chest wall injuries

Monday, March 18, 2013

There is a great regional rivalry when it comes to barbeque and which style makes ribs taste better. Is it the marinated Memphis, the Kansas City rub, the Carolina vinegar or the plain smoke of Texas? Regardless, we rarely think of the meat we eat as the muscles that help animals, including us humans, breathe. For those who have bruised or broken rib, or like David Wright of the Mets, pulled a rib muscle, it is an injury that is hard to ignore and harder to fix. After injuring an intercostal muscle, Mr. wright couldn’t play for the US national baseball team and returned to spring training to try to mend before the start of the baseball season.

Intercostal muscles are those that are attached to and located between the ribs and are responsible for moving the chest wall during breathing.  We breathe like a bellows with the ribs swinging out and the diaphragm (the muscle that divides the chest and abdomen) pushing down, sucking air into the lungs. Exhaling reverses the process and air is pushed out of the lungs. There are three layers of intercostal muscles that do the work of the rib movement, the external intercostal, the internal intercostals and the innermost intercostals, share the work of breathing and any injury to these muscles affects the ability of air to get into and out of the lungs. The muscle is often injured with a twisting motion; imagine a batter swinging while at bat, or lunging for a line drive in the field. But the injury can also be due to a direct blow, where the ribs don’t break but the muscle take the brunt of the injury.

Muscles don’t like to be hurt and when injured, go into spasm to protect themselves. The diagnosis is usually pretty easy. The patient often knows that they fell or twisted with immediate onset of pain. Sometimes, though the mechanism of injury is a little tougher to find and may be as simple as an aggressive cough or sneeze. Often a chest x-ray is done and not to look for broken ribs. Instead, the most important consideration is the under lying lung. Did the injury cause a collapsed lung (pneumothorax) or a pulmonary contusion (bruise)? It isn’t worth the extra x-rays and radiation to look for a broken rib, since it doesn’t affect treatment.

Chest wall pain, whether it is from the rib or intercostal muscle causes the body not to want to take a deep breath. It hurts too much and the body isn’t stupid. This is not necessarily a good thing when it comes to the ability to breathe. Failure to take a deep breath prevents the lung from fully expanding and those dark and warm crevices are prime breeding grounds for infection, leading to pneumonia. For that reason, treatment is focused on pain control and deep breaths. This plan, however, delays healing, trading length of recovery for pneumonia prevention.

Normally when a muscle is injured, the treatment is rest, ice and compression, allowing the damage to heal. Hurt your arm and a sling is prescribed. Hurt your leg and you get crutches. But the opposite treatment is recommended for the chest wall injury and with every breath the injured muscle fibers are ripped and stretched, delaying the healing process.

It may take 4-6 weeks for an injury to heal. Sleeping is tough and many patients find that sleeping upright or in a recliner is easier, since the ribs don’t have to lift up against gravity like they do when lying flat. Still after a few hours of sleep, those muscles go into spasm and the first twist and move in the morning after they finally get comfortable can be excruciating and dreaded beginning on morning number 2. Fortunately, one morning, perhaps in a couple of weeks, that first move hurts a little less and there is a light at the end of the tunnel.

Ice is one of the basics of treatment, as is ibuprofen as anti-inflammatory, but wrapping ribs prevents deep breaths and is no longer recommended. Instead, many patients get sent home with an incentive spirometer, a plastic toy that gives a visual clue about how deep the needed breath has to be. All this suffering is inflicted to prevent pneumonia, the lung infection characterized by fever, cough and shortness of breath.

Intercostal muscle injuries are frustrating. While Mr. Wright and the Mets hope that he heals quickly and is ready for opening day, there is no quick fix to shorten the recovery time.  And just like barbeque, you know it’s ready, when it’s ready…a not a moment sooner.

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lessons learned in the spring

Monday, March 4, 2013

Spring training was once a time when baseball players gently pushed their bodies into game playing condition. Times have changed and players are supposed to report in shape and ready to hit the field. But working out in a gym is not the same as throwing, hitting and fielding on the diamond and the injury reports from Arizona and Florida are witness to that difference. Injury reports are filled with injured knees, pulled groin muscles, hamstring strains, torn tendons and shoulder strains.

Baseball asks special skills of its players. The 162 game season stretches over 6 months with playing conditions ranging from stifling heat and humidity to freezing cold and snow flurries. On defense, the game requires the athletes to stand in the field for prolonged periods of time and then sprint aggressively without warning. Throwing produces forces that can damage tendons, muscles and ligaments, while batting is associated with major torque on the upper and low back. It is no wonder that in the first days of summer, with the season only a third complete, that players start to feel the wear and tear of the game they play.

Muscles are used to move the body. They attach to bone either directly or with a tendon and span across a joint. When a muscle contracts, a joint moves and activity happens. The movement of a muscle depends upon the coordinated sliding motion of many muscle fibers. To do extreme work, the muscle requires increased blood supply to provide oxygen, glucose and electrolytes to allow the individual muscles cells to do their job. And it’s important that the whole muscle be warmed up as well.

Think of the muscle as a spring. If the spring is cold, there will be little opportunity to stretch. If asked to aggressively stretch, the cold metal of the spring may break. If the spring is well used and is pulled far apart, it may not be able to return to its original shape and may loose the ability to recoil. Muscles work similarly.

A poorly warmed up muscle that is asked to do aggressive work, may not be able to respond. Muscle or tendon fibers may tear and be damaged. To protect itself, the muscle may go into spasm. This causes pain and the muscle may want to protect itself even further, going into more spasm. Treating the injury requires addressing both the pain and the spasm part of the equation.

Ideally, prevention is the best way of treating muscle strains. Warming up muscles is just as good an idea on the construction as it is on the baseball diamond. Stretching once the muscles are warm also works well and it may not be such a good idea to stretch cold muscles. But just as ball players are asked to use their muscles unexpectedly, injuries at work and home also happen when the body is asked to perform a task when it isn’t ready.

If a muscle is strained, treatment has a few basic cornerstones. Rest, ice and elevation will help decrease the inflammation that arises when muscle fibers are torn. Anti-inflammatory medications like ibuprofen will also help with pain control and sometimes a doctor may prescribe a muscle relaxant to ease the spasm.

Time is the important healer allowing the injured muscle to recuperate. Unfortunately, in this regard, life also mimics sports. The season is short and players want to get back into the game sooner than later and sometimes return too some. In the real world, people also want to get back to work quickly. Nobody wants to have their pocketbook hurt in addition to the pain of their injury. But time is what it takes for muscles to repair themselves. While it may be only a few days until the muscle can start working again, it may take weeks for the cells, fibers and whole muscle to return to the pre-injury form. The potential for re-injury in this time frame is greatly increased.

To survive the season, a player has to first survive spring training. The athleticism of the sport has to be tempered by the athlete listening to his body, understanding when it is ready to react and when it might be on the edge of damage. Some learn how to listen while others need the pain of injury to teach the lesson.

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