Repetitive strain injury

Training smart is more than building the most muscle in the least time. It's eating right, hydrating properly and getting enough rest. Most important, and most often overlooked, training smart means protecting yourself from injuries that can compromise your ability to work out or sideline you completely.

You're probably careful to avoid acute injuries at the gym--dropping weights on your foot, walking into mirrors, etc.--but you may be unaware of the potential for chronic injuries. Bothered by a sore shoulder that's gradually deteriorating or a weak knee that gets a little better only to get a little worse? Chronic injuries tend to develop slowly. This makes them harder to anticipate, but it also makes them easier to prevent. With a little preparation, you can significantly reduce their likelihood as well as their severity.

REPETITIVE RISK

Chronic injuries typically develop from overuse and recurrence. The initial stress is insufficient to cause detectable harm, but over time the damage builds to the point of pain and discomfort. Overuse injuries go by a number of names, including repetitive stress injury, repetitive stress syndrome or cumulative trauma disorder.

"Those are all terms for overload injuries to tissue, whether it's overload to muscle or overload to bone or some connective tissue around the muscle or joint," says Edward R. Laskowski, M.D., co-director of the Mayo Clinic Sports Medicine Center in Rochester, Minn. Such problems are a common hazard of the workplace, especially among typists, factory workers and others forced to repeat the same task for hours on end. Carpal tunnel syndrome is the most familiar example.

In their simplest form, repetitive stress injuries in the gym are caused by a drastic increase in exercise intensity, duration or frequency. This is often seen in weekend warriors or in newbies just starting a sport or training regimen. Despite good intentions, they risk eventually getting up close and personal with an ice bag, an orthopedist or both. When beginning a new workout, follow these guidelines:

* Start slow and gradually add extra weight, reps or time.

* Never increase intensity or duration more than 10 percent from one week to the next.

* Allow at least a 24-hour break between activities involving the same muscle groups.

* Depending on the intensity, up to 72 hours' rest may be needed.

OVERUSED AND ABUSED

As many as half of all exercise injuries result from overuse, reports Clinics in Medical Science. But it's not always an overly ambitious workout that gets you into trouble. The difference between pushing yourself and pushing yourself too far may lie in other factors, such as technique, muscle imbalance, anatomical factors, or equipment.

* "Technique is so key--I can't overemphasize it," Laskowski says. "One of the most common reasons for [injury] in the gym is faulty technique. That's when you get a buildup of microtrauma and strain over time, which can lead to a problem. If you're doing moves the right way, that's going to alleviate most of the problem."

* Imbalance occurs in joints when opposing muscles--the quads and hamstrings for the knee, the triceps and biceps for the elbow--aren't developed evenly. When one group gets trained significantly more than its antagonist, the resulting imbalance can cause undue joint strain.

* The same is true of a muscle that is too tight or too lax. Either condition changes the mechanics of the joint and the way the muscles move it. Tight muscles are more prevalent, underscoring the importance of warming up, cooling down and stretching daily.

* Outerwear has a big impact on inner wear and tear. The right running shoe, for example, provides support for flat feet or high arches, while the wrong shoe only exacerbates existing problems.

To minimize injuries, check out "Avoiding the Danger Zone" on page 82 (also read Fast Track's "Perfect Form" in every issue of MEN'S FITNESS). If you're still uncertain--or if you need special instruction or equipment due to your body's proportions or alignment--consider hiring a certified personal trainer to individualize your workout program.

GET SOME RELIEF

Be sure to warm up, progress slowly and use strict form. You can avoid potential trouble in the early stages by paying close attention to any signs of fatigue or distress. If you detect an unfamiliar ache or pain, rest is the best cure. Ice and anti-inflammatory medications (e.g., ibuprofen) will reduce swelling and pain.

If an injury is unresponsive or lingers, visit a sports-medicine specialist. "If the problem persists more than two months, go to an orthopedic doctor and get checked out," says Marc J. Friedman, M.D., a founding partner of the Southern California Orthopedic Institute in Van Nuys, Calif. "You may want to get an MRI to make sure you don't have a full-thickness tear."

A minor tear will heal over time given adequate rest, but a full tear will only get worse, causing a decrease in performance and degradation of the injured tendon. "More often than not, an injury can be addressed nonoperatively," says Laskowski. "But if the tissue's been compromised to the point that you've torn your rotator cuff or something like that, then surgery may be necessary."

Assuming surgery is not required, your physician will likely prescribe some combination of rest, ice, drugs and therapy. Medication normally consists of anti-inflammatories but may include steroids, such as a cortisone injection. Therapy generally entails exercises for flexibility as well as muscle strength and balance, and often involves ultrasound or similar modalities. Physical therapists may recommend elbow or knee braces, shoe orthotics, heel lifts or other devices to speed recovery and correct mechanical deficiencies.

AN OUNCE OF PREVENTION

A little common sense goes a long way toward reining in repetitive strain. If your muscles are tired or sore, chances are your body needs rest. A short break or a decrease in training volume can help fend off many injuries. If problems persist, seek the appropriate medical attention.

Laskowski believes that the foundation for injury prevention happens in the gym, not on the court or playing field. "Take the time beforehand to do the appropriate flexibility and strength-training exercises specific to your activity, rather than using your sport to get you in shape," he advises. "In other words, you shouldn't play your sport to be in shape; you should be in shape to play your sport."

AVOIDING THE DANGER ZONE

If you want to train without injury, you have to be methodical and attentive. "Be intelligent; be scientific," urges Van Nuys, Calif., orthopedist Marc J. Friedman, M.D. "If it hurts every time you're on a machine, guess what. You're using the machine wrong. Either you're doing too many reps, or adding too much weight, or the angle of the treadmill is not right, or your body position is off--something is wrong. So you've got to analyze what's causing that."

If a particular exercise or movement causes pain, stop doing it. Find out what the problem is so you can continue the activity minus the pain. You may have to alter your training slightly or find a different exercise to work the same muscle group, but it's worth the effort to be able to train pain-free.

The following exercises can cause problems for some individuals. If you're one of them, try the suggested modification.

1. Bench Press A common bench-press mistake is lowering the bar all the way to the chest. A lot depends on your chest size and the length of your arms, but as a general rule, you should stop when your elbows reach the level of the bench. Going any farther puts too much stress on your shoulder joint.

2. Cable Flye By itself, elbow movement away from the body puts a lot of stress on the shoulder, so avoid dramatic jumps in reps or weight. Doing flyes with too much weight or allowing your hands to pass behind the front of your body can cause injury to a poorly trained shoulder joint.

3. Lat Pull-Down To play it safe, perform lat pull-downs to the front. Bringing the bar behind your head places additional stress on the shoulder and cervical spine. When performing pull-downs to the front, keep your head and chest up and focus on bringing the bar to your upper chest and squeezing your shoulder blades together.

4. Overhead Press This exercise can overstress the shoulder, so if you already have shoulder problems avoid overhead presses. If you choose to perform overhead movements, keep the weights in line with your body, never behind the head, and stop when your arms reach 90 degrees in the down position.

5. Biceps Curl To protect yourself, and to work the right body part, keep your wrists rigid when doing any curling movements. Excessive movement at the wrist in either direction (flexion or extension) puts extreme pressure on the tendons that attach near the elbow. In time, tendinitis will likely develop.

6. Squat There's probably no better whole-body exercise than the squat, but it can put a lot of stress on the knees. To reduce the forces at the knee, your feet should be shoulder-width apart, toes painting straight ahead; stop when your thighs are parallel to the floor. For most people, the risks of going lower outweigh the benefits.

7. Knee Extension There are two potential causes of knee pain during knee extensions: 1) foot movement and 2) hyperextension. Rotation of the foot changes the position of the knee, leading to undue stress. Make sure your feet are painting straight up, and don't rotate during the exercise. If you experience pain at the end of the move, try stopping just short of lockout.

8. Treadmill Running puts a lot of stress on your feet, ankles, knees and back. The better treadmills absorb some of the impact, but big changes in incline can cause ankle and knee pain. Keep elevation increases to no more than a few degrees per week.

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WHERE DOES IT HURT?

Overuse injuries present themselves in different ways. Broken bones, torn tendons, ruptured muscles and the like are possible, but repetitive strain tends to show up as less severe but equally disruptive ailments, such as tendinitis, bursitis and stress fractures.

A sore, achy feeling is a common first indicator. The joint may be swollen, tender or feel hot. Discomfort usually occurs during or immediately after a particular movement, but as the condition worsens, pain may arise at any time, even when you're asleep. The severity and frequency of pain escalates as the injury progresses.

Other signs of injury include decreased strength, fatigue, tingling or numbness; loss of joint mobility; and reduced coordination. In the case of a stress fracture, pain is usually limited to the fractured area and brought on by stress or impact to that region. In some cases, sophisticated testing may be necessary for a proper diagnosis.

Tendinitis is the inflammation of the tendons, the tough, elastic bands of connective tissue that attach muscle to bone. Repetitive trauma is typically the cause.

Tendinitis of the shoulder, particularly the rotator cuff, is prevalent among swimmers and athletes who perform repeated overhead motions. "Tennis elbow" refers to tendinitis of the posterior (outside) elbow, typically caused by bending the wrist backward (think backhand shots), while "golfer's elbow" affects the anterior (inside) elbow, often as a result of bending the wrist forward (think follow-through).

Runners often experience tendinitis of the knee (when overuse causes the patella to move up and down outside its normal groove), the Achilles tendon (due to uphill or downhill running, inadequate shoes, or biomechanical errors) or the plantar fascia (caused by repetitive heel striking).

Bursitis is the inflammation of the bursae, which are fluid-filled sacs strategically positioned to reduce friction throughout the body, particularly in the joints. Bursitis is attributable to overuse, infection or arthritis.

"It's impossible to make the distinction between bursitis and tendinitis without getting an MRI or doing an arthroscopy," says orthopedist Marc J. Friedman, M.D. "Unless you can see the inflammation in the bursae and/or the damage to the tendon, you can't really tell."

Stress fractures are partial fractures, often hairline cracks in the bone, caused by repeated stress. They occur throughout the body, but are most common in the lower extremities, mainly the tibia and fibula bones of the ankle. Pain in the lower leg, especially from running, can also be attributed to shinsplints.

"You have to make a distinction between shinsplints, that is, inflammation of the muscles that attach to the inner aspect of the tibia, and an actual fracture--a little crack," says Friedman. "You probably can't see the stress fracture on an X-ray, so you have to get a bone scan. The key is that stress fractures are usually unilateral, shinsplints bilateral." (For more information, see the Prehab Workout, page 74.)

Tim Fritz is a freelance writer and certified strength and conditioning specialist in southeast Florida.

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