By R.J. Anderson
R.J. Anderson is an Assistant Editor at Training & Conditioning.
Training & Conditioning, 14.6, September 2004, http://www.momentummedia.com/articles/tc/tc1406/swellingquads.htm
It was Tuesday, Jan. 13, 2003, and Kristin Giardina was getting ready to go to work. In addition to being a full-time student at Belmont University and starter on the women’s soccer team, Giardina also worked part time at a Chili’s restaurant in downtown Nashville, Tenn.
A junior who would be the team’s top returning defender as well as its captain in the fall, she had just completed a strenuous weightlifting session with the rest of her teammates. The workout followed an especially difficult session held the day before—one that included drop sets to exhaustion on the leg press.
Tuesday also marked only the second time Giardina had worked out since returning from winter break, which she figured was the reason she was sore. Very sore. So sore that it was nearly impossible for her to lift her legs high enough to step into the bathtub.
That night at work, Giardina was in so much pain that she only lasted about half a shift before leaving. "When I got home I couldn’t sleep because my legs hurt so bad," she says. "Then, later that night, I noticed my urine had turned a dark color, and I knew I needed to see the athletic trainers in the morning."
Giardina met with the Belmont athletic trainers on Wednesday morning and they made an appointment with Andrew Gregory, MD, FAAP, Assistant Professor of Orthopaedics and Pediatrics at Vanderbilt University and Team Physician at both Vanderbilt and Belmont. After attending her morning classes, Giardina, who could barely bend her knees due to the pain and swelling in her quadriceps, met with Gregory. He sent her straight to the emergency room.
Gregory diagnosed Giardina with bilateral compartment syndrome. "It’s a condition in which muscles, in this case the left and right quadriceps, swell to the point that the muscle’s blood supply becomes constricted," says Gregory. "The muscle swells so much that blood can’t get to it, and eventually the muscle starts to die."
Gregory says that in Giardina’s case, the condition was a result of overexertion. "She basically exercised her quad until she couldn’t do any more," he says. "She had been off for winter break and hadn’t done intense conditioning. When she came back, she just pushed it too far."
Surgery was scheduled for midnight, with Philip Kregor, MD, a surgeon at Vanderbilt University Medical Center, performing the operation. Kregor made an incision in the fascia in each of Giardina’s quads, allowing the muscle to swell outside the lining, which reinstated blood flow to the muscle. The incisions in the fascia would remain open for five days, requiring Giardina to remain in her hospital bed until they were stitched.
Compartment syndrome is considered very rare, and neither physician had ever seen the condition in a patient’s quadriceps. "I had seen it once in a basketball player, and that was in the calf muscle," says Gregory. "But in that case, the player had been struck in the calf by another player’s leg, so it was more an acute trauma than an overuse injury, as was the scenario with Kristin."
It turns out the compartment syndrome was only the beginning of Giardina’s troubles. As a result of the damage to her quadriceps, she was also experiencing rhabdomyolysis, a life-threatening condition where protein from the muscle leaks into the patient’s blood stream, damaging the kidneys. It was rhabdomyolysis that caused Giardina’s urine to darken.
"That was the real danger," says Gregory. "Kristin actually had some shutdown in her kidneys and there was concern that she was going to have to go on dialysis—we actually made arrangements to do so, but luckily she didn’t get to that point."
The bilateral compartment release surgery ultimately proved successful. However, after the operation, Giardina experienced a pneumonia-like illness that extended her stay in the hospital. To make matters worse, Kregor predicted that while she would one return to full strength, it was unlikely Giardina would make it back in time for her senior season in the fall. Her spirits were crushed.
During her nine-day stay at the hospital, Giardina was visited nearly every day by Gregory, who monitored her status closely. Christy Recinella, MEd, ATC, Athletic Trainer for the Belmont women’s soccer team at the time, was also a frequent visitor to the hospital, providing Giardina with support and companionship.
Once discharged from the hospital, Giardina spent nearly four days using a walker to get around. After she was able to walk on her own—albeit only short distances—Giardina began working with Recinella in the athletic training room on basic rehabilitation exercises consisting of quad sets, straight-leg raises, ankle pumps, and flexibility exercises. Giardina says that Recinella worked hand-in-hand with her to facilitate the program.
"Because it was such a rare condition, there was no set protocol for a rehab program," says Giardina. "So we just went by how I felt from day to day. If my legs got tired, I would tell the athletic trainers and they would let me rest. They trusted my judgement and didn’t try to push me too hard."
After two months, Giardina was cleared to begin more aggressive rehabilitation by adding light weights and more repetitions. Four months post-surgery, she began jogging, and it was at this point that Danielle Santangelo, MA, ATC, took over as Athletic Trainer for the women’s soccer team and began supervising Giardina’s rehab.
Most of Giardina’s rehab took place in the athletic training room using ankle weights and light dumbbells, and Santangelo says they did a lot of stretching and core work. But Giardina was hesitant about lifting weights again. "The first time we went back in the weightroom as a team, it was really tough," says Giardina. "I didn’t want to be there, but I knew that I had to face any fear that I had. I think if I hadn’t worked out with the rest of the team, it would have taken away from the team unity. And as captain, I definitely did not want to do that."
Despite the frustration of rapid fatigue and constant soreness, Giardina gradually worked her way back until she restored full function. On Aug. 15, she was cleared to participate in the fall soccer season, starting with preseason workouts. "At first it was kind of tough," says Giardina. "I was having trouble getting my touch back. My teammates played all spring together, so of course they had some chemistry with each other that I had lost a bit."
Santangelo adds that double sessions, as well as Nashville’s hot summer days, made it imperative that they approach Giardina’s rehab conservatively, especially since her condition was one brought on by overexertion. "We wanted her to do at about 40 percent of what everyone else was doing," says Santangelo. "We gradually built her up and listened to how she was feeling. If she was really sore, we would back off that day, or if she felt okay, we just kept plugging along. We were also careful to keep her hydrated, and to do everything we could do to prevent heat injuries or cramping.
"Kristin really wanted to be out there all the time, especially since she was the leader of the team," Santangelo adds. "But she knew that she needed to be smart and hold back a little bit so she could get herself back into shape and to make it through the whole season."
Other than one minor setback—a muscle hernia where the fascia incision had been, which sidelined Giardina for two days—the preseason proved relatively uneventful. Once the regular season began, Santangelo continued to bring Giardina along slowly, allowing her to play about 20 minutes in the first half of each game. Five games into the season, Giardina was back to starting at her center back position, where she would anchor the defense for the rest of the season.
Santangelo says that after watching her run during the preseason, she knew Giardina would be able to play, but she didn’t realistically expect her to play 90 minutes per game, especially with only a day or two between contests. "Kristin didn’t require too much time off during practices in between games," says Santangelo. "And really, the only extra work we did with her was 10 minutes of extra stretching before and after games and 20 minutes of leg massage after games."
A biology major with minors in athletic training and mathematics, Giardina graduated magna cum laude this past May and is slated to attend physical therapy school at Belmont in August. "My injury really solidified my career goal of becoming a physical therapist," says Giardina. "I know first-hand the frustration of wanting to do more and not being able to. It made me realize that I want to help other people the way I was helped."
Helping people is something Giardina has already done. "The conditioning work that led to Kristin’s injury was very general—it was probably too much too soon and not individualized enough," says Santangelo. "It’s definitely something we discussed, and it has been addressed program-wide. In that respect, this instance benefited the rest of the athletic department and all of our athletes. Now we do a lot more baseline max testing and have our athletes utilize partners who are on their same level as far as training goes."
Gregory, too, thinks that a couple of important lessons came out of the athletic department’s experience with Giardina. "One, when someone comes back and they haven’t been doing much conditioning, you have to build them back up," says Gregory. "You have to start slowly again, even though they are an elite athlete at the college level. And two, you have to listen to the athlete. If they say they’ve had enough, then you have to trust that they are being honest with you and not just trying to get out of the work."