Ask DAN - October 2008
From the October, 2008 issue of Scuba Diving Magazine. Topic #8: Musculoskeletal Issues
Divers of all ages are susceptible to musculoskeletal injuries. From sprained ankles to joint replacement surgery, it's a broad topic to be sure. Long-term musculoskeletal problems are more common among older people, and since a significant segment of the diving population is aged 40 and above, it's no wonder DAN receives a large number of calls through its medical hotline about diving with these types of problems. Here's a look at the most common musculoskeletal issues divers face and the implications they, and their associated medications, have on diving.
The Top 7 Musculoskeletal Problems
The list of ailments that fall under the category of musculoskeletal issues is long. Each condition has its own set of symptoms and considerations, but what they all have in common is a need to understand, to heal and to adapt. None of these conditions automatically preclude a person from diving, but it's crucial to understand the increased risks they can present to a diver, and how those risks can be reduced and avoided.
There are two major categories of arthritis: osteoarthritis (OA) and rheumatoid arthritis (RA). Both involve the inflammation of bone and cartilage, most often in the joints, and both tend to advance with age. There are two primary concerns when diving with arthritis: restricted mobility and impaired blood flow. Decreased mobility happens during painful "flare-ups," when the joints or affected areas are inflamed. These episodes can impair movement, making it hard to complete simple tasks like opening or closing a tank valve. The second major concern is impaired blood flow as a result of swelling. This can affect gas exchange between tissues, possibly compromising the body's ability to off-gas the nitrogen absorbed during a dive. There are no conclusive links between arthritic flare-ups and decompression illness (DCI), but it's a good idea to refrain from diving during peak periods of inflammation. Joint pain can also mask signs and symptoms of DCI, making an accurate diagnosis difficult should concerns arise after a dive. On the upside, a regular exercise program can actually help relieve arthritis. Movement helps preserve joint flexibility, and the "weightless" environment underwater takes weight-bearing pressure off the taxed joints.
Tendons are the connective tissues between muscles and other parts of the body that transmit the force of any movement. Tendonitis, or inflammation of the tendons, is usually the result of overuse or trauma. In minor cases, rest and/or anti-inflammatory medication is all that's required to resolve the problem. Torn or ruptured tendons may require surgery, but again, given time, the tendons can fully heal. While the tendons are inflamed, special care should be taken if you choose to dive. The pain associated with tendonitis can impair or restrict movement, and swelling may affect gas exchange between tissues or compromise a DCI diagnosis. Continued use of an inflamed tendon can prolong the condition and even worsen it, so at the very least, protect the area with adapted movement and ask for assistance to avoid overdoing it, or even better, stay out of the water until you're healed.
Sprains are traumatic joint injuries that damage surrounding soft tissue, and sometimes the ligaments as well. With joint dislocation, the joint is displaced, often as the result of a trauma or impact. In both cases, the soft tissue surrounding the joint is often damaged, resulting in swelling. The biggest concerns when dealing with sprains and dislocations are limited mobility, pain, decreased strength and impaired blood flow. Stay out of the water until they heal and you've completed rehabilitation to avoid impeding or prolonging the healing process. It is possible to have recurring joint dislocations, either as the result of a weakness created by an initial injury or a genetic, structural abnormality. In these cases, diving is not recommended. Should the joint dislocate during the course of a dive, the trauma to the surrounding soft tissue might increase the risk of DCI, and compromised mobility and strength may jeopardize the safety of the diver and his or her buddy. Recurrent joint dislocations can be surgically corrected or improved with physical therapy, so consult your doctor or orthopedic surgeon to discuss your options.
No matter what the severity, bone fractures need to heal before a diver returns to the water. The primary concern with bone fractures is swelling and the increased risks inherent to that condition. But along with must-stay-dry casts, bone fractures also bring with them general weakness, impaired movement, and possible neurological and vascular problems. They also come with symptoms that mirror DCI, such as pain and numbness, burning, itching and tingling, which could easily be mistaken for, or worse, mask DCI symptoms.
Though defined as "back or spinal surgery," what is discussed here is disc surgery. Conditions in which the spinal cord is directly damaged are so severe that diving would never be an option without major rehabilitation. "Discs" are the shock-absorbing structures between vertebras. A herniation of the disc may result in the expulsion of disc material into the spinal canal, often causing excruciating pain and neurological problems. Surgery can provide tremendous relief from symptoms and, often, a full return to pre-injury activity. The greatest post-operative diving concerns are any residual disabilities and an increased risk of recurrent injuries. Surgery that produces scar tissue has been suggested as an increased risk factor for decompression sickness. However, this concern isn't supported by any data, and doesn't disqualify people from scuba diving. The greater concern is preventing re-injury. Dive equipment is heavy, so get help with carrying and lifting dive gear, and learn to don and doff your gear in the water.
Common joint replacement surgeries involve the knees, hips and shoulders. Because it reduces weight-bearing stresses, the water is actually a wonderful place for post-operative rehabilitation and exercise. But this does not include diving until the surgical site and surrounding bone are completely healed. Time and strict adherence to a rehabilitation program make it likely that joint replacement surgery patients can return to the water. When it's time to re-enter the water following joint replacement, use the same precautions you would after any surgery. Take it slow, adapt as necessary, and keep your depth/time exposure conservative.
The 411 on musculoskeletal meds
There are literally hundreds of specific medications used in the treatment of musculoskeletal issues, but most fall into one of three basic categories:
NSAIDs / Aspirin
These are the most commonly used drugs, and in addition to aspirin, they include such familiar names as Motrin, Advil (both ibuprofen) and Naprosyn (naproxen), nonsteroidal anti-inflammatories/pain relievers often available over the counter. These can negatively affect platelet clotting, which can cause increased bleeding in the case of barotraumas or DCI that affects the brain or spinal cord directly.
Corticosteroids
Usually used to relieve severe joint pain and inflammation, corticosteroids may affect electrolyte and fluid levels, often causing imbalances. Mood changes and muscle weakness are also known side effects.
Narcotics, muscle relaxants and benzodiazepines
These are potent medications used to treat serious musculoskeletal disorders, and most are only available by prescription. Even if the condition itself does not rule out diving, these medications often will, as they can impair the user's mental status. Check the bottle--any medication that carries a warning regarding alcohol consumption is thought to interact with nitrogen narcosis in the same manner as alcohol.
