Exercise with Care – Fitness is not Risk-Free

Early one morning you're out jogging along your favorite path, getting the heartbeat going a little faster and feeling good, when suddenly, your ankle twists and your leg gives way. You groan in pain and mutter something about that hole you stepped in not being there yesterday.

What next?

Should you walk on that sore ankle? Should you rush to a doctor, or treat the injury yourself? Should you apply heat or cold to the injury? Should you take something for the pain? Which medications are safe? Which are helpful?

First, just stop, advises Gabe Mirkin, M.D. According to this author of several books on physical fitness and sports medicine, pain is a way your body talks to you. Stopping whatever you are doing prevents further damage and allows you to assess the situation.

Robert Nirschl, M.D., assistant professor of orthopedics at Georgetown University, in Washington, D.C., offers this advice: "Look for signs of inflammation such as swelling, redness, tenderness, fever--generalized or local--or pain that persists with or without continued activity." Any of these signs--or others, such as decreased mobility or weight-bearing ability of the affected limb, or a "popping" or "snapping" sound--indicates the need for immediate treatment.

Mirkin advocates the "RICE"
program for a traumatic injury:

Rest-Ice-Compression-Elevation. Stop the activity, cool the injured area with ice or a coldpack, wrap an elastic bandage around it, and elevate the injury above the head to reduce swelling.

There are exceptions to the RICE regimen. Ice or coldpacks should not be used on people who have problems with arteriosclerosis (hardening of the arteries), or on an extremity that may become gangrenous, such as a foot injury in someone with poor blood circulation.

But aside from those exceptions, the RICE treatment should begin immediately after an injury occurs to reduce swelling to the area and promote healing.

Writing in The Sports Medicine Book, Mirkin and Hoffman advise consulting a physician after beginning RICE if one or more of the following conditions exists: traumatic injury to a joint; severe pain; pain in a joint or bone that persists for more than two weeks; infection, signaled by pus, red streaks, swollen lymph nodes, or fever; or injury that you feel should be checked.

As Mirkin and Hoffman point out, these are only guidelines. Your own intuition is often better and more relevant to the particular situation than anything in a book or magazine. When in doubt, have it checked out. It is far better to consult a physician needlessly than to hesitate and suffer permanent injury.

In general, cold is highly recommended for treating sports injuries. By constricting the blood vessels, cold decreases swelling by inhibiting blood flow to the injured area. With decreased swelling there is less inflammation, and more rapid healing.

Heat has the reverse effect and therefore should be avoided in case of traumatic injury. The hot bath that feels "oh so good" relaxes the walls of the blood vessels, increasing the flow of blood and fluid to the injured area, making the inflammation worse. "If there is swelling," cautions Nirschl, "no heat, no warmth, until the injury is healed."

Over-the-counter pain relievers for minor sports injuries get a rather mixed review. Vincent Karusaitis, M.D., a medical review officer in the Food and Drug Administration's Center for Drug Evaluation and Research, explains that aspirin and related drugs are helpful for short-term relief for minor sports injuries.

"Aspirin and aspirin-like compounds reduce temperature and inflammation, and relieve pain," says Karusaitis. "Some people, however, are allergic to aspirin, so they can take an analgesic that doesn't contain aspirin, such as acetaminophen, to reduce the pain and fever, though it has no anti-inflammatory action."

Lee Geismar, a chemist with FDA's division of over-the-counter drug evaluation, voiced concern over any medication's potential to "cover up" pain and allow people to ignore a serious injury. Geismar explains, "That's why the label says '10 days.' After 10 days, if you still feel pain, it's not a minor injury. It might be serious, and should be seen by a doctor."

Mirkin went even further in cautioning injured athletes about using pain relievers at all. "They stop the pain," he explained, "but the prostaglandins that cause the pain are part of the healing process. There have been studies indicating that blocking prostaglandins may inhibit healing. . . . You're better off taking nothing." He recommends rest and keeping in shape during recovery with a sport that stresses uninjured parts of the body.

A warning note: Aspirin--even children's aspirin--should not be given to children and teenagers suffering from or recovering from flu, chicken pox, or other viral illness. Use of aspirin in such cases has been associated with Reye syndrome, a rare but serious--and sometimes fatal--condition.

Experts are even less enthusiastic about topical treatments such as creams, ointments and liniments in treating injured muscles. FDA categorizes these treatments as "topical counterirritants": "externally applied substances that cause irritation or mild inflammation of the skin for the purpose of relieving pain in muscle, joints, or viscera distal to the site of application." In other words, the burning of your skin takes your mind off your aching muscles. As Geismar puts it, "It's like pinching your big toe so that you forget about your headache."

There is no scientific proof that topical treatments, even those that contain aspirin, ease aching muscles, though the rubbing or massaging of the area can itself be soothing. Since the medications often contain irritants, such as menthol, the labels caution against bandaging the applied area tightly or for too long.

If your sports injury is a blister, be sure to keep the top layer of skin in place for faster, less painful healing and to lessen the chance of infection. The Complete Sports Medicine Book for Women, by Mirkin and Mona Shangold, M.D., recommends removing the fluid by making a small hole at the edge of the blister with a sterilized needle, gently pressing the fluid out, applying antiseptic ointment, and bandaging the area. If redness or pus develops, consult a doctor.

Whatever treatment you choose, fitness experts are unanimous in agreeing that the injured area must be rested until the pain is gone, then gradually rehabilitated back to normal. "Unless the area of the injury is properly rehabilitated," cautions Nirschl, "you are at high risk for the same problem recurring."

With foresight, planning and care, you can prevent most sports injuries and treat some yourself. Sooner than you think, you can be out jogging on that favorite path once again, cautiously avoiding that pesky hole.

Getting Off On The Right Foot

"To thine own self be true," Shakespeare wrote, and a long, hard look at yourself is the first recommendation of experts in preventing athletic injuries. Determining realistic goals, choosing appropriate activities, starting out slowly, progressing gradually, and taking the time for proper warm-ups and cool-downs can prevent a lot of sports injuries. So will a few short and easy preventive measures.

"Before you start any exercise, sports, or fitness program, you need to educate yourself," advises Neil MacDonald, director of the Sports Medicine Center in Baltimore, "and the first thing to educate yourself about is yourself. A person has to realize that he's 35 years old and 20 pounds overweight, not a high-school athlete."

After having a complete physical examination, including a stress test and a family history, you can plan a fitness program that is suited to your individual needs and preferences. Anyone can benefit from a thorough check-up, but certainly if you are over 40 and have a history of heart disease or problems with overweight, smoking or drinking, a complete evaluation is essential before beginning a regimen of vigorous exercise. In addition, your attending physician might have some good ideas on how best to carry out your fitness program.

Before you can accomplish, or even begin, a fitness program, experts say, you must choose realistic goals: You must identify what you want to accomplish and tailor your exercise program to those long-range aims. According to Robert Nirschl, M.D., assistant professor of clinical orthopedics at Georgetown University and medical director of the Virginia Sports Medicine Institute in Arlington, "Don't take up a sport to get into shape; get into shape to take up a sport. A 50-pound overweight man with an arthritic knee should get rid of the fat and strengthen his muscles to protect that weak knee before he takes up weekend racquetball, football or jogging."

Once you have set reasonable goals, you'll avoid a lot of injuries by starting out modestly and progressing slowly. "Going too far too fast is self-defeating," explains Nirschl. "You may get some short-term benefits, but you can't sustain that kind of performance, [and you might] get an injury; your whole fitness program ends in three days."

So, "you have to walk before you can run" is a good motto, both figuratively and literally. Indeed, MacDonald recommends walking rather than jogging to a lot of people these days, and even then he has them work up slowly. Even 10 minutes of vigorous exercise per day can help you maintain your health, though you can improve your condition substantially by working up to 30 minutes every other day.

MacDonald points out that non-athletes achieve maximum cardiovascular benefits from exercising vigorously for at least 30 minutes three to four times a week. Working out every day increases the "risk-benefit" ratio: The risk of injury may outweigh the fitness benefit gained.

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Gabe Mirkin, M.D., advocates 48-hour recovery periods between strenuous workouts, and stopping activity if there is discomfort. An "alternate day" exercise program--allowing the body 48 hours to recover from workouts--can be accomplished in various ways, explains the fitness author and columnist. A young, athletic person might work out "hard/easy"--push himself or herself hard one day, easy the next. An older person might alternate sports, so as not to constantly stress the same parts of the body; someone over 50 might work out every other day, and just rest or do some gentle stretching on alternate days.

Not only should your entire fitness program start out slowly and progress gradually, but each day's regimen should include a warm-up that gently brings your body up to a level where it can do vigorous exercise, and then a cool-down to return to a normal activity level. A few minutes of walking, for example, might be a good way to begin and end each session of jogging. Stretching after warm-ups and cool-downs is also generally recommended.

Though most of us are busy and want to accomplish a lot in a short time, warm-ups, cool-downs, and stretching add only minutes to the regimen. In fact, if you are strapped for time, fitness experts recommend reducing the amount of time spent on vigorous exercise, rather than cutting out warm-ups, cool-downs, or stretching. They not only help prevent injuries, but help the body exercise and function more efficiently in the long run.

Michael McGinnis, M.D., deputy assistant secretary for the U.S. Office of Disease Prevention and Health Promotion, suggests some general measures to help prevent sports injuries: Wear properly fitting shoes. Walk or run on familiar, well-known routes. Drink plenty of fluids. Don't run in the heat of the day. Don't run at night or twilight, or, if you must, wear reflectors and light-colored clothing.

Also, wear clothing appropriate to the weather. Simply wearing more or fewer layers of clothing can prevent hypothermia--the extreme loss of body heat--or hyperthermia--too much body heat.

Wearing clothing with no seams or soft seams can prevent chafing and irritation of the skin. Wearing properly fitting shoes and the right thickness of socks can also prevent blisters, another common sports injury.

FDA / FDA Consumer