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Announcer: Health information from expects, supported by research. From University of Utah Health, this is TheScopeRadio.com.

Interviewer: This week's listener question is with Dr. Emily Harold. She's a sports medicine expert from the University of Utah and the question is: "Ice or heat for a sprained ankle?"

Dr. Harold: That's a very good question. I get this question a lot in clinic. So, typically, ice decreases blood flow to an area, which causes less swelling, whereas heat will bring blood flow to an area which can cause more swelling. Usually, in the first two to three days after an injury, we would recommend ice only. You put the ice on for about 10 to 15 minutes.

Make sure you put something between the ice and your skin so you don't freeze your skin because you can then get freezer burn. Take the ice pack off and once your skin re-warms, you can re-ice the area. So you could ice it as many times as you want during the day as long as you follow those rules.

Once it's been about three days, you can put heat on the injury. Especially for muscle injuries, that tends to help warm up the area and make it a little easier to walk and get around during the day. The heat is also 15 minutes, put the barrier between the hot pad and your skin and let your skin go back to normal temperature before you would use heat again.

Typically, the rule of thumb for us is after three days, you would ice after you do an activity and you would heat prior to doing the activity. That way, you bring the blood flow before the activity and warm up the area. And then after you are done, you put the ice on the decrease on the information that might develop afterward.

Interviewer: How long is it until we can stop icing or putting heat on it?

Dr. Harold: Typically, I let pain be the guide. For a lot of people, within a few days, they don't need to ice or heat the injury anymore, although for some people that have some persistent pain that will last for a few weeks. And they tend to heat before activity and ice at the end of the day.

Interviewer: When is it time to go to the doctor if this doesn't stop?

Dr. Harold: If it's been about one to two weeks and you don't feel there's any difference in your pain, then I think it's time to be evaluated.

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updated: July 18, 2018
originally published: January 26, 2017

Dr. Miller: Strains, sprains and fractures. How do you tell which is which? We're going to talk about that next on Scope Radio.

Hi, I'm Dr. Tom Miller and I'm here with Dr. Emily Harold. Emily is a Professor of Sports Medicine here at the University of Utah in the department of Orthopaedics. Emily, tell me the difference between . . . well, what do we do? What do we start with? Is there a difference between strains and sprains and . . .

Dr. Harold: Yeah, there is a difference. So, typically, when we talk about a sprain, we're talking about an injury to a ligament. A ligament is a structure that connects one bone to another bone. When we talk about a strain, we're talking about an injury to a muscle. So they vary in terms of what we're describing and they also vary a little bit in terms of treatment.

Dr. Miller: So ligaments are the tough, fibrous tissues that connect joints together? Would that be fair?

Dr. Harold: Yes, that's fair.

Dr. Miller: So you have them in your ankles, your knees, your hips, any major joint?

Dr. Harold: Any major joint. It's a tough, fibrous tissue that connects the two bones together.

Dr. Miller: And yet a sprain is a problem between the tendon and the muscle?

Dr. Harold: Exactly. So, typically, sprains can either be located at where the tendon and the muscle connect, or sometimes they'll be within the muscle themselves.

Dr. Miller: Which is more common, sprain or strain? And also, why is it important to know the difference between the two? Is that something that the general audience should be familiar with or is that more something that a physician needs to know?

Dr. Harold: I think that it's important to know the difference because when we talk about an ankle sprain we're talking about injury to a ligament that connects the two bones. And therefore, the recovery and the treatment for that injury is going to be a little bit different than when we're talking about a hamstring sprain, which is an injury to the muscle itself.

Dr. Miller: Treatments are different?

Dr. Harold: Treatments are different. When we talk about an ankle sprain or ligament sprain, we grade those one through three, with one being just a very mild injury to the ligament and three being a complete tear in the ligament.

Dr. Miller: So, obviously, a complete tear would result in a lack of function or a severe impairment of function.

Dr. Harold: Exactly, and depending on the joint, the treatment is a little bit different. So when you hear of an ACL sprain, a complete tear of the ACL, which would be a grade three sprain, typically results in a surgical intervention.

Dr. Miller: How about the minor stage one and stage two? Are those treated with physical therapy, typically?

Dr. Harold: Typically, those are treated more with physical therapy to help get the joint moving again. Ice, anti-inflammatories. And they take about two to four weeks to recover, whereas a grade three sprain can take up to six weeks to recover.

Dr. Miller: So you're a sports medicine physician. You treat a lot of athletes and also weekend warriors, I imagine. Tell me a little bit about what are the major sprains that you see, and then later on the major strains.

Dr. Harold: So the major sprains I see would be an ankle sprain, as well as, a lot of times, knee sprain. So MCL, different ligaments in the knee that can get sprained. The major strains I see are rotator cuff, which are the muscles in the shoulder, and then I also see a lot of calf and hamstring.

Dr. Miller: So let's take a sprained ankle. That's a fairly common injury, I would think, among athletes and just people who are exercising on a day-to-day basis, and step off a curb incorrectly. Do you always need an x-ray of that? I mean, how does one proceed? Let's say they have swelling, they have pain, does that need to be evaluated by a physician? And how would they know?

Dr. Harold: That's a good question. So there is a set of rules called the Ottawa Ankle Rules, that came out of Canada, where they looked at a lot of patients who had an ankle sprain and they tried to determine which ones were at risk for a fracture and which ones were at risk just for a ligament injury. And so there are some rules you can follow. One is if you can walk on your ankle right after the injury, that's a good sign.

Dr. Miller: Bear weight and walk.

Dr. Harold: Bear weight, exactly. The other is we look for tenderness on either side of the ankle on the bony prominences, both on the inside and the outside of the ankle, as well as if anyone has tenderness on the outside or the lateral part of their foot.

Dr. Miller: And if you have either of those debilities, what next?

Dr. Harold: Then you should come in and get an x-ray, just to make sure that you don't have a fracture with the injury.

Dr. Miller: So you could go to an urgent care clinic, you could go to your primary care physician or even a sports medicine physician?

Dr. Harold: Yeah, all three would be able to handle that with an x-ray and let you know if it's a fracture or just a sprain.

Dr. Miller: So sometimes, there's this difficulty in distinguishing whether it's a fracture or whether it's actually just a sprain?

Dr. Harold: Yes.

Dr. Miller: Okay. Other joints that are concerning for either fracture or strain? I think of ankle, most commonly, and then knee is one where . . .

Dr. Harold: Ankle, knee, I think wrist.

Dr. Miller: Wrist?

Dr. Harold: I'll see some people who fall on their wrist and there's concern whether it's a fracture, or whether it's a sprain or a strain. And that doesn't have a set of rules to guide x-ray so, typically I'd say if it's really swollen and if you have limited movement, those are the times that I would get an x-ray.

Dr. Miller: So if you're lacking function in that hand because of swelling and pain, that needs to be checked out, especially if it goes on any longer than maybe a day. Or if it just hurts incredibly, it needs to be checked out. Okay. So let's talk about strains. You've mentioned hamstring.

Dr. Harold: Yes.

Dr. Miller: And is that the most common that you're familiar with or that you deal with on a day-to-day basis?

Dr. Harold: Because I treat a lot of the younger athletes, I see that probably most commonly.

Dr. Miller: And what do you do to rehabilitate that? What's the main treatment there?

Dr. Harold: The main treatment there is to keep from over-stressing it when it's still injured. So usually, we start with some gentle stretching, usually some physical therapy. Avoid any kind of sprinting or any kind of activity that really stresses it until it slowly heals with time, and that can take up to a month.

Dr. Miller: I imagine you work very closely with physical therapists?

Dr. Harold: Yes.

Dr. Miller: And so a person with either a sprain or strain would end up maybe going to a physical therapist if it was a non-operative injury?

Dr. Harold: Yeah, absolutely, and I would say at least 90 to 95% of all of them are non-operative.

Dr. Miller: That's great to know.

Dr. Harold: So most injuries require physical therapy, some time off from the activity that really bothers it, but very few ever go on to require surgery.

Dr. Miller: Emily, you mentioned something earlier, talking about non-steroidals. Could you talk about that and what a non-steroidal is?

Dr. Harold: Yeah, a non-steroidal is a drug that helps with inflammation. If you get them over the counter, brand names like ibuprofen, Aleve, or naproxen, Advil, those are medicines that people take to help with inflammation. Now, I think it's worth noting that it hasn't been shown to heal anything quicker, it's more of a pain alleviator.

Dr. Miller: Should they go to the drug store and pick up ibuprofen or Naprosyn, common non-steroidals that are available without a prescription? Or do you have a certain way that you prescribe them or tell them how to use them so that they don't overuse those types of medicines? Because they do have side effects.

Dr. Harold: Yeah. I typically tell my patients that if they have a lot of pain, they should take the dose that is written on the over-the-counter bottle and take that for pain only. And once their pain starts to get better, they should stop the medication as they tolerate it. There are some doctors who will tell people to take it constantly for one or two weeks. Again, I don't think there's any data behind either option. I think it's more of a physician and patient preference.

Dr. Miller: So, Emily, we just talked about sprains, strains and fractures. Could you just summarize what we said? And we said quite a bit but I think, for the audience, a little bit of a recap would be good.

Dr. Harold: Absolutely. So a sprain is an injury to a ligament, which is a piece of tissue that connects a bone to a bone. A strain is an injury to where the muscle and tendon are connected. And a fracture is any break in the bone, regardless of how many pieces it is in or how big it is. All of these are treated a little bit differently, and . . .

Dr. Miller: I think, as you said, 90% of them . . .

Dr. Harold: . . . most of them are non-operative.

Dr. Miller: . . . that don't require procedure and operation to heal.

updated: December 21, 2022
originally published: October 4, 2016

Interviewer: Coming up next we're going to talk about a common hiking hazard and how to make sure it doesn't happen to you. That's next on The Scope.

I want you to think about it. When you go hiking, what problems do you normally run into? Maybe sore feet, tired legs, blisters. Pretty common problems, but today Dr. Emily Harold, a sports medicine specialist at University of Utah Orthopedic Clinic, is here to tell us about one of the more common hiking problems that isn't something that a lot of people really think about, and that's dehydration. And when I heard about this I'm like, "Really? Dehydration? Don't we all drink enough water? It seems like everybody's got a bottle of water."

Dr. Harold: Well, I think we all drink some water. I think that we don't all drink enough water. I mean, I think that we are blessed to live in a great state that has an amazing climate, and it's a very low humidity climate. And because it's a low humidity climate, when you're outside and it's hot outside and the sun's beating down, a lot of times your sweat dries quicker and you don't really realize how much you're sweating. And it can almost be pleasant when it's 80 degrees outside in this environment versus 80 degrees in Houston, Texas, in which case everybody knows they're sweating.

And so a lot of times people are sweating more than they realize and they're losing more water than they realize and they don't replenish enough, and that can lead to headaches, and tiredness, and in extreme forms can even lead to things like heat exhaustion, heatstroke, which can cause a lot of damage over time.

Interviewer: So if I was just going out for like an hour or two hike, do I really need to take water? Is that enough time to start getting symptoms of dehydration?

Dr. Harold: It's enough time. We would recommend at least a quart an hour. So if you're going to go out for a two-hour hike, one, we recommend probably drinking a liter before you go. And then while you're out, at least a quart an hour while you're out. More if you are running, trail running, doing activities that are more than just walking.

Interviewer: You've covered more endurance-based events like marathons and whatnot, and you say that it can really be common in those events. Explain that a little bit.

Dr. Harold: It's a common problem. A lot of times in marathons, people are out on the course for four, five, six hours. On a hot day, they don't drink enough fluid when they're out running and a lot of times when they come in after they cross the finish line, they can have some dangerously high body temperatures, 103, 104, 105. And so we really kind of institute a rapid cooling part and we try to give IV fluids for hydration, but it's very important that you drink enough water, especially when the temperature gets up above 70.

Interviewer: And when that sun's out, is it even worse?

Dr. Harold: Yeah, because the sun dries the sweat off a little quicker, and so you don't get the same cooling effect as you get when it's a little cloudier.

Interviewer: So drinking water, very easily preventable of dehydration. What about extra salt in those situations?

Dr. Harold: It is recommended that if you're out for more than an hour that you do ingest some salt.

Interviewer: Really? And above and beyond what I would normally get in my diet?

Dr. Harold: I think that's why trail mix became so popular. Because people realized if they went walking for a long time, that salt that comes from peanuts and that kind of thing can actually help to retain some of that water that you're drinking, and that helps to replenish their water stores a little easier.

Interviewer: Gotcha. And then also we're talking about kids. If you go out hiking for a couple hours with kids, that has a different effect on a kid than it might an adult.

Dr. Harold: Exactly, and if you're like my kids, you like to run ahead and you're constantly exploring. So you're not drinking water and no matter how much you tell them to drink water, by they time they're to start drinking when they're thirsty, they've already gotten a little bit dehydrated. So it gets really important just to watch your kids' water bottles. I usually recommend bringing a water bottle for each kid and having them drink from it, so you can monitor how much they're consuming.

And if you get somewhere and you realize they haven't really drunk very much water at all, then you can push their fluids a little bit just to keep them from getting dehydrated.

Interviewer: How often does heat exhaustion and heatstroke really lead to things? I mean is that not too common, more common than I might think?

Dr. Harold: I think both. I think we'll see a lot of hyperthermia or high temperatures sometimes in the emergency room. Usually if you catch them early and you cool people quickly, it doesn't lead to bad outcomes. Now if you have someone who is in Canyonlands or Moab and gets lost and wanders, that's something that can lead to heatstroke and it can lead to some, exactly, brain injury.

Interviewer: Just kind of wrap up, then, for myself or for my kids, what would I look for for symptoms to indicate they need to be drinking more water? Or is it just monitor water drinking?

Dr. Harold: I think it's easy enough to monitor water drinking. A lot of the symptoms are kind of difficult. Things like fatigue, they get that when they hike anyway. Headache is a common one. So if your child or you notice that you are starting to get a headache when you're walking, a lot of times that's because you're dehydrated. So that's the earliest one.

Interviewer: So in that instance drink water, get out of the sun for a little bit, rest for how long?

Dr. Harold: Exactly. Find a shady spot.

Interviewer: How long would you want to rest for?

Dr. Harold: Some people find a shady spot, drink some water, you want to rest for probably a good 10, 15 minutes until you start to feel better.

Interviewer: Yeah, and that will start to go away. And then you're fine to go back out again?

Dr. Harold: Absolutely.

Interviewer: I mean, this seems just like one of those topics that I don't think a lot of people think about and a lot of people don't think is really all that serious in their life.

Dr. Harold: Yeah, I think that's my final thought. It's something that I know I could do better at and most of us can do a better job of hydrating, but it is something that can lead to problems and it does make for a much more comfortable walk if you're properly hydrated.

updated: June 16, 2021
originally published: August 24, 2016

Announcer: Need reliable and wellness information? Don't listen to the guy in the cube next to you, get it from a trusted source, straight from the doctor's mouth. Here's this week's listener question. On The Scope.

Interviewer: All right. Today's listeners question: "When I go walking, I feel great except for about after 3 miles, my left arch gets really sore. So bad usually, I have to turn around and head back. Usually gone by the next day, but I'd like to be able to walk more than just three miles. What can I do?"

Dr. Harold: That's a good question. I think, a lot of times, arch pain comes from a muscle that helps to support the arch. One thing you could do is to look in the mirror at home and stand flat on your feet barefoot and see if one foot has more of a collapsed arch than the other. That could be an indication that that muscle might be a little bit weak.

The other thing you can try is to stand on just the foot that hurts and do toe raises just on that foot. Do them repetitively, 10, 15 toe raises and see if that recreates the pain. If it does and the pain is coming from this muscle that helps to hold up your arch, then what's happening is that that muscle is getting a little fatigued as you hike. And then, after a while, it can no longer support the load and it causes pain. That's something that can be fixed with good arch supports when you hike, as well as some therapy to strengthen that muscle.

Other possibilities, some people can get foot pain and the arch that's unrelated to that muscle. It's more sometimes a burning pain they get in the arch with prolonged walking. Sometimes it's also related to either footwear or occasionally is related to socks as well in the shoe that cause some friction and some abrasion and some pain there. So maybe try and change the socks or the shoes around and see if one shoe is better than another.

Announcer: You are listening to the Scope, powered by University of Utah Health Sciences. This is The Scope. Find us online at thescoperadio.com.

Interviewer: Preventing tendon injuries, that's next on The Scope.

Announcer: Health tips, medical news, research, and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: You know, once you have them, tendon injuries can take a long time to improve so it's really better to prevent them from happening in the first place. Dr. Emily Harold is a sports medicine specialist at University of Utah Orthopedic Clinic. Now, there are a lot of different tendon-based injuries, but all of them can be avoided is your contention.

Dr. Harold: Yes, tendon injuries are overuse injuries and whether you have it in your Achilles tendon or your patella tendon or tennis elbow, all of them are basically caused by the same kind of overuse. And all of them can be avoided if you practice some good tips to make sure you don't overstress your joints.

Interviewer: Okay. Ao when you say "overuse," is it just like when I go to the gym and work out and my muscles get sore, it's because I've used them a little harder than I should? Is it the same thing with the tendons or different?

Dr. Harold: Similar things. Our tendons are actually where the muscle connects to the tendon, and the tendon connects to the bone. And so they help your muscles work. And so when we say "overuse," if you're using the muscles in the same way on a repetitive basis that you have not yet had the correct training to do, that puts a lot more stress on the tendon and that can cause some inflammation and can lead to some tendonitis, where pain, as most people feel when they develop it.

Interviewer: So if I never played tennis before, never ran before, and all of a sudden I'm out there all the time doing that activity, it takes those tendons time to adapt is what I feel like you're saying.

Dr. Harold: Yes, exactly. And anytime you've ever gone out in the spring and done a lot of yard work after you haven't done it in a while, that kind of thing, you can notice that you get more pain in joints. What happens with tendonitis is you keep overusing the tendon without enough time for the tendon to rest in between using it again. So it's not like you go out one day and then the next day you take off. It's you go out every day over and over again, and you're not used to that activity. And that puts a lot of stress to on the tendon that causes it to break down.

Interviewer: Okay. Is the breakdown in a similar way like muscles break down?

Dr. Harold: Similar. It's a breakdown that's more of a chronic inflammation of the tendon that doesn't allow the tendon to heal. So over time of repetitively doing it, if you were to look at the tendon under a microscope, you would see the tendon actually looks different than a healthy tendon. It has areas where there are different amounts of blood flow. It has some areas where the cells have changed and that causes a source of pain over time.

Interviewer: When we start experiencing that pain, really, how advanced is your tendonitis by that point? I've been under the impression it's fairly advanced by then.

Dr. Harold: It's usually fairly advanced. Typically, it starts as a kind of pain that some people get off and on, and then usually what happens, it doesn't keep you from doing anything when it initially starts. So you feel the pain, but then you keep doing that same activity because you want to do it. And then it gets to the point where you can't do that activity anymore, and at that time it's very severe. It can be really hard to treat. Some of these tendon injuries can take three to six months of real good therapy and treatment to recover. And so it's much better to prevent them from happening in the first place.

Interviewer: All right. So what can be done so we don't develop tendon issues in the first place?

Dr. Harold: Well, I think first, you need to pay attention to what your body is telling you. If you're someone who doesn't do a lot of running and then you want to train for a marathon, you need to start slow. You know, just go out and running 5, 6, 7 miles a day. When you do that, you put a lot of stress on the tendons that doesn't need to happen. So, one, pay attention to your fitness level, or your activity level, and make sure if you want to have a goal of reaching something, that you start slow and build up over time.

Interviewer: That's so hard to do, right?

Dr. Harold: Very hard to do.

Interviewer: Yeah, I've heard something like 5% in the case of running, for example.

Dr. Harold: Yeah, it is painfully slow. So if you out and run a mile, I saw people start every other day for about a week, and then you can increase by 5% either mileage or time. Meaning, if you run a 10-minute mile, next week you're running a 9.45 mile. But it's that that slow. It's so painful that almost no one does it, which is why we see a lot of tendon injuries.

Interviewer: Okay. So what are some other things I can do?

Dr. Harold: Other things you can do is make sure after you do exercise that you stretch afterward. A lot of people will warm-up stretch prior to exercise. It's actually much better to do it after when the muscle's warm. That's when you get the most benefit from stretching, and so that will help as well.

Interviewer: So what should I do to warm up, then, if I'm not stretching? Because I think a lot of people stretch to warm up, right?

Dr. Harold: Right. So typically, we say you want to start with about a five-minute warm-up that brings up the heart rate. So things like a light jog, brisk walking, riding a bike for five minutes, something to that extent.

Interviewer: But not stretching. Stretching after your activity.

Dr. Harold: Stretching after, not before.

Interviewer: Okay. And what are some other things? I hate tendonitis so I want to avoid it.

Dr. Harold: Another thing is to make sure that you're doing proper technique. So if you're going to go to the gym and you're going to lift weights, make sure that someone has shown you how to do techniques. You don't put undue stress on the muscles and the tendons. So don't just walk in off the couch and start doing the machines. Take one of those introductory classes. Or, I mean, now there's great stuff online. You can even get on YouTube and watch some technique. You just have to be careful it's coming from reputable sources.

Interviewer: It's using your body properly because otherwise, you're putting that undue stress on that tendon.

Dr. Harold: I think we've all had it where you sprain your ankle, and then you do out and you hurt the ankle on the other side or the knee on the other side just because your mechanics aren't the same. So it's important that people pay attention to appropriate mechanics when they do activity to keep them from overstressing an area.

Interviewer: So quickly, because this is about trying to prevent, but if you do have an issue, a tendon issue, I'd imagine the earlier you treat it, the better.

Dr. Harold: Yeah, absolutely. When you start to feel that pain in the tendon, make sure that you stop doing the activities that bother it. And then, initially, you can start with the ice and the anti-inflammatories. The earlier you catch it, the quicker it is to get better, but a lot of times, you will need some supervision with a therapist or other medical professional to try and fully resolve that issue before you go back to that activity.

Interviewer: So tendon issues aren't just a part of activity in life. You can actually make it that you are relatively pain-free if you do it smart.

Dr. Harold: Yes, you can make it so you don't have them very often.

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