Why do we sleep?

Exercise, Health, Lifestyle

sleeping problems

What is sleep?

Sleep is a state of altered consciousness of the mind and body which typically lasts for several hours every night. It involves the inactivity of the nervous system, relaxation of all the muscle of the body and is considered important for optimal health.

Sleep pattern

The normal sleep pattern involves the alternating REM (rapid eye movement) and NREM (non-rapid eye movement) sleep that occurs in a 90-minute interval cycle in a typical night’s sleep.

There are four phases:

Stage 1: Light sleep – between being awake and sleeping

Stage 2: Initiating sleep, drop in the body temperature, regular heart rate and breathing.

Stage 3 and 4: The deepest form of sleep when the breathing slows down and the blood supply to all the organs increases, the repair process begin, muscles are relaxed, the blood pressure goes down, various hormones like growth hormone are released.

What is the importance of REM and NREM?

REM makes up about 25% of the night’s sleep: It first begins about 90 minutes after falling asleep. Lasts for some time and recurs about every 90 minutes. In the REM stage, the brain is more active, heart rate is raised and intense dreams can occur. At this stage, brain development occurs as the area of learning in the brain is stimulated.

Like deep NREM sleep, REM sleep also helps protein binding for growth.

During the NREM sleep, the body restores its functions of the brain, repairs and regrows tissues, promotes growth, and improves the immune system.

Benefits of sleep 

Normal Brain function and development: Sleep is essential for maintaining the normal levels of cognitive skills. ( This include speech, memory, innovative and focused thinking.)

Emotional well-being: Sleep can give you a feeling a sense of freshness, motivation and relaxation.

Physical health:

  • Sleep will help maintain hormonal balance in the body. For example, the hormones that regulate hunger and insulin regulation for blood sugar levels.
  • It is involved in the healing process of your heart and blood vessels.
  • It can support growth and development in children and teens by releasing hormones that builds muscle mass and helps the body repair.
  • It plays a role in puberty and fertility. 
  • It can improve immunity and help fight infections better.

Good physical performance levels:

  • Sleep can improve concentration, focus, awareness and general activeness of your body. 
  • It improves your ability to perform skillful activities.

How much sleep is recommended?

Age Recommended Amount of Sleep
Newborn babies about 17 to 18 hours per day
Preschool children about 11 to 12 hours per day
School children Minimum 10 hours per day
Teenagers about 9 to 10 hours a day
Adults (including the elders) about 7 to 8 hours a day

Sleep deficit 

Sleep deficiency can increase the risk for some chronic health problems.

  • Heart disease: Lack of sleep will keep the heart rate elevated leading to increased calcification (calcium deposits) in the blood vessels of the heart. There is also an increase in CRP (C-reactive protein), which is released with stress and inflammation that can lead to heart problems.
  • Obesity: Lack of sleep can interfere with appetite regulation due to imbalances in the hormones that regulate hunger. This can lead to eating at night when your body’s metabolism is low causing excessive fat storage leading to obesity.
  • Diabetes: Due to the increase in food intake and lack of rest, hormonal imbalances can affect the insulin response in the body. The metabolism of glucose is affected due to insulin resistant that can lead to type 2 Diabetes.
  • High blood pressure: With insufficient rest, the heart rate remains elevated. This raises the blood pressure which may cause hypertension.
  • Stroke or transient ischemic attack (mini-stroke):  It is related to elevated heart rate and hypertension that can lead to a reduction of blood supply to the brain leading to a stroke or mini-stroke.
  • Depression and attention-deficit hyperactivity disorder (ADHD): Due to lack of rest and interference in the brain function, lack of sleep can cause problems with thinking, mood swings, depression and hormonal imbalances that may lead to ADHD and depression.

Sleep Disorders – There can be about 81 disorders.

  • Insomnias (Sleeplessness): There can be difficulty at the beginning of sleep, maintaining sleep, abrupt waking from sleep, waking too early or poor quality sleep. This sleep difficulty can occur despite all attempts of trying hard to sleep.  This can be related to mental disorder, restless leg syndrome, sleep apnea or due to drug side-effects.
  • Sleep-related breathing disorders: Cheyne-Stokes breathing pattern is characterized by a gradual increase in the breathing followed by a gradual decrease and holding of breath for 5 to 50 seconds. This type of respiratory problem is also typically seen with other medical problems of the heart and kidney.
  • Sleep apnea: Irregular breathing pattern with disruption or episodes of breathlessness. It can be due to lack of sleep causing arterial oxygen desaturation (reduction in oxygen in the blood).
  • Hypersomnias (Narcolepsy): This involves daytime sleepiness and may be related to dysfunction in the brain due to increased lack of sleep at night or misaligned circadian rhythms (body clock).
  • Circadian rhythm sleep disorder: The “body clock” or the circadian rhythm is the 24-hour cycle that tells your body when to sleep and helps to regulate many other physiological processes. Disturbances can occur between the person’s sleep pattern and the pattern that is desired. For example, one cannot sleep when sleep is desired.
  • Parasomnias: The parasomnias consist of abnormal sleep-related movements, behaviors, emotions, perceptions or dreaming. It occurs while falling asleep, sleeping, between sleep stages, or during arousal from sleep. They are disorders that cause sudden waking up or a state of disturbed sleep.
  • Sleep-related movement disorders: Restless legs syndrome, sleep-related rhythmic movement disorder, large movements of the body or legs while sleeping can affect normal sleep pattern.

Other problems: 

Snoring is a sound produced by breathing. Snoring can also lead to impaired health as it can disturb the sleep of the individual and their sleeping partner. 

Sleep talking and sleep walking can be associated with REM sleep behavior disorder or sleep-related eating disorder. Usually, the person can get a sensation of falling, a sensory flash of walking to a place or a sleep-onset dream that can cause talking or walking. 

Who can be at risk of sleep disorders?

  • Working on odd timings/shifts:  Job timings that are against the internal body clock and working long hours.
  • Lifestyle problems: People who take medications to stay awake to complete tasks and studies. Other problems like alcohol or substance abuse.
  • Known or unknown medical condition: People who take medications that have side-effects that interfere with sleep. People with underlying unknown problems like stress and anxiety.

How is sleep problems diagnosed?

  • Blood Tests can be done to help find other underlying medical problems that can cause sleep problems.
  • Sleep studies (polysomnography): The electric activity in the brain (Electroencephalogram studies), behavior and other changes are observed while the person is asleep to study the problems associated.

How to get a good amount of sleep?

  • Sleep schedule should be kept the same every night. Avoid differences that may disturb your body clock.
  • Avoid strenuous exercise or doing work before bed as that will keep your brain active and delay sleep.
  • Avoid cigarettes (nicotine) and caffeine. Nicotine and caffeine are brain stimulants so both substances can interfere with sleep.
  • Getting enough fresh air and sun during the day can also help a good night’s sleep.
  • Learning relaxation techniques like breathing exercises can help.
  • Taking a warm shower before sleep can also relax the body. Keeping the bedroom cool and dark will also help prevent any disturbances.

If you have any type of sleep issues due to a shift-work schedule, it’s best to speak to your employer or consider visiting the experts to better understand your issues and eliminate the worry of any underlying medical condition.

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Varicose and Spider Veins – What are they and How to avoid them.

anatomy, Common conditions, Exercise, Health

main pic veins

What are Varicose and Spider veins?

Varicose veins are abnormal, dilated blood vessels (veins) caused by a weakening in the vessel wall. They may appear as swollen, twisted clusters of blue or purple veins.

Varicose veins are sometimes surrounded by thin, red capillaries also known as spider veins.

(group of tiny blood vessels located close to the surface of the skin, also called telangiectasias) – Refer Fig 1.

varicose veins
Fig 1: Varicose vs Spider veins

Role of veins and formation of abnormal veins

Veins carry blood back to the heart and have one-way valves that prevent the blood from back-flowing. The calf muscles act as a pump by which the blood is pumped back from the legs towards the heart as shown in Fig 2.

Deep Leg Veins

Fig 2: Normal blood flow through Veins, Calf muscle pump

If those valves of the veins become weak from extended periods of increased pressure and swelling, the blood can back up and collect within the veins. This causes the vein walls to weaken and bulge with blood, causing the veins to appear swollen and twisted as shown in Fig 3.

deformed valves

Fig 3: Normal vs Abnormal blood flow

Who can get it and where does it happen?

Varicose veins and spider veins can occur both in men and women. However, women are known to be affected more than men due to their hormonal predisposition and changes during pregnancy that affect the veins. 

These abnormal veins can develop anywhere, but most often appear on the legs and in the pelvic area because as compared with other veins in the body. This is because, lower limb veins work harder to carry blood back to the heart with forces from the body weight and gravity acting at the same time. This pressure can be stronger than the one-way valves in the veins.

Most varicose veins are seen on the surface of the skin as the superficial veins get swollen with blood collected in it that get raised on the surface and at times above the surface of the skin.  

Signs and Symptoms

Some may not have any symptoms but may be concerned about the appearance of the veins. Symptoms usually worsen after prolonged standing or sitting as the blood pools or collects in the veins of the lower limbs. 

Print

Fig 4: Swelling, Skin changes and Ulcers due to varicose veins

If symptoms occur, they may include:

  • Tiredness, burning, throbbing, tingling or heaviness in the legs
  • Itching around the vein
  • Swollen legs (Refer Fig 4)
  • Muscle cramps, soreness or aching in the legs
  • Brown discoloration of the skin, especially around the ankles (Refer Fig 4)
  • Leg ulcers (Refer fig 4)
  • Rarely varicose veins can form a painful blood clot, referred to as superficial thrombophlebitis (inflammation of a vein).

Risk factors and causes of abnormal veins

Varicose veins are related to increased pressure in the leg veins or defective valves in the veins.

They can happen due to reasons:

  • Idiopathic: The exact cause of this problem is unknown.
  • Heredity: A family history of varicose veins can put a person at risk of developing abnormal veins.
  • Advancing age: With aging veins can lose elasticity causing them to stretch. The valves in your veins may become weak, allowing blood that should be moving toward your heart to back-flow.
  • Prolonged standing or sitting.
  • Being overweight puts extra pressure on your veins, which means damage to the valves, making them more prone to swell.
  • Pregnancy: Pregnancy increases the volume of blood in your body but decreases the flow of blood from your legs to your pelvis. This circulatory change is designed to support the growing foetus but it can produce an unfortunate side effect — enlarged veins in your legs.
  • Hormonal influences during pregnancy, postmenopausal hormonal replacement therapy and use of birth control pills can cause excessive swelling in the lower limbs that hampers blood flow through veins. 
  • Wearing tight clothes can put pressure on the veins which can cause abnormal blood flow.
  • Injury to the veins due to trauma or accidents.
  • Other health conditions that cause increased pressure in the abdomen including liver disease, fluid in the abdomen, previous groin surgery or heart failure.

How is Varicose and Spider veins diagnosed?

A physical examination of the body especially the legs while the person is standing is done. A Doppler ultrasound scan can also check the blood flow in the veins near the skin’s surface and the deep veins. 

When to seek medical care?

  • Walking or standing becomes painful.
  • Soreness develops on or near a varicose vein
  • Your feet or ankles swell up very frequently.

If immediate care is not taken, symptoms may worsen. Complications may develop if there is an underlying disease in the deep veins or in the perforating veins which connect the deep and superficial veins.

  • Chronic venous insufficiency: Untreated venous problems may progress to a chronic condition of abnormal blood flow through the veins.
  • Venous stasis ulcers that result when the enlarged vein does not provide enough drainage of fluid from the skin. As a result, an ulcer (open sore) may form.
  • Fungal and bacterial infections may occur as the result of skin problems caused by the fluid buildup (edema) in the leg. These infections also increase the risk of tissue infection (cellulitis).
  • Thrombophlebitis: Inflammation of the vein due to blood clot formation.
  • Venous hemorrhage: Bleeding through the veins due to micro-tears and ruptures.

How to prevent varicose veins and its complications?

Lifestyle modifications:

  • Losing weight if you are overweight
  • Exercising regularly (especially walking)
  • Avoiding prolonged periods of sitting or standing
  • Avoid wearing tight-fitting undergarments and clothing that constricts the waist, groin or legs.
  • Avoid crossing your legs while seated.
  • Elevating your legs while sitting and sleeping will help.
  • When you need to stand for long periods, take frequent breaks – sit down and elevate your feet.
  • Do ankle pump exercises as shown in Fig 5.

ankle pumps

If you still develop varicose or spider veins, it is best to seek medical attention to know more in details on exercises and lifestyle changes that can be personalized to your needs.  

Why is Deep Vein Thrombosis Dangerous?

Common conditions, Exercise, Health, Lifestyle

DVT What is thrombosis?

Thrombosis is a process by which there is clotting of the blood in a part of the circulatory system. This causes a partial or total obstruction thus preventing blood from flowing normally through the circulatory system. This clot is known as a thrombus. 

What is Deep Vein Thrombosis(DVT)? 

A blood clot (thrombus) in the deep venous system is known as DVT. These clots are formed in the deep veins which are a part of the circulatory system that helps bring deoxygenated blood back to the heart. These veins have one-way valves that function to transport blood from various parts of the body to the heart as shown in Fig 1.

veins of our body

Fig 1: Deep veins of the body

Which body part can be affected with DVT?

There is a greater risk of developing DVT in your lower limbs than upper body as the deep lower limb veins work harder to carry blood back to the heart with forces from the body weight and gravity acting on them at the same time. In addition, if there are other factors that increases the pressure exerted on the valves in the deep lower limb veins, there are more chances of blood collecting within the veins thus making the lower limbs deep veins more susceptible to DVT.

Why is DVT dangerous?

There is a risk of a partial or complete detachment of this thrombus formed in the deep veins. This allows the thrombus to move with the blood flow and block other blood vessels. This process is called as venous thromboembolism.

pulmonary embolism

Fig 1: Thromboembolism

As shown in Fig 1, the thrombus blocks the blood vessel and cuts off the circulation to a particular body part or organ. This will lead to a lack of oxygen to the tissue (ischemia) and a loss of tissue function. The clot can also reach other blood vessels that supply the vital organs of the body, putting the body at a dangerous risk of stroke, lung, heart problems and post-thrombotic syndrome (PTS).

Post-thrombotic syndrome is a chronic(long-term) problem that occurs with DVT and involves chronic leg pain, swelling, redness, and ulcers (sores).

How does a thrombus form in the deep veins?

Blood clotting is the transformation of liquid blood into a semi-solid gel. The blood has a protein called fibrin. Fibrin is usually in its inactive state but when tissues or blood vessels are damaged, it becomes active. This process is called coagulation. The main reason of thrombus formation can be explained by the Virchow’s triad as shown in fig 2.

cause of thrombus

Fig 2: Main causes of thrombus formation

Conditions of prolonged bed rest or immobility which could be lifestyle-related or due to other reasons may cause stasis of blood within the veins that may lead to clot formation. Also, if there is an imbalance of the coagulation and anti-coagulation factors in the blood which may be caused by an injury or acute/chronic inflammation to the blood vessel walls may cause blood clot formation.

Who is at risk of developing DVT?

  • Anyone with vein trauma due to broken hip or leg fractures during accidents.
  • Long periods of air travel coupled with lack of movement in sitting position can cause excessive swelling in the legs and stagnation of blood flow leading to clot formation.
  • Bed bound individuals post-surgery, muscular paralysis from a spinal cord injury, pregnancy or having recently given birth, especially by C-section, causing swelling and lack of calf muscle strength that impair blood circulation in the legs.
  • People with inherited blood clotting disorder.
  • People who have cancer as tumors shed particles that contain procoagulant activity.
  • Smoking affects blood circulation and stiffens the blood vessel wall making a smoker at higher risk of DVT.
  • Side-effects with the use of hormone therapy, including that used for postmenopausal symptoms among women.
  • Individuals with varicose veins, which are swollen, twisted and painful may develop clots.
  • People with a history of heart attack, stroke or congestive heart failure have high levels of cholesterol in the blood that lead to inflammation and possibly clot formation.

Signs and Symptoms of DVT

  • Pain, swelling and tenderness in one of your legs (usually your calf)
  • Affected area can be very painful and heavy.
  • Warm skin in the area of the clot.
  • Redness of the skin, particularly at the back of your leg below the knee.

How is DVT diagnosed?

A physical examination may not be enough as there may be individuals with no possible signs of DVT. Diagnostic tests will be necessary to confirm the condition.

  • Doppler ultrasound scan:  A clot may be visible in the image. Sometimes a series of ultrasounds are done over several days to determine whether a blood clot is growing or to detect any formation or movement of a clot.
  • Blood test: An elevated level of a clot-dissolving substance called D dimer will be found in the blood.
  • Venography. A dye (contrast agent) is injected into a large vein in your foot or ankle. An X-ray procedure is then undertaken that creates an image of the veins in your legs and feet, to look for clots. 
  • CT or MRI scans. Both computerized tomography (CT) scan and magnetic resonance imaging (MRI) can provide visual images of your veins and may detect any clot formed. 

When to seek medical care?

  • If you get swelling, redness, and pain in your leg, it may indicate a blood clot and immediate medical attention should be given. Sometimes there may not be any signs or symptoms or these symptoms could be due to other inflammatory condition or infection, therefore, it is difficult to make the diagnosis without seeking medical advice.
  • If there is associated pain in the chest or breathlessness further concern exists that you may be at risk of a pulmonary embolus. This could be a potential danger hence if you are at risk its best to discuss with your doctor about taking medications for preventing clot formation.

How to prevent DVT?

  • Compression stockings for bed bound individuals.
  • Early ambulation Post-surgery – getting the individual out of bed walking to allow good circulation of blood. If not possible, use a continuous passive motion (CPM).
  • Low dose of anti-coagulants can also be prescribed by the doctor.
  • During long flights, it is recommended to move frequently and/or use compression stockings.
  • Ankle exercises can help pump the blood from the legs upwards to the heart.
  • Lifestyle modifications –  smoking cessation and increased exercise.

If in doubt or experiencing any of the symptoms, always seek medical advice immediately. When detected early, it’s much easier to deal with.

Pregnancy – Things to note

Exercise, Health, Lifestyle, Pregnancy

preg main

Pregnancy is a time when the mother undergoes many physical and physiological changes. These changes happen so that the mother’s womb can nurture and host the growing baby. However, there are other possible effects of these changes on the musculoskeletal, cardiovascular and respiratory system of the expectant mother. Therefore, it is important to be aware of these effects in order to help the expectant mother to cope with the challenges of pregnancy.

What are the effects of the hormonal and Physiological changes during pregnancy?

Hormonal changes: Progesterone and Relaxin are two hormones whose levels are extraordinarily high during pregnancy. 

  • They cause changes in the collagen fibres of the connective tissues of the joints and soft tissue structures.
  • Loosening of ligaments decreases the stability of the joints.

Weight gain: Excessive weight and gravity can slow down the circulation of blood and body fluids mainly in the lower limbs. 

  • This can cause excessive workload on the body with physical activity
  • Excessive fluid retention
  • Swelling in the limbs and even face.

Postural change: 

PregnancyPosturePositions
Fig 1: Improper postures and good posture

Improper postures as shown in Fig 1, due to increased weight gain and forward shift of the centre of gravity. It can also affect balance and gait.

Improper postures:

  • increased lower back curvature – lumbar lordosis,
  • compensatory curving of the upper back – kyphosis or scoliosis,
  • rounding of shoulders 
  • forward chin position

Muscular changes:  As the baby grows the mother’s abdominal muscles and ligaments get stretched.

  • Weakness of the abdominal muscle 
  • Less support or bracing to the spine

Due to weight gain, improper posture and possibly lack of gait control, there will be an excessive strain to the muscles of the hips, knees and ankles.

Blood Pressure changes: Pregnancy hormones can suddenly affect the blood vessels by narrowing or expanding them, causing a drop or sudden increase in blood pressure. This if may affect the blood supply to the vital organs like the brain and in severe cases may also affect the growing baby. 

Low blood pressure may cause:

  • Dizziness 
  • Brief loss of consciousness (passing out)

High blood pressure in pregnancy is also known as pre-eclampsia which may worsen to a condition called eclampsia.

Symptoms of Eclampsia:

  • Severe headaches and convulsions.
  • Problems with your vision, such as blurred vision, flashing lights or spots in front of your eyes.
  • Tummy (abdominal) pain, vomiting later in your pregnancy (not the morning sickness of early pregnancy).
  • Sudden swelling or puffiness of your hands, face or feet.

Changes in the Respiratory system: As the uterus enlarges, the movement of the diaphragm (main breathing muscle) may be limited. The uterus moves upwards, it progressively obstructs the downward movement of the diaphragm as shown in fig 2.

diaphragm pushed up
Fig 2: Uterus and abdominal contents pushing the diaphragm

It can force the diaphragm upwards mostly towards the end stage of pregnancy causing:

  • Breathlessness: difficulting in breathing normally.
  • Painful ribs: Rising pressure pushes the rib cage out sideways and forwards, resulting in pain in the front of the lower ribs, also known as rib flare.

Increased Metabolic Rate: Basal or resting metabolic rate (RMR) is the amount of energy the body uses while at rest. Due to hormonal changes, this RMR increases significantly during pregnancy that may put the pregnant women at a higher risk of developing hypoglycemia or low blood sugar leading to light-headedness and fainting.

Risk of health conditions during Pregnancy 

  • Ligament and joint sprain: As the ligaments are lax due to hormonal changes, there is more risk of ligament and joint sprains especially in the ankle joint during pregnancy. Ligaments of the feet become lax and with the additional weight of pregnancy, results in flat feet and development of painful conditions like plantar fasciitis, Achilles tendonitis etc.
  • Supine hypotensive syndrome (Restriction of blood flow): The enlarging fetus compressing the aorta and inferior vena cava against the lumbar spine, restricting blood flow.
  • Painful joints: Incorrect posture causes abnormal curves like kyphoscoliosis and scoliosis which may cause issues for anesthesia during pregnancy and delivery. They also exert excessive strain and fatigue on the body, particularly in the spine, pelvis and other weight-bearing joints (i.e. knees). This results in aches and pains, such as lower back, with the pain spreading to the buttocks, thighs and down the legs.
  • Low back Pain: The extra weight of the baby coupled with the shift in weight distribution may strain the back muscles and can cause muscular spasms. Excessive pressure placed on the back may also cause low back disc herniation that may affect the spinal nerves.
  • Posterior pelvic pain (PPP): Lax ligaments of the body allows the pelvis to enlarge, in preparation for childbirth. Also, due to the growing uterus, some of the core muscles around the pelvis get ‘stretched’ and weakened. This affects the stability of the sacroiliac (SI) joints – the joints between the tail bone and the pelvic bones on either side at the lower back region as shown in Fig 2.
SI Joint
Fig 2: Sacroiliac joint
  • Diastasis recti: “Diastasis” means separation. “Recti” refers to your abdominal muscle called the “rectus abdominis.” The rectus abdominis muscle runs in the front of the stomach and is excessively stretched during pregnancy. Sometimes the pressure increase due to baby growth may be too much causing the muscle to separate as shown in Fig 3. 
Diastasis recti
Fig 3: Separation of Rectus abdominis muscle.

This separation in the abdominal muscles may lead to:

  • Low back pain: due to lack of bracing to the spine.
  • Hernia: a condition when the abdominal contents can protrude out due to increasing pressure from growing baby and lack of support by the abdominal muscles. Umbilical hernia as shown in Fig 3.
umblical hernia

Fig 3: Umbilical hernia

  • Pubic symphysis pain: The weight-bearing joints, such as the pelvis, is increasingly stressed and loaded during pregnancy. Coupled with the instability that relaxin causes, the pelvis is susceptible to pain and injury. Sometimes due to stress, the pubic symphysis may be separated causing a condition known as symphysis pubis diastasis as shown in Fig 4. This commonly occurs during delivery.
Pubic symphysis
Fig 4: Symphysis Pubis Diastasis
  • Transient osteoporosis: This is a bone condition that happens during pregnancy and symptoms disappear within weeks of labour. It has no known cause, although hormones, nutrient deficiency, and other causes have been proposed. There is a sudden drastic loss of bone mass and swelling in the affected portion during pregnancy. This causes weakness of the bones which may lead to fractures during delivery and other complications for the mother.
  • Gestational Diabetes: Due to hormonal changes in your body, your cells can become less responsive to insulin. When the body needs additional insulin, the pancreas dutifully secretes more of it. However as the cells are unable to respond to it, your blood glucose levels rises too high resulting in gestational diabetes. This may lead to excessive weight gain and development of diabetes post pregnancy.
  • Carpal tunnel syndrome: “Water retention” or swelling in ankles, feet and hands in late pregnancy may lead to joint stiffness and nerve compression syndromes, such as carpal tunnel syndrome.
  • Varicose veins: Varicose veins of the legs may occur during pregnancy or worsen during this period. This is due to a reduction in the vascular tone and changes in the collagen structure in the body (due to progesterone and relaxin) that affect the veins. 

How to prevent health conditions during pregnancy?

Always monitor your health status and evaluate the presence of any specific health condition at an initial stage.

It is important to understand your body in order to avoid conditions and the potential complications it may cause. Proper treatment planning is undertaken at an early stage to ensure the safety and health of both the expectant mother and the baby. 

 As most of these conditions can be prevented with lifestyle and dietary changes, it is best to consult with the experts to know more in details about how to manage and prevent them. 

Restless Legs Syndrome

Common conditions, Exercise, Foot, Health, Lifestyle

restless leg syndrome

What is restless legs syndrome?

Restless legs syndrome (RLS) is a neurological disorder that is characterized by an uncomfortable sensation in the legs and rarely the arms. This leads to an overwhelming urge to move them continuously.

These movements may,

  • happen to partially or totally relieve discomfort.
  • begin or worsen during periods of rest such as lying or sitting
  • worsen during sleep, causes time to time movements also known as “periodic leg movements”.

It has also been suggested that RLS would be called “Willis-Ekbom disease”, as an homage to the two pioneers Thomas Willis and Karl-Axel Ekbom who first reported this condition. 

What causes RLS?

  • Unknown cause
  • Genetic cause

RLS symptoms are related to hyperexcitability of the central nervous system- brain and spinal cord due to a possible deficiency of a chemical called dopamine. Dopamine plays a role in controlling muscle movement and may be responsible for the involuntary leg movements associated with RLS.

  • Disorder of the peripheral nervous system

The peripheral nervous system involves the nerves that carry signals from different parts of the body to the brain. The most likely possibility is the presence of hypoxia (lack of oxygen) caused by changes in blood flow or metabolism in the lower limbs that irritates the sensory nerves of the legs causing restlessness. 

  • Iron-deficiency anaemia – low levels of iron in the blood can lead to a drop in dopamine, triggering restless legs syndrome
  • Chronic (long-term) health conditions – such as chronic kidney disease, diabetes, Parkinson’s disease, rheumatoid arthritis, an underactive thyroid gland or fibromyalgia.
  • Radiculopathies: Radiculopathies are problems with the nerves and occur due to nerve compression at the spine caused by disc herniation and protrusion and/or disc degeneration. It is most commonly seen in the lower back regions (Lumbar spine). Nerve compression could cause referred pain and tingling sensations along the back of the leg to the feet that may be a secondary cause for RLS. 
  • Pregnancy – particularly from week 27 until birth; in most cases, the symptoms disappear within four weeks of giving birth
  • Side effects of certain medication: Antidepressants, Antipsychotic medicine, Lithium (used in the treatment of bipolar disorder), Calcium channel blockers (used in the treatment of high blood pressure), Antihistamines, Metoclopramide (used to relieve nausea). 
  • Lifestyle problems: Excessive smoking, caffeine/ alcohol, obesity, stress and lack of exercise.

Who can be affected with RLS?

  • Both the genders are affected but women are twice as likely to develop RLS than men which is still unknown and is suggested to be related to genetics, body functions or emotional differences. 
  • People of all ages can be affected but more commonly seen among middle-aged people secondary to other health conditions.

What are the signs and symptoms of RLS?

Signs and symptoms may vary from day to day, in severity and frequency from person to person during rest and most often during sleep. 

  • Abnormal sensations (Paresthesias)- pulling, creeping etc.
  • Unpleasant abnormal sensations (Dysesthesias)- the sensations range in severity from uncomfortable to irritating to painful example, tingling, burning, aching or like electric shocks.
  • Periodic leg movements during sleep
  • Typical movements like pacing and walking, jiggling the legs, stretching and bending, tossing and turning, rubbing the legs.
  • Inability to sleep leading to sleep disorders like insomnia (lack of sleep) due to increased urge to move or sudden waking up from sleep due to periodic leg movements.
  • Hyperactivity may be seen among children with RLS.
  • Fatigue/tiredness, lack of concentration, problems with cognitive function (related to thinking, attention and decision making) due to lack of sleep and excessive movements in the leg most often felt throughout the day.

How is RLS diagnosed?

There are no diagnostic tests that can diagnose RLS.

A thorough clinical assessment of the patient is necessary to be able to diagnose this condition. 

  • Clinical history: The history of the patient about signs and symptoms associated with RLS will be important for the diagnosis. The frequency, duration, and intensity of symptoms the aggravating and relieving factors as well as their tendency to occur during day and night time will be noted.
  • Family and Medical History: Family history and problems of other health conditions and the use of medications will be noted that may be the suggestive cause for RLS.
  • Neurological and physical examination: Examination of other underlying conditions related to muscle or nerve problems. 
  • Blood tests: blood test can be done to identify iron and vitamin deficiencies as well as other medical disorders associated with RLS.  
  • Sleep studies such as polysomnography (a test that records the individual’s brain waves, heartbeat, breathing, and leg movements during an entire night of sleep) may identify the presence of periodic leg movements and other problems of sleep.
  • RLS in children: This may be difficult since it may be hard for a child to describe any uncomfortable sensations in the leg and the urge for leg movements, when and how often the symptoms occur, and how long they last.
  • Misdiagnosis: RLS may be often misdiagnosed as “growing pains” or “Attention Deficit Hyperactivity disorder” (ADHD) in children and may be mistaken to be an onset of another neurological disease, such as Parkinson’s disease in adults.

How can this condition be treated?

  • Most symptoms can be treated by therapeutic treatments that improve the blood circulation of the legs, muscle flexibility and allow the nerves of the legs to relax. This can help diminish the uncomfortable sensations caused by restless legs syndrome.
  • Identification and treatment of other health problems are important to reduce the symptoms of RLS.  
  • Intake of diet rich in iron and vitamins will be beneficial.
  • Reducing smoking and alcohol consumption.
  • Stress management will help reduce symptoms and improve sleep.

Severe problems with RLS can be also be treated along with prescribed medications that improve the dopamine levels in the body. However, RLS may generally be a lifelong condition.There may be periods of no symptoms but may eventually reappear sooner or later. Adhering to the treatment methods can help reduce the symptoms at all times. 

Common Injuries of the Achilles Tendon

Ankle, Common conditions, Exercise, Foot, Injury, Lifestyle, Pain

Achilles tendon injury

The thickest and the strongest tendon in our body is the tendon of the calf muscles of the leg also known as the “Achilles tendon”. 

achilles Tendon main

Fig 1: Calf muscles and Achilles tendon

As shown in Fig 1, the calf muscles of the leg include the gastrocnemius and the soleus muscles that tapers and merges with a tough connective tissue of the Achilles’ tendon. The Achilles tendon then inserts into the heel bone (calcaneus).  Functions of the Achilles Tendon

  • Downward Movement of the foot: When the calf muscles contracts and pulls the Achilles tendon it causes the foot to push downward. This contraction enables: gait, standing on the toes, running, and jumping.
  • Bending the knee: The gastrocnemius muscle helps in bending the knee (flexion) during walking and running.
  • Transferring body weight: With each step of walking each of the Achilles tendon help to distribute the person’s body weight. Depending upon the speed, stride, terrain and additional weight being carried or pushed, each Achilles tendon may be subjected to approximately 3-12 times a person’s body weight.
  • Ankle stability: Along with the other muscles of the leg the Achilles tendon contributes to the stability of the ankle joint.

What surrounds the Achilles tendon? The Achilles tendon is protected by the Achilles tendon sheath and bursae. The sheath is the covering of the tendon that protects the tendon from friction and allows smooth movements. Similarly, the bursae around the Achilles is a thin fluid-filled sac that help to reduce friction between tendon and other tissue areas of the heel.

achilles Bursas

Fig 2: Bursae around the Achilles tendon

As shown in Fig 2, there are two bursae present at the heel. One of the bursae is present in between the surface of the tendon and the surface of the calcaneus at the distal attachment of the Achilles tendon. It is called the “retrocalcaneal bursa”. The other bursa is present between the calcaneum and the skin and is called as the “subcutaneous calcaneal bursa”. 

Brief History on Achilles tendon injuries

Because of the Greek Achilles legend, the Achilles heel is known as a vulnerable part for injury. Hippocrates described that “this tendon if bruised or cut causes the most acute fevers, induces choking, deranges the mind and at length brings death”. It was first reported that a ruptured tendon was to be wrapped with bandages dipped in wine and spices. Since then the cause and treatment of Achilles tendon injuries have brought growing interests among many researchers. 

What causes an Achilles tendon injury?

  • Overuse injuries

This is mostly sports related and is due to overuse of the calf muscles causing an injury to the Achilles tendon. Overdoing or rapid action of the calf muscles or resuming too quickly after a layoff can stress the Achilles tendon. For example, while running or walking faster, up and down on steeper hills or stairs  more powerful movements such as lunges, jumps, or push off.

  • Misalignment and muscle imbalances

Short or tight Achilles tendons or calf muscles, unequal leg length, over or under arched foot, disproportionally weak calf muscles.

  • Improper Footwear 
  • Side effects of certain medications  

Medications (Quinolone / Fluoroquinolone and Cortisone) can weaken the Achilles tendon and this may lead to an injury. Cortisone shots in or near the Achilles tendon may reduce pain in the Achilles tendon, but the weakness in the tendons persists which can an injury during activities.

  • Accidental trauma
  • Inflammatory conditions

Achilles injury may occur in relation to inflammatory illnesses, such as ankylosing spondylitis, reactive arthritis, gout or rheumatoid arthritis.

  • Genetic 

Individuals with a genetic predisposition like hypermobile people are reported to be more at risk of developing Achilles tendon problems. This is because they have excessive laxity in  ankle joints that lead to the wear and tear of the Achilles tendon. 

Achilles tendon injuries

achilles tendon injury locations

Fig 3. Locations of injury

As shown in Fig 3, different types of Injuries to the tendon can occur along different locations of the tendon. 

Musculotendinous junction: This explains the junction between the calf muscle and the Achilles tendon.

Mid portion of the tendon: This explains an injury midway between the top and bottom of the Achilles tendon.

Insertional Achilles tendon injury is an injury at the bottom of the Achilles tendon, where the Achilles tendon connects with (inserts into) the heel bone.

Non-insertional Achilles tendon injury means an injury to any part of the Achilles tendon except at the Achilles tendon – heel bone connection.

Types of Achilles injuries

The spectrum of Achilles injuries ranges from an acute inflammatory irritation to severe cases of rupture of the tendon as shown in Fig 4. The types of condition may co-exist depending on the severity of the injury.

Achilles Tendon course of injury

Fig 4: Types of Achilles Tendon Injuries

Tendonitis and tenosynovitis

Achilles tendonitis is an acute inflammation of the Achilles tendon as shown in Fig 5. Tenosynovitis is an inflammatory condition of the Achilles tendon sheath, rather than an inflammation in the Achilles tendon itself.

Tendonitis insertion

Fig 5: Achilles Tendonitis

Achilles Tendinosis (Tendinopathy): This is the degeneration and micro tears of the Achilles tendon that occurs over time due to overuse of an already inflamed and weak tendon (Refer Fig 6).

Both Achilles tendonitis and tenosynovitis can occur in parallel with, or lead to Achilles tendinosis.

Print

Fig 6: Tendinosis of Achilles tendon

Tendon Ruptures (Partial or complete tendon tear) Achilles tendon rupture is often described as an abrupt break with instantaneous pain that is felt in the foot or heel area. It occurs rapidly while performing activity like running or standing on the toes, which generates intense force on the tendon, leading to partial or complete rupture as shown in Fig 7.

Rupture complete

Fig 7: Complete and partial tear of the Achilles tendon

What can happen if you have an Achilles tendon injury?

  • Pain and tenderness along the Achilles tendon and at the back of the heel that worsens with activity.
  • Thickening of the tendon
  • Bone spur formation at the insert of the tendon
  • Bruising and Swelling around the tendon area.
  • Fibrosis and scarring may be seen in Achilles Tenosynovitis and tendinosis.
  • Restriction of Achilles tendon’s motion within the Achilles tendon sheath.
  • Bursitis: Inflammation of the bursas around the Achilles tendons.
  • Snapping or popping noise can indicate a tendon rupture.
  • Difficulty in moving the foot or pointing your toes (in complete tears of the tendon)
  • A limp may be seen on weight bearing immediately after an Achilles tendon rupture
  • Ankle instability
  • Nerve or blood vessel damage: Signs include numbness, tingling, pins-and-needles sensation in your foot and bruised skin.

How is an Achilles tendon injury diagnosed? An initial examination of the ankle can help differentiate a tendon rupture from other types of injury. When an Achilles tendon rupture occurs, it will not be possible for the individual to stand on toes as shown in Fig 8.

achilles tendon rupture and normal

Fig 8: Achilles tendon rupture of the Left heel

 An MRI or X-ray investigation can also be taken to further confirm the severity of the injury and differentiate the type of injury to the tendon. For example, an MRI scan of a ruptured Achilles tendon is shown in Fig 9.

Complete tear MRI

Fig 9: Achilles tendon rupture

When to seek expert care?

If you felt a sharp pain like a direct hit to the Achilles tendon or if you heard a distinct snap at your Achilles tendon, it calls for a medical emergency. If you have just begun with pain in the back of heels with swelling or discomfort in the Achilles tendon, it would be wise to seek expert assessment and treatment care. What may seem like a mild inflammation may lead to degeneration and rupture. Thus, an initial treatment for tendonitis will not only reduce problems of the tendon but will restore its strength and function which is important to prevent worsening and recurrence of the condition.  

What is Blood Pressure?

Exercise, Health, Lifestyle

Blood pressure main

What is blood pressure (BP)?

Blood pressure is the pressure exerted by the circulating blood on the walls of the blood vessels.

What system is it part of and why?

BP is a part of the blood circulatory system, which is also known as the cardiovascular system(Refer Fig 1)

  • The heart
  • The blood vessels – arteries and veins
CirculatorySystem

Fig 1: The Circulatory System

The heart acts as a pump that is responsible for,

  • pumping oxygenated blood carried by the arteries to our organs
  • pumping deoxygenated blood that it receives through the veins from our organs. 

One of the functions of the circulatory system is to regulate the blood pressure for maintaining good blood flow throughout the body. This is required in order to transport nutrients and oxygen for every body part, for regulating body temperature, pH balance and for normal functioning of the body.

For example, when the heart pumps out oxygenated blood through the arteries, the blood flow exerts a force on the walls of the arteries. This force is measured as arterial blood pressure as shown in Fig 2. Any problems with this arterial BP may lead to a problem with the normal functioning of the body.

blood pressure

Fig 2: Arterial Blood pressure 

How is Arterial BP measured? 

The instrument that can measure the blood pressure is called Sphygmomanometer (Refer Fig 

Sphygmomanometer

Fig 3: Sphygmomanometer

It consists of:

  • a cuff,
  • a pump, and
  • a calibrated mercury scale

Typically two numbers that are being recorded on the scale which is written as a ratio. For example, BP of 120/70 mmHg, where 120 is the top number and 70 is the bottom number.

BP Measurement

Fig 3: Measuring BP

As shown in Fig 3, the BP is measured in four steps,

Step 1: Locate the pulse on an artery of the arm

Step 2: The health professional wraps the cuff around your arm and inflates it to squeeze your arm. This is done to temporarily press on the artery and close the blood flow in your arm. 

Step 3:  After the cuff is inflated, the health professional will slowly let air out. While doing this, he or she will listen to your pulse with a stethoscope and watch the mercury level on the calibrated scale to accurately note the measurements. The first pulse sound is heard and simultaneously measured on the scale.

Step 4: As the successive pulse sounds continue the professional hears it until the last pulse sound is heard which is again measured. 

The scale used is in “millimeters of mercury” (mmHg) to measure the pressure in your blood artery.

Blood pressure numbers- what does it indicate? 

systole and diastole

Fig 4: Systole and Diastole of the heart

The top number- Systolic pressure

The top number, which is also the higher of the two numbers, is the measure of the pressure in the arteries when the heart beats or contracts to pump the oxygenated blood. This is also known as the systole of the heart as shown in fig 4. 

The bottom number- Diastolic pressure

The bottom number is also the lower of the two numbers. It indicates the pressure in the arteries when the heart muscles are relaxing between two heart beats and refilling with blood. This is also known as the diastole of the heart as shown in fig 4.

BP Categories

Fig : BP Categories

Fig 5: BP Categories

Typically more attention is given to the top number (the systolic blood pressure), however, both the systolic and the diastolic pressures are important for indicating if a person is at risk of any heart disease.

What are the risk factors that will lead to high or low BP?

Risk factors

High BP

Low BP

  • Family history of High BP
  • Advanced age
  • Men get High BP more than women
  • Sedentary lifestyle
  • Poor diet, excessive salt intake
  • Drinking too much alcohol
  • Obesity
  • Smoking
  • Stress
  • Sleep apnea- a sleep disorder in which tissues in the throat collapse and block the airway.
  • Prolonged bed rest
  • Pregnancy
  • Trauma- loss of blood from major trauma, dehydration or severe internal bleeding
  • Certain medications
  • Abnormally low heart rate 
  • Endocrine problems- thyroid problems, Diabetes
  • Severe infection
  • Severe allergic reaction
  • Anemia
  • Nutritional deficiency- low blood volume due to Vit B12 and folic acid deficiency
  • Extreme heat- hot sauna and hot bath

When to seek Medical help?

There’s a common misconception that people will experience symptoms such as nervousness, sweating, difficulty sleeping or facial flushing. But the truth is that changes in blood pressure can be a symptomless condition. If you ignore your blood pressure because you think symptoms will alert you to the problem, you are actually taking a risk. It is important to know your blood pressure numbers as everyone should prevent blood pressure problems.

However, there are few signs and symptoms that may possibly occur with low and high BP. 

Signs and symptoms 
High BP Low BP
  • Severe headaches
  • Severe anxiety
  • Shortness of breath
  • Nosebleeds
  • Blood spots in the eyes
  • Facial flushing

 

  • Dizziness or lightheadedness
  • Fainting
  • Dehydration and unusual thirst
  • Lack of concentration
  • Blurred vision
  • Nausea
  • Cold, clammy, pale skin
  • Rapid, shallow breathing
  • Fatigue
  • Depression

 

How to manage BP problems?

Routine Check-up: Most people are unaware of their BP problems and going for a check-up will detect any blood pressure problems. This will prevent any potential health conditions. 

Understand your normal level of BP: There is no healthy level of high blood pressure or low blood pressure.  Your healthcare professional will determine your treatment goals based on your overall lifestyle and your body.

Lifestyle modifications

  • A nutritional diet, which may include reducing salt depending on High or low BP, Vitamin and mineral rich diet.  
  • Physical activity – exercise
  • Maintaining a healthy weight
  • Stress management
  • Smoking cessation support
  • Alcohol limitations
  • Prescribed medication in specific cases

Take precautions while exposed to heat 

When your body gets heated up during hot weather or during a hot tub or sauna bath, your blood pressure could drop and your heart rate may increase to counteract a drop in blood pressure. Normally, these events don’t cause problems. However, if you have an existing low BP you may be at risk of fainting, falls and heart problems.

Some of the precautions can be,

  • Limit your exposure to heat. Most experts say no more than five to 10 minutes is safe.
  • Stay hydrated.
  • Regulate water temperature during hot tub or sauna baths.

Conclusion

Managing blood pressure requires an individual’s adherence to the lifestyle changes and habits. It is advisable to get early assessment and treatment of your blood pressure problems in order to have a healthy circulatory system and to prevent the risk of many health conditions.    

Ankle Injuries – Sprain, Strains and Fractures

Common conditions, Exercise, Injury, Lifestyle, Pain

Ankle sprain main

An ankle injury is the most common type of injury that may involve the bones of the ankle and other soft tissue structures. Three are three types of injuries that are observed at the ankle:

  • Sprains
  • Strains
  • Fractures

Sprains are injuries to the ligaments that connect one bone to another. An ankle sprain may involve an injury to one or more ligaments that stabilize the ankle and the foot. 

Strains are injuries that involve musculotendinous (muscle and tendon) structures. Both sprains and strains can occur due to over-stretching or tearing of the ligaments and tendons due to sudden twisting of the ankle joint or when excessive forces are applied on them.

Fractures are injuries that involve bones of the ankle joint. It ranges from a simple break in one bone to several fractures, which causes your ankle to move out of place and puts you in great pain.

Who could be at a risk of an ankle injury?

Ankle injuries may occur among,

  • Dancers
  • Sports persons- Gymnasts, basketball players, players participating in jumping sports etc.
  • Women wearing unstable high heels
  • Hypermobile people who already have laxed ankle ligaments 

Types of Ankle injuries

  • Lateral ankle injury

This is the most common injury to the ankle. Often, an inversion sprain could be an associated with a fracture and a strain to the peroneal tendons.  

An inversion sprain happens when the ankle in twisted inwards with an inward rolled foot as shown in Fig 1.

inversion injury

Fig 1: Lateral ankle injury

  • The Medial ankle injury

This type of injury occurs at the inner aspect of the ankle. Like a inversion sprain, the eversion sprain may also be associated with fractures of lower ends of the leg bones and strains to the tibialis anterior muscle.  

Eversion sprain happens when the ankle is twisted out with the foot rolled outwards as shown in Fig 2.

eversion injury

Fig 2: Medial ankle injury

High Ankle Injury

This type of injury is very rare. A high ankle sprain happens when the tibia bone rotates injuring the ligaments that hold the lower end of the two leg bones (tibia and fibula) as shown in Fig 3.

Severe injuries may cause fracture to the lower ends of the leg bones.

syndesmosis injury

Fig 3: High ankle injury

Severity of an ankle sprain 

An ankle ligament sprain can be graded according to the severity of the tear in the ligaments as shown in Fig 4.
 
lateral ankle sprain

Fig 4: Grades of ankle sprain

Sign and Symptoms of Ankle Injury
 
    • Swelling: Increased fluid in the tissue due to inflammation and soft tissue damage.
    • Pain:  Depending upon the severity of the injury and the structures involved, pain intensity can vary. 
    • Redness/ Warmth/ Tenderness: Caused by increased blood flow to the area.
    • Unstable ankle: The affected side feels weak and difficult to weight-bear.
    • Deformity: Severe injuries can cause fractured bones to move out of place and make the ankle look deformed.
Causes of Ankle Injury
Trauma
  • Stepping in a hole or a stone
  • Running on uneven ground
  • Fall or slippage on wet floor
  • Contact injury during sports like basketball, when a player is accidentally hit by an opponent causing the foot to roll inwards as shown in Fig 5.
Basketball

Fig 5: Lateral ankle sprain during basketball

Muscle imbalances

Lack of flexibility in muscles can hamper joint movement. For example, if the calf muscles are very tight, it will affect the stability and mobility of the ankle joint. In such a state, if one engages in any physical activity like running there could be a potential risk of twisting an ankle. Sometimes even lack of warm-up and stretching could be the cause of muscle imbalances.

  • Lack of Postural control

Postural control is defined as the act of maintaining, achieving or restoring a state of balance during any posture or activity.

It helps to maintain a good base of support for balance so that the force of gravity can act on the center of mass (COM) of the body. Centre of mass is the point in the body where the entire body weight is concentrated (located in the lower end of the spine) as shown in Fig 6.

Figure_10_03_05

Fig 6: Line of gravity and base of support

During sports, sudden quick body movements or external forces like a push or a contact by an opponent will affect your balance. If you lack postural controlm you may lose balance and risk hurting your ankle. 

Diagnosis of an ankle injury

Most ankle injuries are usually straightforward ligament strains. However, the clinical presentation of subtle fractures can be similar to that of a ankle sprains and these fractures can be easily missed on initial examination. Fractures are usually detected via X-ray scans. If any fracture is left untreated, it may cause excessive pain and disability to an extent that you may not be able to bear weight on the joint. Therefore, an X-ray or an MRI scan is often recommended to understand the severity of the injury.

For example, a lateral ankle sprain showing fractured bones in an X-ray is shown in fig 7. 

ankle sprain with bone fracture

Fig 7: Lateral ankle sprain with fracture of the lower end of fibula bone

Ankle Injury management

Usually, ligament injuries heal in about 6-12 weeks and fractured bones take about 3-6 months to heal. This is however largely dependent on the severity of the injury and lifestyle of the individual so complete healing time frame may vary. 

Even after the healing process, ankle injuries may cause long term instability if not healed correctly. This may also be the cause of recurrent ankle sprains. An expert assessment of ankle mechanics is very important to decide on how long to protect and rehabilitate an ankle after an injury. The treatment plan will aim to restore the normal functions of the ankle and make return-to-play decisions based on the stability of the ankle thus preventing recurrent ankle injuries.

Shoulder 101

anatomy, Exercise

shoulder

The main joint of our upper limb is the shoulder joint which can be moved in various positions when looked at in a three-dimensional perspective. In order to be able to have these movements, many other components help in order to maintain a stable shoulder. In short, there is a complex interplay between the shoulder joint, other joints, muscles and ligaments that make the shoulder a complex and unique part of our body.

Anatomy of the Shoulder Complex

The Shoulder complex consists:

  • The true joint called the Shoulder joint (Glenohumeral joint – GH)
  • The Clavicular joint with the scapula (Acromioclavicular joint – AC)
  • The Scapular joint with the body wall (Scapulothoracic joint – ST)
  • The Clavicular joint with the breastbone sternum (Sternoclavicular joint – SC).

The shoulder joint (GH) is made of two main bones that articulate with each other forming the ball and socket joint. The ball of the arm bone(humerus) and the glenoid cavity of the shoulder blade(scapula) is articulated at the shoulder joint (GH joint). Similarly, on the inner chest, the clavicle articulates with sternum to form the SC joint while on the outer end towards the shoulder the clavicle articulates with the acromion process of the scapula bone to form the AC joint. Both GH, SC and AC are true joints with union by fibrous, cartilaginous or synovial tissues. Lastly the ST joint, while this is not a true bony joint, its muscular attachments create a shoulder joint complex.SHOULDER

The humeral head (ball) is about three times larger than the glenoid fossa. Actually, only 25 percent of the humeral head articulates with the glenoid fossa. Glenoid cavity (fossa) forms a very shallow socket as compared to the hip socket of the hip joint. Therefore, the humeral head articulates with a smaller open and shallow saucer- type of articulation, lacking stability in its own. However, it is with all the soft tissue structures both inside and outside the joint that are responsible for the overall stability of the arm during movements.

Soft tissue structures that support the Shoulder Joint

The important soft tissue structures are:

  • Articular Cartilage
  • Labrum
  • Joint Capsule
  • Ligaments
  • Muscles

Articular Cartilage

A smooth, white tissue that covers the humeral head (ball) and the glenoid fossa to make it easier for the two bones to move at the joint. It allows the bones to glide over each other with very little friction.

Articular cartilage

Labrum 

Since the head(ball) of the upper arm bone is larger than the glenoid fossa, the articular cartilage forms a soft fibrous tissue rim called the labrum which surrounds the socket to help fit the head into it thus stabilizing the joint.

labrum

The socket can be divided into four regions namely anterior (front), posterior ( back), superior (the upper end near your head), and inferior (the lower end which is towards the elbow). Based on these regions the labrum is also called as superior, inferior, anterior and posterior labrum.

labrum 2

Joint Capsule

The shoulder joint capsule is a membranous sac that encloses the entire joint. The joint capsule of the shoulder is attached along the outside rim of the glenoid labrum of the glenoid cavity and attaches to the neck of the arm bone. The capsule by itself is quite loose and it is the surrounding reinforcement by the muscles, tendons, and ligaments that are largely responsible for keeping the shoulder joint stable.

capsule of the shoulder

Ligaments

In the shoulder, there is a group of ligaments that is responsible for the stability of the shoulder.

ligaments

Glenohumeral Ligaments (GHL)

This ligament attaches from along the outer glenoid socket covering the joint to the upper part of the arm bone.

  • Superior (upper) GHL
  • Middle GHL
  • Inferior (lower) GHL

Coraco-acromial Ligament (CAL)
This ligament attaches from the coracoid process to the acromion process of the shoulder blade (Scapula).

Coraco-clavicular Ligaments (CCL)
These two ligaments (trapezoid and conoid ligaments) attaches from the clavicle to the coracoid process of the scapula. This ligament can carry the load and is extremely strong. These tiny ligaments (with the AC joint) keep the stability between the scapula and the clavicle and thus keeping your shoulder ‘square’.

Transverse Humeral Ligament (THL)

This ligament protects the long head of biceps tendon muscle in the groove of the arm bone.

Muscles for the stability of the Shoulder Joint

Muscles of the shoulder connect the shoulder girdle, the clavicle and arm bone.

  • Muscles that origin from the spine and attaches to scapula and/or clavicle
  • Muscles that origin from the clavicle or scapula and/or body wall(ribs) to the top end of the humerus.

Trapezius, Levator scapulae, Rhomboids and Serratus Anterior

Originate from the base of the skull and/or spine and connect the scapula and clavicle to the trunk of the body.

traps, levator...

  • Trapezius forms cross-shaped web along the neck and run from the spinal column out to the shoulder blade and clavicle bone. It helps to shrug the shoulders.
  • Rhomboids and levator scapulae are important muscles that join the shoulder blade to the spinal column helping the scapular movements.
  • Serratus anterior muscle helps to stabilize the shoulder blade on the chest wall. When this muscle is weak, winging of the scapula occurs which is when the shoulder blade protrudes from the back.
winged scapula

Winged Scapula

Deltoid, Pectoralis major, Pectoralis minor, Latissimus dorsi, Teres major, Serratus Anterior

These arise from the clavicle and/or scapula and/or body wall and connect to the upper end of the arm (humerus) and anchor the shoulder joint to our body.

MUSCLES PECS

  • Deltoid muscle is a muscle that is responsible for overhead activities. It helps to move the arm sideways up.
  • Pectoralis major muscle like the deltoid is another powerful muscle which is the main muscle when doing push-ups. It originates from the front of the chest and collar bone and inserts on the upper part of the arm bone (humerus).
  • Latissimus dorsi is another powerful muscle that together with the teres major muscle pulls the arm down to the side. We use this muscle when doing chin-ups.

What are the Shoulder blade movements?

The muscles of the shoulder complex work together to perform a particular action. The Scapula and arm bone move together in a pattern to perform a movement.

The movements of the Scauplo-thoracic joint includes,

  • Depression – Downward arm and shoulder girdle movement
  • Elevation – Upward arm and shoulder girdle movement
  • Retraction – backward shoulder girdle movement
  • Protraction – forward shoulder girdle movement

movements in shoulder

Rotator cuff muscles- small in size, big in importance

The four rotator cuff muscles are important for the stability and movements of the shoulder joint. They are,

  • Subscapularis
  • Supraspinatus
  • Infraspinatus
  • Teres minor

Rotator cuff

These muscles connect the shoulder blade (Scapula) to the arm bone (Humerus) supporting the entire shoulder joint during movements.

The major function of the four rotator cuff muscles is to work simultaneously with each other to allow the arm to move freely in numerous positions. They do all this while pulling the humeral head downward and inward within the glenoid fossa.

Movements at the shoulder joint

The main movemnts at the GH joint are:

  • Flexion-Extension
  • Abduction-Adduction
  • Internal and External rotation

MOVEMENTS AT THE SHOULDER

  • Supraspinatus assists with lifting the arm with the deltoid above the head (abduction). This is the most common muscle / tendon to tear in the shoulder.
  • Subscapularis twists the arm behind (Internal rotation) the back.
  • Infraspinatus and the teres minor twists the arm outwards(External rotation) and sideways from the body.
  • Subscapularis assists with Deltoid, Biceps, coracobrachialis, Tere major to bring about shoulder forward flexion movement.
  • Triceps, latissimus dorsi, pectoralis major, teres major brings the arm backwards (Extension).

Why is the Rotator cuff is so important?

In order to prevent upward dislocation of the arm or tear within the inner soft tissue structures like labrum and capsule of the shoulder, balanced rotator cuff strength and function are necessary.  All the rotator cuff muscles work together stabilizing the humeral head within the glenoid while the larger muscles like the ltissimus dorsi, pectoralis major and deltoid produce the forces necessary for movements.

Common Injuries to the shoulder

  • Broken collar bone (Clavicle)
  • Dislocations of the shoulder
  • Frozen shoulder (Adhesive capsulitis)
  • Rotator cuff injury or strain (tendonitis or tendinopathy)
  • Acromioclavicular joint sprain
  • SLAP Tear (Superior Labrum Anterior Posterior tear)
  • Bankart’s lesion (Anterior inferior Labral tear, sometimes a part of the genoid cavity bone is also broken)

Most injuries to the shoulder are due to sudden trauma or repetitive trauma to the soft tissues and bones. Some of the injuries occur because of improper exercise selection, faulty technique, lack of warm-up, lack of dynamic stretches, dehydration and many more. However, knowing the anatomy and functions of the joints and soft tissue structures of the shoulder complex not only gives you a better understanding of it but will possibly give you a prospective as to how important is their role in maintaing the stability of the shoulder.

What is Tennis Elbow

Common conditions, Exercise, Lifestyle, Pain

tennis player massaging elbow

You just upped the load of your weight training or might have recently engaged in an activity which was strenuous and involve repetitive movements of the wrist and elbow. This later results in a burning sensation on the outer aspect of the elbow which is painful, sore and very sensitive to the touch. All this describes a condition called  ‘Tennis elbow’ which is more commonly known as lateral epicondylitis among clinicians.

Tennis elbow was thought to be common only among tennis players. However, this condition has been affecting more than just sports people as it is actually common in occupations which involve repetitive forearm rotational activities.

It has been estimated that only 5-10% of cases occur in tennis players. More often than not, recreational players are more susceptible than elite tennis athletes due to improper stroke technique or faulty equipment use.

Pain in the elbow was first described as ‘writer’s cramp’ by Runge in 1873 and later was called ‘Lawn Tennis Arm’ now known as Tennis elbow or lateral epicondylitis. Nirschl and Pettrone in 1979, described the pathoanatomy of the area as tendinosis.

Though the acute stages of tendon injury can have an inflammatory component, chronic tennis elbow is considered as a degenerative pathology rather than a tendonitis. Degenerative in this sense as it is more a failed reparative process of the tendon with associated cellular changes rather than active inflammation causing the pain. Therefore, terms like “tendinopathy” and “epicondylalgia” are more often being used by professionals to describe this painful condition which affects both office workers and sports people alike.

All about Lateral Tendinopathy (‘Pathy’ meaning non-inflammatory disorder) or Lateral Epicondylalgia (‘algia‘ meaning pain)

  • What is the lateral epicondyle of the Elbow? 

The elbow joint consists of three long bones which meet in the middle portion of the arm. The upper arm bone (humerus) meets the two inner bone of the forearm (ulna) and the outer bone of the forearm (radius) to form a hinge joint. The radius and ulna bones are responsible for rotational movements of your forearm.

Lateral epicondyle

The elbow functions to move the arm like a hinge (forward and backward) and in rotation (twisting outward and inward). The outer bone of the elbow is referred to as the lateral epicondyle and is a part of the humerus bone.

  • What are the tendons that attach to the lateral epicondyle?

A tendon is a part of the muscle. Tendon function by joining the muscle to the bone providing leverage to perform a movement.

At the lateral epicondyle, the tendons of the extensor muscles start and runs along the forearm. Extensor muscles again end into tendons that pass over the wrist and attach to your fingers. These tendons cause upward or outward movement of the wrist and fingers.

extensor muscles

Extensor Carpi Radialis Brevis (ECRB) – Commonly affected muscle

When performing movements at the wrist or by holding the wrist downwards with the forearm in pronation (Palm facing downwards). The extensor muscles especially extensor carpi radialis brevis is at its maximum length.

ECRB

As the origin of ECRB muscle lies proximal to the axis of rotation for bending and straightening the elbow, it is subjected to shearing stress and most commonly affected in movements of the forearm and wrist.

extensor_carpi_radius_brevis

What are the causes of lateral tendinopathy or epicondylalgia?

  • Overuse injury

The repetitive motion of the wrist or any activity that requires excessive constant gripping/squeezing can cause injury to the extensor tendons.

Individuals who perform multiple sets of dips, push ups and chin ups can also develop pain and injury. Repetitive exercises that involve excessive wrist extension and forearm rotation stresses the extensor tendon. Especially beginners who are trying to perform exercises which their bodies are not used to. They may be executing these exercises with improper posture, incorrect body alignment or bad technique, which predisposes them to painful symptoms of lateral tendinopathy.

  • Weak Scapula Muscles

In a research study published in Journal of Orthopaedic & Sports Physical Therapy (2015), impairments of scapular musculature strength and endurance in individuals with tennis elbow was found. This suggested that muscles of the shoulder and scapula play a role in movements in the forearm and improving the strength and endurance of these muscles will prove beneficial.

  • Faulty techniques

During Racket sports, the overload occurs at the extensor tendons especially in the backhand stroke that is hit with improper technique. The key is to use the body weight and strength from the shoulder than overloading the forearm extensor muscles alone. In a faulty stroke, the elbow is straightening doing the racket motion. 

In the game of tennis, the following maneuvers can lead to tennis elbow:

1. One-handed backhand with poor form and increased load on extensor tendons.

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2. A late forehand swing resulting in bending the wrist significantly stressing the extensor origin.

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3. Snapping and turning the wrist while serving with full power

twisting

  • Faulty Equipments

Racket 

A rigid and small size racket causes more compressive forces on the extensor muscles. Even though a stiff racket gives the player more power and control, a lot of compressive forces affect the forearm. The grip of the racket if too small or too large may require more strength to hold the racket. In both cases, the player may have to grip the racket too tightly to prevent it from twisting, and high grip force may increase the risk of injury.

Strings

High thicker string tension is problematic for the forearm because it reduces the dwell time of the ball on the strings. The lesser contact time of the tennis ball means that the shock of the ball impacts more to the forearm muscles.

Tennis ball

Old, wet and soft tennis balls affect the impact and contact point on the racquet requiring more effort from the forearm muscles during impact.

 What happens if you have an injury?

Tendinopathy is the result of overuse activity of the extensor muscles causing the tendons at the lateral epicondyle to have micro tears and reduce its blood supply. The tendon tissue develops large nociceptors that cause severe pain. Pain substances (substance-P and CGRP) irritates the surrounding nerve fibers to possibly inflame which further adds to the chronic nature of the painful condition. With the amount of pain, stiffness sets in causing weakness in the extensor muscles of the forearm affecting grip strength and daily activities. Chronic degenerative changes are seen in the collagen tissue of the extensor tendons that further worsens the condition.

Considering its severity from mildly irritating to a debilitating chronic painful condition, it can have a significant impact on social and occupational life.

How can you prevent tennis elbow?

If your injury is caused by an activity that involves placing repeated strain on your elbow joint, such as tennis or repetitive push-up workouts, changing your technique may alleviate the problem. Identifying and learning correct techniques, postural awareness and feedback for an experienced coach would be beneficial.

The best advice is to avoid too much stress on the muscles and tendons surrounding your elbow engaging in overuse activities. Mostly the condition is reversible with rest and treatment which will help prevent the condition getting worse.

Having said that, if it’s just an irritation, there are some precautions you would need to consider immediately while playing tennis. Watch out for faulty strokes or a playing situation which seems to exacerbate the problem. Get more information on the racket dynamics, tennis ball type and strings so that you can avoid injuries due to faulty equipment use.

Due to the insidious nature of the condition and a wait-and-see approach by many individuals, this condition becomes more chronic and debilitating. If pain persists and restricts the movements of the elbow, it will be best for you to get your elbow examined by experts to prevent any further damage.