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Timely tips for treating injuries in budding gardeners

As gardening jobs get into full swing, Dr Geoff Davies gives basic advice on how to avoid the hazards, and outlines how to treat injuries that occur

ardening can be extremely therapeutic and a good form of exercise for many people if carried out with care. Although gardening seems relaxing and suitable for anyone, in reality it involves some of the toughest physical work a person does all year. Even in a small garden, tasks may include digging, raking, bending, reaching, lifting and carrying, which use muscles that perhaps have not been exercised for weeks or months. Injuries often result from inappropriate or excessive lifting or carrying, or to overzealous activities such as digging, fence painting or hedge cutting.

Back problems

Many garden activities can lead to back problems, including pulling weeds, raking a lawn and digging. Other potential causes of low back pain are the frequent squatting and kneeling required for planting and weeding. Disc prolapse can occur in the garden but more commonly seen are pulled muscles and generalised muscle soreness due to their unaccustomed use.

Prevention of back injuries is the best option and can be lessened by avoiding digging for long periods, using wheelbarrows and other appropriate lifting gear for heavy duties and remembering appropriate lifting techniques involving bending the legs and keeping the back straight.

Tennis elbow/golfer's elbow

Several garden tasks can precipitate such elbow problems, including long painting sessions, using pruning equipment and cutting hedges with shears. Such overuse injuries, as in the sporting scenario, can be avoided.

Ensuring regular breaks are taken during such activity avoids excess stress on the forearm musculature which otherwise may lead to tendonitis. The use of appropriate tools, in good working order, especially power tools such as hedge trimmers and power saws, will help to reduce the risk of elbow problems.

Established tendonitis needs to be managed appropriately to reduce the risk of a chronic problem developing. Tennis elbow is a degenerative problem rather than an inflammatory condition.

It involves an angiofibroblastic degeneration at the origin of extensor carpi radialis brevis. Although degenerative in nature, it is often a response to overuse and overload. A stretching and strengthening programme for the long wrist extensors can speed recovery and reduce the risk of recurrence. Injection of local steroid can be reserved for those cases that do not respond.

Golfer's elbow is a similar problem but affecting the origin of the long wrist flexors. Again, a simple stretching and strengthening regime will aid recovery, with local steroid injections being reserved for more resistant cases.

Olecranon bursitis

This can occur as a type of overuse injury and with repetitive minor trauma. The function of the olecranon bursa is to allow the skin to glide freely over the bony prominence of the olecranon. It is a closed sac lined by synovium that is interposed between the skin and triceps tendon and the olecranon process.

With bursitis the walls of the bursa become thickened and oedematous and the bursal cells produce excess fluid. With significant trauma the bursal sac can contain frank blood. Repeated episodes of lesser trauma give rise to a chronic inflammatory process with a persistent effusion.

Management involves identifying and remedying any precipitating factors where possible. Symptomatic treatment with rest, ice and compression, possibly with oral anti-inflammatories, is the initial treatment.

Fluid in the bursa can be aspirated aseptically to improve comfort followed by the application of a pressure dressing. More chronic cases can be treated with aspiration and injection of steroid, often with good results. Surgery can be used to remove the bursal sac if symptomatic despite maximal conservative treatment. Occasionally a septic bursitis can occur but prompt treatment with antibiotics is usually curative.

Prevention is better than cure, so the use of elbow pads in those with symptoms should be considered.

Ankle sprains

As in everyday life, gardeners can sustain such injuries often associated with uneven ground, inappropriate footwear, obstacles and slippery surfaces. Being aware of such risks and taking care in the garden can help reduce ankle injuries.

Most sprains involve the lateral ligament complex and most are managed conservatively. Initial assessment involves appropriate examination of the ankle joint and deciding whether an X-ray is needed.

The Ottowa rules for ankle injury recommend an X-ray if there is bony tenderness of either malleoli or inability to weight bear. This seems an obvious suggestion but if followed appropriately will reduce the number of unnecessary X-rays performed.

The majority will involve damage to the anterior talo-fibula ligament. With more significant injuries the calcaneo-fibula ligament is involved and with severe injuries the posterior talo-fibula ligament is damaged. Most injuries can be conservatively managed as follows:

 · Protection with ankle bracing to prevent re-injury while ligament heals.

 · Rest for injured ankle until normal heel-toe gait is restored.

 · Ice on ankle to decrease swelling and relieve pain.

 · Compression as soon as possible to decrease swelling.

 · Elevation: the initial step for reducing swelling.

 · Medication: NSAIDs for pain relief.

 · Mobilisation early on when pain free to expedite return to activities.

 · Modalities: exercise and proprioception training to prevent re-injury.

Plantar fascitis

This inflammatory condition affecting the origin of the plantar fascia on the calcaneum can be caused by excessive digging, especially in unsuitable footwear. The plantar fascia originates on the medial calcaneal tuberosity and inserts on the proximal phalanx of each toe. It helps to support the medial longitudinal arch and as such is important in weight redistribution during the gait cycle.

The condition usually presents with localised heel pain which is often bilateral and can be very debilitating. Avoidance of long periods of digging and ensuring the use of good solid-soled footwear can help avoid this. The following important pointers should be noted1:

 · X-rays are generally unhelpful

 · Ignore 'plantar spur'

 · Rest/stretching/orthotics first-line

 · No evidence to say heel cups beneficial

 · Reserve injection for chronic cases

 · Only consider surgery after 12 months' conservative treatment.

Patella bursitis

Bursae are synovial-lined cavities that normally contain a thin film of fluid that overlie bony prominences around the knee. They serve to reduce friction during knee motion.

Repetitive trauma from overuse, or more commonly, chronic irritation results in local inflammation and fluid collection within the bursa. The prepatellar bursa is the most commonly affected and is known also as housemaid's knee, which is often caused by excessive kneeling, especially on hard grounds.

Such activity can result in tissue damage and inflammation of the various bursa associated with the patella. Patients present with swelling, pain and tenderness well localised to the inflamed bursa.

Swelling can be dramatic, but it is always confined to the general area of the inflamed bursa.

With prepatellar bursitis, the bony contours of the patella are obscured, unlike an intra-articular effusion.

Weight-bearing or gentle range of motion does not significantly increase pain, although the patient will notice tightness and secondary pain as flexion is increased.

This helps to distinguish bursitis from septic arthritis which is markedly painful to any range of motion or weight bearing.

Avoid long periods of kneeling. The use of pads or other aids will help to reduce the pressure on the patella and reduce the risk of bursitis developing.

Established bursitis may need relative rest from precipitating activities, non-steroidal anti-inflammatory drugs and occasionally aspiration of the bursa (sometimes with injection of steroid).

Tools with specially developed extended handles can allow the user to carry out tasks such as weeding without kneeling or bending.

Other garden hazards

 · Cuts and wounds Tetanus is a theoretical risk, so gloves should be encouraged.

 · Poisons Gardeners must responsibly label household toxins.

 · Power tools/machinery Common sense will help to avoid dangerous

and potentially fatal injuries. Vigilance and appropriate protective gear

should be advised.

Gardening

may seem suitable for anyone, but

it's some of the toughest work

of the year~

Checklist to help prevent injury

and accidents in the garden

 · Do not do too much too soon (particularly novice gardeners)

 · Take regular breaks while working

 · Avoid excessive bending and twisting at the knees; lift items carefully by bending the knees

 · Make use of labour-saving tools that can help

reduce overuse injuries

 · Use appropriate protective equipment

Reference

1. MacAuley D, Best T. Evidence-based Sports Medicine. London: BMJ Books, 2002

clinical

clinical

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