Overuse Syndromes

by Dr. Tom Myers

We’ve all seen it or had it—the slow, duck-like waddle or shuffling gait after hiking in or out of the Canyon. Affectionately known as the “Canyon Shuffle,” it is without a doubt the backcountry trekker’s most common dance. If you hike long enough, steep enough or heavy enough, you’ll get it—sooner or later. Same thing goes for Canyon boaters, especially guides, just a different extremity. If you row or paddle long and hard enough, especially against the wind, your shoulders, elbows and wrists will let you know you’ve overdone it and pronto. These acutely painful, sore muscles and joints are akin to one another and all fall in a class of conditions called “acute overuse syndromes.” They are caused by prolonged, repetitive, vigorous overuse of extremity joints, tendons and muscles, which results in an acute inflammatory reaction within the tissues. Treatment is directed primarily at trying to minimize this reaction.

Definitions:

  • Tendonitis – Inflammation of tendons
  • Bursitis – Inflammation of the bursa (lubricating sacs around joints)
  • Arthritis – Inflammation of joints
  • Myositis – Inflammation of muscle

(“itis”= inflammation)

The diagnosis is typically based on the history of how the symptoms developed and physical exam findings. Regarding the history, there usually is no to minimal trauma. There is a gradual onset of pain in joints, and muscles, with worsening stiffness, especially in the mornings. On exam, the joints, tendons, or muscles involved are often tender to the touch. There may be swelling around the areas involved as well. There is pain or “soreness” with movement of the extremity, especially active movement (the victim moves the joint versus you moving it for them), and range of motion tends to be limited secondary to pain and stiffness.

So what to you do?

Fortunately, there is a clever little acronym that covers the initial treatment protocol for acute overuse syndromes as well as most traumatic injuries, and it’s easy to remember. It’s R-I-C-E or plain, old “rice.” It stands for: rest, ice, compression and elevation. (Throw a little TLC in with the RICE and you’ll have a great jumpstart on the road to recovery.)

The “RICE” Treatment

R = REST

  • Stop or quit using injured part.

I = ICE

  • Use ice frequently for first 48 hours (20 minutes/hour several times daily if possible). It reduces swelling, dulls pain, and relieves muscle spasm by constricting blood vessels. (Four stages of sensation occur with ice application to skin: cold, burning, aching, and then numbness.)
  • Remove ice after numbness develops (about 20 min) to prevent frostbite, and never place ice directly on skin.
  • Reapply ice up to every 1-4 hours while awake.
  • To intensify the cold, place wet cloth between skin and ice pack.
  • Substitute cold Colorado River water (48? F) in a zip lock baggie if available. (Soaking in cold river water is possible but this requires walking to and from river, and having the injured extremity in a dependent position which can worsen swelling.)

C = COMPRESSION

  • To reduce swelling, bleeding and for support.
  • Typically use elastic bandage (ACE). Wrap starting several inches below injury and work upward. Over wrap preceding wrap by 50%.
  • Do not wrap too tight! (may cause more pain, numbness or tingling, and cold, pale or blue discoloration to skin).

E = ELEVATION

  • Reduces swelling.
  • Elevate extremity above level of heart.
  • Medications can also be helpful for treating overuse syndromes. A non-prescription anti-inflammatory such as Ibuprofen (Advil), 400- 600mg 3-4 times daily, or Naprosyn (Aleve) 220mg, one or two twice daily, or Aspirin 325mg tablets, two every four hours, can reduce inflammation and relieve pain. (Caution: do not take more than one anti-inflammatory medication at a time, and take the medication with food to avoid stomach irritation.) For muscle cramping at night, non-prescription Diphenhydramine (Benadryl), 25-50mg every 4-6 hours, may aid sleeping by causing drowsiness and secondary muscle relaxation.

More Definitions:

  • Ibuprofen – “Breakfast of Champions,” “Vitamin I”
  • Squeaky Shins“- pain and tenderness over the tendons along side the shin of the lower leg. Due to tendon inflammation and swelling, a “squeaking” or crunching sensation or crepitations (like walking on frozen snow) can be heard and felt in the leg.

Other therapeutic measures include adding moist heat after 48 hours, i.e. a moist heating pad. If in the Canyon, place a wash cloth soaked in warm water into a zip lock baggie, and apply it on the extremity in 30 minute intervals. This is incredibly soothing and beneficial. Additionally, for muscle cramping try gently massaging the muscle. Light stretching can also be of comfort, but try to do so while applying steady pressure (squeezing) to the muscle to avoid triggering more spasms.

What should you not do?

Do not try to “walk it off” or “row it off” if you can avoid it, as you risk making the condition worse. Remember, limit activity as much as possible; rest is important. Do not confuse the use of ice and heat. And avoid wrapping elastic bandages too tight around a limb, causing a constricting or tourniquet effect which will worsen swelling and pain.

What about prevention?

Begin training several weeks in advance. Pre-hiking, rowing/paddling conditioning is essential, and ideally you should try to train up to, if not beyond the level of exertion anticipated, i.e. “The best way to train for Canyon hiking is to hike Canyons.” Other general recommendations include an appropriate stretching/ warm up period, usually 5-10 minutes. Once you’re in the thick of it, plan adequate intervals of rest during activity, 5-10 minutes for every hour of exertion. Finally, use common sense, listen to your body and know when to say when.

Other helpful hints for preventing overuse syndromes:

For hiking:

  • Use proper footwear.
  • Carry a lighter backpack or lighter gear.
  • Use a walking stick (ski poles).
  • Consider a supportive knee wrap or elastic sleeve.

For rowing boats:

  • Alternate downstream pull (“Major Powelling”), with forward push strokes to use different muscle groups.
  • Consider counterweights for oars and “oar rights” to prevent wrist tendonitis.
  • Consider supportive wrist or elbow wraps/ elastic sleeve.

Strains and Sprains

General Considerations: Hikers

  • 90% of serious hiking injuries occur going downhill.
  • 60% involve the ankle, knee or foot (ankle sprains are most common).
  • 50% of evacuations are heat related
  • 15% involve the wrist
  • The heavier the pack, the worse the injury

Most Common Hiking Injuries:

  • Ankle sprain
  • Knee sprain
  • Ankle fracture
  • Wrist fracture
  • Leg laceration

General Considerations: River Runners

Most injuries occur on shore:

  • 90% on small, calmer river like the San Juan
  • 60% on larger volume rivers with big rapids (i.e. Colorado in Grand Canyon)
  • Serious Injury frequency is low.
  • Most Common ON-River injury:
  • Contusions, head
  • Laceration, leg or foot
  • Fracture, leg or foot
  • Laceration, face
  • Back Sprain

Most Common Cause:

  • Striking against something or someone in boat.
  • Boat flip
  • Hit by oar
  • Getting “pinched” in frame