial tennis elbow, or medial epicondylitis, is caused by forceful repetitive contractions from muscles located on the inside of the forearm. All of the forearm muscles are involved in tennis serves, when combined motions of the elbow and wrist are employed. This overuse injury is common in adults between ages 20–40.

People at risk for tennis elbow are those in occupations that require strenuous or repetitive forearm movement. Such jobs include mechanics, assembly line work, house painting, or carpentry.

Sport activities that require individuals to twist the hand, wrist, and forearm, such as tennis, throwing a ball, bowling, golfing, and skiing, can cause tennis elbow. Individuals in poor physical condition who are exposed to repetitive wrist and forearm movements for long periods of time may also be prone to tennis elbow.

Causes and symptoms

Tennis elbow pain originates from a partial tear of the tendon and the attached covering of the bone. It is caused by chronic stress on tissues attaching a group of forearm muscles known as extensor muscles to the elbow area.

Individuals experiencing tennis elbow may complain of pain and tenderness over either of the two epicondyles. This pain increases with gripping or rotation of the wrist and forearm. If the condition becomes long-standing and chronic, a decrease in grip strength can develop.

Diagnosis

Diagnosis of tennis elbow includes the individual observation and recall of symptoms, a thorough medical history, and physical examination by a physician. Diagnostic testing is usually not necessary unless there may be evidence of nerve involvement from underlying causes.

X rays are usually always negative because the condition is primarily soft tissue in nature, in contrast to a disorder of the bones. However, magnetic resonance imaging (MRI) has been shown to be helpful in diagnosing cases of early tennis elbow because it can detect evidence of swelling and tissue tears in the common extensor muscle group.

Treatment

Heat or ice is helpful in relieving tennis elbow pain. Once acute symptoms have subsided, heat treatments are used to increase blood circulation and promote healing. The physician may recommend physical therapy to apply diathermy or ultrasound to the inflamed site.

These are two common modalities used to increase the thermal temperature of the tissues in order to address both pain and inflammation. Occasionally, a tennis elbow splint may be useful to help decrease stress on the elbow throughout daily activities.

Routine exercises are very important to improve flexibility to all forearm muscles, and will aid in decreasing muscle and tendon tightness that has been creating excessive pull at the common attachment of the epicondyle.

Massage therapy also has been found to be beneficial if symptoms are mild. Massage techniques are based primarily on increasing circulation to promote efficient reduction of inflammation. Manipulation, acupuncture, and acupressure have been used as well.

Contrast hydrotherapy (alternating hot and cold water or compresses, three minutes hot, 30 seconds cold, repeated three times, always ending with cold) applied to the elbow can help bring nutrient-rich blood to the joint and carry away waste products.

Botanical medicine and homeopathy may also be effective therapies for tennis elbow. For example, cayenne (Capsicum frutescens) ointment or arnica, wintergreen, or rue oil applied topically may help to increase blood flow to the affected area and speed healing.

Allopathic treatment

The physician may also prescribe nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation and pain. Injections of cortisone or anesthetics are often used if physical therapy is ineffective. Cortisone reduces inflammation, and anesthetics temporarily relieve pain.

Physicians are cautious regarding an excessive number of injections as they have been found to weaken the tendon’s integrity. In addition, a significant number of patients experience a temporary increase in pain following corticosteroid injections.

A newer method of treatment for tennis elbow is shock wave therapy, in which pulses of high-pressure sound are directed at the injured part of the tendon. The “shock” refers to the high pressure, which breaks down scar tissue and stimulates the regrowth of blood vessels in healthy tissue.

Shock wave therapy sessions take about 20 minutes and have been reported to have a success rate of 80%. Shock wave therapy has very few side effects; one group of German physicians found that temporary reddening of the skin or small bruises were the most commonly reported side effects.

Botulinum toxin, or Botox, is also being tried as a treatment for tennis elbow as of late 2003. Although further research needs to be done, Botox appears to relieve pain in chronic tennis elbow by relaxing muscles that have gone into spasm from prolonged inflammation.

Surgery

If conservative methods of treatment fail, surgical release of the tendon at the epicondyle may be a necessary form of treatment. Although surgical intervention is relatively rare in the treatment of tennis elbow, it is completely succesful in about 70% of cases.


Expected results

Tennis elbow is usually curable; however, if symptoms become chronic, it is not uncommon for treatment to continue for three to six months.

Prevention

Until symptoms of pain and inflammation subside, activities requiring repetitive wrist and forearm motion should be avoided. Once pain decreases to the point that return to activity can begin, the playing of such sports as tennis for long periods should not occur until excellent condition returns.

Many times, choosing a different size or type of tennis racquet or tool may help. Frequent rest periods are important despite what the wrist and forearm activity may be.

Compliance to a stretching and strengthening program is very important in helping prevent recurring symptoms and exacerbation. In some cases, the patient may be advised to change his or her occupation to prevent further injury.

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