EXERCISE WITH CARE -- FITNESS IS NOT RISK-FREE
by Nancy Karkowsky

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 FOOD 

"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. 

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.