Current Issue
Volume: 37
Number: 4
Index: December 2021
Clinical Focus: THE INJURED ATHLETE
Editorial Calendar
April 2010
Clinical Focus: Hypertension
  • Hypertension in athletes
    • Antihypertension medication and its effects on athletes
  • Risk of CVD in professional athletes
  • NSAIDs in sports medicine
  • Arterial and venous injuries in athletes
  • Family history and exercise-induced cardiac remodeling (eg, left ventricular hypertrophy)
  • Physical activity for non-athletes with hypertension
    • Exercise programs for patients with hypertension
  • Sleep changes related to hypertension
  • Resuming exercise after rhabdomyolysis
  • Gender differences in hypertension and treatment options
  • Dietary approaches to prevention and treatment hypertension
  • Exercise and the vascular wall
  • Effects of exercise on aging
  • Association between exercise and atherosclerosis
  • Sodium ingestion and hypertension
  • Arrhythmia and "holiday heart"
  • Increased arterial stiffness in children, patients with type 2 diabetes
  • COPD
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ATHLETIC SHOES: FINDING A GOOD MATCH
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Abstract: When you walk into an athletic-shoe store, chances are you'll be overwhelmed by the selection and feel the marketing magnet of sports celebrities and their namesake shoes. Superstores may carry hundreds of different joggers from a dozen major brands. And the same goes for most other types of athletic shoes, from walkers and cross-trainers to basketball shoes and football cleats.

When seeking the best match between your feet and your sport, you face a decision right away. You can either shop at an athletic-shoe store where employees have special training, or you can spend a few minutes getting to know your feet and your sport or activity before you shop.
Finding the Right Shoe
Just as human feet vary, so do sports and fitness levels. For example, if you only jog a little every week and play some basketball in the driveway from time to time, an all-purpose cross-training shoe should be fine. But if you do a certain sport or activity three or more times a week, you should wear shoes specific to that sport or activity; they may help you avoid injuries such as "shin splints" or ankle sprains.

In general, people who run or do aerobics need shoes with a lot of impact-absorbing cushioning. Walkers need shoes that have extra shock absorption at the heel as well as soles that provide a good roll off the toes. People who play court sports need shoes that help keep the ankle stable during side-to-side movements, which means that the sole can't be too thick.
Which Features Do I Need?
To begin with, you should know if your feet have high, medium, or low arches. It's easy to tell which kind you have. Just wet the bottom of your bare foot and make a footprint on a hard surface. If the forefoot and heel areas are connected by a thin line, you have high-arched feet. If the footprint looks pretty much like the shape of your foot, you have a low arch. A medium arch falls somewhere in between.

For your high-arched foot—because it's not very flexible—you'd ask to see a cushioned shoe. If you're flat-footed, your feet are too flexible, and you'd ask for a motion control shoe. Those who have medium arches would request something in the middle, sometimes called a stability shoe.

Keep in mind any foot problems you've had and try to find a shoe that can accommodate them. Do you have a history of ankle sprains? Then perhaps you should have a high-topped shoe for better ankle support. Have you had deep arch pain? Maybe you need a special arch support. Do you have bunions? Then you need a shoe with a wide toe box.
Getting the Right Fit
The American Orthopaedic Foot and Ankle Society makes several recommendations for getting a good fit:

  • Have your feet measured when they are at their largest: at the end of the day or after a run, walk, game, or practice.
  • Wear your workout socks.
  • Have both feet measured.
  • Try on the shoes, because sizes vary by manufacturer.
  • Make sure both shoes fit.
  • Ensure that the shoe provides at least one thumb's width of space from the longest toe to the end of the toe box.


Shoes should also feel comfortable through the arch, fit well across the ball of the foot, and hold the heel firmly.

Women should be cautious when selecting shoes. Downsized men's shoes have long been offered as "women's" shoes, and some still are. But their heels can be too loose, which prompts women to wear smaller sizes that can cause problems. Women should seek out shoes that fit their feet properly. Some companies, including Nike, Asics, and Reebok, now offer models specifically designed for women's feet. Saucony is noted for shoes that fit women's feet well, because its shoes tend to have narrower heels. At Home With Your New Shoes

While it's true that new athletic shoes should feel comfortable immediately, that doesn't mean they're ready for heavy-duty use. In other words, don't buy a running shoe and run a marathon in it the next day. You need to allow some time for the shoe to adapt to your foot, and your foot to feel at home in the shoe.

Monitor the condition of your shoes as they age. After 300 to 500 miles, the cushioning on most shoes wears out, though air and gel cells may add extra life. It's not a bad idea, if possible, to have two or three pairs of shoes for an activity or sport and rotate them.

This information is not a substitute for medical treatment.

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AVOIDING INFECTIONS:
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Abstract: Staying healthy will help you perform your best at sports and help keep other players healthy, too. Getting the benefits of exercise while minimizing the risks of infection is the goal. Here are some of the things you need to know to ward off contagious diseases while exercising.

Q. Does exercise reduce my risk of getting colds and other infectious illnesses?
A. Perhaps. Some studies seem to show that regular, moderate exercise can improve resistance and immunity to colds and upper respiratory infections, although strenuous exercise may weaken your immune system for a short time.
Q. Can I exercise when I am sick?
A. If the symptoms are mild, probably yes. If the symptoms are all located above the neck (stuffiness, mild sore throat, itchy eyes, etc) and do not worsen with mild exercise, participation in exercise and sports is safe. If, however, the symptoms are severe, below the neck, or generalized (such as fever, muscle aches, productive cough, vomiting, or diarrhea) it is better to rest until the symptoms are gone, and then gradually return to your previous level of exercise.
Q. What can I do to reduce the risk of getting sick?
A. A simple action is most effective: Wash hands frequently! Always wash your hands with soap and water, especially before you eat and after you go to the bathroom. In addition: Try to keep your hands away from your mouth, nose, or eyes. Germs on your hands will transfer to moist areas and then will multiply rapidly. Avoid close contact with people who are ill, small children, and large crowds, when possible. Touch common surfaces in public areas, such as countertops or doorknobs, as little as possible. Don't share water bottles, sports drinks, or soda cans. Don't share personal items, such as toothbrushes, mouth guards, or cosmetics. Keep athletic clothing clean, wash it frequently, and do not share it with others. Get enough sleep and rest. Avoid exercising while badly fatigued. Eat a balanced diet. Be sure to wash fruits and vegetables before eating or peeling. Avoid undercooked meats and foods that have not been kept properly hot or cold before serving. Use only clean utensils.
Q. What should I do if I'm sick?
A. By acting responsibly, you can avoid spreading germs so other people won't get sick. Cover your nose and mouth when you cough or sneeze, then wash your hands! Keep tissues handy and dispose of them properly. Keep skin scrapes, cuts, and wounds properly bandaged. Report any unusual rashes or skin eruptions to your coach, team doctor, or family doctor right away. You may need medicine to control the outbreak and speed healing. Hiding it won't make it go away, and you could infect others. If you're really sick, stay home. Having one person miss practice is better than having the whole team miss a competition because of illness.
Q. Do adults really need vaccinations?
A. Definitely! Maintaining the immunity that you obtained through childhood vaccinations is important. Tetanus shots should be repeated about every 10 years. Adults should have at least two mumps and measles (MMR) shots. Hepatitis B vaccine is a good idea, and you may need other shots if you travel to a foreign country. Influenza vaccine is recommended for anyone who plays team sports during the flu season. Your doctor can help you decide which vaccinations are best for your situation.
Q. Do I need to worry about catching AIDS while playing sports?
A. The risk is extremely small, even if you are competing in a contact sport with or against someone who is HIV positive. It's is important to avoid contact with blood or other body fluids from anyone, whether or not they are known to carry a blood-borne illness. Experts think that the risk of acquiring a blood-borne illness is much greater off the field—by transmission through sexual activity, injected steroids, or other injected drugs—than it is on the field.

Defeating communicable diseases takes a team effort. If you know you have a contagious illness, respiratory infection, open wound, skin eruption or unusual rash, vomiting, or diarrhea, it is important that you isolate yourself from fellow athletes until the problem has been treated and has fully resolved. Self-policing of these situations is an undeniable contribution to the health of your fellow athletes. The inconvenience of not being able to play for a short time may help others to avoid experiencing any serious illness and disability that can arise from it.

This information is not a substitute for medical treatment.

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BLADDER AND 'YEAST' INFECTIONS:
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Abstract: Many women suffer from the discomfort of urinary tract infections (UTIs, also called bladder infections) and vaginal infections (some of which are referred to as yeast infections). Relief can come from understanding the cause of these infections, how to avoid them, and how to treat them.

Urinary Tract Infections
If you have ever suffered through a UTI, you are not alone: One out of every five women has one at least once in her lifetime. There are a number of signs and symptoms that can tell you if a trip to the doctor is necessary. The most common signs are a burning sensation when you urinate or a feeling that you have to urinate more frequently and with more urgency. Your doctor can test your urine and, if you do have an infection, prescribe the best treatment. If your symptoms are accompanied by fever and chills, nausea, vomiting, or blood in the urine, you should seek medical care right away.

Once you've had a urinary tract infection, you may be at risk for repeat infections. But a number of steps can decrease the risk.
  • After urinating, wipe from front to back. This will wipe bacteria (which are normally present) away from the outlet of the bladder.
  • If you are sexually active, urinate both before and after intercourse. This decreases the number of bacteria that will find their way into the bladder during intercourse.
  • If you use a diaphragm for birth control, you may want to consider another method. Diaphragms have been shown to contribute to recurrent bladder infections.
  • If you like cranberry juice, try drinking some. It changes the acidity of urine, which may prevent bacteria from attaching to the bladder wall. This can help reduce the number and severity of infections.
  • Always drink plenty of fluids. This helps flush bacteria out of your bladder. Remember: Dilution is the solution!
Vaginal Infections
Vaginal infections often represent a change in your body's normal balance of microorganisms. Signs of vaginitis include itching, a white cottage-cheese-like discharge, or, with some types of infection, an unpleasant-smelling, gray discharge.

Many factors can trigger vaginal infections, including oral contraceptives, estrogen replacement, pregnancy hormones, antibiotics, and chemicals in lubricants and spermicides. Eating too much sugar or artificial sweeteners may "feed" a yeast infection. Some other things you can do to minimize your risk:
  • Avoid douching frequently. While this may seem to cleanse you, it actually disrupts the normal balance of microorganisms in the vagina and promotes infections. If you are going to douche, be sure to limit it to once a week and use gentle preparations such as 1 tablespoon of vinegar mixed with 1 pint of water.
  • Wear loose-fitting cotton underwear.
  • Change out of sweaty underwear or workout clothes and wet bathing suits promptly.
  • Use sanitary napkins instead of tampons.
  • Avoid feminine sprays and powders, which may irritate sensitive vaginal tissues.
If you do happen to get a vaginal infection, you may want to try treating it at home. There are several over-the-counter medications available as well as home remedies. One type of home remedy is to mix 1 tablespoon of vinegar in 1 pint of water and douche twice a day for 2 to 3 days. Avoid intercourse when you have a vaginal infection because it may prolong your infection.

If your vaginal discharge does not respond to these simple measures or is associated with abdominal pain and cramping or fevers and chills, you should consult your doctor. Often simple office testing can pinpoint the problem and get you prompt relief.

Remember: This information is not intended as a substitute for medical treatment. If you have health concerns, consult a physician.

This information is not a substitute for medical treatment.

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CHOOSING A STRENGTH TRAINING PROGRAM FOR KIDS
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Abstract: Whether your child is involved in sports, does recreational activities, or just needs to be more active, a strength training program can be one part of a well-balanced youth fitness program. Improved muscle coordination gained from strength training can increase athletic performance and help prevent some on-field injuries in sports. You may notice your child gaining more self confidence and better social skills along with muscle strength. Good strength training can improve bone health and also help overweight kids lose unwanted pounds. You want your child's exercise to be safe, but what should you look for before your child begins strength training?

Q. How good is the supervision?

A. The most important safety factor is proper adult supervision. Supervisors should have experience working with children and be trained in youth strength training and safety procedures. Each adult supervisor should be responsible for no more than 10 kids. Look for adults who encourage success by choosing the appropriate exercises and workload for each child. When necessary, adult spotters should help each child to prevent injury if a lift fails. Unsupervised training will always be prohibited.

Q. What should I look for in a gym or weight room?

A. The training room should be clean and free of hazards. The equipment should be designed and sized for children, with weight stacks available in 1- to 5-pound increments. Participants are required to wear appropriate clothing and footwear.

Q. How do I know if it's a good program?

A. In a well-run program, exercises begin with simple movements, such as leg extensions, that work one joint at a time. More complex movements that require muscle coordination, such as squats, are learned before speed and power movements like jumping and throwing. Usually, a variety of single- and multiple-joint exercises are done at each session.

Exercises to strengthen the shoulders, abdominals (stomach), upper back, and lower back are learned to prepare for work with free weights or weight machines. Students are taught to use body weight, elastic tubing, or medicine balls to prepare for using weights. Preparation and adequate warm-ups before each session are designed to prevent injuries.

Weight resistance exercises start with a bar that has no added weights. Proper form and technique must be mastered before weights can be added. The amount of weight, number of repetitions per set, and the number of sets performed are gradually increased over time to maintain training intensity. Kids can easily become bored doing the same exercises day after day, so workout routines should vary enough to remain interesting. Using different exercises will also strengthen various muscle groups to improve balance and coordination.

Students begin with one set of 10 to 15 repetitions with light weights and do six to eight different exercises per session, then cool down. If a child can't do at least 10 repetitions per set with a given weight, the weight is too heavy and should be reduced.

When three sets of 15 repetitions become easy and can be performed at three consecutive sessions, more weight can be attempted. Students learn how to use workout cards to record the number of sets they did at each weight and how to monitor their progress. Instructors are trained in safe ways to evaluate strength gains.

Q. Will my child develop big muscles?

A. You may may see gains in strength and coordination, but it is unlikely you will see any increase in the size of your children's muscles until they go through puberty. Realistic goals are established based on each child's abilities, needs, and expectations. In a well-run program, the focus is on mastering proper form and technique rather than competing to see who can lift the most weight.

Q. How can I help my child enjoy this experience?

A. Children must be old enough to understand and follow instructions and able to attend three training sessions per week for at least 8 weeks. At least 1 day of rest is recommended between sessions. You can help your children reach their full potential by encouraging good eating habits and adequate sleep. Celebrating the small accomplishments and giving loving support for small disappointments will encourage your child to meet new challenges.

FAST FACTS
1. Adult supervision is the most important safety factor in strength training.
2. Children will gain strength, but muscle size will not increase until after puberty.
3. A good program emphasizes proper form and technique rather than competition.


Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

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CONTROLLING HERPES
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Abstract: Herpes simplex is a highly contagious virus that causes cold sores or blisters. A red, swollen bump near the lips, mouth, or face is usually the first sign of an active virus. The following are answers to questions you may have about the virus.

How do you get the virus?
The virus can enter your body through a tiny break in the skin if you come into contact with someone's active sore. Often, people become infected after kissing someone who has a cold sore. Most adults in the United States have been exposed to and carry the virus. Once infected, the virus remains with you throughout your life. Does being infected with the herpes virus mean you will develop symptoms?

No. Most people never know they have the virus and never develop any symptoms from it. In other people, the virus becomes "active" from time to time, creating a red bump or an outbreak of blisters or cold sores.
What causes the virus to become active?
Any infection, such as a cold, can prompt the virus to show itself. It is easier for the virus to become active when your immune (disease-fighting) system is weakened by another illness. Trauma, like a scrape or cut, sun exposure, and even stress can also activate the virus.
How can I tell if the virus is active?
The first sign of the active virus is usually a red, swollen bump. If this appears on your lip, mouth, face, or other part of your body, see your doctor. Often the bump burns, stings, tingles, itches, or hurts as it develops into one or several cold sores or blisters You also may feel sick or lack energy.

People who have had one bout with the virus will recognize the early warning signs if it comes back. They will feel the burning or stinging or itching where they had blisters or cold sores before.
How is the virus treated?
A drug taken orally called acyclovir is the recommended treatment for herpes. If you develop symptoms of the virus, your doctor will probably instruct you to take a pill of acyclovir five times a day for several days.

Once the blisters develop, though, acyclovir does not help. Some nonprescription products, such as antibiotic or benzoyl peroxide lotions, creams, or gels, may help reduce the pain and dry the blisters.
What if the virus comes back?
If you have frequent bouts with the virus, your doctor will probably give you a prescription for acyclovir tablets so you can carry the pills with you at all times. Whenever you feel the burning, stinging, or itching that signals that the sores are coming on, take the recommended dose of acyclovir right away. That way, you can prevent the sores from developing.
How can I keep from spreading the virus to others?
You are infectious until the blisters or sores dry; so until then, do not be intimate with others. Also avoid sharing personal items like toothbrushes, soap, and towels. And refrain from participating in contact sports like wrestling and basketball until your infection goes away.
What can I do to prevent the virus from coming back?
Wear sunscreens, especially those that offer maximal protection. Avoid being intimate with anyone who has blisters or cold sores or whom you suspect may have an active infection until the blisters or cold sores dry.

Remember: Discuss your concerns about the herpes simplex virus with your physician. This information is not intended as a substitute for medical treatment.

This information is not a substitute for medical treatment.

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COPING WITH OSGOOD-SCHLATTER DISEASE
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Abstract: Osgood-Schlatter disease is one of the most common causes of knee pain in active adolescents. It is a generally benign disturbance at the junction of the patellar tendon and the tibial tubercle apophysis, and treatment during its 12- to 24-month course should be matched to severity. Mild symptoms require only patient education and moderation of activity, but severe symptoms call for a period of rest (or, rarely, immobilization) followed by aggressive quadriceps strengthening. Other conditions such as Sinding-Larsen-Johansson disease may occur simultaneously, and long-term effects can include a prominence on the anterior knee or painful kneeling.

Taking a break from activity, applying heat or ice, and stretching may relieve some pain. Exercises can strengthen bone, cartilage, and tendons in your knees and make you less susceptible to flare-ups. And if your symptoms are severe enough that you've had to wear a cast or brace, strengthening exercises can help you get back in action.
What Is OSD?
OSD is an inflammation (irritation) where the tendon from the patella, or kneecap, attaches to the tibia, or shin bone (figure 1). Preteens and young teens are particularly susceptible to stresses in this area, because the bone is growing rapidly at this age. Any activity can cause OSD, but it's more common following activities that involve a lot of jumping and cutting, like basketball, volleyball, soccer, figure skating, and gymnastics.
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A typical symptom of OSD is pain in the front of the shin about 2 to 3 inches below the kneecap. There may also be swelling in the area, especially if you've had the condition for several months. Symptoms can range from mild knee pain only during sports to constant pain that makes participation impossible.
Easing the Pain
If your pain is mild, you can probably continue to participate in your sport. Using a heating pad or warm, moist compresses at the site for 15 minutes before activity and/or using ice for 20 minutes after activity may help.

If symptoms are severe, treatment may include taking a break from sports or wearing a cast or brace. If you don't need a cast or brace, the following stretches for the quadriceps and hamstrings may relieve some of the pain and allow you to continue with your sport. Hold each stretch for 10 seconds, and repeat 10 times for each leg, 2 to 3 times per day.

If there is no improvement after 7 to 10 days of doing the stretching exercises, or if your symptoms worsen, consult your doctor.

Quadriceps stretch. To stretch the quadriceps (the muscles in front of the thigh), lie stomach down and bend one knee (figure 2.2). Using the hand on the same side as the bent knee, reach back and grab your ankle. Pull the foot downward until the heel is touching your buttock, if possible.

Hamstring stretch. The "hurdler's stretch" works the hamstrings (in back of your thigh, figure 2.3). Sit with one leg straight out in front and the other leg bent as shown, and lean forward, keeping your knee straight. Try to lean from your hips and keep your back fairly straight. You'll feel a stretch in the back of your thigh.
Building Strength After a Rest
If you've needed rest or a cast or brace for severe OSD, exercises to strengthen your leg muscles will be helpful afterward. The exercises should focus on your quadriceps.

A typical rehabilitation program starts with straight-leg raises followed by short-arc quadriceps exercises. Wall slides are also helpful. After doing strengthening exercises, it's a good idea to follow with quadriceps and hamstring stretches.

Straight-leg raises. To do straight-leg raises (figure 2.4), lie on the floor with your back propped up a few inches on your elbows. Bend your unaffected knee to a comfortable position. Start with an ankle weight that you can lift 10 times on the affected leg. (Note: At a sporting goods store you can buy an adjustable ankle weight that has 1/2-pound increments.) Tighten the thigh muscles and lift the leg about 12 inches, keeping it straight. Hold for 5 seconds. Slowly lower the leg and relax. Start with 10 repetitions for each leg, and increase to 15. When you can do 15 repetitions, increase the weight by 1/2 to 1 pound and drop back to 10 repetitions. Once you can do 15 repetitions again, add more weight, up to a maximum of 7 to 12 pounds.

Short-arc quadriceps exercises. To do short-arc quadriceps exercises (figure 2.5), lie back with your unaffected knee bent, as for straight-leg raises. Place a couple of rolled-up towels or a blanket under the affected knee to raise it about 6 inches from the floor. Tighten your thigh muscles and straighten the leg until it is about 12 inches from the floor. Hold for 5 seconds. Slowly lower the leg and relax. Start with 10 repetitions for each leg and increase to 15, using the same ankle weight and repetition progression as for straight-leg raises.

Wall slides. To do wall slides, or quarter-squats (figure 2.6), stand about a foot from a smooth wall and lean back against it. Your feet should be shoulder-width apart. Holding a light dumbbell in each hand with your arms straight, bend your knees and slowly lower your body 4 to 6 inches. (If you feel knee pain, you have squatted too far.) Hold for 5 seconds, then rise up quickly. Start with 10 repetitions and increase to 15, gradually increasing the dumbbell weights in the same type of progression as for straight-leg raises.
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Later you can advance to a single-leg wall slide. Do this the same way as a standard wall slide, but keep the unaffected leg about an inch from the floor as you slide, squat, and straighten. Single-leg wall slides allow you to double the resistance on the affected leg. In place of wall slides, working each leg individually on a leg-press weight machine is another way to safely strengthen your quadriceps muscles.

Jumping rope. If you're an athlete, off-season and preseason jumping exercises can also help. A 6-week preseason jump-rope program, starting at 1 minute a day and progressing by 10 seconds each day to 5 minutes, will slowly strengthen the quadriceps muscles.

This information is not a substitute for medical treatment.

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COPING WITH PATELLOFEMORAL SYNDROME
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Abstract: Patellofemoral syndrome (PFS) is one of the most common causes of knee pain in active patients and stems from problems with the kneecap (patella) as it moves over the front of the knee. PFS causes pain in the front of one or both knees, especially after either exercising or sitting for prolonged periods. Some patients will experience minor swelling and the feeling that their knee "catches" or gives way.

Q. What causes PFS?

A. PFS is usually an overuse syndrome caused by doing "too much, too soon." Other risk factors for PFS include decreased strength or flexibility of the upper leg or hip muscles, poor alignment of the leg bones, or a combination of factors.

Q. How is PFS treated?

A. The first step is to reduce the pain and swelling. Frequent use of ice (about 15 minutes at a time), especially after exercise or when the knee is sore, can ease pain. Anti-inflammatory medications (such as ibuprofen or naproxen) can help reduce pain and inflammation (swelling). Once pain eases, you can begin a stretching and strengthening program guided by your doctor to further decrease symptoms and the risk of recurrence.

Q. Which exercises are useful for PFS?

A. Strengthening (figures 1 and 2) and stretching (figures 3 and 4) for the hamstring and thigh (quadriceps) muscles should be included. All stretches should be held for 15 to 20 seconds and repeated three times on each side. Your doctor may also recommend physical therapy or other treatments.
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Q. Can I still train if I have PFS?

A. You can train if you have PFS, but you may find that symptoms tend to come and go depending on your activity level. Keep in mind, however, that the more you train through pain, the longer your knees will hurt. A good rule of thumb is to try reducing the intensity and amount of training by about half. Runners will often benefit from a temporary switch to either swimming or bicycling while the knee recovers. When you are ready to resume or advance your activity, do it slowly. Most patients can tolerate adding about 10% per week to training volume (for example, increasing from 20 miles in week 1 to 22 miles in week 2).

Many factors determine when you can return to activity, so work with your doctor to determine when you can return to full activity or competition.
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Remember: This information is not intended as a substitute for medical treatment. Please consult your physician before starting an exercise program or returning to activity.

This information is not a substitute for medical treatment.

- [ Close note ]


COPING WITH UPPER RESPIRATORY INFECTIONS
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Abstract: Your doctor has diagnosed your problem as an upper respiratory tract infection (URI). Common URIs include viral rhinitis (the common cold), sore throat, and sinusitis (sinus infection). Most URIs are caused by viruses, but some are caused by bacteria. Your physician may have recommended medication to treat your symptoms; these include acetaminophen, ibuprofen, or naproxen for pain or fever and antihistamines and/or decongestants to treat congestion and runny nose. Because they treat bacterial infections, antibiotics will not help a viral URI.

To avoid getting sick in the first place and to prevent spreading your infection to others if you are sick, it is important to take precautions. Wash your hands regularly, and don't share face towels, water bottles, mouthguards, toothbrushes, or other items you put in your mouth.
Q. How can I tell if I have a cold, sore throat, or a sinus infection?
A. Sinusitis is a bacterial infection of your sinuses (the air spaces behind your nose and eyes). Symptoms include thick green mucus, face pain and pressure, headache, postnasal drip, and possibly an ache in your upper molars. These symptoms can also be part of a common cold. The main difference with sinusitis is that the symptoms don't improve after 10 to 14 days, the normal length of a cold.

Other factors such as allergies can cause prolonged "cold symptoms." If your doctor thinks you have sinusitis, an antibiotic may help you feel better faster, although more often than not, sinusitis will improve without antibiotics.

If a sore throat is your main symptom, your doctor may want to take a throat swab to see if group A streptococcus is causing your infection (strep throat). Strep throat is treatable, but you need to take all of your antibiotic as prescribed—even after your symptoms go away.
Q. When can I return to exercise, training, or sports?
A. Your doctor is the best person to offer advice on returning to activity, but we offer some general recommendations.

Common cold or sinusitis.
  • It is all right to continue training and sports if you have common cold symptoms, including congestion, runny nose, itchy eyes, mild headache, cough, or sore throat.
  • Avoid heavy training for a few days. Try to get enough sleep and good nutrition to help symptoms improve as fast as possible.
  • If you have a fever higher than 100°F, muscle aches, significant fatigue, deep cough, wheezing, shortness of breath, or significant headache, rest from training until you feel better. If you play a team sport, stay at home so you don't infect other teammates.
  • Tell your doctor if you plan to fly, because sinusitis symptoms can worsen with pressure changes on airplanes.
  • If you have sinusitis, do not scuba dive.
Strep throat.
  • If you have strep throat, you should rest and avoid team sports until you are feeling better and you have been taking your antibiotics for at least 24 hours.
  • If you have a family member or teammate with strep throat and you develop a sore throat, see your doctor.


Remember: This information is not intended as a substitute for medical treatment. If you have significant health concerns, consult a physician.

This information is not a substitute for medical treatment.

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EXERCISE FOR MIDLIFE WOMEN
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Abstract: Exercise is good for everyone, but it's more important than ever when you reach midlife. While regular exercise may not eliminate symptoms like hot flushes, it can improve your general well-being and increase your strength and stamina in daily life. If you want to lose fat or maintain a healthy weight, exercise is far more effective than diet alone. A physically active lifestyle, along with good nutrition and estrogen therapy, will also help protect you against heart disease, overweight, and osteoporosis.

Three Types of Exercise
A good exercise program includes aerobic activities for your heart, bones, and general fitness; resistance training for muscle and bone strength; and stretching to decrease injury.

Aerobic exercise. Aerobic exercise raises your pulse and gets you breathing harder. Brisk walking, swimming, aerobic dancing, stationary bicycling, and treadmill or outdoor running are all effective means of aerobic exercise. Choose the most enjoyable activity that fits your schedule.

Doing such activities for 20 to 60 minutes 3 to 5 days a week will help maintain heart health and strong bones. If finding a block of time for exercise is difficult, do several shorter sessions each day to reach this goal. To lose weight, do some aerobic activity every day.

If you have not been exercising and feel out of shape, start slowly. Begin by taking 5- to 15-minute walks at a comfortable pace three times a week, and gradually increase your distance and pace, keeping in mind the goals mentioned above.

Strength training. Strength training involves free weights or exercise machines to strengthen individual muscles. Do a series of exercises that focus on your arms, shoulders, and torso two to three times a week. For example, using small dumbbells, do one to three sets of 10 repetitions each of arm curls, upright rowing strokes, and lateral raises. To increase strength, first gradually increase the number of repetitions and then the weight of the dumbbell. Similar exercises to strengthen your hips, thighs, and calves are also important.

If you haven't done this kind of exercise, seek instruction from your doctor, a physical therapist, or a trainer. Guidance is especially important if you have osteoporosis of the spine, since you should avoid lifting heavy weights.

Stretching. Flexibility exercises should also be done two or three times each week. They can best be done after aerobic exercise. Flexibility exercises are most effective if the stretch is done slowly and held for 20 to 30 seconds. If you have osteoporosis of the spine, you should avoid back flexion exercises (bending forward from the waist). Your doctor, a physical therapist, or a trainer can suggest appropriate exercises.
Making It Enjoyable and Safe
Regular exercise can be pleasant, invigorating, and safe if you follow some simple suggestions:

  • Warm up at the start of each session with a few minutes of easy activity, such as leisurely walking. Stretching at the end of the session will keep your body flexible.
  • Exercise at a brisk but comfortable pace; your breathing should be harder and faster than normal, but you should be able to talk.
  • Many people enjoy exercise more and find it easier to do regularly in the company of others. Get together with a friend or join a group that walks, rides bikes, or goes to a gym.
  • If you prefer to exercise at home, invest in equipment like a stationary bicycle or treadmill, and keep it in a convenient place. Listening to music or watching TV while you exercise can add enjoyment.
  • If you feel chest pressure, dizziness, weakness, nausea, or unexpected shortness of breath, stop exercising and relax. If the symptoms persist, seek medical help.




This information is not a substitute for medical treatment.

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EXERCISE FOR MILD CORONARY ARTERY DISEASE
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Abstract: Early warnings can be potent motivators. If your doctor has told you that you are at risk for the type of heart disease known as coronary artery disease (CAD) or that you have mild CAD, that's your call to action. Your doctor's exercise recommendation is something you can do that may help head off worsening symptoms or a heart attack.

Why Exercise?
The science behind your doctor's recommendation is that exercise can help reverse or limit the build-up of plaque (fatty deposits) in the arteries and improve the heart's oxygen supply. Among its many other important benefits, exercise raises the amount of good cholesterol (high-density lipoproteins) in the bloodstream, reduces the risk of developing adult-onset diabetes, modestly lowers blood pressure, and aids weight loss.

The aspect of exercise that may really motivate you, though, is that it makes you feel better. It reduces fatigue and improves your mood. The mental boost you'll get from sticking to your exercise program may even help you feel more like making other lifestyle changes such as giving up smoking or losing weight.
A Comfortable Routine
When doctors prescribe exercise for patients who have CAD or are at risk, they aren't talking about working out until you're out of breath and your muscles are sore. Researchers have shown that aerobic exercise at a moderate intensity provides the benefits you need to improve your heart health. An example of a moderate aerobic activity is 30 minutes of brisk walking each day. Other activities that can be done at a moderate intensity include swimming, biking, and working out on an exercise machine such as a treadmill, stair climbing machine, rowing machine, or stationary cycle.

If you've recently learned you are at risk for CAD or have mild CAD, your physician will help you set up a realistic plan to work up to a moderate level of exercise. If you've never exercised before, start with a few minutes a day—such as a 10-minute walk over your lunch hour—and gradually increase the time until you reach 30 minutes a day.

If setting aside 30 minutes a day to exercise sounds overwhelming, you can get similar heart benefits if you break the time up into three 10-minute activities. For example, you could park your car a little farther from work and walk to the door, walk the dog, vacuum the house, or do a home repair project.
How Can I Play It Safe?
Most patients who have mild CAD can exercise safely, but a very small minority may have problems during vigorous activity. High-tech tests don't always flag the people who will have problems, so—in addition to having the tests that your doctor recommends before you begin—your best bet is to be aware of the warning signs that say, "Stop exercising and call your doctor." These signs include:

  • Abnormal heart rhythm. Irregular heart beats, called arrhythmias, feel like extra heart beats or skipped beats. You may also feel dizzy.
  • Chest pain. Pain or pressure in the center of your chest during or after exercise is a signal that your heart isn't getting enough oxygen. The pain may radiate across your chest or down the left arm. Pain or pressure in your back, throat, or stomach may also be a warning sign.
  • Dizziness. Dizziness during or just after exercise may be a symptom of a serious circulation problem.
  • Fatigue. Unusual tiredness during or after exercise can be a heart-related symptom.


Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

- [ Close note ]


EXERCISE FOR OSTEOPOROSIS
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Abstract: For patients who have osteoporosis, exercise is an essential part of treatment. Just as regular workouts build muscle, they also maintain and may even increase bone strength. By strengthening your muscles and bones and improving your balance, exercise can reduce the risk of falls and resulting fractures. Exercise works well with estrogen or other medications that increase bone density and strength. Exercise, medication, and proper diet combat osteoporosis more effectively together than any one treatment alone could do. Remember that you're never too old to exercise.

Here are some tips on how to start a program of weight-bearing exercise and resistance training that will benefit your bones and muscles and also help your general health.
Weight-Bearing Exercise
For most people who have osteoporosis, brisk walking is ideal. It can be done anywhere, requires no special equipment, and carries minimal risk of injury. If walking is too difficult or painful for you, workouts on a stationary exercise cycle are a good alternative.

The full benefits of walking come from a regular schedule—at least 15 to 20 minutes 3 to 4 days per week. But if you haven't been active for years, you may need to start modestly. Start at whatever level is comfortable for you. Five-minute walks are fine at first, but try increasing their length by 1 minute every other time until you reach the optimal exercise level.

Walk briskly enough to become slightly short of breath. A little puffing shows that you're working your body hard enough to improve your fitness. If you have certain lung, heart, or other medical conditions, you should consult your doctor about a safe level of activity.
Resistance Training
Lifting weights or using strength-training machines strengthens bones all over your body, especially if you exercise all of the major muscle groups in your legs, arms, and trunk. Following a program designed by your doctor or a physical therapist is important. Joining a gym or fitness facility is a good way to begin because there you may have access to trainers who can advise you on proper technique.

Strength training is a slow process, so start at a low level and build up gradually over several months. For each exercise, select weights or set the machine so the muscle being trained becomes fatigued after 10 to 15 repetitions. As muscles strengthen, gradually add more weight. But don't increase the weight more than 10% per week, since larger increases can raise your risk of injury. Remember to lift with good form, and don't sacrifice good form to lift more weight.
Tips for Trouble-Free Exercise
  • Lift and lower weights slowly to maximize muscle strength and minimize the risk of injury.
  • It's best to perform your resistance workout every third day. This gives your body a chance to recover.
  • Avoid exercise that puts excessive stress on your bones, such as running or high-impact aerobics. Avoid rowing machines—they require deep forward bending that may lead to a vertebral fracture.
  • Stiffness the morning after exercise is normal. But if you're in pain most of the following day, your joints are swollen, or you're limping, stop the program until you are again comfortable, and cut your weights and repetitions by 25% to 50%. If bone, joint, or muscle pain is severe, call your doctor.
  • If a particular area of your body feels sore right after exercise, apply ice for 10 to 15 minutes. Wrap ice in a towel or baggie, or just hold a cold can of soda to the spot.
  • Vary your routine to make it more interesting. For example, if your strength-building program involves 12 separate exercises, do six in one session and the other six in the next.


This information is not a substitute for medical treatment.

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EXERCISE YOUR INDEPENDENCE
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Abstract: Stiff joints, weak muscles, lack of energy-many of these "aging pains" are actually due to inactivity. It's a vicious cycle: The more you slow down, the harder it is to get moving again.

Aerobic exercise like walking or swimming is an important part of staying fit, and your doctor can recommend a program for you. But for many older patients, stretching and strengthening exercises offer the greatest gains. As you become stronger and more flexible, you'll find that you can get back to activities you thought you had left behind. And that can mean the difference between life in a chair and a life of active pursuits.
For Safe, Enjoyable Exercise
A few precautions and tips are useful for any exercise program:

  • Warm up before strength and flexibility exercises with about 5 minutes of aerobic activity, such as walking or other light movement.
  • Expect some minor muscle aches after exercise, particularly when you're just starting. But if discomfort is severe enough to require a painkiller, or if it lasts more than a couple days, consult your doctor.
  • Exercise is good to share: Find or organize a group of like-minded people and work out together.
  • Get into the fitness habit. Do your strength workout while watching the 6 o'clock news or while listening to your favorite radio program.
  • Be patient. It may take 6 weeks before you start to see and feel the benefits of exercise.


Stretching Strategies
Exercises that gently stretch muscles and work your joints will prevent stiffness and keep you limber.

Exercises shown in figures 1 and 2 stretch the front and back of your thighs. To stretch your neck muscles, turn your head left as if looking at your shoulder, then turn it right. Repeat 10 times. To stretch your shoulder muscles, shrug your shoulders, trying to touch them to your ears. Then let them droop. Roll your shoulders forward in a circular motion, then backward. Repeat each shoulder motion 10 times.
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Strength Training Basics
Older muscles react just like younger ones—when asked to do more, they become stronger. People in their 60s, 70s—even nursing home residents in their 90s—have shown remarkable gains from strength training.

Exercise machines like Nautilus or Cybex are excellent devices for building muscles, and they may be your best bet if you're a member of a health club. But you can get a great workout at home with simple, inexpensive equipment such as wrist and ankle weights.

With your doctor's help, adopt a program that strengthens all the major muscles of your body. A sample program shown in figures 3 to 7 strengthens the biceps, upper arms, shoulders, abdomen, trunk, and knees. Do it three or four times a week, skipping a day between workouts. Or do some strength training daily: upper-body exercises one day, trunk and lower body the next.

Start with light weights—maybe just a pound or two—that you can lift 8 to 12 times.
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Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

- [ Close note ]


EXERCISE-THE BEST MEDICINE
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Abstract: The human body thrives on movement, which brings pleasure and stimulates creativity. Medically, exercise stimulates blood flow and tissue growth in muscle and bone. It also relieves the fatigue of nervous tension and sedentary activity. And the benefits extend even further: Exercise is also a potent tool for preventing and treating disease.

Convincing Evidence
In recent years researchers have learned a lot about the benefits of exercise. More physicians are asking about their patients' fitness levels and making specific exercise recommendations because exercise has proven to give patients an extra edge when it comes to avoiding or minimizing diseases:
  • Heart disease. Exercise helps reverse established disease and helps control the risk factors for heart disease (high blood pressure, high cholesterol, obesity). Exercise also lowers triglycerides and raises high-density lipoproteins (HDL)—the "good" fats.
  • Stroke. Exercise prevents strokes and helps restore function after a stroke.
  • High blood pressure. Exercise is a nondrug therapy for treating mild-to-moderate high blood pressure, and it helps patients who are on drug therapy for severe high blood pressure.
  • Diabetes. Exercise can prevent or delay the serious vascular complications of diabetes; regular exercise can reduce the need for insulin.
  • Arthritis. Exercise improves endurance, strengthens muscles, and increases joint flexibility and range of motion.
  • Osteoporosis. Exercise can prevent and reverse bone loss, which can stave off the disabling effects of fractures and bone degeneration.
  • Excess body weight. Exercise helps patients achieve and maintain healthy body fat levels.
  • Depression. Exercise reduces depression and anxiety, increases feelings of well-being, improves the ability to handle stress, and improves self-image.
  • Cancer. Exercise reduces the risk of colon and breast cancer.
  • Chronic obstructive pulmonary disease. Exercise is an effective rehabilitation component that provides physiologic and psychological benefits—even for those who have severe air-flow obstruction.
Getting Started
Your doctor will help you plan an exercise routine that you can comfortably accommodate (see back for prescription form). You'll find it's easier to stick with your routine if the activities you choose are (1) fun and (2) accessible—meaning safe, nearby, and inexpensive.

The bulk of your exercise program will focus on aerobic activities that are moderately strenuous—for example, walking, running, cycling, or swimming. The objective is to get the lowest possible heart rate at rest (40 to 50 beats per minute) and to get 120 to 150 beats per minute during exercise. To spice up your weekly routine, your doctor will advise you to vary your program to include nonaerobic activities such as golf, bowling, gardening, or strength training.

It is important to perform stretching exercises before and after any physical activity; their purpose is to prevent muscle strains, and when performed regularly, they also increase flexibility, strength, and circulation.
Earn Extra Activity Points
Staying active throughout the day can add to your daily exercise totals. Simple ways to achieve this are to:
  • Walk briskly during chores, shopping, or errands.
  • Restrict sitting to activities that require it, such as eating, learning, writing or keyboarding, and essential driving.
  • Contract and relax all muscle groups (upper body, abdomen, leg) during sitting activities.
  • Get up and move for 5 to 10 minutes of each hour of sitting activities, or use breaks to walk or stretch.
Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

- [ Close note ]


EXERCISE: KIDS GO FOR IT
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Abstract: Exercise is good for everybody. For kids, it pays double: increasing vitality today while building the foundation for a healthy tomorrow. Active youngsters are stronger, leaner, and more fit. They have extra energy and feel better about themselves. They get a head start on lifestyle habits that will protect against heart disease, diabetes, and osteoporosis.

There's no better investment in your child's present and future health than promoting safe, regular exercise.

Q. What exercise is best?

A. Children and adolescents, like adults, should participate in vigorous physical activity on a regular basis—at least a half hour, three or four times a week.

The best kind of exercise is one your child will do regularly. Help him or her find activities that are fun and rewarding. Baseball, walking, soccer, jumping rope—anything's OK if it's enjoyable and done safely.

Preaching or pushing kids into activities they don't like is likely to backfire. Youngsters who learn that exercise is a chore all too often become inactive adults.

Remember, too, that exercise needn't be organized. Encourage your child to take the active option in daily life: Walk instead of ride, take the stairs, not the elevator, develop an interest in hands-on activities like building a snowman. Short bursts of activity add up.

Q. What about safety?

A. Minor mishaps such as bruises and sprains are a fact of life for on-the-go youngsters, but simple precautions will minimize the risk of serious injury.
  • Make sure your kids' activities are right for their age, size, and physical development. Highly competitive distance running may be great for a high schooler but too stressful—and not much fun—for an 8-year-old. Contact sports can pose unnecessary dangers for smaller kids. When in doubt, check with your doctor.
  • Keep team spirit healthy. Competition is fine—if it isn't overdone. Coaches and parents with a "winning-is-everything" attitude encourage kids to push too hard and to play when injured. Talk it over with the people who run your child's school or league team.
  • Ensure the use of proper protective equipment for each sport or activity, including helmets for bikers.
  • Seek medical advice if your child is limping after exercise, or if muscle soreness lasts throughout the day or night. A child sidelined by an injury shouldn't get back into action until he or she is pain-free.
Q. Is it good to get the whole family involved?

A. Kids learn by example: When a father gets involved with his child's activity, the child is three times more active than children with inactive parents. Why not foster fitness together? Make long walks, cycling, and active vacations a family tradition.

Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

- [ Close note ]


EXERCISES FOR PATIENTS WITH KNEE OSTEOARTHRITIS
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Abstract: Rest is an important part of the treatment for osteoarthritis, but it must be balanced by regular exercise. Exercise is essential for two reasons: It keeps your joints from becoming stiffer, and it strengthens the muscles surrounding the joints. Strong muscles provide needed support, making movement easier and reducing pain.

This program for patients with knee osteoarthritis consists of five main exercises (figures 1, 2, 4, 5, and 7), along with three alternatives (figures 3, 6, and 8) in case the main exercises are too difficult.

To get the most out of these exercises, you need to gradually increase the number of repetitions and sets over the course of 7 weeks. The accompanying chart (table 1) can be used as a guide as you do the strength exercises. It will be helpful to mark the date when you start each new stage.
Stretching Exercises
Figure 1: Unloading the knee. Put a light weight (5 to 10 pounds) on your ankle and sit in a position that allows the leg to dangle (eg, on a bench, tall stool, edge of bed). Hold for 5 to 15 minutes, 1 to 3 times a day. Repeat for the other knee.
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Figure 2: Knee extension. Sit in a chair and rest your foot on another chair across from you so that the knee is slightly raised. Gently push the raised knee toward the floor using only leg muscles. Hold the stretch for 5 to 10 seconds, then rest a minute. Repeat 10 times. Do every day up to 3 times a day.
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Figure 3: Alternative knee extension exercise. Sit on the floor or bed with your legs extended, and place a rolled-up towel underneath your Achilles tendon. Gently push your raised knee toward the floor. Hold the stretch for 5 to 10 seconds, then rest a minute; repeat 10 times. Do every day up to 3 times.
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Figure 4: Knee flexion. While sitting, loop a long towel underneath your foot. Gently pull on the towel with both hands to bend the knee, raising your foot 4 or 5 inches off the floor. Hold for 5 to 10 seconds, rest a minute, and repeat 10 times. Do with both knees every day, up to 3 times a day.
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Strength (Resistance) Exercises
Figure 5: Quadriceps setting. While sitting in a chair, straighten your leg and hold. Repeat 5 to 10 times. Do the exercises with both knees, up to 3 times each day.
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Figure 6: Alternative quadriceps exercise. Lie on a flat, firm surface with legs extended. Then raise one leg 1 foot off the surface and use it to trace a "T" pattern in the air. To start, repeat 5 to 10 times. Do the exercises every day, up to 3 times each day.
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Figure 7: Wall slide. Leaning with your back against a wall, bend your knees 30°, sliding down the wall, then straighten up again. Move slowly and smoothly. Keep your feet and legs parallel, and center your kneecap over your second toe. Repeat 5 to 10 times, 1 to 3 times a day.
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Figure 8: Resisted knee extension. If the wall slide exercise (figure 7) is painful, then use a piece of rubber exercise tubing such as Thera Band. Loop the tubing around the bottom of your foot, hold onto the ends while in a sitting position, and bend your knee about 30° (maximum). Straighten your knee against the resistance of the tubing, pushing as hard as is reasonably comfortable. Hold. Do 5 to 10 repetitions, 1 to 3 times per day.
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Progression of Strengthening Exercises
Week Repeats Sets Weekdays Weekend
1 5-10 1 MWF off
2 10 1 Daily off
3 10 1 Daily Sat or Sun
4* 10 1 Daily Sat or Sun
10 1 MWF Sat or Sun
5 10 2 Daily Sat or Sun
6* 10 2 Daily Sat or Sun
10 1 MWF Sat or Sun
7 10 3 Daily Sat or Sun
*Extra set to be done after a rest period.
Dealing With Soreness
If you have increased soreness after doing these exercises, it may help to ice your knee or knees for 10 to 20 minutes. Place a bag of ice or frozen vegetables over the joint, with a towel between to protect the skin. Other helpful measures include elevating your leg on a chair, and taking acetaminophen before or after exercise if ice alone is inadequate.

If increased soreness or pain lasts for more than 2 hours after exercise, you should cut back to fewer repetitions of the strength exercises; then gradually build up again.

Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

- [ Close note ]


EXERCISING THE FROZEN SHOULDER
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Abstract: Frozen shoulder (also called adhesive capsulitis) results from shrinking and scarring of a previously normal joint. It involves significant shoulder pain and loss of movement. The pain can last from weeks to many months. Loss of movement can last months to years. Fortunately, you can take steps to control the pain and regain motion.

Frozen shoulder can occur in many situations, including shoulder injury, diabetes, thyroid problems, and heart or lung conditions. But usually the cause is unknown.
Controlling the Pain
Pain control is only required if the pain interferes with sleep or daily activities. The easiest method is applying ice packs to the shoulder for 20 to 30 minutes at a time. Higher levels of pain may require cortisone shots or medication prescribed by your doctor.

Pain control also means avoiding shoulder motions or positions that are painful. Such motions include activities that raise the arm to the side or rotate the arm outward. Daily activities that might aggravate the pain include reaching overhead, reaching into the back seat of a car, trying to open a heavy door, and driving a car. Some experts believe that trying to push through painful activities can actually prolong the course of the disease.

Once you identify your own particular set of aggravating activities, try to find other ways to do them. For example, open the heavy door with both hands or push the door open with your buttocks. When driving, don't hold your hands near the top of the steering wheel. If your right shoulder is affected, avoid using a car that has a manual transmission. For activities in which you reach overhead, stop doing them, use the other arm, or use a step stool or ladder.

Beginning exercises. The following exercises may help improve shoulder motion. Begin with the pendulum exercises (figure 1). When these can be done comfortably, try the table crawls (figure 2).
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Advanced exercises. The more advanced exercises are supine wand flexes (figure 3), use of pulleys (figure 4), standing wand flexes (figure 5), and standing wand abduction (figure 6). Each exercise should be done 10 to 15 times, followed by a rest and 10 to 15 more repetitions (two sets). It is probably not necessary to do all four advanced exercises. Choose the two that cause no increase in pain and feel the most challenging.
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When you have progressed to the advanced exercises, it is no longer necessary to do the pendulums or table crawls. Exercises should be done every day, but it is important to remember to be patient. Adhesive capsulitis almost always resolves completely, though it may take months or even years to do so.

This exercise program should be done with caution. Do not push through pain. If symptoms increase, contact your physician.

Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.


This information is not a substitute for medical treatment.

- [ Close note ]


EXERCISING WITH DIABETES:
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Abstract: If you have diabetes, one of the best things you can do for yourself is to stay-or begin to be–active. A regular exercise program can help stabilize your blood sugar, reduce your need for insulin and medication, and keep your weight under control. Diabetes increases the risk of heart disease, but exercise can lower it. Best of all, exercise helps you get more out of life.

Because of some of the risks of your disease, however, it is important to consult your doctor before starting an exercise program. He or she may want to conduct a thorough physical exam to help you design a safe, pleasurable program. You may need a stress test to evaluate your heart and to determine the best level of exercise for you.
What Activities?
The activities most likely to help control your disease and reduce the risk of heart disease are aerobic—exercises such as walking, jogging, biking, or swimming that you do strenuously enough to raise your pulse and make you breathe harder. You'll get maximum benefits if you participate in 30 minutes or more of such activities at least three times a week. In addition, strength training (weight lifting) can also help improve fitness and heart health.

If you haven't been active, build up to this level slowly. Start by walking 5 minutes a day, at a comfortable pace. Increase the length and speed of your walk as you feel stronger.

And remember: Any exercise is better than none. Physical activity built into your day—taking the stairs instead of the elevator, parking at the far end of the lot for a longer walk to your office—helps to satisfy your need for exercise.

Which exercise? Choose a sport or activity you will enjoy doing regularly. But some activities may not be suitable:

  • If you become dizzy or lightheaded when exercising in an upright position, swimming or biking are better than hiking or jogging.
  • People who have retinopathy should avoid activities that sharply raise blood pressure, such as weight lifting.
  • If you have poor sensation in your feet, take special care to choose proper footwear (see below), and consider low-impact exercise (swimming, biking, or rowing) rather than walking or jogging.
  • Activities like scuba diving and rock climbing can be dangerous if there's any possibility of hypoglycemia (low blood sugar).
  • Lifting weights can complement an exercise program nicely. However, most people who have diabetes should use light weights and lift them 12 to 15 times for each exercise, rather than lift heavy weights just a few times.
Staying Safe
Prevent injuries by warming up before exercise with 5 to 10 minutes of moderate activity and then stretching, and by cooling down slowly for 5 to 10 minutes after exercise. Walking at a medium pace is a good warm-up or cool-down activity.

Exercise changes your body's metabolism in healthful ways (for example, it increases the rate at which you burn glucose for fuel). But you must take steps to regulate the process properly. Planning for trouble-free activity with the help of your doctor may include these steps:

  • Check your blood sugar levels before and after workouts and every 20 to 30 minutes during prolonged exercise. (Many activities burn 500 to 600 calories an hour!) If your blood sugar is under 100 mg/dL, take a snack containing 15 to 30 grams of carbohydrate before you exercise. If your blood sugar is excessive (over 250 mg/dL for people with type 2 diabetes; over 200 mg/dL for those with type 1), postpone exercise until you bring it down.
  • Know the signs of hypoglycemia (for example, dizziness, sweating, trembling, double vision), and have a snack ready if they occur.
  • Exercise 1 to 2 hours after a meal.
  • Avoid exercise at times of peak insulin activity. Morning exercise is ideal. People who have type 1 diabetes should avoid evening exercise, if possible.
  • Adjust your insulin dosage, if necessary. (Follow your doctor's advice, but this usually means reducing the dose of short-acting insulin before exercise.)
  • Patients who take oral antidiabetic drugs may need to change their dosages. Follow your doctor's advice.
  • After prolonged or intense exercise, you may need extra carbohydrate foods for up to 24 hours to refill muscle starch reserves. Keep in mind that it takes 550 grams of carbohydrate to restore glycogen levels after a glycogen-depleting activity, such as endurance running or cycling. Beware of delayed hypoglycemia!
  • Drink lots of fluids: about a pint 2 hours before exercise, and enough fluid to replace what you sweat away during a long workout.
  • Wear shoes that fit well, have cushioned midsoles (silica gel or air), and have a toe box that is comfortably wide and longer than your longest toe. Socks should also fit well and should be made of a material that wicks moisture away to keep your feet dry.
  • Avoid alcohol around the time of exercise (even the night before a morning workout).
  • Wear a Med-Alert or similar identification bracelet or tag where it can be seen easily.
  • Know yourself. Become aware of your own pattern of blood-glucose response to exercise.
Making It Fun
If exercise is going to do you good, you need to keep at it—so it needs to be a pleasure, not a burden. Many people find it most enjoyable to work out with others—a friend or a group that takes regular morning walks, for example. Also, you're less likely to skip sessions if someone is depending on you.

Finding a pleasant setting for exercise will also help keep you motivated. Try a park near work where you can walk, or find a clean, attractive health club.

If your schedule is tight, make exercise time productive: Prop your newspaper up on your stationary bike, or park your treadmill in front of the TV so you can watch the early-morning business report.

And remember: Exercise is a way of life—enjoy it!
Information Sources for Active Patients With Diabetes


Here are some resources for people who have diabetes and want to know more about exercise:

  • The American Diabetes Association's site on the World Wide Web has an exercise section (https://www.diabetes.org/exercise/) featuring frequently asked questions, a monthly profile of an active person with diabetes, articles on exercise and diabetes, and information on ADA-affiliated biking and walking events. The ADA's phone number is (800) 342-2383.
  • The Web site of the International Diabetic Athletes Association (https://www.diabetes-exercise.org) offers information about membership, which includes a quarterly newsletter. The site also offers information on regional chapters and association events. The association's phone number is (800) 82021-4322.
  • MiningCo.com (https://home.miningco.com/index.htm), a commercial Web site that evaluates other Web sites, offers an extensive and up-to-date listing of links on exercise and diabetes in its health and fitness section. Topics range from exercise and insulin to exercise resources for people who have limited mobility.


Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

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EXERCISING-OR NOT-WHEN YOU ARE SICK
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Abstract: You're not feeling great. You have a sore throat, stuffy head, and runny nose. But you feel like you could maybe log a few road miles. Should you?

Whether you're a low-key exerciser or a competitive athlete, knowing when to work out if you don't feel well can be difficult. When you have an infection such as a cold, "stomach flu," or contagious skin condition, you (and, often, your doctor) need to decide how exercise might affect your health, your performance, and the health of others. Of course, it's also good to avoid infection in the first place.
Should You Play On?
The first question to ask your infected body is if you need to push it. When your body is fighting an infection, your performance and fitness benefits will likely be less than optimal, so why bother? Missing a few days of training is not the end of the world-and it may even be a better option. And if you're a competitive athlete, taking yourself out may be the best thing for the team.

Sometimes, though, physical activity helps you feel better. For example, working out can sometimes temporarily clear a stuffed-up head when you have a cold.

So if you think exercise might help, or if you can't bear to miss a workout, do a "neck check" of your symptoms.1 If your symptoms are located "above the neck"—a stuffy or runny nose, sneezing, or a sore throat, for example-then exercise is probably safe. But start at half speed. If you feel better after 10 minutes, you can increase your speed and finish the workout or game. If you feel miserable, though, stop.

On the other hand, your "neck check" may reveal "below-the-neck" symptoms. Avoid intense physical activity if you have any of these symptoms: muscle aches, hacking cough, fever of 100°F or higher, chills, diarrhea, or vomiting. Exercising when you have below-the-neck symptoms may mean, at best, that you'll feel weak and dehydrated. Worse, you may risk such dangerous conditions as heatstroke (dangerously high body temperature) and heart failure.

You can resume exercising when "below-the-neck" symptoms subside. However, when recovering from an illness that prevented you from working out, it's important to ease back into activity gradually. A good rule of thumb is to exercise for 2 days at a lower-than-normal intensity for each day you were sick.
Stop the Spread
If you're on a team, an additional concern is whether you will infect others. And if you're healthy, you may wonder about someone else infecting you. For common illnesses like the cold, practice commonsense hygiene like washing your hands frequently and directing coughs and sneezes away from others.

Some infections, though, are readily spread in sports and require athletes to be sidelined while they are contagious. Two such conditions are measles and herpes simplex (a virus that often causes cold sores or blisters and is transmitted via skin-to-skin contact, as in wrestling). If you may have such an infection, see a doctor for treatment and information about when to resume sports.

Other conditions can also spread readily. So in addition to regular hygiene, athletes need to refrain from sharing water bottles and towels. Infections have been known to pass to other athletes via both routes.

You should also be properly immunized against diseases such as measles, mumps, tetanus, and rubella. Also, some athletes may benefit from an influenza vaccine. Ask your doctor what immunizations you need.
Common Cold, Common Sense
As is often true, deciding to exercise when you are sick largely involves common sense. Taking precautions about spreading infection and listening to your body can go a long way in getting you back into action without serious problems.

Remember: This information is not intended as a substitute for medical advice. If you have concerns about your health, consult a physician.

This information is not a substitute for medical treatment.

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EXTEND YOURSELF FOR LOW-BACK PAIN RELIEF
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Abstract: Your back may have "gone out" the moment you leaned over to pet your pooch, but don't blame poor Rufus for the agony you're now in. Most likely, your back has undergone years of abuse as you slouched in front of the TV and hunched over a desk.

Though you may hate to admit it now, Mom was right when she pestered you to sit up straight. For most of us, low-back pain is a cumulative process, resulting from chronic poor posture and sedentary habits. A flexed (or hunched over) back is bad news—it can stress or damage the disks that cushion the bones in your spine. Poor lifting and bending habits can also contribute to low-back pain.
Practice Proper Posture
But it's never too late to heed Mom's advice. Practicing proper posture is crucial to prevent future bouts of back pain (figure 1). And it may very well take practice. You will likely find that you tire easily in this new seated position.
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That's because the lumbar extensor muscles you use to keep the arch in your back are probably the most underused in your body. Most people with chronic low-back pain can dramatically increase the strength of the lumbar extensor muscles, sometimes even tenfold. That's a pretty impressive gain when you consider that most women can only increase their bench press strength 50% and most men can only double theirs.

So if you can only hold a correct seated posture for a few minutes at a time, that's OK. You can work up to longer sessions as your extensor muscles gain strength. Keep in mind that they can powerfully maintain the stability of your spine.

Another option when you sit is to use a lumbar roll or cushion to help keep the curve in your lower back. This kind of passive conditioning can reduce your symptoms. But only active conditioning—when your muscles are actually working—will let you develop the muscle tone you need for maximum spinal stability.
Extension Education
When back pain strikes, your first impulse may be to take to your bed. But recent studies have found that activity is the better antidote. For most people, low-back pain results from too much flexion, so exercises that place the back in the opposite position (extension) are best.

But that's not true for everyone, so be sure to have your back evaluated by a physician before you begin an exercise program. For example, pregnant women usually have back pain because the baby's weight causes them to hyperextend their back. So extension exercises can make their pain worse. Extension exercises are also inappropriate for people who have spinal stenosis. For whatever reason, if an exercise increases your pain you should stop it immediately and consult your doctor.

That many people with low-back pain do benefit from extension exercises was first discovered by Robin McKenzie, a New Zealand physical therapist1. Perhaps you've felt the urge to counter the effects of sitting slouched over by getting up and arching your back (figure 2). What you're doing is an extension exercise.
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Extension exercises have many variations. The most basic extension exercise starts from a position lying on your stomach (figure 3). As your lumbar extensor muscles grow stronger, you will be able to do more advanced versions of this exercise (figures 4 and 5). Another exercise to try is in a standing position (figure 6).
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Back in Business
Keeping your back healthy is something you want to work on every day—not just when pain strikes. And remember that regular aerobic exercise is an important part of any conditioning program. A regular walking or swimming program is an excellent choice for someone who has low-back pain. Of course, if exercise increases your pain, stop and consult your physician.

This information is not a substitute for medical treatment.

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HEALING HEEL PAIN: HELP FOR PLANTAR FASCIITIS
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Abstract: If your feet, especially the heels and arches, hurt when you step out of bed in the morning, you may have plantar fasciitis. It may take 6 months or longer for the pain to go away, but there are some things you can do in the meantime to cope with the pain and heal faster.

Q. What is plantar fasciitis?

A. Strong, fibrous bands connect the bones inside the bottom of your foot (figure 1). "Plantar" means the sole of the foot, and "fascia" means band (like a rubber band). When the plantar fascia is injured or irritated, it's called plantar fasciitis. The damage leads to pain in your heels and arches.
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Q. What causes plantar fasciitis?

A. Sometimes it is caused by overuse, but other factors may contribute, such as improper footwear, flat feet, or high-arched feet. If your calf muscles are weak or your feet are not flexible, you may develop the condition. Runners often suffer from plantar fasciitis if they increase the distance or intensity of their workouts too fast.

Q. What can I do to lessen the pain?

A. Follow your doctor's instructions and apply ice for 10 minutes several times a day (especially after activity and at bedtime), using an ice bath or cubes in a bag. If ice cubes aren't available, a bag of frozen peas works well, or you can roll your feet on frozen juice cans or chilled soda cans. If you do this while standing, hold a chair for balance.

Your doctor may prescribe painkillers, such as aspirin or ibuprofen. Foam heel cups or shoe inserts (called orthotic devices) may also be helpful. You may need an injection into the heel, or you may need to wear a splint at night. Your doctor may recommend surgery, but this is usually a last resort.

In addition to other therapies, stretching and strengthening exercises for the Achilles tendon (the cord you can feel at the back of your ankle) and the calf muscles will help you heal faster. These exercises are done barefoot.
  • Do heel raises on the stairs to help stretch and strengthen the Achilles tendon and the plantar fascia (figure 2).
  • Walk on your toes only, then walk on your heels only, then walk backward to the starting point. Carry hand weights (10 to 20 pounds) to increase the value of these exercises.
  • Walk or run barefoot whenever possible.
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As the pain decreases and your strength improves, gradually return to your usual activities. Exercises that keep your full weight off your feet, such as bicycling or swimming, will help you maintain fitness during recovery.

Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

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HOME EXERCISES FOR TENNIS AND GOLFER'S ELBOW
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This information is not a substitute for medical treatment.

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HOW TO FIT A MOUNTAIN BIKE
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Abstract: Having a mountain bike that fits you well is important not only for comfort but also for helping to prevent injuries. A bike that's the wrong size or poorly adjusted increases your chance of developing an overuse injury. The best way to adjust your bike so that it correctly fits your body is to follow these guidelines with the assistance of someone who understands the relevant anatomy and has experience working with cyclists. It is very difficult to perform some of the measurements on yourself. (These guidelines also apply to fitting a road bike, except where indicated.)

Frame Size
Correct frame size is determined by straddling the bike in a standing position. (For basic mountain bike terminology, see figure 1 (not shown); for frame sizing, see figure 2.) Lift the entire bike off the floor until the top tube is pressing against your crotch. The distance between the bottom of the mountain bike's tires and the floor should be 3 to 6 inches1 . (For a road bike, a 1- to 2-inch clearance is usually adequate.) Some newer mountain bikes do not have a traditional top tube; for them you have to rely more on comfort and balance to select the right frame size. If you are buying a new bicycle, test-ride as many bikes as possible and select the one that is the most comfortable.
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Foot Placement
This varies, depending on what type of pedal system you use. If your bike has simple platform pedals or pedals with toe clips and straps, all you need to know is that the widest part of the foot should be centered over the pedal axle. If you use clipless pedals, which firmly attach to cleats bolted to your cycling shoes, you must also make sure that your cleats are adjusted so that your foot placement on the pedals is the same as your natural foot position while standing. For example, if one of your feet toes out slightly when you stand, then your cleats should be adjusted so that your foot toes out slightly when you ride2 . This is usually accomplished by trial and error, but in difficult cases, a good bike shop should be able to help you find the right cleat position.

Most modern pedal systems offer a choice of cleats; some fix the foot to the pedal in a single position, and others allow some internal and external rotation (floating) of the foot while pedaling. The latter type may be less likely to cause overuse injuries.
Saddle Position
Correctly positioning the saddle will help maximize power and stability while minimizing the risk of knee pain. To make adjustments, you will need a goniometer or another device for measuring the knee angle, a carpenter's plumb line and level, and an allen wrench for moving the saddle. Note that after the saddle adjustments are made, you may need to fine-tune them in 1/4-inch increments every few rides until you find the optimal position.

Height. To set the saddle height, sit on the bike in a normal riding position with the crankarms straight up and down (figure 3). With your foot at bottom dead center (6 o'clock position), your knee should be bent at an angle of 25° to 30°1 , 2 . To measure knee angle precisely, center the goniometer at the lateral femoral condyle, and point the ends toward the greater trochanter at the hip and the lateral malleolus at the ankle. Some mountain bikers prefer a lower seat to improve off-road stability and maneuverability.
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Fore and aft. To set the saddle fore and aft position, drop a plumb line from the front of your patella, or kneecap, while sitting on the bike with the crankarms horizontal (figure 4). Adjust the saddle forward or backward until the kneecap of your front leg is directly over the pedal axle1 , 2 . Some mountain bikers prefer to have the saddle about 1/2 inch back from this position to improve rear wheel traction while climbing. The knee angle (saddle height) should be rechecked after changing the fore and aft position, and vice versa.
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Tilt. Use a carpenter's level (figure 5) to ensure that the saddle is level or tilted slightly upward so that you remain seated on the widest part of the saddle. Women may prefer to have the front of the saddle tilted down slightly.
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Upper-Body Position
Determining upper-body position or reach is less exact than other aspects of bike fit and is influenced by your experience, flexibility, and comfort2 . A comfortable reach will allow you to maneuver the bike easily without shifting your center of gravity too far forward.

Factors that determine upper-body position include the top tube length, stem length, and saddle fore and aft position. Proper frame selection is important, since changing upper-body position usually involves buying a longer, shorter, or more or less angled stem.

A good upper-body position will allow you to sit comfortably on the bike with your arms relaxed and your elbows slightly bent. You should not feel cramped, and your elbows should not interfere with knee motions. Beginners usually prefer the stability provided by a more upright position, while advanced cyclists often prefer to have their upper body lean forward in a more aerodynamic position. Handlebar height is also a matter of preference, but as a general rule the handlebars should be 1 to 2 inches below the top of the saddle.

This information is not a substitute for medical treatment.

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HOW TO STAY ALIVE IN DEEP POWDER SNOW:
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Abstract: For skiers and snowboarders who seek out deep powder, the same snow that thrills can also kill. Experts who chart skiing injuries have documented a significant risk: suffocation after falling, often headfirst, into deep snow depressions around trees (tree wells) or even on open ground. Similar to avalanche-related deaths, most incidents have occurred at ski resorts in the western United States and Canada, though the same risk would be present wherever deep powder conditions are found.

Hazardous tree wells generally are found in areas that get little skier traffic. The low-hanging branches of coniferous trees may create a sheltered area around the base of the tree, where a well of loose snow with air pockets can form. Usually there is no easy way to identify a dangerous tree well by sight, but the risks are greatest during and after major snowstorms.

Tree wells tend to form on the downhill sides of trees, because snow on the uphill side tends to creep downward and become compacted against the tree. Tree wells are also more common in areas sheltered from the wind, because strong winds break up snow crystals and increase snow density.
Stay on Safe Ground
Prevention is all-important because the odds of surviving deep snow immersion are low. Skis and snowboards can end up flush with or below the snow surface, making it difficult for searchers to locate victims. In an experiment in which 10 volunteers were temporarily placed in a simulated tree well, none could rescue themselves.

The most important prevention step is resisting the urge to ski through the trees during extreme powder conditions, no matter how inviting the untracked powder looks. But if the powder is too appealing and you find yourself skiing on timbered slopes:
  • Buddy up with another skier or snowboarder and stay within sight of your partner. That means stopping and watching your partner descend, then proceeding downhill while he or she watches you.
  • Carry the same personal rescue gear as backcountry skiers: an avalanche beacon, shovel, probe, and whistle.
  • Remove your pole straps. Trapped skiers have difficulty removing the pole straps, which can hamper efforts to escape or clear an air space to breathe.
What If You Go Down?
If you are sliding toward a tree well or a deep snow bank, do everything you can to avoid going down: grab branches, hug the tree, or anything to stay above the surface. If you go down, resist the urge to struggle violently. The more you struggle, the more snow will fall into the well and compact around you. Also, your skis or snowboard may knock snow off the branches. Instead of panicking, try first to make a breathing space around your face. Then move your body carefully in a rocking manner to hollow out the snow and give you space and air.

Hopefully, your partner will have seen what happened and will come to your rescue within minutes. If not, experts advise staying calm while waiting for assistance. Survival chances are excellent if you maintain your air space. Over time, heat generated by your body, combined with your rocking motions, will compact the snow, and you may be able to work your way out.

Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

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KEEPING TENNIS ELBOW AT ARM'S LENGTH:
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Abstract: Tennis elbow involves damage to the forearm muscles and tendons. Rehabilitation from this painful condition usually includes rest, icing, stretching exercises, improving tennis technique, and using an elbow strap called a counterforce brace. But perhaps the most important part of rehabilitation is strengthening exercises, which both promote recovery and help keep tennis elbow from returning.Two types of exercise will help you regain strength: exercises with weights and exercises without.

Exercises without weights. Effective strengthening exercises without weights can be done with a thick rubber band and a tennis ball. Do these exercises first with your elbow bent at your side, then progress over time to doing the exercises with your arm out straight in front.

For the finger extension exercise, place a thick rubber band around your fingers and thumb near the base of your fingers. With your palm facing the floor, spread your fingers apart as much as possible. Hold for 3 seconds, then release. Repeat until your fingers and forearm grow tired. After this becomes easy, slide the rubber band closer to your fingertips. When you can readily do the exercise from the fingertips, graduate to a thicker rubber band.

To do the hand squeeze, hold a tennis ball in your palm. Squeeze the ball firmly and hold for 3 seconds, then relax. Repeat until your muscles grow tired. If this exercise is difficult at first, start with a foam ball or racquetball and progress to a tennis ball.

Do these two exercises several times each day. It's a good idea to have tennis balls and rubber bands in convenient places, like at your desk and by the telephone. Continue to do tennis ball and rubber band exercises through the duration of the weight training program described below.

Exercises with weights. Before each weightlifting session, work up a light sweat with 3 to 5 minutes of brisk walking, cycling, or jogging, or warm the elbow directly by using a hot pad. Also, progress gradually: This is extremely important to prevent reaggravating the injury. If you have been prescribed a counterforce brace, wear it while doing the following exercises (figures 1 and 2).

Begin with no weight, and do a set of 10 to 15 repetitions (reps) daily. Once you can comfortably do 30 reps for two consecutive sets, use a 1-pound weight and go back to 10 to 15 reps. Work up to 30 reps.

Over time, increase the weight in 1-pound increments to 3 pounds, then in 2-pound increments to 5 to 7 pounds. But work up to only 20 reps with 3-pound weights and above. At the 3-pound level, gradually work toward straightening your elbow (but not locking it) and not supporting your arm.

Progress in each exercise at its own rate. You will achieve heavier weights faster on some than on others. Ice your elbow for 10 to 20 minutes after each exercise session.

Most important, do not cause pain. If any exercise causes pain, modify it by decreasing the weight, decreasing the number of reps, or reducing the range of motion. If you still feel exercise-related pain after taking one or more of these steps, check with your doctor or physical therapist.
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Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

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LOW-PRESSURE WORKOUTS FOR HYPERTENSION
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Abstract: Regular exercise is a central part of your program for controlling hypertension (high blood pressure). For most people who have hypertension, a few sessions of moderate physical activity each week will reduce blood pressure significantly and lower the risk of stroke and heart attack. If your blood pressure is just mildly elevated, exercise (along with a healthy diet and lifestyle) may be enough to bring it down to normal. If you need medication, exercise probably will make it more effective, and possibly allow you to take a lower dose.

Endurance Exercise
The best type of exercise for lowering blood pressure is aerobic activity that makes you breathe faster and gets your heart rate up. This can be brisk walking, jogging, swimming, or working out with machines like a treadmill or cross-country ski simulator. Choose one or more activities that will be convenient and enjoyable to do regularly.

For maximum benefit:

  • Exercise three or more times each week.
  • Take 5 minutes to warm up (with slow walking or stretching), do 25 to 30 minutes of exercise, and then spend 5 minutes cooling down with slower activity.
  • Exercise hard enough to bring your pulse rate up to a level that will strengthen your cardiovascular system. To compute a target heart rate, subtract your age from 220 and multiply by 0.7. (Example: If you are 55 years old, your target rate is 115.) If your target heart rate is difficult to achieve, use a value 10% to 20% lower and build up to the target. If you're taking blood pressure medication that can reduce heart rate (such as a beta-blocker), ask your doctor about your target heart rate.
  • Ease into it. If you haven't been exercising, start slowly: Walk for 20 minutes, for example, at a pace relaxed enough that you can converse. Gradually build up to longer, more strenuous workouts.


Strengthening Exercises
Your doctor may also suggest a weekly session of resistance exercise to increase your overall fitness and strengthen your upper body. This may mean using light weights (like dumbbells) or doing a series of exercises with Nautilus- or Cybex-type machines.
Exercise Safely
Moderate exercise poses very little risk for most people who have high blood pressure. If you are at high risk for heart disease (for example, if you have high cholesterol, are overweight, or have a family history of early heart attack), your doctor may recommend a stress test—monitoring your heart while you exercise under supervision—to find the level of exercise best for you.

To stay on the safe side, stop exercising and consult your doctor if you experience any of the following:

  • Unusual discomfort in your chest, jaw, or arm;
  • Dizziness; or
  • Extreme shortness of breath.


Make It Fun
Enjoy yourself. Make it easier to exercise consistently by choosing activities you enjoy in an environment you find pleasing (like a health club, outdoors, or while listening to music). Build regular sessions into your schedule. Exercise with friends and make it a social occasion.

Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

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MOBILIZE AGAINST DEPRESSION
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Abstract: Mainstay treatments for depression-psychotherapy and prescribed drugs–are extremely effective. But there are also things you can do for yourself to feel better, and one of the best of these is exercise.

While exercise cannot take the place of medical care and therapy, it often is highly beneficial. Studies have shown that regular physical activity can brighten mood, increase energy, and improve sleep. It may not work this way for everyone, but most exercisers of all ages increase their stamina and reduce their risk of diseases like diabetes, heart disease, and osteoporosis. Especially when you are depressed, it is good to know that you are taking positive action for your health.
What Kind of Exercise?
No one form of exercise has been shown to be superior for depression. Aerobic activities (for example, brisk walking, jogging, swimming, and biking) and nonaerobic activities (stretching and weight training) are both beneficial. Walking at any pace, the most readily available exercise, may be an especially handy option.

What is important is to choose a physical activity that you enjoy—and to do it regularly. You do not need to push yourself to extremes. In fact, studies have shown that moderate exercise improves mood more than excessively long, hard workouts. Your goal should be to feel pleasantly tired, a normal feeling after any physical activity.

A program that many people find easy, pleasurable, and valuable is 30 to 45 minutes of walking, three to five times a week. The American College of Sports Medicine also recommends strength training two to three times a week and flexibility workouts two to three times a week.

But if you are not used to exercise, you may need to work up to this level gradually. Just a few minutes of walking (or other exercise) is a good place to start, and you may find that in a few weeks you want to do it longer and more often.
Be Realistic
Many people who have depression experience a lack of energy, fatigue, and difficulties with motivation, which can present significant exercise hurdles. The key is to start slowly and be patient with yourself: Time is on your side. As your depression lifts with the help of treatment, you will probably find it easier to exercise. The half-hour walk that looks impossible today may feel invigorating 3 weeks from now.

Don't let exercise become a burden. Try to fit it into your schedule as much as you can: Taking a 15-minute walk at lunchtime may make a lot more sense than getting up an hour earlier for a morning workout. You get similar fitness benefits when you break your exercise into smaller, more manageable chunks throughout the day.
Maximize the Pleasure
What kind of exercise is most enjoyable for you? Choose activities and settings that will increase the fun. Here are a few things that others have found useful:

Make it social. Exercise is a good way to spend time with other people. Join an aerobics class or a regular walking group, or simply arrange for a lunchtime stroll with a health-minded coworker.

Exercise outdoors. Trees, grass, pleasant surroundings—nature has a way of lifting spirits and putting things in new perspectives. Outdoor light has been shown to improve mood, especially during the winter months.

Create a positive environment. Put on your favorite music while you work out at home, or wear headphones when you jog or stroll, as long as you're away from heavy traffic.

Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

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OVERTRAINING SYNDROME
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Abstract: Overtraining syndrome is a common cause of underperformance in athletes. Symptoms such as persistent fatigue, muscle soreness, reduced coordination, weight loss, mood changes, and frequent illness may accompany performance decrements, but they may also be signs of underlying medical conditions. Reliable and practical diagnostic laboratory tests for overtraining have not yet been identified. Clinicians can prescribe relative or complete rest and strive to identify and correct the training, nutritional, and psychosocial factors that contributed to the athlete's condition.

You've been feeling exhausted, achy, edgy, and burned out. Worse yet, your personal relationships are suffering and you're stressed over so many demands on your time. On top of that, your athletic performance has "hit the wall," and you just can't seem to do any better. What's wrong?

You may have an easily explained problem, such as an infection sapping your strength, or you may be training too hard. Constant muscle soreness, difficulty sleeping, or frequent colds may be your body's way of telling you to take it easy for a while. If you keep pushing, you may develop overtraining syndrome.
Q. What is overtraining syndrome?
A. Too much physical training and too little rest and recovery after hard workouts cause a great deal of stress on muscles, joints, and bones. If you are further stressed by worries about money, fear of failure, or conflicts with friends, teachers, or teammates, your body may reach a point where it can no longer repair the damage.
Q. But isn't fatigue normal after a hard training session?
A. Tiredness and some decrease in athletic ability are expected after a series of difficult workouts. You feel better after a few days of rest or lighter training, and your performance improves. If you always feel sore and tired and your performance suffers, it might be overtraining syndrome.
Q. How can I tell if I have overtraining syndrome or something else?
A. Talk to your team doctor or your personal physician. The symptoms are similar to many other medical problems (table 1), so your doctor will need to examine you to rule out other causes. He or she may recommend that you adjust your schedule to see if 2 weeks of lighter training and more rest will help.
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Q. How is overtraining treated?
A. Overtraining is treated like other injuries, such as a broken bone, and is a serious condition. A period of complete rest is often recommended. The longer you were overtraining, the longer you will need to rest. You may be able to do some light cross-training during the 6- to 12-week recovery period. You can use the time to work on other sources of stress, such as grades or personal relationships. Eating well will give your body fuel for healing, and you might enjoy massage or whirlpool baths.
Q. Can overtraining be prevented?
A. Yes. The key is to include rest and recovery time in your training schedule. A heavy week of training should be balanced with some light training or a day off. Heavy weeks and months of training should include time for recovery so that you are well rested before important competitions. Keeping a training log (figure 1) is an easy way to track your progress and watch for symptoms of overtraining. Let your coach and team doctor know early in the process if you have symptoms of overtraining. Prevention is the best cure.
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This information is not a substitute for medical treatment.

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PATIENT ADVISER
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Abstract: Getting hit in the nose can be scary, especially if it starts bleeding a lot. Your nose is at risk in a collision with another player or piece of sporting equipment, and striking the bones in your face can be very painful. That's why wearing protective gear, like a helmet and a mouth guard, is so important when playing sports.

If you do get hit in the face, be sure to report it to the coach or team doctor right away.

Q. What should I do if I get a bloody nose?

A. The first step is to stop the bleeding and try to prevent swelling. Sit or lie down with your head and shoulders higher than your waist and legs. Tilt your head back slightly, and press on the bridge of your nose. If you can, place an ice pack on your nose and another ice pack on the back of your neck. Breathe through your mouth until the bleeding slows down. A nasal spray (the kind you use when you have a cold) may also help. You will not be allowed to return to play until the bleeding has completely stopped.

If the bleeding doesn't slow down in 10 minutes and stop in 1 hour, or if your mouth tastes salty, you will need to go to the emergency room or urgent care office.

Q. How do I know if my nose is broken?

A. If you heard a crunching sound (like biting into uncooked macaroni) when you got hit, your nose could be broken. It might still look OK, or it may look like it is pushed off to one side. If you're not sure, it's best to have a doctor check it anyway. It will probably swell up in an hour or two, so go to the doctor as soon as you can, so that he or she can see it before it swells.

Q. How can the doctor tell if my nose is broken?

A. The doctor will do an exam to see if any bones are broken. The best time to do this is before too much swelling occurs. Otherwise, you will have to wait 3 to 5 days for the swelling to go down before the doctor can tell what happened. X-rays are usually not needed, but your doctor will decide if they would be useful.

Q. How is a broken nose treated? A. If the nose has been pushed out of place, it can usually be moved back into position, either within an hour (before it swells too much) or after the swelling goes down (after a week). You may also choose to have the repair done after the sports season or when the school year ends. If the nose is broken but still in place, you will not need surgery.

Q. When can I return to play?

A. If you are in a noncontact sport, like swimming, you may return as soon as the bleeding is completely stopped, you have no headache, and you can see clearly. If activity makes the bleeding start again, it's too soon to go back. If you can't see because the swelling blocks your vision, you need to wait until the swelling goes down. Applying ice for 20 minutes at a time may help.

If you play a contact sport, like soccer or hockey, you may be able to return in 1 or 2 weeks, but only if you wear a special protective mask. You might get hit in the nose again while playing, so a face mask is required. Your doctor will decide when it is safe for you to return to sports.

A displaced or broken nose can mask a more serious injury. A nose that doesn't heal properly may cause problems later in life. To prevent injury, always wear protective gear and play it safe.

This information is not a substitute for medical treatment.

- [ Close note ]


PATIENT ADVISER
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Abstract: Staying healthy is important at any stage of life, but especially while you are pregnant. You want to give your baby the best possible start by eating right, not smoking, getting enough rest, and exercising.

Q. Is it safe to exercise while I am pregnant?

A. Yes, as long as you do not have any medical condition that would make exercise risky for you or your baby. Your doctor will determine if you are healthy enough to exercise and help you choose the exercises that are right for you. Be sure to follow all your doctor's instructions carefully.

If you are already active, you may need to set a slower pace. You can maintain your fitness level, but pregnancy is not a good time for heavy training or improving performance. Your doctor can help you set reasonable limits.

Q. I am not used to exercising. When should I start?

A. Many women find that the second trimester is a good time to begin. The nausea and vomiting of the first trimester have eased, and you are still able to move easily. Exercise may help reduce excessive weight gain, which means less stress on your lower back, knees, and ankles in the third trimester.

Q. What kind of exercises can I do?

A. Walking, swimming or pool exercises, low-impact aerobics, and yoga for pregnancy are all good choices. After the fourth month, avoid exercising while lying flat on your back. Be careful not to overstretch! Biking may be done on a stationary bicycle. Skiing, scuba diving, and exercises that have a high risk of falling or require sudden changes in direction should be avoided. Also, avoid working out in hot, humid environments, especially during the first 3 months. Doing a variety of exercises will help avoid boredom.

Q. How much should I exercise?

A. Try starting with about 15 minutes per session, three times per week, at a pace that increases your heartbeat. Your doctor can show you how to check your pulse and tell you what your safe heart rate should be. You can move at a slower pace or stop and rest if you need to. You should be able to carry on a conversation while you are working out and not feel excessively short of breath at any time. Work up to 30 minutes per session, four times a week.

Q. What else do I need to know?

A. A baby needs about 300 calories per day to develop normally. Your doctor can help you figure out the right amount of food to eat. Remember to drink enough fluids, including water, limit caffeine, and avoid alcohol intake. Contact your doctor right away if you have:

  • Significant shortness of breath;
  • Vaginal bleeding, amniotic fluid leakage, or other unusual discharge;
  • Dizziness or headache;
  • Pain in the chest, stomach, or hip; or
  • Decreased fetal movement during exercise.


Exercise is just one part of a healthy lifestyle. Pregnancy is a great time to develop healthy habits that will last a lifetime for you and your baby.

This information is not a substitute for medical treatment.

- [ Close note ]


PATIENT ADVISER
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Abstract: Calcium is important for building strong teeth and bones and for preventing osteoporosis. It is especially important that adolescents and young adults get adequate amounts of calcium. In women, bone density can increase until around age 30. After that, bone mass is maintained or lost at a slow rate until menopause, when the rate of bone loss increases.

Your bones are like a bank. You can deposit calcium until around age 30, and then for the rest of your life you have to withdraw the calcium that you have "saved." This is why it is critical to build strong bones when you are young!

Q. How much calcium do I need?

A. Women should get between 1,000 mg and 1,500 mg of calcium every day. That is typically three to five servings of dairy foods daily. The average American consumes less than 800 mg of calcium a day. It is especially important that women who do not have regular periods (at least 10 to 12 a year) or those using certain types of contraception (such as Depo-Provera shots) get adequate calcium. Irregular periods and Depo-Provera shots have been shown to deplete calcium in bones.

Q. What is the best way to get calcium?

A. The best way to get calcium is in your regular diet. The calcium content of some common foods is shown in table 1. Read food labels for more precise information.
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If you can't get enough calcium from your diet, you should take a calcium supplement. Calcium supplements come in many forms. You need to look for the amount of elemental calcium in a supplement.

Many calcium supplements also contain Vitamin D to improve calcium absorption in the digestive tract. You should get between 400 and 800 IU of Vitamin D a day (see table 1). In general, there is little evidence that any one type of calcium supplement is more effective than another. Taking calcium with food in doses of 500 mg or less improves absorption. If you take two calcium supplements a day, you should take them at different meals, if possible.

Q. Are there side effects from taking too much calcium?

A. Calcium supplements are usually tolerated very well. Some people may have some problems with constipation, bloating, or excess gas. Switching calcium preparations or drinking more fluids may relieve these symptoms. Weight-bearing exercise, such as walking or using free weights, also helps build strong bones. Be sure to drink enough water to replace the fluids lost by sweating during exercise. A healthy lifestyle includes drinking eight glasses of water every day. Drinks that contain caffeine are not as beneficial as water or sports drinks for preventing dehydration.

Remember: This information is not intended as a substitute for medical treatment. If you have a medical concern, consult a physician.

This information is not a substitute for medical treatment.

- [ Close note ]


PATIENT ADVISER
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Abstract: Exercise is an important part of treating–and preventing–ack pain. Your doctor will show you which exercises are right for you and tell you how often, how long, and in what order you should do them. Often, relief for back pain is a goal that can only be achieved by a team approach of physician, therapist, and patient. Your full participation is essential.

Part 1. Initial Exercises
The exercises your doctor recommends as you begin treatment will help you control pain and maintain muscle tone. When done correctly, these exercises should cause little or no pain. Figures 1 through 4 demonstrate some exercises to help you begin.
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Part 2. Stabilization and Strengthening Exercises
As you get stronger, the next goal is to improve back strength and function. Figures 5 through 9 show exercises that are designed to stabilize the spine while keeping it in a safe position.
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Part 3. Hip and Hamstring Stretches
Tight hip and hamstring muscles often contribute to low-back pain. Exercises that stretch these muscles (figures 10 and 11) are an essential part of recovery and may prevent new pain from developing.
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Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

- [ Close note ]


PATIENT ADVISER
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Abstract: The muscles, joints, and bones of the shoulders form a base of support that allows your arms to swing, lift, or throw (figure 1). One of these bones, the collarbone, is also called the clavicle. Above your arm is an extension of the shoulder blade called the acromion. Where these two bones meet at the top of the shoulder is the acromioclavicular (AC) joint. The AC joint is not the shoulder joint. The shoulder joint is where the bone of the upper arm (humerus) meets a shallow socket that is also part of the shoulder blade.

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Q. What is a 'separated shoulder'?

A. A separated shoulder is a dislocation of the AC joint that can be caused by a direct or indirect blow to the shoulder. The ligaments that keep the clavicle in proper position become stretched or torn.

There are six different types of AC joint separations. The most common types can be treated by your doctor without a cast or surgery. Because some shoulder separations may need surgery, you should see your doctor for diagnosis and treatment. If surgery is not necessary, most separated shoulders can be treated with an arm sling followed by special rehabilitation exercises, such as those described on the next page.

Q. Does an AC joint separation show on x-rays?

A. X-rays are necessary to show if the clavicle is broken. They can also help distinguish which of the six types of AC joint separation may have occurred.

Q. What other injuries can happen to the AC joint?

A. The end of the clavicle can break. The broken bones may need surgery because the ligaments can't hold the broken parts of the bone in proper position. Your doctor will carefully examine the injury to decide whether surgery is necessary.

Q. Is arthritis a concern?

A. Arthritis can affect the AC joint just like any other joints. A separated shoulder or a broken clavicle may increase your future risk of developing arthritis of the AC joint. Weight lifters and people who do upper-body workouts or play sports that involve shoulder strength or throwing may also be more likely to develop AC joint arthritis. Arthritis can also develop with normal aging.

Q. What can I do to minimize joint damage?

A. Once symptoms develop, discontinue any pain-provoking exercises. Weight lifters should avoid "locking out" the bench press, use a narrower grip on the bar, and avoid bending the elbows below horizontal. Follow your doctor's instructions for care after injury, and be sure to do the recommended exercises to regain strength and range of motion. Your doctor or physical therapist will show you how to do the exercises and tell you how often to do them.

Q. Which exercises help?

A. Unless your doctor tells you otherwise, perform the following exercises two or three times a week. Do 12 to 18 repetitions per set, and do three sets of each. Begin by using 1- or 2-pound hand weights, and gradually increase the weight to 8 pounds as you are able. Consult your doctor if you experience more than mild discomfort when doing any of these exercises.

The first three exercises (figures 2 through 4) increase strength and flexibility. In addition, two exercises help stabilize the scapula. The "push-up plus" (not illustrated) is just like a regular, full-length push-up except that as you come up, you emphasize pushing your back toward the ceiling as high as possible. (Bent-knee pushups do not work as well for this exercise.) The seated press-up (figure 5) is another scapular stabilizer.
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Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

- [ Close note ]


PREGNANT WITH BACK PAIN? SUGGESTED COMFORT TACTICS
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Abstract: Pregnancy, especially the later stages, is fertile ground for back pain. Your center of gravity shifts because your uterus expands. Your abdominal muscles lose tone. And hormonal changes temporarily loosen important support structures-ligaments and tendons-leaving you with joints and muscles in the back and pelvis that seem to groan under the stress of increased weight.

Up to 50% of pregnant women will experience back pain, which can last up to 6 months after delivery. There are three types of pregnancy-related back pain: low-back pain when you stand or sit, pain worst in the back of your pelvis and deep in your buttocks, and night pain in your lower back that occurs only when you are in bed.

Though back pain is largely unavoidable, your doctor can advise you about ways to minimize the discomfort. It will help to be more conscious of your posture: Try to keep your spine in a neutral position—neither swaybacked nor flat. Wearing flat or low-heeled and well supported shoes reduces the stress on your spine. If you must stand for long periods, take breaks or—if you can't do that—place one foot on a low stool, alternating your feet. If your job requires sitting, you can reduce the stress on your lower back by putting one foot on a low stool.

Many doctors prescribe strengthening and flexibility exercises to reduce back pain. Try the ones in figures 1 through 3 for starters. When done correctly, they're easy to perform at home and should not be painful; don't do the exercises if they cause pain. If exercise and preventive measures aren't effective, your doctor may advise other options such as icing or heating the area or wearing a support device.
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Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

- [ Close note ]


PREVENTING URINARY INCONTINENCE IN ACTIVE WOMEN
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Abstract: No matter what you've heard, incontinence-or involuntary urine loss-is not a normal part of aging. And it is treatable.

Millions of people have urinary incontinence. Women who participate in sports and exercise may be particularly susceptible because impact can weaken the pelvic floor muscles. These muscles are responsible for controlling urine flow.

Your doctor may prescribe various treatments, including drugs and surgery. But many women find help with less dramatic measures.
Fluid and Food
For starters, avoid drinking too much fluid. Limit fluid to less than 2 liters (or 2 quarts) per day, but your urine should appear clear like water. Don't limit your fluid intake before, during, and after exercise. Limit your fluid intake after 6 pm if you have problems with waking up at night to urinate or with bed-wetting. Also, add fiber to your diet to avoid constipation.

In addition, limit bladder irritants like nicotine, caffeine, alcohol, carbonated drinks, tea, chocolate, citrus fruits, tomatoes, apple juice, cranberry juice, spicy food, and foods with the sweetener aspartame.
Activity Selection
You may need to avoid sports that weaken the pelvic floor, like those involving jumping with legs apart. High-risk sports are gymnastics, volleyball, basketball, handball, karate, horseback riding, high-impact aerobics, and dance. Medium-risk activities are jogging, tennis, skiing, and skating. Activities with little risk include swimming, bicycling, walking, rowing, low-impact aerobics, and others in which at least one foot touches the floor at all times.

It may help to change sports for a while or modify your sport as you pursue other treatments. If you continue a sport that makes you incontinent, do Kegel exercises (below) before and during your workout, or insert a tampon.
Kegel Exercises
One of the most important steps is pelvic floor, or Kegel (rhymes with eagle), exercises. The pelvic floor muscles lie deep in your pelvis, and strengthening them can help you better control your urine flow.

Your goal is to stop urine leakage when exercising, coughing, sneezing, laughing, or lifting-all of which can put pressure on the bladder. Eventually, you'll be able to do Kegel exercises anywhere at anytime.

Ask your doctor to show you how to do Kegel exercises. He or she will feel your pelvic floor muscles with a finger while you try to contract these muscles. If you still cannot locate your pelvic floor muscles, a physical therapist or nurse can help you by using other aids and techniques.

A Kegel exercise should feel like you are stopping your urine stream or preventing the passage of stool. Firmly tense the muscles around your vagina and anus by inwardly lifting and squeezing them. Hold this contraction to the count of 5 (gradually work up to 10), then relax.

At first, do your exercises while lying on your back with your head and shoulders supported by a pillow and your arms at your sides. Bend your knees and place your feet flat on the floor about 12 inches apart. Eventually do Kegels while sitting and standing. Start with one set of 10, three times a day. Work up to 20 sets of 10 each day.

Here are other helpful hints for doing Kegel exercises:
  • Contract your pelvic floor muscles without lifting your buttocks, tightening your stomach or thigh muscles, or moving your legs.
  • Do not practice stopping your flow of urine. It will disrupt your voiding patterns.
  • Do not hold your breath or strain.
  • Be patient and faithful. Improvement takes 6 to 8 weeks. You need to do Kegel exercises indefinitely.
For further information and support, write to: National Association for Continence, Box 544, Union, SC 29379, or call 1-800-252-3337.

Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

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RELIEVING LOW-BACK PAIN WITH EXERCISE
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Abstract: If you suffer from low-back pain, the most important part of your treatment is something only you can give yourself: exercise. Regular workouts make pain go away faster. By strengthening the muscles that support your back and improving your back's flexibility, exercise reduces the chances of another acute attack.

A full program has two parts. The first component is aerobic exercise to get your whole body in good condition (aerobic exercise like walking or biking uses large muscles and gets your heart and breathing rates up). The second component is specific exercises designed to strengthen your back muscles and increase or maintain flexibility. Your doctor will tell you when to begin each type of exercise.
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In addition to your exercise program, your doctor may suggest learning about the importance of posture and proper technique for sitting, lifting, and other activities. You may also need the help of a physical therapist or other professional, and may need medication for some period of time. But none of these can take the place of exercise.
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Part 1: Aerobic Exercise
The best aerobic exercises for people who have low-back pain are walking, swimming, and biking (perhaps on a stationary exercise bicycle). These allow you to work out without subjecting your back to the repeated impact produced by jogging or aerobic dance.

To keep your back and whole body (including your heart and lungs) in top condition, build up to a regular schedule of 20 to 40 minutes of exercise 3 to 5 days a week. Your workout should be strenuous enough to raise your pulse to 60% to 85% of maximum (to estimate your maximum heart rate, subtract your age from 220).
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Following the guidelines below will help you succeed:

If you aren't used to exercise, start slowly. Any activity is better than none. Try to walk, at a comfortable pace, the distance of 2 to 3 telephone poles (or 2 to 3 short city blocks). With your doctor's approval, increase the pace and distance gradually: Within 3 months you should be able to achieve the full schedule.
  • IMPORTANT: Good posture is essential to minimize strain on your back while you exercise:


If you bike, adjust the pedals and handlebars so you can sit up straight, without leaning forward. Avoid racing bikes.

If you walk, stand comfortably straight without slouching. Preserve a slight arch in your lower back, and keep your stomach muscles slightly tensed.
Part 2: Back Exercises
A good back-exercise program helps your back in two ways: First, it strengthens and stabilizes the muscles of the back and abdomen so they can support your back and protect it from strain. Second, it keeps your back and hamstring (back of the thigh) muscles flexible. Tight back muscles are more vulnerable to injury; tight hamstrings can lead to low-back strain or sprain.
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Figures 1 to 4 show exercises that many patients find helpful. However, the causes of back pain are highly individual, so your doctor will probably modify or add to these exercises. Your doctor may want to instruct you (or have an aide or physical therapist work with you) to make sure you know how to do the exercises correctly.

Be sure to follow these guidelines as you start your program:

  • A little discomfort in the low-back area is natural as you get your back in condition, but sharp pain means you're pushing too hard.
  • Always warm up before back exercises by walking or doing gentle calisthenics.
  • Many people find that applying heat before exercise and ice afterward keeps discomfort to a minimum. (Some people use the reverse order; do what feels best for you).
  • Doing the exercises with proper form maximizes benefits and minimizes strain.
  • IMPORTANT: Stretches must be gentle: Never push beyond the comfort zone. Hold stretches, don't bounce.


Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

- [ Close note ]


SIDESTEPPING BURNERS:
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Abstract: If you play football or any other contact sport, you might have experienced or heard about "burners" or "stingers." These are nerve injuries that can result from a blow to or a fall on the head, neck, or shoulder. Burning and stinging in the neck and arm are common symptoms, but some athletes also experience numbness, tingling, or shoulder weakness.

Players often shrug burners off, but it's best to let someone on the medical team know about your symptoms-nerve injuries are nothing to mess with. Shoulder weakness can develop, even after your symptoms go away. And a weak shoulder can make a player vulnerable to another burner. Regardless of how serious your burner is, your doctor or trainer can recommend specialized neck and shoulder rehabilitation exercises that help you maintain or regain your muscle strength. The payoff for you is peak performance and fewer injuries.

Your best bet, though, is to prevent a burner from ever occurring. The game plan for that includes improving your muscle balance with a targeted muscle strengthening program, well-fitted protective equipment, and proper blocking and tackling technique.

Perfect your muscle balance. Many players spend a lot of time building up their "glamour" muscles: the pectorals, front of the shoulder, and biceps. However, weight lifters who neglect the muscles behind the shoulder and the muscles of the upper back can develop a round-shouldered, head-forward posture that throws the neck out of alignment. In other words, poor muscle balance leads to bad posture, which can make a player vulnerable to nerve problems. Proper posture, with the shoulders back and the chest out, keeps nerve pathways free and clear.

Exercise to improve your posture consists of stretching the neck and pectoral muscles and strengthening the upper-back, shoulder, and armpit muscles. Start by warming up your neck muscles. Gently turn your head back and forth and bend your neck from side to side. Strengthening exercises are described in figures 1-5. Start out slow with light weights on machines or lightweight free weights.
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Push-up "plusses" can be added to this group of exercises without any equipment. Do a traditional push-up, then add an extra push by fully extending your arms. "Scapular squeezes" are also a very effective posture-enhancer: Simply try to squeeze or touch your shoulder blades together by moving your elbows toward each other behind your back.
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Equipment. Shoulder pads and neck rolls are designed to prevent extreme neck movements; however, they can't do their job if they don't fit properly. Equipment that attaches to the chest should be firmly fixed. Make sure your pads and equipment are appropriate for your weight and height. Coaches and the medical staff may have additional fitting tips. If burners are a recurring problem, consider placing lifts under your shoulder pads or wearing a Cowboy Collar (McDavid Knee Guard, Inc, Chicago) or other device that limits neck motion.
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Technique. Poor blocking or tackling technique is responsible for some burners, especially in players who sustain repeated burners. Ask a coach to observe your technique and recommend changes.

Remember: This information is not intended as a substitute for medical treatment. If you have concerns about your health, consult a physician.

This information is not a substitute for medical treatment.

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SIMPLE STEPS FOR INCREASING ACTIVITY AND LOSING WEIGHT
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Abstract: It's probably no surprise that being inactive or overweight increases the risk of heart disease and other diseases. And most people know that regular exercise (combined with healthy eating, of course) helps fight excess weight.

What you might not know is what, exactly, "regular exercise" means. For years we have been told that for exercise to "count," it had to be done for at least 30 minutes, three or more times a week. Also, it had to be hard enough to cause you to sweat and breathe hard. This type of exercise is definitely effective. However, day-to-day activities like playing with the kids, housework, or gardening are exercise, too—and they can also help you boost fitness and shed pounds. Boost Exercise

For those striving to lose or maintain weight, regular physical activity—whether traditional exercise like walking or lifestyle activities like yard work—is important because it:
  • Burns calories;
  • Slows down the loss of muscle that typically comes with aging;
  • May speed your metabolic rate, which is how fast your body burns calories, even at rest; and
  • Is strongly associated with successful long-term weight control.
If you are able to participate in and enjoy traditional aerobic exercise like brisk walking, running, swimming, in-line skating, aerobics classes, or bike riding, by all means do so. But being overweight may make it harder to do these more traditional workouts regularly. You may find that you get out of breath quickly or simply do not enjoy them.

If so, it may help to focus first on how you can burn more calories by building more motion into your daily activities. Some examples:
  • Parking the car at the far end of the parking lot;
  • Gardening, mowing, and doing other yard work;
  • Vacuuming, dusting, and doing other housework;
  • Using stairs instead of elevators and walking instead of using moving walkways;
  • Walking during lunch breaks; and
  • Playing with children.
The goal is to be active for 30 minutes on most, if not all, days. To make it easier, remember that your 30 minutes can be broken into shorter periods of 8 to 10 minutes or more. For instance, you could pull weeds for 10 minutes in the morning, walk for 15 minutes at lunchtime, and vacuum for 10 minutes in the evening. This is especially helpful to those who have busy schedules.

The key is to choose activities you will enjoy or can easily plug into your routine and then do them regularly. You may find that your exercise program is easier if you pick a variety of activities.

The more you increase your daily activities, the fitter you'll become. As you gain fitness, you may find that you can add regular walks or another aerobic activity to your regimen. Stretching exercises and strength exercises like weight lifting will round out your program. Increasing your fitness is good even if you don't lose weight: It'll mean more stamina, less tiredness, and even a shot at a longer life! Decline Reclining

Cutting back on TV watching and other physically inactive pursuits is another important change for adults and children trying to lose weight. A physical activity log (next page) can help in identifying active and inactive times. Make copies of the log and keep a record for a few days. The results will surprise you. The log can help you identify times when you could work activity into your day.

Daily Physical Activity Log
Hours Minutes of Physical Activity Notes
12:00 midnight-1:00 am
1-2:00 am
2-3:00 am
3-4:00 am
4-5:00 am
5-6:00 am
6-7:00 am
7-8:00 am
8-9:00 am
9-10:00 am
10-11:00 am
11:00 am-12:00 noon
12-1:00 pm
1-2:00 pm
2-3:00 pm
3-4:00 pm
4-5:00 pm
5-6:00 pm
6-7:00 pm
7-8:00 pm
8-9:00 pm
9-10:00 pm
10-11:00 pm
11:00 pm-12:00 midnight
Total Activity _____ minutes
Date: ______________________________


This information is not a substitute for medical treatment.

- [ Close note ]


STEPS TO TAKE FOR CLAVICLE FRACTURES
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Abstract: The bones that reach from the middle of your chest to the shoulders form the struts that make up the front of the shoulder. They can be broken when they are overstressed.

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Q. What is a fracture of the clavicle?

A. The clavicle (or collar bone) connects the breastplate (sternum) to the shoulder blade (scapula). It is the most commonly broken (fractured) bone in the body. Fractures may occur in sports activities, falls, or other accidents.

Q. What should I do if I think my collar bone is broken?

A. It is best to seek medical attention as soon as possible. Before you go to an emergency department or urgent care facility, the arm should be supported by holding it close to the body, or by using a sling. Over-the-counter pain medication such as acetaminophen or ibuprofen can be used to help relieve pain. Ice can also help to reduce pain and swelling, but ice should be used for only 15 to 20 minutes at a time. You must be careful not to freeze the skin. If the injury causes shortness of breath or difficulty swallowing, you should seek immediate medical attention.

Q. How are clavicle fractures treated?

A. An x-ray is usually needed to confirm that there is a fracture. Nearly all fractures can be successfully treated with immobilization using either a sling or a special brace called a "figure-of-eight" splint. The sling or splint should be worn until there is no discomfort during normal use of the arm. As the pain in the clavicle subsides, you should begin gentle motion of the shoulder. Your doctor may show you some exercises or send you to a physical therapist for instructions.

Usually, clavicle fractures heal in 4 to 5 weeks in children, 6 to 8 weeks in adolescents, and 10 to 12 weeks in adults. Nearly all clavicle fractures will heal without surgery.

Q. How will I know when my fracture is healed?

A. Having full motion of the shoulder and experiencing no pain when pressing on the fracture site are two good signs that the fracture has healed. Your doctor may want you to get an x-ray to confirm that the bone is completely healed.

Q. What if my fracture does not heal?

A. If the fracture does not heal, an operation may be necessary. Many factors determine whether a clavicle fracture will need surgery, so you should discuss the options with your doctor.

Q. What result can be expected once the fracture heals?

A. Most patients will have full shoulder motion and can return to all activities without limitations. Occasionally, a small bump remains over the site of the fracture. It is extremely rare for this bump to cause any pain or affect the function of the shoulder.

Q. When will I be able to play sports again?

A. Many factors are involved in determining when it is safe to return to sports activities after a clavicle fracture. In helping you to make a decision, your doctor will consider your age, how severe the fracture is, the amount of healing, and the type of sport that you will be playing.

This information is not a substitute for medical treatment.

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STEPS TO TAKE FOR CLAVICLE FRACTURES
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Abstract: The bones that reach from the middle of your chest to the shoulders form the struts that make up the front of the shoulder. They can be broken when they are overstressed.

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Q. What is a fracture of the clavicle?

A. The clavicle (or collar bone) connects the breastplate (sternum) to the shoulder blade (scapula). It is the most commonly broken (fractured) bone in the body. Fractures may occur in sports activities, falls, or other accidents.

Q. What should I do if I think my collar bone is broken?

A. It is best to seek medical attention as soon as possible. Before you go to an emergency department or urgent care facility, the arm should be supported by holding it close to the body, or by using a sling. Over-the-counter pain medication such as acetaminophen or ibuprofen can be used to help relieve pain. Ice can also help to reduce pain and swelling, but ice should be used for only 15 to 20 minutes at a time. You must be careful not to freeze the skin. If the injury causes shortness of breath or difficulty swallowing, you should seek immediate medical attention.

Q. How are clavicle fractures treated?

A. An x-ray is usually needed to confirm that there is a fracture. Nearly all fractures can be successfully treated with immobilization using either a sling or a special brace called a "figure-of-eight" splint. The sling or splint should be worn until there is no discomfort during normal use of the arm. As the pain in the clavicle subsides, you should begin gentle motion of the shoulder. Your doctor may show you some exercises or send you to a physical therapist for instructions.

Usually, clavicle fractures heal in 4 to 5 weeks in children, 6 to 8 weeks in adolescents, and 10 to 12 weeks in adults. Nearly all clavicle fractures will heal without surgery.

Q. How will I know when my fracture is healed?

A. Having full motion of the shoulder and experiencing no pain when pressing on the fracture site are two good signs that the fracture has healed. Your doctor may want you to get an x-ray to confirm that the bone is completely healed.

Q. What if my fracture does not heal?

A. If the fracture does not heal, an operation may be necessary. Many factors determine whether a clavicle fracture will need surgery, so you should discuss the options with your doctor.

Q. What result can be expected once the fracture heals?

A. Most patients will have full shoulder motion and can return to all activities without limitations. Occasionally, a small bump remains over the site of the fracture. It is extremely rare for this bump to cause any pain or affect the function of the shoulder.

Q. When will I be able to play sports again?

A. Many factors are involved in determining when it is safe to return to sports activities after a clavicle fracture. In helping you to make a decision, your doctor will consider your age, how severe the fracture is, the amount of healing, and the type of sport that you will be playing.

Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

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STEPS TO TAKE FOR DENTAL INJURIES
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Abstract: Many active patients may experience dental (tooth and jaw) injury while participating in contact sports or other activities. Injuries can range from minor to severe, so it is important to be aware of the kinds of injuries and what to expect in treating them. Although activities are never risk-free, patients and their doctors can take steps to reduce-and, more important, to prevent-injury.

Q. What should I do if I think I injured my tooth while playing sports?

A. Have an athletic trainer or team physician examine your teeth and mouth before returning to play. Some tooth injuries can be serious, and those injuries will require you to see a dentist immediately.

Q. If a tooth is knocked out, what should I do?

A. First, find the tooth. If you can't find it, don't forget to look for it in your clothes and on the ground where the injury took place. You can even have your opponents check their clothes for the missing tooth if they collided with you.

Second, after finding the tooth, do not handle it by the root. Hold the tooth only by the part that you can see when it is in the mouth: the hard enamel surface or "crown." Do not scrub the tooth. If it is dirty, gently rinse it with clean water.

Third, have an athletic trainer or team physician examine your mouth for other injuries and, if possible, place the tooth back into socket. If help is not possible, seek immediate attention at your local dentist or emergency room. Transport the tooth in sterile saline (not contact lens solution), milk, or, as a last resort, tucked in your cheek. If the tooth is out of the socket for more than a couple hours, it has a low chance of surviving.

Q. Should "baby" or first teeth be put back in if they get knocked out?

A. No. Baby teeth should never be reimplanted.

Q. Should I be worried about a loose tooth?

A. Yes. Loose teeth can be caused from simple loosening of the ligaments holding the tooth into the socket. But, occasionally, loosening can be caused by a fracture (break) through the tooth root or the bones supporting the teeth. You should see a dentist, who will have x-rays taken to determine the cause.

Q. How can I best prevent injuries to my teeth?

A. Mouth guards (figure 1) can help avoid injuries. Many types of mouth guards are available for athletes and other active patients. The most common ones are off-the-shelf models, which are the cheapest and easiest to find but, unfortunately, do not provide the best protection. The mouth guards that offer the most protection are custom-made models fashioned by dentists. This type is formed to match your teeth and provides the best fit. Custom mouth guards are more expensive, but they are worth it to protect your teeth and avoid large dental costs and pain from an injury.

Q. Which sports usually require mouth guards?

A. Mouth guards should be worn in any sport or activity in which one might expect a dental injury. The American Dental Association recommends mouth guards for many common sports, including football, basketball, boxing, field hockey, ice hockey, lacrosse, volleyball, water polo, wrestling, racquetball, and skateboarding.
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Remember: This information is not intended as a substitute for medical treatment. Please consult your physician if you have medical concerns.

This information is not a substitute for medical treatment.

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STRONGER SHOULDERS FOR SWIMMERS
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Abstract: Strong shoulders are essential for competitive swimmers, who make as many as 1 million shoulder rotations per week while training. It's no surprise that shoulder pain is common, but four simple exercises can help you prevent much of the discomfort. Please check with your doctor before beginning these exercises if you are currently injured.

These exercises (figures 1 through 4) should be done after swimming or in a separate session. Doing them just before swim training may actually increase your risk of injury by stressing fatigued muscles while swimming.

Total-body conditioning, muscle strength, and endurance are essential for success in competitive swimming. Good core strength, a sleek position in the water, and strong shoulders should lead to faster times and fewer injuries. Be sure to discuss any questions or concerns about training with your coach or team doctor.

Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

© 2021, by The McGraw-Hill Companies, Inc. Permission to photocopy is granted for educational purposes.
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This information is not a substitute for medical treatment.

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TREATING AND AVOIDING HERPES AND TINEA INFECTIONS IN CONTACT SPORTS
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Abstract: Sports that require skin-to-skin contact between competitors, such as wrestling, create environments where infections can spread. Skin screening checks are made before any wrestling competition, but this usually doesn't happen with other sports. Two of the most common skin infections are herpes gladiatorum (caused by the same virus that causes cold sores) and tinea gladiatorum, also known as ringworm (caused by a fungus). These skin infections can spread rapidly among teammates, coaches, and opponents, so it is very important to treat the infection as soon as it is discovered. Athletes who have active skin infections can be disqualified from competition and withheld from practice.

Q. How do I know it's not just an ordinary rash?

A. Herpes rash usually begins with tingling, burning, or itching at the infection site. This pain is a clue that it may be serious. Scattered clusters of tiny, red, blister-like lesions appear on the face, neck, arms, underarms, back, or chest (figure 1). The blisters are filled with clear fluid, but the tops may scrape off on the mat or clothing. The rash usually develops 2 to 5 days after exposure to another infected person. You may also have a fever or headache and feel very tired or not feel like eating.
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Tinea (ringworm) appears as round or oval rough patches that have red or raised edges (figure 2). Wrestlers usually get them on the head, neck, arms, and upper back or chest. Sometimes they look like acne, impetigo (a bacterial infection), or early herpes rash.
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Q. What should I do if I notice a skin outbreak that might be herpes or tinea?

A. Tell your coach or team doctor immediately! The sooner you begin treatment with an antiviral or antifungal cream or pill prescribed by your doctor, the sooner you can return to play. Early recognition will help prevent further spread. Having one person miss practice is far better than having an entire team disqualified from an important meet.

Q. How can I avoid catching a skin disease from another player?

A. A thorough shower with soap and hot water as soon as possible after every practice, meet, or tournament is the best defense. Wash athletic clothing in hot water after every use. Wrestlers should wear headgear to protect the scalp, and all athletes should shampoo thoroughly after every session. Even though these organisms don't survive long on dry surfaces, wrestling mats should be cleaned with disinfectant at least once a day.

Q. Will I be disqualified from play?

A. If you have a herpes rash that is oozing, yes. National Collegiate Athletic Association (NCAA) rules state that simply covering the rash will not allow you to compete. High school rules state that you must wait 48 hours after the last new blister forms, and all blisters must be dry and scabbed over with a firm crust before you can compete. (A doctor will decide this.) You must also be taking oral antiviral medicine for at least 5 days before and at the time of the meet or tournament.

If you have tinea, and you have only one spot, you may be allowed to participate if the rash is in an area that can be securely covered. The bandage must not come loose during competition. If the spot cannot be covered, or if you have more than one lesion, you must wait 72 hours after the last spot forms, and you must be using antifungal medicine. Again, your doctor decides on when you may participate.

Q. I had a rash and it went away, but now it keeps coming back. Can I prevent it?

A. A rash that comes back in the same place may be caused by a virus or fungus. The skin may heal, but the organisms stay in your system. New outbreaks happen when the skin is weakened. Ask your doctor if you need medication to get rid of it completely or to prevent outbreaks during the season. Cold sores can also be treated to stop them from coming back. A herpes infection will require taking pills, but your doctor may decide to treat a tinea infection with either pills or an ointment.

Teamwork with every player, coach, athletic trainer, and team doctor involved will help you defeat the spread of skin infections.

This information is not a substitute for medical treatment.

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WEIGHT LOSS SUCCESS:
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Abstract: Deciding to start a new diet and exercise plan can seem overwhelming if you try to change everything at once. By starting slowly and making gradual changes, you can build on your successes to reach your goals.

Q. Where do I start?

A. Begin by setting clear goals. Setting goals can be broken down into smaller, easier steps. The best goals are attainable (you honestly feel, "Yes, I can do that"), measurable (how often, how far, how long), and leave a little "wiggle room" so you don't feel too confined. Choose foods you enjoy so you'll want to stick to your diet, and pick activities you like to do.

First, you'll need to set your weekly goals. Some examples of weekly goals are:
  • Walk 10 to 15 minutes a day at lunchtime, 5 days a week.
  • Walk up one flight of stairs, then take the elevator the rest of the way, every day at work.
  • Read food package labels and be careful about portion sizes.
Then look at your goals and see if you need to do anything else this week to help meet these goals. A typical weekly "to do" list might be:
  • Buy new walking shoes on Saturday.
  • Buy a pocket calendar to record my progress each day.
  • Use a set of dishes that has small plates and small bowls, so servings seem larger.
Next, choose an appropriate reward and make a firm commitment to yourself that you will do what it takes to achieve the reward. An example would be "If I walk up three extra flights of stairs every day this week, I can go to a movie on Friday night. " You might want to tell a trusted friend about the goal and have him or her hold you to it. Avoid rewards that sabotage your progress, like a dinner out.

Q. What if I don't feel like sticking with the program?

A. It's important to set realistic goals and make a firm commitment to work toward your goals every day. You will naturally feel more motivated on some days, less on others. Avoiding the temptation to give in to excuses will make you successful in the long run. For extra motivation:
  • Picture yourself enjoying the reward as you are doing the activity. Imagine how good you will feel when you know you have met your goal.
  • Keep a simple record of progress and setbacks. Focus on all the positive changes you have made. Do you see a pattern? Would making a change in your routine help you get past a stumbling block?
  • Plan alternatives ahead of time. Whenever possible, eat meals at home or bring them with you. If it's raining, walk at the shopping mall. If you work through lunch, walk off the tension after work.
  • Use stick-on notes to post inspirational messages on the refrigerator door handle, for example, "Nothing tastes as good as being thin feels."
  • Don't let minor setbacks stop you cold. Plan to resume your healthy eating habits at the next meal and resume activity if you miss a day. Give yourself permission to make a new start tomorrow.
  • Ask a spouse, friend, coworker, or child to join you! Having a buddy will help you both get moving when you don't feel like it, and you'll have someone to share your goals and rewards with.
Q. What's the next step?

A. Pretty soon, your weekly goals will seem like part of your lifestyle. That's when it's time to make your goal just a little bit harder, so your program remains energizing, productive, and enjoyable.
  • Add a little distance when walking 10 to 15 minutes is no longer challenging. A pedometer (available at department or sporting goods stores) is an easy way to keep track of how many steps you take and how far you go.
  • If you can't walk up a whole flight of stairs, walk up half a flight and down again. Add a few more steps each time until you are able to do a whole flight. Then make the goal a flight plus two steps and down again. How many can you do? Enjoy the challenge!
  • Weight loss isn't the only marker of success, but consistently weighing yourself once a week helps you know if you are making enough changes to meet your goals. If you begin to regain weight, check your food portion sizes. You may not notice a gradual increase until your weight loss stops.
Q. What about over the long term?

A. Meeting your weekly goals will help you reach your longer-term goals. Midrange goals (things you can do in 4 to 6 months) will help you stay on track. Examples of midrange goals are:
  • Walk 30 to 60 minutes a day .
  • Have more energy to play with the grandchildren.
  • Learn to cook great-tasting healthy meals and snacks.
Then, set long-range goals—something you can do in 6 months to a year. Some examples of long-range goals are:
  • Buy a smaller belt. Buy stylish clothes that fit and feel comfortable!
  • Take a vacation that includes hiking or biking through beautiful terrain.
  • Lose 10 pounds before the next class reunion.
By using small goals as building blocks to larger goals, lifestyle changes become manageable. You can expect to lose about 10% of your initial body weight in the first 6 months. Even if you don't lose much weight, the health benefits of a more active lifestyle are worth the effort. When you look back a year from now, you'll be amazed how far you've come!

FAST FACTS
1. Set realistic goals.
2. Make gradual changes and build on your successes.
3. Choose rewards that will not sabotage your progress.
4. Don't let a minor setback stop you. Begin again tomorrow.



Remember: This information is not intended as a substitute for medical treatment. Consult a physician before beginning a diet or exercise program.

This information is not a substitute for medical treatment.

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WHEN TO RETURN TO PLAY AFTER AN ANKLE SPRAIN
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Abstract: An ankle sprain may not seem like a big deal, but returning to play without proper rehabilitation will increase your chances of injuring your ankle again—maybe even more seriously. Taking the time to fully recover will actually put you back in the game faster. The checklist on the other side of this page will take the guesswork out of knowing when you are ready to return to play safely.

After the diagnosis of ankle sprain has been confirmed by your physician, your rehabilitation will be done in four phases. Phase 1 requires patience and rest. In phase 2 you can begin to move the ankle more and gradually build up the muscles in your lower leg. Phase 3 concentrates on regaining your balance and overall strength. When you reach phase 4, you will be almost back to your preinjury level.

It is important to follow your doctor's or physical therapist's instructions and do the prescribed exercises correctly. Doing too much, too soon can cause more damage. Not doing enough will also lengthen the time it takes to recover. If moving on to the next phase causes pain, you may have to go back to an earlier phase. Ask your doctor if you have questions or concerns about how fast you are progressing.

This chart (figure 1) will help you figure out when you can return to play. By marking the number of days since injury as you complete each phase of rehabilitation, you can make a rough estimate of when you will be ready to return to play. By knowing the number of days at the completion of phase 4, you can find your actual return-to-play date.
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Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

For more on specific exercise for ankle rehabilitation see the article "Rehabilitating Ankle Sprains" by Richard Sandor, MD and Scott Brone, PT, CSCS

Ankle Rehabilitation Checklist
Note: All items on this list should be checked before returning to play.

Name: __________________________ Date of Injury: ________________

Phase 1: Ready to Start Rehabilitation [checkbox] A. I am wearing the protective tape, brace, or wrap that my doctor prescribed. [checkbox] B. I can stand on the injured leg without pain. [checkbox] C. Pain and swelling have gone down.

Phase 1 complete. Date __________________ Days after injury __________

Phase 2: Beginning Level [checkbox] A. My ankle does not feel too stiff to draw the letters of the alphabet with my toes. [checkbox] B. Strength in my calf and ankle muscles is back to normal. [checkbox] C. I know when I need to wear an ankle brace or taping and how to apply it. [checkbox] D. Neither low-impact aerobic exercise nor weight lifting causes pain or swelling.

Phase 2 complete. Date __________________ Days after injury __________

Phase 3: Intermediate Level [checkbox] A. Balance when standing on the injured leg is as good as the uninjured leg. [checkbox] B. Increasing my aerobic exercise or weight lifting does not cause pain or swelling. [checkbox] C. My general strength is back to preinjury level.

Phase 3 complete. Date __________________ Days after injury __________

Phase 4. Advanced Level [checkbox] A. My return-to-running program has been completed without pain or limitation. [checkbox] B. I can do sport-specific movements and skills without pain or limitation. [checkbox] C. My coach or physical education teacher knows about my special needs for gradual return to play and my long-term needs to prevent future injury.

Phase 4 complete. Date __________________ Days after injury __________

Cleared for full participation. Date __________________ by Dr ______________________________________ (signature)



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This information is not a substitute for medical treatment.

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YOUR EXERCISE TREATMENT FOR LUNG DISEASE
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Abstract: Exercise is a vital part of your treatment for lung disease. By following a regular training program, you will increase your endurance and become stronger and better able to perform the activities of daily life. Shopping, cleaning, and just moving about will become easier and more comfortable. You will be less troubled by shortness of breath, your spirits will lift, and you'll sleep better. In short, you'll enjoy life more. Exercise also has general health benefits, such as protection against heart disease, high blood pressure, high cholesterol, and excess weight gain.

Before You Start
Before prescribing a program, your doctor will probably want to determine your capacity for exercise by closely observing you on a treadmill or stationary exercise cycle. He or she will watch your heart, lungs, and blood oxygen levels carefully to establish a safe exercise level for you. You will very likely start the program itself under supervision, so you will learn how to work out safely and efficiently.

The best exercises are aerobic activities that get your heart pumping faster: Walking or using the stationary exercise cycle are ideal because they work the largest muscles in the body. Swimming (or calisthenics in the water), aerobic machines like a stairclimber, and arm exercises can also be helpful. You and your doctor should work together to determine what activities are most comfortable and effective for you.

It is important that the exercise program be tailored closely to your needs. If you require supplementary oxygen, it will be available. Medications like inhalers to help open your airways can be used if necessary.
Getting Into the Program
For maximum benefits, it's best to walk or pedal at a rate that raises your heart rate to 60% to 80% of its maximum (a number determined by testing), for 20 to 30 minutes, 3 days a week. It may take weeks or months to get there, or you may never reach this level at all.

But that's all right—the main goal is to improve your ability to exercise, and any improvement is beneficial. Most lung patients make substantial gains: In 6 weeks, it is not uncommon to see a 70% to 80% improvement over your initial ability.

Here are some guidelines to follow as you start to exercise:

  • Start slowly: If you can only walk (or cycle) for 2 minutes at first, do that. There's no rush. Find a pace that's right for you, and improvements will come. Your doctor will help you set appropriate personal goals.
  • Be consistent: Even modest workouts will bring noticeable benefits—if you keep them up conscientiously. But if you exercise fewer than three times a week, it is unlikely to help very much.
  • Break up sessions: If you can only walk for 5 minutes at a time, schedule two sessions (no more than that) on your exercise days.


Big Bonus: Less Worry
Shortness of breath (dyspnea) is a problem for almost everyone who has lung disease. You're bound to experience it when you exercise. Keep in mind that if you're following a program designed for you, dyspnea isn't dangerous. One of the big benefits of exercise will be your growing ability to tolerate some shortness of breath without anxiety.

Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

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YOUR GUIDE TO EXERCISING WITH ASTHMA
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Abstract: Years ago, everyone thought strenuous physical activity was dangerous if you had asthma, but now we know better. Exercise is not only safe if done properly, it's an integral part of treatment. Regular workouts will make you stronger and more energetic and reduce your risk of heart disease, diabetes, and other health problems. What's more, your asthma is likely to improve. Studies have shown that physically fit people have fewer attacks, need less medication, and lose less time from work or school.

Controlling Symptoms
Chronic asthma control. To make sure asthma doesn't interfere with your ability to exercise, keep it under control. If your doctor has prescribed medications like inhaled corticosteroids for daily use, use them faithfully. Take the necessary steps to control allergies. Visit the doctor on a regular schedule, follow his or her instructions about monitoring your condition at home (using peak flow testing, for example), and be sure to report any problems promptly.

Exercise-induced asthma. Even if your asthma is well-controlled, you may develop coughing, shortness of breath, chest pain, or nausea if you exercise without taking precautions. But several simple steps can prevent this exercise-induced asthma:

  • Warm up with 10 minutes of stretching or light activity (like walking) before you work out more strenuously.
  • Avoid exercising in cold, dry air. You'll probably have less trouble in the winter if you work out indoors. If you are active outside, cover your mouth and nose with a scarf or breathing mask to warm the air you breathe.
  • If your doctor recommends it, prepare for exercise with two puffs of a beta-agonist inhaler 15 minutes before you exercise. This will keep your airways open and prevent symptoms.
  • After exercise, cool down gradually with 10 to 15 minutes of lighter activity, like walking or stretching.
The Exercise Plan
Exercise specifics. For full benefit, try to exercise for 20 to 30 minutes, four or five times a week, strenuously enough to raise your heart rate to 60% to 85% of maximum. (Your maximum heart rate is roughly equal to 220 minus your age.)

Choose an aerobic activity you find enjoyable; jogging, biking, and swimming are all good. If steady activities like these provoke symptoms despite precautions, substitute sports that involve short bursts of intense activity, like tennis, volleyball, or half-court basketball.

Take it easy. If you develop asthma symptoms during exercise, don't try to push your way through them. Stop what you're doing and take two more puffs from your beta-agonist inhaler. If this doesn't bring relief within 15 to 20 minutes, seek medical help.

For Trouble-Free Workouts
  • Don't exercise on days when your symptoms are bothersome, such as when you're wheezing or coughing.
  • Avoid areas where air pollution is high (like near a highway). On days when pollution is worse than normal or the pollen count is particularly high, exercise indoors or not at all.
  • Vary your routine to keep things interesting. Go in-line skating one day, use an exercise bike another.
  • Join with others. Exercise is more fun—and harder to skip—when it's a social event.


Remember: This information is not intended as a substitute for medical treatment. Before starting an exercise program, consult a physician.

This information is not a substitute for medical treatment.

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