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Patient Handouts

Patient Information Sheet – Achilles Tendinopathy

8 Nov, 08 | by Karim Khan

By Dr Chris Milne, Sports Physician

1. What is it?

It is a disruption of some of the fibres of the achilles tendon. There may be some minor inflammation, but not as much as previously thought.

2. What causes it?

Overuse, plus some wear and tear disruption of the tendon. Poor alignment through the foot and ankle can play a part.

3. Symptoms – What you notice

  • Pain – Usually worse with activity over a 2-3cm length of tendon.
  • As the pain progresses you find you are unable to run as far before it comes on, and the pain may stick around for an hour or two after exercise.
  • Usually there will be localised swelling at the painful site.

4. Signs – What the doctor finds

  • Swelling – usually spread over a 2-3cm length of tendon.
  • Tenderness – at the painful site in the tendon.
  • Occasionally there may be a small very tender nodule at 0.5cm in size. This may indicate a small partial tear.
  • Often associated with flat feet and over-pronation.

5. Investigations

An ultrasound scan may show the amount of fibre disruption. It can also show up a partial tear of the tendon, or associated peritendinitis. If there are significant new vessels, then adjunctive treatment may be required.

6. Treatment

  • First aid – ice massage and Voltaren Emulgel are useful. If you are away from home, use some crushed ice or a packet of frozen peas wrapped in a towel.
  • Rest from running until the initial soreness subsides. You should be able to continue swimming or cycling, plus gentle walking.
  • Once the initial soreness has settled (usually after a week or two) you should start a progressive strengthening programme as below (see recovery sequence Step 3).
  • If you have flat feet and have not been supplied with orthotics, a podiatry consultation will probably be arranged.
  • If the achilles tendon is not improving despite good adherence to the calf strengthening programme of 90 repetitions per day, adjunctive treatment may be required.
  • Surgery is only required if there is a significant partial tear, or if the problem has not settled much over 3-6 months.

7. Recovery time

Average recovery time is 2-4 months.

8. Recovery sequence

  • Step 1 Ice packs, Voltaren Emulgel.
  • Step 2 Physiotherapy – advice regarding stretching and strengthening exercises. Ultrasound therapy may be useful in some cases.
  • Step 3 Progressive strengthening exercises (calf raises). Start with both legs together, and build up progressively until you can manage 3 sets of 15 single leg calf raises twice a day (90 calf raises a day). Do these off the back steps of your house.
  • Step 4 Continue swimming and cycling as much as the pain will allow.
  • Step 5 Restart running, beginning slowly on grass for 5-10 minutes, and build up your normal training over the next 2-3 months.

Patient Information Sheet – Calf Strain

16 Oct, 08 | by Karim Khan

runnersbjsm

CALF STRAIN (also known as tennis leg)
BY Dr Chris Milne, Sports Physician

What is it?
It is a strain of one of the muscles of the lower leg. Usually it is the medial gastrocnemius muscle that is injured.

What causes it?
It usually occurs when you are running fast or changing direction. Because the gastrocnemius muscles pass over two joints, they have a difficult job to do and are prone to overload when they are lengthening against resistance.

Symptoms – what you notice

  • Pain – in the inside of the calf, about halfway between the knee and ankle. The pain is usually of sudden onset, and severe enough to make you stop running straightaway.
  • Weakness of toe-off action (ankle flexion).
    You may notice tracking of blood below the skin a few days after the injury. This is a good sign, as it helps the injured muscle heal.

Signs – what the doctor finds

  • Tenderness over a 2-3cm length of tissue, usually at the junction between the lower end of the calcaneal muscle and the upper end of the achilles tendon.
  • Pain and weakness on resisted ankle flexion (toe-off action).
    There may be some evidence of referred pain from the low back.
  • In rare cases, there may be a contour defect over the injured area. This is easier to see when the muscle contracts against resistance.

Investigations
Usually none are required. If the injury is not healing as expected, an ultrasound scan may be ordered.

Treatment

  • First aid – an ice pack applied over the injured area is useful. Take Panadol or anti-inflammatory tablets.
  • A graduated physiotherapy rehabilitation programme is the main part of treatment.
  • An orthopedic felt wedge put under the inside part of the heel can help in the early recovery phase. It acts as a chock and takes some tension off the injured calf muscle.
  • Surgery is hardly ever required, unless there is a significant tear of the upper part of the achilles tendon.

Recovery time
Average recovery time is 2-4 weeks. Don’t be tempted to push things too quickly, as recurrent strain in a partially healed injury is quite common.

Recovery sequence

  • Step 1 Ice packs, pain relief, orthopedic felt wedge in footwear.
  • Step 2 Physiotherapy treatment to restore full range of motion of the knee and ankle, then build strength and endurance.
  • Step 3 Don’t run, but you should be able to start swimming or cycling a few days after the injury. Keep doing upper body weights and calf raises.
  • Step 4 Restart running, beginning slowly on grass.
  • Step 5 Build up pace and add stop-start routines.
  • Step 6 Run figure eights.
  • Step 7 Perform cutting and turning exercises.
  • Step 8 Team training and skill sessions.
  • Step 9 Resume playing, half a game at first.

Hot Topic: Current Anti-Doping Policies

7 Aug, 08 | by Karim Khan

legs bjsm

A recent editorial by Babette Pluim entitled, “A doping sinner is not always a cheat” [excerpt below], has created some fiery discussion amongst BJSM editors and readers this month.

The doping rules these days are really tough. The basic principle is: first offense gets a 2 year ban, second offence a lifetime ban. Everyone seems to agree that doping is cheating, and those who cheat should be sanctioned, so if an athlete provides a positive sample in any sporting situation, the inference must be that they are cheating. Unfortunately, both for the athlete and the anti-doping system, that is not always the case.

Here is a selection of BJSM editors’ & readers’ reactions:

“Drug cheats – or are they?”
By Dr Tim Wood, Chief medical officer for the Australian Open Tennis Championship and a member of Tennis Australia’s Anti-Doping Review Board

With the formation of the World Anti-Doping Agency (WADA) and the universal harmonization in the fight against the drug cheats in the late 90s everyone applauded. What we didn’t realize at the time was how many ’innocent’ victims would be caught up in the new rules and regulations. I therefore applaud Dr Babette Pluim’s BJSM editorial which reviews the positive doping cases recorded by the International Tennis Federation from 2001-07. She found that the majority of so-called ‘positive’ tests are no more than innocent mistakes by players and officials alike. Nevertheless, the trauma suffered and the tainting of these players is irreversible.

Having been involved in professional tennis for the last 7 years, I also experience frustration at the paperwork required to allow player with genuine medical conditions to take legitimate, scientifically proven drugs that certainly do not enhance performance. The most recent ‘crazy redtape’ is the requirement for a full Therapeutic Use Exemption (TUE) to allow an athlete to have intravenous fluid during elective surgery (Babette has some stories about that!).

Fortunately, it would appear that sanity may be about to prevail on at least three fronts. First, abbreviated TUEs (ATUES for those in the know, even though it sounds like a sneeze) that are currently required for intra-articular cortisone injections will be changed to notification via ADAMS (WADA’s web-based anti-doping management system). Second, ATUEs for beta-2 agonists will be valid for four years instead of needing to be renewed annually but this will come with more stringent proof of the player’s asthmatic status. And finally, many of us hope that the intravenous rule will revert to the 2007 ruling ‘… except for genuine medical situations’.

Everyone involved in professional sport strongly supports WADA and their efforts to catch the cheats but the rules shouldn’t catch innocent athletes, particularly those with genuine medical conditions.

swimmer bjsm

“WADA is on the verge of losing the plot”
By John Orchard, Sports Physician

The idea to create the World Anti-Doping Agency (WADA) was a good one, particularly for international sports. It meant that rogue states like the USA, which had a track record of going soft on their own athletes who tested positive, could be forced to implement universal sanctions.

The big problem with WADA is that it is a monopoly. And it is being run increasingly like one, currently under the Presidency of our own ex-politician John Fahey. WADA’s aim should be to stamp out cheating in sport. This is quite difficult to do, as the cheats are usually very clever. WADA instead is trying to maximise scalps of athletes who “test positive for drugs”, without apparent concern for whether they are actually cheating. Instead of concentrating only on the genuinely performance-enhancing (and usually difficult-to-detect) drugs, the WADA banned list is ever-expanding. It now includes commonly used medications which are much easier to detect and “might conceivably” be used for performance-enhancing in rare circumstances. Whether these rare circumstances exist when an athlete tests positive don’t seem faze WADA, as there is a presumption of guilt rather than innocence.

Banned medications now include asthma puffers and cortisone injections, which are generally considered by doctors and scientists to not be performing-enhancing. Intravenous fluids, including those given for an anaesthetic as part of surgery, are now also banned as of 2008. The status quo is now the farcical situation that the vast majority of athletes are breaking the WADA code whenever they go in for elective surgery. In theory, the only thing stopping these athletes from being suspended is that drug testers aren’t (yet) following them into hospitals.

An editorial just published in the British Journal of Sports Medicine found that in the last 5 years of drug testing in tennis, it was accepted that 68% of the players who were banned for positive drug tests were not actually cheating. They were banned presumably because WADA wanted to increase their tally of convictions. They include cases such as known asthmatics taking puffers such as Ventolin for asthma attacks, but whose ‘permits’ to treat their asthma with appropriate medication had either recently expired or been faxed to the wrong number. In 2009, WADA has plans that asthmatics should apply to a panel to ‘prove’ they have asthma, or else they will be banned from sport for using their puffers. The Howard government basically held the funding gun to the head of all Australian sports in 2005 and forced them to sign up to WADA, despite many sports fearing the situation we are now in. This being that the universal drug code has become draconian and the sports have signed away all rights to do anything about it.

runner bjsm

“Accidental cheating?”
By Giuseppe Lippi, Associate Professor of Clinical Biochemistry, Università di Verona

In an overview of the 40 most recent cases of doping in tennis, Babette Pluim highlighted that in only 13 of the cases (32%) was a prohibited substance taken to enhance performance, whereas most frequently banned substances were taken with no intent to enhance performance or without (significant) fault or negligence.1

I definitely agree that products that are on the list of prohibited substances should be critically reviewed, but I also emphasize that the current anti-doping policy is essentially a costly, repressive, zero tolerance approach, which seems only partly successful.2 It is also to mention, however, that there may be additional explanations to justify adverse findings on antidoping testing, which have little to do with cheating.

The use of dietary supplements is commonplace in sports, most elite athletes using some form of licit supplementation to burst athletic performance and improve recovery after training or competition. Nevertheless, there is widespread evidence that some of these legitimate products, especially those sold on the “black market”, contain banned substances that are not claimed as a result of poor manufacturing practice or adulteration.

Contaminants mostly include anabolic androgenic steroids, hormones, ephedrine and caffeine.3,4 Indeed, in some cases the adverse findings might be the consequence of deliberate cheating. However, we should still consider the possibility that some positive tests might arise from unintentional consumption of prohibited substances, contaminating dietary supplements. In this respect, not only antidoping agencies should focus on products that are truly harmful and performance-enhancing, but they should also issue a clear regulation on the use of nutritional supplements and establish appropriate bans for inadvertent use of banned molecules. Doping is always to blame, especially when the athletes use illicit methodsor substances that might produce a serious risk for their health. However, as different sanctions are imposed when crimes are intentional or preterintentional, bans should also be clearly differentiated from deliberate and unintentional positivity to banned substances.

References

1. Pluim B. A doping sinner is not always a cheat. Br J Sports Med 2008;42:549-50.

2. Kayser B, Smith AC. Globalisation of anti-doping: the reverse side of the medal. BMJ 2008 Jul 4;337:a584. doi: 10.1136/bmj.a584.

3. Maughan RJ. Contamination of dietary supplements and positive drug tests in sport. J Sports Sci 2005;23:883-9.

4. Linksvan der Merwe PJ, Grobbelaar E. Unintentional doping through the use of contaminated nutritional supplements. S Afr Med J 2005;95:510- 1.

Tennis Elbow Handout

30 May, 08 | by Karim Khan

tennis_ball_bjsm

Another excellent patient handout.

Patient Information Sheet 8 – Tennis elbow

More Patient Handouts

18 May, 08 | by Karim Khan

Feel free to download these handouts and use them!

Patient Information – Shoulder dislocation

Patient Information – Rotator cuff strain and impingement

Patient Handouts

12 Apr, 08 | by Karim Khan

Dr Chris Milne has been kind enough to share his patient handouts. Feel free to use them:

Chris Milne’s Patient Handout 1: AC joint strain

Chris Milne’s Patient Handout 2: Rotator Cuff tear patient handout

Another article “Intravenous fluids and TUE requirements” has been supplied by the Australian Sports Drug Medical Advisory Committee (ASDMAC).

Intravenous fluids and TUE requirements From the World Anti Doping Agency – WADA

Each year WADA refreshes the list of prohibited substances and methods. In the 2008 list, under the category of prohibited methods, subcategory ‘Chemical and Physical Manipulation’, WADA has included the following statement ‘IV infusion is prohibited. In an acute medical situation where this method is deemed necessary, a retroactive TUE will be required’. This article discusses this decision and its implications.

Please feel free to send your patient handouts to the blog. We could end up making the Wikipedia for patient handouts on this site!

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