Knee injuries part 1: Basic anatomy & ACL tears

Today, we will be discussing knee injuries, the scourge of all competitive athletes. We have all heard of horror stories about freak knee injuries and long training lay-offs. However, few athletes have a good understanding of what actually occurs when they “tweak” their knee.

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Just a “tweak”

Let’s start by taking a look at the anatomy of the knee:

Knee anatomy 101

The knee joint is basically the junction between the femur (thigh bone) and the tibia (shin). It allows for movement in the form of extension (kicking out) and flexion (curling in) of the shin. There are various factors that ensure that the joint is stable and movement occurs only in the ways stated above and not in any other direction.

Firstly, the joint is supported by various ligaments. Ligaments are tough, fibrous connective tissue that help to hold the joint together and prevent any unwanted movements. The main ligaments of the knee joint are the collateral ligaments and the cruciate ligaments.

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The medial (side on the inner part of the thigh) and the lateral (side on the outer part of the thigh) collateral ligaments prevent the shin from moving side to side with respect to the thigh.

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a) MCL resisting sideways movement of the shin outward (Valgus angulation) b) LCL resisting sideways movement of the shin inwards (Varus angulation)

The anterior and posterior cruciate ligaments prevent the shin from moving forward and backward with respect to the thigh. They also prevent the shin from twisting around the long axis of the thigh.

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Left panel: ACL preventing forward movement of the shin; Right panel: PCL preventing backward movement of the shin

Secondly, there is a tough protective capsule surrounding the knee. This capsule is filled with synovial fluid, a kind of lubricating fluid that helps reduce friction.

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Thirdly, the joint is supported by the tone of the muscles. The quadriceps and the hamstrings help to stabilize the joint by pulling the two ends of bone together.

Lastly, the joint also has a rim of connective tissue called the menisci that encircle the  surface of the joint. Each meniscus improves the stability of the joint by creating a better fit between the thigh and the shin. The menisci also help to distribute the load evenly over the joint during movement.

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Furthermore, the surfaces of the joint in contact with each other are lined with cartilage, which act as a protective cushion that prevents bone from grinding against bone.

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That in a nutshell, is the basic anatomy of the knee. Knowledge of the structures of the knee is important, as it is these structures that get damaged in knee injuries.

Anterior cruciate ligament tears

Introduction

The anterior cruciate ligament (ACL) is the most commonly injured knee ligament. In the United States there are between 100,000 and 200,000 ACL ruptures per year. [1]

ACL tears can occur via contact or non-contact injuries. Contact-related ACL injuries usually occur from a direct blow causing hyperextension or valgus deformation (Knee collapsing inwards) of the knee. This is often seen when an athlete’s foot is planted and an opponent strikes or lands on him on the outer aspect of the planted leg.

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Outside leg kick on planted foot

It can also occur if the knee is forcibly twisted, such as in a heel hook.

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Outside heelhook

Non-contact ACL injuries occur when an athlete who is running or jumping suddenly decelerates and changes direction (e.g. cutting) or pivots or lands in a way that involves rotation or valgus stress of the knee.

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“Cutting” movement

Predisposing factors

Gender

Interestingly, female athletes have higher rates of non-contact ACL tears as compared to male athletes across most sports. [2] Several explanations have been proposed by researchers:

Female athletes tend to have quadriceps-dominant deceleration. Dominance refers to the muscle group being used preferentially to control deceleration. Several studies have found that in female athletes the quadriceps group generally contracts first during deceleration, while in men the hamstring group generally contracts first. The quadriceps muscles are less effective at preventing the tibia from moving forward with respect to the femur, which increases the stress placed on the ACL. [3]

Studies have also shown that women generally have weaker hamstrings and greater strength imbalances between the two muscle groups, and such imbalances increase knee instability. [4]

These findings suggest an important role for injury prevention training designed to correct relative muscle weakness and imbalance.

Increased valgus angulation of the knee during sudden changes in direction or landing greatly increases the stress placed on the ACL.

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An athlete landing with valgus angulation

Several biomechanical studies have found that female athletes are more likely to place their knees in positions of increased valgus angulation when changing direction or landing. [5] Thus, training to correct faulty biomechanics may reduce susceptibility to ACL injury.

Studies of ballet and modern dancers illustrate the importance of relative muscle weakness and poor biomechanics as risk factors for ACL tears. Dance training involves holding positions that strengthen the knees, hip stabilizers and torso, and perfecting jumping and landing technique.

Female dancers sustain ACL injuries at much lower rates than female athletes in other sports. [6] Studies of high level dancers and team sport athletes performing a 30 cm single leg drop-landing have noted that female dancers and male athletes (dancers and team sport participants) land in a similar fashion, with little or no knee valgus and greater hip and trunk stability, whereas female team athletes demonstrate significantly greater knee valgus and less hip and trunk stability.

Footwear and floor surface

Many studies have concluded that the risk of ACL injury increases when there is increased traction between the foot and the floor. This may occur when wearing shoes with good grip or playing on a particularly rough surface. [7] Increased traction when the foot is planted may lead to more stress on the ACL during cutting movements or during contact injuries.

This is relevant to wrestling, as many wrestlers compete/train in wrestling shoes which provide increased traction. It is difficult to say for sure if wrestling shoes increase risk of knee injuries. There have not been any studies comparing the rates of ACL tears in wrestlers who wear shoes and those that do not. Moreover, the high-cut nature of wrestling shoes offer protection against ankle injuries, so there may be some injury-prevention potential.

Personally, I still use wrestling shoes when wrestling as it is simply so much easier to take someone down with the increased grip that the shoes provide. Moreover, shoes are compulsory in most wrestling events and it makes sense to train under competition conditions.

How do ACL tears present?

During the injury:

  • There may be a “Pop” sound indicating rupture of a ligament
  • Immediate pain in the knee

After the injury:

  • Swelling occurs immediately after injury (in contrast to meniscus injuries where swelling occurs hours later). This occurs due to rupture of blood vessels and the leaking of blood into the joint space.
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Swelling of the right knee

  • After the initial swelling has improved,  there may be instability of the knee. Movements such as squatting, pivoting, stepping laterally, and activities such as walking down stairs, in which the entire body weight is placed on the affected leg, can elicit a feeling of the knee “giving out”

Other structures may be damaged along with the ACL in severe injuries. Common injuries include tears of the MCL and medial meniscus (also known as the “unhappy triad”). This may lead to more severe instability of the knee.

What should I do if I tweak my knee?

If you sustain a knee injury, you should stop training/competing immediately. Continuing with activity may worsen the damage to any structures in the knee. The RICE (Rest, ice, compression of the affected knee, elevation of the leg) protocol is useful when there is acute swelling of the knee.

Ideally, you should be evaluated by a trained medical professional to determine the nature and extent of the injury. However, this may not always be possible, as healthcare can be expensive and it may be time-consuming to seek help.

In situations such as this, a good rule of the thumb would be to avoid strenuous activity until the acute swelling of the knee has resolved. It may be possible that a less severe injury such as a MCL, LCL or meniscus tear has occurred. If there are symptoms such as instability of the knee or inability to fully extend the knee (“Locking” on extension may indicate possible meniscus injury), you should seek medical help.

If not, you can try  returning to training gradually. It is hard to say exactly how long without knowing the nature and the extent of the injury. Therefore, it is still recommended to seek advice from a medical professional.

What can a doctor do for me?

A good doctor/physio should be able to diagnose an ACL tear by examining the injured knee. However, they may still order an X-ray (to rule out any fractures) and an MRI (to confirm the diagnosis and to help with any operative planning).

ACL tears can be managed with or without surgery. Management without surgery involves rest, physiotherapy and pain/anti-inflammatory medication. Surgical management involves reconstruction of the ACL. In most cases, partial tears of the ACL can be managed without surgery with an emphasis on physiotherapy and working on proper sport-specific biomechanics.

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Reconstructed ACL

The decision to have surgery is based on multiple factors, including the athlete’s level of activity, functional demands placed on the knee, and the presence of associated injuries to the meniscus or other knee ligaments.

  • Level of activity: Athletes participating in high-demand sports that involve a lot of cutting, jumping, pivoting, and quick deceleration should undergo surgery. Most competitive athletes should undergo surgery if they hope to return to their pre-injury level of performance.
  • Associated injuries: Athletes with injuries to multiple knee structures (eg, ACL plus meniscus or medial collateral ligament) generally need surgical reconstruction due to the increased instability of the knee.
  • Significant instability: Athletes with significant knee instability that limits daily function should undergo surgery. Studies have shown that there may be an increased risk of osteoarthritis in patients with injuries to multiple knee structures and significant knee instability [8]

Rehabilitation

I won’t go into detail about the details of rehabilitation, as this is better explained by a qualified physiotherapist. However, the overall principles of rehabilitation include restoring full range of motion in the knee, strengthening the quadriceps and hamstrings, and enhancing balance, proprioception, and core strength. Compliance to rehabilitation is essential if an athlete hopes to return to his/her sport as soon as possible.

When can I return to training after surgery?

There is no consensus on the exact time athletes should return to their sport after knee surgery. However, a premature return increases the risk for re-injury and failure of the reconstructed ligament. In general, athletes may safely return to sport once their repaired knee demonstrates strength, proprioception, and function roughly equal to the unaffected knee. Most athletes return to full activity and sports between 6 and 12 months following surgery, depending upon the sport and their compliance with rehabilitation.

How can I prevent an ACL tear?

Research has consistently shown that a well-designed neuromuscular training program can help reduce the risk of non-contact ACL tears. [9] Again, it is beyond the scope of this article to discuss the exact exercises involved in such a program. Such programs are best designed by knowledgeable athletic trainers or physiotherapists.

However, I will summarize the key findings of existing research on the topic.

  • Programs that incorporated high-intensity jumping plyometric exercises reduced injury rates.
  • Programs that included biomechanical analysis and provided direct feedback to the athletes about proper positioning and movement reduced injury rates.
  • Programs that incorporated strength training of core muscles and lower limb muscles reduced injury rates, although strength training alone did not.
  • Balance training alone is unlikely to reduce injury rates, although it may enhance other prevention techniques.
  • Athletes must participate in prevention training at least two times per week for a minimum of six consecutive weeks to accrue any benefit.

Therefore it can be seen that for a program to successfully reduce ACL injury rates, it must incorporate different training modalities (strength, balance, plyometrics, and movement analysis) and must be done on a consistent basis.

In addition, studies have shown that wearing knee braces does not help prevent ACL injuries. [10]

Reduction of contact ACL injuries is a lot more difficult. Freak accidents do happen, especially in contact sports like MMA, BJJ and wrestling. However, promoting a safe training environment can potentially help reduce injury rates. This can include not training in an over-crowded training environment (in order to minimize accidental collision injuries).

Summary

Knee injuries are unfortunately very common. However, we are getting better at understanding how to prevent, treat and rehabilitate severe knee injuries such as ACL tears, which is good news for all athletes. All athletes should try to understand the basic anatomy of the knee and should know what to do in the event of an unlucky knee injury.

 

 

 

 

 

 

 

 

References:

[1] Gordon MD, Steiner ME.. Anterior cruciate ligament injuries. In: Orthopaedic Knowledge Update Sports Medicine III, Garrick JG. (Ed), American Academy of Orthopaedic Surgeons, Rosemont 2004. p.169

[2] Agel J, Rockwood T, Klossner D. Collegiate ACL Injury Rates Across 15 Sports: National Collegiate Athletic Association Injury Surveillance System Data Update (2004-2005 Through 2012-2013). Clin J Sport Med 2016; 26:518.

[3]  Chappell JD, Creighton RA, Giuliani C, et al. Kinematics and electromyography of landing preparation in vertical stop-jump: risks for noncontact anterior cruciate ligament injury. Am J Sports Med 2007; 35:235.

[4] Myer GD, Ford KR, Barber Foss KD, et al. The relationship of hamstrings and quadriceps strength to anterior cruciate ligament injury in female athletes. Clin J Sport Med 2009; 19:3.

[5] Hewett TE, Myer GD, Ford KR, et al. Biomechanical measures of neuromuscular control and valgus loading of the knee predict anterior cruciate ligament injury risk in female athletes: a prospective study. Am J Sports Med 2005; 33:492.

[6] Liederbach M, Dilgen FE, Rose DJ. Incidence of anterior cruciate ligament injuries among elite ballet and modern dancers: a 5-year prospective study. Am J Sports Med 2008; 36:1779.

[7] Thomson A, Whiteley R, Bleakley C. Higher shoe-surface interaction is associated with doubling of lower extremity injury risk in football codes: a systematic review and meta-analysis. Br J Sports Med 2015; 49:1245.

[8] Barenius B, Ponzer S, Shalabi A, et al. Increased risk of osteoarthritis after anterior cruciate ligament reconstruction: a 14-year follow-up study of a randomized controlled trial. Am J Sports Med 2014; 42:1049.

[9] Hewett TE, Ford KR, Myer GD. Anterior cruciate ligament injuries in female athletes: Part 2, a meta-analysis of neuromuscular interventions aimed at injury prevention. Am J Sports Med 2006; 34:490.

[10] Rishiraj N, Taunton JE, Lloyd-Smith R, et al. The potential role of prophylactic/functional knee bracing in preventing knee ligament injury. Sports Med 2009; 39:937.

 

Concussions

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Earlier this year, Jordan Parsons, a former Bellator MMA fighter, was tragically killed in a hit-and-run accident. He was subsequently diagnosed with chronic traumatic encephalopathy (CTE) after a post-mortem brain autopsy. CTE is a progressive degenerative disease found in individuals who sustain repeated blows to the head. Parsons is the first MMA fighter to be publicly diagnosed with the condition.

Dishing out and receiving head trauma is part and parcel of the combat sports. Many athletes have understandably become concerned about how head trauma will affect them in the long run.

Today, we will be discussing concussions in detail, with specific focus on recognizing the symptoms of a concussion, the potential complications and what to do should you sustain such an injury.

What is a traumatic brain injury?

Traumatic brain injury (TBI) occurs when an external force injures the brain. It encompasses a broad range of injuries to the brain of varying severity, ranging from a mild concussion to severe bleeding within the brain. For the purpose of this discussion we will be focusing on mild TBI.

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Examples of severe TBI – bleeding within the skull or brain

What is a concussion?

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Concussions are a subset of mild TBI. A concussion is a trauma-induced alteration in mental status that may or may not involve loss of consciousness.

Concussions are commonly caused by a direct blow to the head, face, neck. However blows sustained elsewhere on the body can cause a concussion as long as sufficient force is transmitted to the head.

Symptoms of concussions

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  • Confusion and amnesia

These are the hallmark symptoms of concussions. They may be apparent immediately after the head injury or may appear several minutes later. There is almost always loss of memory of the traumatic event. In addition, there is often loss of recall for events immediately before (retrograde amnesia) and after (anterograde amnesia) the head trauma.

An athlete with amnesia may be unable to recall details about recent plays in the game or sequences in a fight. They may also be unable to recall details of well known current events in the news and may repeatedly ask a question that has already been answered.

  • Headache
  • Dizziness (vertigo or imbalance)
  • Nausea and vomiting

Over the next hours and days, athletes may also complain of:

  • Mood and cognitive disturbances

Cognitive – Feeling mentally foggy or slow, disorientation, difficulty concentrating, slow or incoherent speech, word-finding difficulty.

Mood – Irritability, sadness, emotional instability, nervousness.

  • Sensitivity to light and noise
  • Sleep disturbances (Drowsiness etc.)
  • Seizures

Post-traumatic seizures occur in fewer than 5 percent of mild or moderate traumatic brain injury (TBI), and they are more common with more severe TBI. About half occur within the first 24 hours of the injury; one quarter occur within the first hour.

Other findings include:

  • Issues with balance
  • Lack of coordination
  • Issues with vision
  • Fatigue
  • Numbness/tingling
  • Neck pain

It is important to recognize that the alteration in mental status characteristic of concussions can occur without loss of consciousness. In fact, the majority of concussions in sports occur without loss of consciousness and are often unrecognized.

Complications of concussions

Most athletes make a complete recovery and return to full function. Nonetheless, there are a variety of short and long-term complications that have important implications.

Second Impact Syndrome

Second-impact syndrome (SIS) occurs when the brain swells rapidly, and catastrophically, after a person suffers a second concussion before symptoms from an earlier one have subsided. The condition is rare but it is generally leads to death. No risk factors for SIS could be identified with any certainty and current research is controversial. For example, it is unclear why this is not a more frequently reported occurrence in boxers, who are at high risk of repeated concussions within a short time span.

Chronic Traumatic Encephalopathy

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Chronic traumatic encephalopathy (CTE) is the term used to describe brain degeneration caused by repeated head traumas. Repeated concussions can cause long term cognitive impairment and neuropsychological symptoms (behavior, personality changes, depression, and suicidal thoughts). It can also cause parkinsonism, as well as speech and gait abnormalities.

There have been increasing reports of dementia among NFL players with a history of multiple concussions. One cohort study found that neurodegenerative disease-related mortality was three times higher in retired NFL players compared to the general US population; Alzheimer disease-related mortality was four times higher [1]

The incidence is approximately 20 percent in professional boxers (though much less common in amateur boxers). The number of professional bouts (typically greater than 20) appears to be more important than the number of “knockouts”. The total number and type of head blows, particularly if the angle of impact or failure to stabilize the head results in rotational head movements, may be important as well, but it is difficult to quantify [2,3,4]

Athletes at particular risk of chronic impairments include:

Athletes with more severe symptoms after concussion, in particular early onset of headache after injury, fatigue/fogginess, early amnesia, dizziness, and disorientation. These individuals are likely to also have a longer recovery from concussion.

● Athletes with a history of multiple concussions . Most studies involving professional athletes have found a relationship between sustained neurocognitive impairments and increasing concussion exposure (However, there is insufficient data to make the same association in amateur athletes). A threshold of injury (number/severity of concussions required before CTE occurs) has not been established.

What should you do if you sustain head trauma?

If you sustain any traumatic injury (to head or anywhere else on the body), first determine if there are any new neurocognitive symptoms (dizziness, feeling “slow”, amnesia etc.) or loss of consciousness. If any of these are present, it is likely that a concussion has occurred.

The most important next step is to remove yourself from harm’s way. No athlete should be permitted to return to training or competition the day a concussion is diagnosed. Avoiding repeat head trauma is critical to a quick recovery.

Certain red flags should prompt you to visit the nearest emergency department immediately, as more serious injury (eg, cervical spine injury, intracranial hemorrhage, skull fracture) may have occurred. These include:

  • Prolonged loss of consciousness (eg, longer than one minute) ‒ Although there is no high quality evidence to support this threshold, one minute is commonly used by doctors to determine that the duration of loss of consciousness may represent a more dangerous condition.
  • Concern for cervical spine injury – based upon the mechanism of injury (eg, falling on your head), complaints of neck pain, weakness or loss of sensation in the limbs.
  • High-impact or high-risk mechanism of injury – For example, the athlete’s head forcefully hitting the floor after a high amplitude throw. This may increase the chance that bleeding has occurred within the skull or brain.
  • Post-traumatic seizure ‒ While seizures may occur in mild TBI, they are more common in severe TBI when there is bleeding within the skull or brain. Therefore, any athlete who develops seizure activity following head trauma should be taken immediately by ambulance to the emergency department for evaluation.
  • Persistent nausea and vomiting – See above
  • Significant and progressive worsening in the athlete’s condition – Such findings suggest a more serious injury and typically become evident within the first several minutes to a few hours after head trauma (may take longer in athletes over 60 years). The patient’s mental and physical status may deteriorate and there may be progressive drowsiness, slurred speech, difficulty or inability to walk.

Cognitive rest (Rest from mental exertion) is also an important element of concussion treatment, particularly during the first 24 to 48 hours. For patients with severe symptoms or concerning medical examination and test results, complete cognitive rest (No use of phone, no texting, no music, no watching of TV, no usage of computer). For those with milder symptoms and less concerning examination and test results, limited activity is permitted provided it does not worsen symptoms. Exposure to video games, loud music, prolonged screen time, or mental activities requiring high levels of focus and concentration frequently induce symptoms and prolong recovery time. Therefore they should be avoided for a few days after injury.

Proper sleep during this period of physical and cognitive rest is also important. Lack of exercise can affect energy and appetite, and can quickly influence sleep patterns. Lack of quality sleep will influence daytime energy, concentration, irritability, headaches, and several other symptoms and can potentially slow recovery

Even if red flags are absent, it is wise to visit a doctor for a complete assessment as it is easy to miss mild concussions. The doctor can also determine the appropriate next steps, including the amount of cognitive and physical rest warranted before returning to school or sport.

It is also important to ensure that a responsible adult is with the concussed athlete for the first six to eight hours after concussion primarily to monitor for any acute worsening during this time.

When can I train again?

The most recently issued 2012 Consensus Statement on Concussion in Sport proposed a six-day graduated return to play protocol in which the athlete makes a step-wise increase in functional activity, is evaluated for symptoms, and is allowed to progress to the next stage each successive day if asymptomatic. If symptoms occur, then the patient should drop back to the previous asymptomatic level and reattempt progression after 24 hours. [5]

graduated-return-to-play-protocolHowever, when in doubt, it is always better to err on the side of caution. Premature return to play, when an athlete is still symptomatic, places him or her at great risk for subsequent injury, including recurrent concussion.

Retirement from contact sports

Making the decision to retire from contact sports is a difficult decision, as there may be significant financial considerations for professional athletes. It should ideally be made with input from a doctor experienced in the assessment and management of sports-related concussions.

Factors to consider:

  • How many diagnosed concussions has the athlete experienced?
  • Are concussions occurring with progressively less force? (I.e low threshold for injury)

  • Are the symptoms experienced after concussion of increasing intensity?

  • Is the cognitive dysfunction experienced after a concussion becoming more severe?

  • Is the duration of recovery progressively increasing?

  • Are there structural brain abnormalities on neuroimaging (CT, MRI scans)
  • Are there non-resolving or prolonged neurocognitive deficits (behavior, personality changes, depression, and suicidal thoughts etc.)

Retirement, while painful, may ultimately spare the athlete from more serious complications further down the line.

Conclusion

Head trauma is always a risk in combat sports.  Coaches and athletes should be educated adequately so that they are able to recognize the symptoms of concussions and are aware of the need for physical and cognitive rest after such injuries. This is important so that a repeat concussion while the athlete is symptomatic does not occur.

While it is unrealistic to assume that concussions can be completely prevented, training safely and intelligently can help reduce this risk. It is probably unwise for athletes to spar hard too frequently.

Concussions, especially if they are recurrent, have the potential to have long-term effects on an athlete. However, with appropriate medical treatment, adequate physical and cognitive rest, full recovery is likely for most athletes.

References

[1] Lehman EJ, Hein MJ, Baron SL, Gersic CM. Neurodegenerative causes of death among retired National Football League players. Neurology 2012; 79:1970.

[2] Jordan BD. Chronic traumatic brain injury associated with boxing. Semin Neurol 2000; 20:179.

[3] Loosemore M, Knowles CH, Whyte GP. Amateur boxing and risk of chronic traumatic brain injury: systematic review of observational studies. BMJ 2007; 335:809.

[4] Ryan AJ. Intracranial injuries resulting from boxing. Clin Sports Med 1998; 17:155.

[5] McCrory P, Meeuwisse WH, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013; 47:250.

[6] Concussion and mild traumatic brain injury [Internet]. Uptodate.com. 2016 [cited 18 November 2016]. Available from: https://www.uptodate.com/contents/concussion-and-mild-traumatic-brain-injury

 

BjjBrick Podcast

Hey everyone! I’ve been featured as a guest on the BjjBrick Podcast!

Link: BjjBrick Podcast Episode 157

Topics of discussion include:

  • Causes of cauliflower ear
  • Going to the doctor for cauliflower ear
  • Signs of cauliflower ear
  • The treatment process for cauliflower ear
  • Who is likely to get cauliflower ear
  • Draining your ear at home
  • What happens to your brain when you are choked out
  • Cerebral Hypoxia
  • Getting dizzy during a choke
  • Skin infections
  • Identifying bacterial, fungal, and viral infections
  • Common infections in BJJ
  • Ring worm
  • Staph infections
  • A story about an knee injury
  • Training and having a busy schedule

Give it a listen and let me know what you think!

Cauliflower ear

Hi everyone! I apologize for the long break between posts. I’m currently doing my general surgery posting and it’s been pretty grueling. Hopefully, I’ll be able to get back into the groove of writing.

Today we’ll be talking about cauliflower ear and auricular hematomas. Cauliflower ear is the permanent deformity that results when an auricular hematoma is not fully drained, recurs, or is left untreated.

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What is an auricular hematoma?

Before we talk about the injuries that can occur to the ear, we need to have an understanding of the anatomy of the ear.

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The ear is actually composed of 3 main parts: the outer, middle and inner ear. Today we’ll be focusing on the outer ear because it is most vulnerable to trauma.

The auricle (also known as the pinna) is the visible part of the ear that lies outside the head.

The auricle has a framework of cartilage that provides it with its shape. Adjacent to the cartilage is a dense layer of connective tissue called the perichondrium. The cartilage has no blood supply and is dependent on the perichondrium for its blood supply and nutrients.

ear layers

Shearing forces to the auricle (from a direct blow to the ear, or grinding of the ear against a surface) can lead to the lateral (forward facing side) perichondrium separating from the underlying cartilage. This can tear the perichondrial blood vessels, which leads to bleeding within the enclosed space. The blood is trapped, leading to the formation of a hematoma.

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How does cauliflower ear develop?

The hematoma acts as a physical barrier between the cartilage and its perichondrial blood supply. The cartilage, unable to get a sufficient supply of fresh blood, starts to die. It then thickens and scars, and new cartilage starts to form. However, this process is disorganized, leading to asymmetrical cartilage formation and ear deformity.

Treatment of auricular hematomas

If you sustain an injury to your outer ear, pause and evaluate the severity of the injury. You should be extra cautious if you sustained a blow to your ear. Should that happen, look out for certain red flags that indicate a more severe underlying issue:

Head injuries – loss of consciousness, amnesia before or after event, persistent headache, vomiting.

Damage to middle and inner ear – loss of hearing, feeling that the room is spinning around you.

If any of these red flags are present, you should head to the nearest emergency department.

If the injury is less severe (grinding force against your ear etc.), determine if a hematoma has formed.

If your auricle feels painful when you exert pressure on it, but there are no signs of bleeding (hematoma etc) aside from some redness, the injury is unlikely to be severe. You do not need to see the doctor and you can treat it yourself by applying ice and taking over-the-counter painkillers (paracetamol etc.) to ease the pain. Simple bruising, without any formation of a hematoma, can be treated in the same way.

If a hematoma has formed, you should seek medical attention as soon as possible. Early drainage of the hematoma and re-apposition of the perichondrial layer to the underlying cartilage restores perfusion to the cartilage and reduces the likelihood of cauliflower ear. If left alone, the hematoma will begin to clot and organize within 48 hours.

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There are multiple reasons I recommend visiting a healthcare professional as opposed to self-drainage with a needle. Firstly, the doctor/nurse can give you a local anesthetic injection to help ease the pain.

Secondly, hematomas that are greater than 2cm or have been present for greater than 48 hours may need to be incised and drained using a scalpel instead of a regular needle. This should ideally be done by a trained professional.

Lastly, it isn’t enough to simply drain a hematoma. A compression dressing must be applied to the ear to prevent the re-accumulation of blood within that space. Without this, the hematoma will simply recur and you’ll end up back at square one.

You should refrain from activity that places your ear at risk of additional trauma until the ear is healed (No hard sparring, though light drilling may be possible).  Full return to training can occur as early as seven days after the initial injury if the hematoma does not re-accumulate.

Prevention

It it is strongly recommended that protective headgear be worn to prevent auricular hematomas. In a 1989 survey conducted by the Department of Otolaryngology, Ohio State University, Columbus (1); auricular injuries occurred more frequently among collegiate wrestlers who were not wearing headgear (52 versus 26 percent for auricular hematoma and 27 versus 11 percent for cauliflower ear, respectively.)

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That being said, not everyone likes wearing headgear. I personally don’t wear headgear because I don’t like how warm and stuffy they make my ears feel. I’m a hobbyist and I frankly don’t train enough to accumulate that much abuse to my ears (though a freak blow to my ear could definitely still happen).

Conclusion

If you have an auricular hematoma, drain and compress it as soon as possible!

I hope this post was useful to you! Let me know what you think and feel free to give me suggestions for my next post!

References

(1): Schuller D, Dankle S, Martin M, Strauss R. Auricular Injury and the Use of Headgear in Wrestlers. Archives of Otolaryngology – Head and Neck Surgery. 1989;115(6):714-717.

(2): Assessment and management of auricular hematoma and cauliflower ear [Internet]. Uptodate.com. 2016 [cited 21 August 2016]. Available from: http://www.uptodate.com/contents/assessment-and-management-of-auricular-hematoma-and-cauliflower-ear

(3): Ganti L. Atlas of emergency medicine procedures.

Skin infections (Part 3): Fungal

Hi everyone! I know you’re probably sick of reading about skin infections. However, for the sake of completeness, we need to finish our discussion by talking about fungal skin infections.

Fungi are widespread in the environment. Fungal infections in humans can generally be classified into 3 categories:

  1. Superficial skin infections
  2. Deeper subcutaneous infections
  3. Widespread systemic infections

Today we will be focusing on superficial infections, as these are more common in combat sports. There are many species of fungi that can cause these infections.

Tinea corporis (ringworm)

Tinea corporis is a cutaneous fungal infection occurring in sites other than the feet, groin, face, or hand.

ringworm 1Tinea_crprs_plaq

What to look out for:

  1. Red, scaly, circular or oval patch
  2. Usually itchy
  3. Continues to grow and spread outwards from the center
  4. Central area clears, while an advancing raised border remains (forming a ring-like lesion)

Tinea Pedis (athlete’s foot)

Tinea pedis (also known as athlete’s foot) is the most common fungal skin infection. Infection is usually acquired by means of direct contact with the fungi, as may occur by walking barefoot in locker rooms or swimming pool facilities.

pedis

Interdigital tinea pedis

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What to look out for:

  1. Red, itchy, erosions or scales between the toes
  2. May sometimes be painful

Moccasin-type tinea pedis

superficial3

What to look out for:

  1. Patchy, dry scaling on the soles and sides of the feet
  2. On a red base

Tinea cruris (Jock itch)

Jock itch is common in athletes in the groin region due to copious amounts of sweating and tight-fitting clothing.

Tinea_cruris_3

What to look out for:

  1. Red, itchy patch on the upper and inner part of the thigh
  2. Patch grows and spreads outwards
  3. Central area clears slightly
  4. Red, elevated border that may have tiny fluid filled blisters

Treatment of fungal skin infections

If you notice a fungal infection on your skin, you should stop training and visit a doctor. These infections are contagious and spread via skin-on-skin contact.

The doctor can usually diagnose a simple fungal infection by looking at it. However, ringworm can sometimes be confused with other ring-like skin eruptions. One such example is eczema (treated with topical steroids). If a fungal infection is misdiagnosed and initially treated with a topical steroid, the appearance of the infection may be altered, making diagnosis more difficult. The infection may also worsen (steroids suppress the immune system) and progress to a deep-seated infection of the follicles. (Majocchi’s granuloma). Therefore, the doctor might do a skin scraping and utilize a microscope to confirm the diagnosis.

The doctor might give you antifungal drugs that can be directly applied to the affected area of the skin. Treatment is generally administered once or twice per day for one to three weeks. Oral antifungal drugs may be prescribed for patients with extensive skin involvement and patients who fail topical therapy.

Prevention of fungal skin infections

The same prevention tips for bacterial and viral skin infections still apply. Here are some other guidelines that can help keep fungi away from your skin.

  1. Always wear slippers or sandals when at the gym, pool, or other public areas. That includes public showers.
  2. Dry yourself well after showering (don’t forget your feet and in between the toes!)
  3. Consider using talcum powder for your feet and groin if you have recurring infections

Conclusion

That sums up our discussion about skin infections! I hope this 3-part series has taught you a thing or two about common conditions of the skin. I also hope it has underscored the need to maintain good personal hygiene.

Stay tuned for the next post about cauliflower ear!

 

Skin Infections (Part 2): Viral

Hello everybody! Today we will be resuming our discussion about skin infections. Besides bacteria, viruses are also a common cause of skin infections. Without further ado, let’s jump straight into the dirty details:

Viral Infections

Viral warts

These common and non-cancerous warts are caused by the Human papilloma virus (HPV). HPV infects the epidermal cells of the skin. Infection with HPV occurs by direct skin contact. Minor skin trauma predisposes patients to infection, though infection may also occur in normal skin. Patients may also spread a wart to an uninfected part of their own skin.  The time period between infection and the appearance of the warts is approximately two to six months.

Viral warts are divided into three main categories: common warts (verruca vulgaris), plantar warts (verruca plantaris), and flat (plane) warts (verruca plana)

Common warts

Verruca_vulgaris_hand_2Verruca_vulgaris

What to look out for:

  1. Dome-shaped thickening of skin that grows outwards
  2. Most common on fingers, top of the hands, knees or elbows but may occur anywhere
  3. Black dots (key defining feature distinguishing it from a corn) on the surface of the warts which can be seen when skin debris on the wart is scraped of with a blade or file. The black dots are actually capillaries and thus bleeding may occur if you pick at the wart

The natural tendency to pick or scratch at existing warts can spread them to unaffected skin, a process known as autoinoculation.

Flat warts

Most common on the top of the hands, arms and face

Flat_warts_foreheadFlat_warts_linear

What to look out for:

  1. Small smooth-surfaced bumps on the skin
  2. Slightly elevated
  3. Flat-topped
  4. Skin-coloured or pink.

Damaging a flat wart (e.g., shaving the neck) may cause the virus to spread, eventually leading to crops of several hundred flat warts.

Plantar warts

plantars-wartLargeplanterwartPlantar_warts_close_view

What to look out for:

  1. Thick wart that grows inwards (rather than outwards like a common wart)
  2. On the soles of the feet
  3. Black dots (capillaries)
  4. Several plantar warts may accumulate beneath the surface of the epidermis, with the surface resembling one large wart.
  5. Plantar warts may be painful when walking

Plantar warts may be mistaken for calluses. Skin lines pass around a wart while they pass through a callus. Warts have the characteristic black dots while calluses do not.

Infection can occur when someone who already has a wart walks barefoot, leaving behind viral particles. The particles can then be picked up by another person who is walking barefoot.

Treatment of viral warts

Most viral warts will go away on their own. For most people, treatment of viral warts is not mandatory. However, it is highly recommended that grapplers avoid training and get their warts removed by a doctor, so that they do not infect their training partners.

A variety of interventions are available for treatment. Common methods include chemical or physical destruction of infected tissue (e.g. salicylic acid, cryotherapy, surgery, laser), or other stronger medications. In general, the approach is dependent upon the type of wart  and influenced by consideration of wart location, treatment side effects, clinician skill, and patient preference.

Molluscum Contagiosum

Molluscum contagiosum is another virus that can infect the skin. It is a common disease of childhood. The disease also occurs in healthy adolescents and adults, often as a sexually transmitted disease (on the genitals) or in relation to participation in contact sports.

Molluscum is spread by direct skin-to-skin contact and thus can occur anywhere on the body. The virus can be transmitted via autoinoculation by scratching or touching a lesion. For example, if the lesions develop on the face, shaving may spread the virus.

Infection can also be spread via fomites (any object or substance capable of carrying and transferring infectious organisms) on bath sponges or towels or through skin contact during participation in contact sports  An association of molluscum with swimming pool use also has been reported.

The time period between infection and the appearance of the characteristic bumps on the skin is between two and six weeks.

molluscum_contagiosum_genitalMolluscum_neck

What to look out for:

  1. Firm, dome shaped bumps (2 to 5 mm in diameter) on the skin
  2. Shiny surface and central indentation
  3. May appear anywhere on the body except the palms and soles. The most common areas of involvement include the torso, armpit, crook of elbow, behind the knee, and inner thigh

Treatment of molluscum

In most patients, individual lesions usually spontaneously resolve within two months and the infection often clears completely within six to twelve months. In a minority of cases, disease persists for three to five years

It is technically possible to continue training while infected with molluscum. Care must be taken to reduce the risk of transmission to others. Bumps in areas that are likely to come in contact with others should be covered with a watertight bandage and a rashguard.

The main issue with this is that smaller bumps that are harder to notice may not be covered up, and your partners may still end up getting infected. Therefore, train at your  own (or your partners’) risk.

Regardless of whether you decided to stop training, it is recommended that grapplers get their molluscum treated by a doctor. Like viral warts, there are many methods available (cryotherapy, lasers etc.)

Herpes Simplex Virus

Herpes simplex virus type 1 (HSV-1), also known as herpes labialis, is the virus responsible for “cold sores” on the mucosa of the mouth. (HSV-2 is responsible for herpes on the genitals)

HSV-1 may be associated with combat sports, where it is often called Herpes gladiatorum (a.k.a. wrestler’s pox, mat pox). Transmission is primarily by direct skin-to-skin contact and abrasions may facilitate a portal of entry.

herpes-simplex

What to look out for:

  1. Early stage (<6 hours): Itching, tingling or burning sensation followed by:
  2. Clustered, small, painful, fluid-filled blisters on a red base which heal with crusts over about 1 to 2 weeks.
  3. Headache, generalized illness, sore throat and fever may be reported.
  4. May lead to recurrent infections, as the virus can hide and remain dormant within your nerves

Herpes simplex may be confused with early impetigo. Accurate diagnosis requires laboratory testing by the doctor.

Treatment of Herpes gladiatorum

It is important to stop training as soon as possible and see the doctor. Treatment of herpes gladiatorum is with oral aciclovir or similar agents and is most effective if commenced at the first symptoms of an outbreak (<48 hours after onset of blisters). Topical aciclovir may also be given.

How to prevent viral skin infections

Besides the general guidelines that were recommended in Part 1 of the series, here are a couple more recommendations:

  1. Do not share towels or bath sponges
  2. Wear flip-flops in communal showers. While this may seem a little extreme, walking barefoot on a wet floor may put you at risk. It is worth mentioning that my microbiology tutor, a part-time rugby coach in his free time, insists on wearing flip-flops in communal gym showers.
  3. If you do have a viral skin infection, do not pick and scratch at the bumps. This is a good way to avoid autoinoculation.

Conclusion

Viral skin infections can be a real pain. However they tend to be a little less serious than bacterial infections. With appropriate treatment, they are usually easy to deal with. Stay tuned for the final part of the series, where I’ll be talking about fungal infections!

 

 

Skin Infections (Part 1): Bacteria

“Staph” – the mere mention of the word strikes fear into the hearts of grapplers everywhere. Skin infections are pretty common in grappling due to the large amount of skin-on-skin contact. These infections can be caused by bacteria, viruses, fungi or any other parasites. Today, we will be talking about bacterial skin infections.

To understand skin infections, we first need to understand the anatomy of the skin:

Skin-Anatomy-2

The skin essentially has 3 layers: epidermis, dermis and subcutaneous tissue. Any one of these layers can get infected. In general, the deeper the infection, the more serious it is.

Everyone knows about staph ( a.k.a Staphylococcus aureus).  However, Streptococcus pyogenes is also a very common cause of skin infections.

Warning: Some of these images are pretty graphic

Overview of bacterial skin infections

Screen Shot 2016-07-06 at 6.56.15 pm

Impetigo

Impetigo is a highly contagious infection of the superficial layer of the epidermis. It can be caused by both staph and S. pyogenes. Impetigo can happen when bacteria invade an area of normal skin or when there is infection of areas of minor skin trauma (cuts, abrasions, eczema).

Non-bullous impetigo

This is the most common form of impetigo (70% of the cases)

impetigo

What to look out for: It starts out with papules (small swellings of the skin), that progress to become vesicles (small fluid filled sacs) lying on an area of redness. The vesicles then rupture to form the characteristic honey-coloured crust on a moist red base.

Bullous impetigo

Less common in adults and less contagious.

MRSA3

What to look out for: the vesicles enlarge to form fluid filled bullae (larger blisters) with clear yellow fluid, which later becomes darker and more cloudy. Ruptured bullae leave a thin brown crust.

Bullous_impetigo_crusting

Treatment for impetigo

If you have impetigo, you need to stop training and see the doctor! It is highly contagious and you can easily spread it to your training partners via skin-on-skin contact. Do not share towels, gis or any other gear/equipment with anyone.

The doctor will give you topical antibiotics such as mupirocin and depending on how widespread the impetigo is, he/she may give you an oral antibiotic such as augmentin.

Don’t worry! Impetigo goes away pretty quickly with treatment and it usually does not leave any scars.

Erysipelas and cellulitis

Cellulitis and erysipelas are infections resulting from bacterial entry via breaches in the skin barrier. They are deeper infections than impetigo as they involve the dermis and are thus more serious. Erysipelas involves the upper dermis and superficial lymphatics while cellulitis involves the deeper dermis and subcutaneous fat.

Erysipelas

erysipelas-pictures-4

What to look out for: A painful area of redness, swelling and warmth. The lesion is usually raised above the level of the surrounding skin and there is a clear boundary between infected and non-infected skin. Patients with erysipelas tend to have systemic symptoms such as fever and chills.

Cellulitis

cellulitis_05_

What to look out for: A painful area of redness, swelling and warmth. The lesion is not raised and there is no clear boundary between infected and non-infected areas. Patients with cellulitis tend to have a slower and less aggressive course with development of localized symptoms over a few days’ time, though fever and chills may still occur.

Treatment of erysipelas and cellulitis

Unlike impetigo, erysipelas and cellulitis are not contagious as they involved the deeper dermis layer of the skin. However, it is still wise to stop training, because you may be systemically unwell (fever, chills etc.). It is essential that you see a doctor because antibiotics must be given.

IV antibiotics are needed if you have a severe infection, while oral antibiotics are sufficient for most patients who are systemically well.

Abscesses, furuncles and carbuncles

Skin abscesses are collections of pus within the dermis and deeper skin tissues. A furuncle (or “boil”) is an infection of the hair follicle in which pus and other material extends through the dermis into the subcutaneous tissue, where a small abscess forms. A carbuncle is a coalescence of several inflamed follicles into a single inflammatory mass with drainage of pus from multiple follicles.

All 3 can develop in healthy individuals with no predisposing conditions other than skin or nasal carriage of Staphylococcus aureus. Any process leading to a breach in the skin barrier can also predispose to the development of  skin abscesses, furuncles, or carbuncles.

Skin abscesses

Skin_abscess

Blausen_0007_Abscess

What to look out for: A painful, fluctuant (movable and compressible), red nodule, frequently surmounted by a pustule (pus containing blister) and surrounded by a rim of redness and swelling. Fever, chills, and generalized illness are not common.

Furuncles

furuncle-pictures

What to look out for: Similar to an abscess (hard, tender, red, fluctuant nodule), but centered around a hair follicle. May discharge pus and may be associated with fever and generalized illness.

Carbuncle

Carbuncle_new_2

156x150_carbuncles_ref_guide

What to look out for: Swollen painful area discharging pus from several points. May be associated with fever and generalized illness.

Treatment of abscesses, furuncles and carbuncles

Abscesses, furuncles and carbuncles are contagious. Thus you need to stop training. (are you starting to see a trend here?). They also may cause scars (more incentive to get them treated early).

For small furuncles, warm compresses to promote drainage are usually sufficient treatment. Larger furuncles, carbuncles, and abscesses require incision and drainage by a healthcare professional.

Oral antibiotics may be given if there are multiple lesions, a single abscess ≥2 cm, extensive surrounding cellulitis, signs of systemic infection, or inadequate clinical response to incision and drainage alone.

Necrotizing fasciitis (A brief mention)

There has been plenty of talk in the media about deadly “flesh-eating” bugs. This usually refers to necrotizing fasciitis, which is an infection of the deeper subcutaneous tissues that results in progressive destruction of the muscle fascia and overlying subcutaneous fat, and has a high mortality rate.

Necrotizing fasciitis is not caused by any special “flesh-eating”  bacteria. They are usually caused by good ol’ staph and S. pyogenes. The same organism can cause infections of differing severity depending on the layer of skin involved.

Thankfully, necrotizing fasciitis is extremely rare. It usually occurs to individuals after surgery or severe trauma (car accidents etc.). Other conditions associated with necrotizing soft tissue infection include diabetes, drug use, obesity and suppressed immune systems. Thus it is unlikely that the average grappler will get necrotizing fasciitis.

No images because they are all excessively gory (Google at your own risk)

What to look out for (just in case):

The affected area may be red (without sharp margins), swollen, warm, shiny, and extremely painful. The pain is usually out of proportion to the size of the lesion.

The process progresses rapidly over several days, with changes in skin color from red-purple to patches of blue-gray. Within three to five days after onset, skin breakdown with large blisters (containing thick pink or purple fluid) and gangrene can be seen. By this time, the involved area is no longer tender but has become numb secondary to clotting of small blood vessels and destruction of superficial nerves in the subcutaneous tissue.

Treatment of necrotizing fasciitis

Necrotizing fasciitis is an emergency. IV antibiotics and surgery is absolutely necessary to save the patient’s life. If you have necrotizing fasciitis, training BJJ will be the last thing on your mind.

Antibiotics and resistance

While it is true that antibiotic overuse has led to the rise of antibiotic resistant bacteria, antibiotics should not be avoided if you have a serious skin infection. In situations like this, antibiotics (+/- incision and drainage) are critical in ensuring that an infection does not spread. Therefore, it is wise to seek medical help whenever you suspect you have a bacterial skin infection.

There has been a rise in the prevalence of community acquired MRSA (Methicillin-resistant Staphylococcus aureus) in many countries, though it is still pretty rare. This is a cause for concern. MRSA is usually a hospital acquired infection (antibiotics are spammed in hospitals and the bugs that survive tend to be uber tough). However, many people on the internet make MRSA out to be some sort of unstoppable monstrosity that kills simply by touch. MRSA is still sensitive to some antibiotics, such as vancomycin. Thus getting an MRSA infection is not a death sentence (though it is still extremely serious).

Prevention of bacterial skin infections

There has been much debate about the need for special soaps (Defense soap etc.) for grappling. I will not discuss the pros and cons of the various soap types out there. The results are pretty controversial and I am simply not well-read enough or qualified to pass judgment.

However, I believe that all this argument detracts from the main point: don’t be a disgusting Neanderthal that neglects personal hygiene. 

Preventing bacterial skin infections is not rocket science. Here are some simple guidelines:

  1. Shower after class. You can use whatever type of soap you want, but make sure you scrub your body properly.
  2. Do not train with open wounds. Your skin serves as your body’s first line of defense against pathogens. Training with an open wound is akin to going to battle with a shield full of holes. Cover up your wounds!
  3. Don’t train with anyone that has a skin infection. Now that you know what the common bacterial infections look like, make sure you look out for them on your training partners.
  4. Train in a clean academy. Make sure your academy cleans their mats regularly.
  5. Don’t be that guy who trains in unwashed gis/training attire. Make sure you change and wash your gear regularly.

Conclusion

Bacterial skin infections suck. They take away precious time on the mat and are frankly quite disgusting. Good personal hygiene can help prevent the dreaded staph and S. pyogenes infections. However, if you do happen to get infected, don’t panic! Most skin infections are not that serious and are easily treated.

Stay tuned for the rest of the series, where I talk about viral and fungal skin infections.