Handout on Health: Sports Injuries
This publication is for athletes at all ages and levels, for people who exercise, as well as for health care professionals, coaches, and others who want to find out more about sports injuries. This publication describes the different types of musculoskeletal sports injuries, how they can be treated and prevented, and recent treatment advances from research. It also highlights risk factors and contains a resource list. If you have further questions after reading this publication, you may wish to discuss them with a health care professional.
Introduction
In recent years, increasing numbers of people of all ages have been heeding their health professionals’ advice to get active for all of the health benefits exercise has to offer. But for some people—particularly those who overdo or who don’t properly train or warm up—these benefits can come at a price: sports injuries.
Fortunately, most sports injuries can be treated effectively, and most people who suffer injuries can return to a satisfying level of physical activity after an injury. Even better, many sports injuries can be prevented if people take the proper precautions.
This publication answers frequently asked questions about sports injuries. It discusses some of the most common injuries and their treatment, and injury prevention. The publication is for anyone who has a sports injury or who is physically active and wants to prevent sports injuries.
It is for casual and more serious athletes as well as the trainers, coaches, and health professionals who deal with sports injuries.
Illustrations
Information Boxes
Appendix
What Are Sports Injuries?
The term “sports injury,” in the broadest sense, refers to the kinds of injuries that most commonly occur during sports or exercise. Some sports injuries result from accidents; others are due to poor training practices, improper equipment, lack of conditioning, or insufficient warm-up and stretching.
Although virtually any part of your body can be injured during sports or exercise, the term is typically reserved for injuries that involve the musculoskeletal system, which includes the muscles, bones, and associated tissues like cartilage. Traumatic brain and spinal cord injuries (relatively rare during sports or exercise) and bruises are considered briefly in the appendix at the end of this publication. Following are some of the most common sports injuries.
Sprains and Strains
A sprain is a stretch or tear of a ligament, the band of connective tissues that joins the end of one bone with another. Sprains are caused by trauma such as a fall or blow to the body that knocks a joint out of position and, in the worst case, ruptures the supporting ligaments. Sprains can range from first degree (minimally stretched ligament) to third degree (a complete tear). Areas of the body most vulnerable to sprains are ankles, knees, and wrists. Signs of a sprain include varying degrees of tenderness or pain; bruising; inflammation; swelling; inability to move a limb or joint; or joint looseness, laxity, or instability.
A strain is a twist, pull, or tear of a muscle or tendon, a cord of tissue connecting muscle to bone. It is an acute, noncontact injury that results from overstretching or overcontraction. Symptoms of a strain include pain, muscle spasm, and loss of strength. Although it’s hard to tell the difference between mild and moderate strains, severe strains not treated professionally can cause damage and loss of function.
Knee Injuries
Because of its complex structure and weight-bearing capacity, the knee is a commonly injured joint.
Lateral View of the Knee
Knee injuries can range from mild to severe. Some of the less severe, yet still painful and functionally limiting, knee problems are runner’s knee (pain or tenderness close to or under the knee cap at the front or side of the knee), iliotibial band syndrome (pain on the outer side of the knee), and tendinitis, also called tendinosis (marked by degeneration within a tendon, usually where it joins the bone).
More severe injuries include bone bruises or damage to the cartilage or ligaments. There are two types of cartilage in the knee. One is the meniscus, a crescent-shaped disc that absorbs shock between the thigh (femur) and lower leg bones (tibia and fibula). The other is a surface-coating (or articular) cartilage. It covers the ends of the bones where they meet, allowing them to glide against one another. The four major ligaments that support the knee are the anterior cruciate ligament (ACL), the posterior cruciate ligament (PCL), the medial collateral ligament (MCL), and the lateral collateral ligament (LCL). (See illustration “Lateral View of the Knee.”)
Knee injuries can result from a blow to or twist of the knee; from improper landing after a jump; or from running too hard, too much, or without proper warm-up.
Compartment Syndrome
In many parts of the body, muscles (along with the nerves and blood vessels that run alongside and through them) are enclosed in a “compartment” formed of a tough membrane called fascia. When muscles become swollen, they can fill the compartment to capacity, causing interference with nerves and blood vessels as well as damage to the muscles themselves. The resulting painful condition is referred to as compartment syndrome.
Compartment syndrome may be caused by a one-time traumatic injury (acute compartment syndrome), such as a fractured bone or a hard blow to the thigh, by repeated hard blows (depending upon the sport), or by ongoing overuse (chronic exertional compartment syndrome), which may occur, for example, in long-distance running.
Shin Splints
Although the term “shin splints” has been widely used to describe any sort of leg pain associated with exercise, the term actually refers to pain along the tibia or shin bone, the large bone in the front of the lower leg. This pain can occur at the front outside part of the lower leg, including the foot and ankle (anterior shin splints) or at the inner edge of the bone where it meets the calf muscles (medial shin splints).
Shin splints are primarily seen in runners, particularly those just starting a running program. Risk factors for shin splints include overuse or incorrect use of the lower leg; improper stretching, warm-up, or exercise technique; overtraining; running or jumping on hard surfaces; and running in shoes that don’t have enough support. These injuries are often associated with flat (overpronated) feet.
Achilles Tendon Injuries
An Achilles tendon injury results from a stretch, tear, or irritation to the tendon connecting the calf muscle to the back of the heel. These injuries can be so sudden and agonizing that they have been known to bring down charging professional football players in shocking fashion.
The most common cause of Achilles tendon tears is a problem called tendinitis, a degenerative condition caused by aging or overuse. When a tendon is weakened, trauma can cause it to rupture. (See illustration “Lateral View of the Ankle.”)
Achilles tendon injuries are common in middle-aged “weekend warriors” who may not exercise regularly or take time to stretch properly before an activity. Among professional athletes, most Achilles injuries seem to occur in quick-acceleration, jumping sports like football and basketball, and almost always end the season’s competition for the athlete.
Lateral View of the Ankle
Common Types of Sports Injuries
Fractures
A fracture is a break in the bone that can occur from either a quick, one-time injury to the bone (acute fracture) or from repeated stress to the bone over time (stress fracture).
Acute fractures: Acute fractures can be simple (a clean break with little damage to the surrounding tissue) or compound (a break in which the bone pierces the skin with little damage to the surrounding tissue). Most acute fractures are emergencies. One that breaks the skin is especially dangerous because there is a high risk of infection.
Stress fractures: Stress fractures occur largely in the feet and legs and are common in sports that require repetitive impact, primarily running/jumping sports such as gymnastics or track and field. Running creates forces two to three times a person’s body weight on the lower limbs.
The most common symptom of a stress fracture is pain at the site that worsens with weight-bearing activity. Tenderness and swelling often accompany the pain.
Dislocations
When the two bones that come together to form a joint become separated, the joint is described as being dislocated. Contact sports such as football and basketball, as well as high-impact sports and sports that can result in excessive stretching or falling, cause the majority of dislocations. A dislocated joint is an emergency situation that requires medical treatment.
The Shoulder Joint
The joints most likely to be dislocated are some of the hand joints. Aside from these joints, the joint most frequently dislocated is the shoulder. (See illustration “The Shoulder Joint.”) Dislocations of the knees, hips, and elbows are uncommon.
What’s the Difference Between Acute and Chronic Injuries?
Regardless of the specific structure affected, sports injuries can generally be classified in one of two ways: acute or chronic.
Acute Injuries
Acute injuries, such as a sprained ankle, strained back, or fractured hand, occur suddenly during activity. Signs of an acute injury include the following:
Chronic Injuries
Chronic injuries usually result from overusing one area of the body while playing a sport or exercising over a long period. The following are signs of a chronic injury:
What Should I Do if I Suffer an Injury?
Whether an injury is acute or chronic, there is never a good reason to try to “work through” the pain of an injury. When you have pain from a particular movement or activity, STOP! Continuing the activity only causes further harm.
Some injuries require prompt medical attention (see the section “Who Should I See for My Injury?”), while others can be self-treated. Here’s what you need to know about both types:
When to Seek Medical Treatment
You should call a health professional if:
To learn about treating sports injuries, see the section “How Are Sports Injuries Treated?”
When and How to Treat at Home
If you don’t have any of the above symptoms, it’s probably safe to treat the injury at home—at least at first. If pain or other symptoms worsen, it’s best to check with your health care provider. Use the RICE method to relieve pain and inflammation and speed healing. Follow these four steps immediately after injury and continue for at least 48 hours.
The Body’s Healing Process
From the moment a bone breaks or a ligament tears, your body goes to work to repair the damage. Here’s what happens at each stage of the healing process:
At the moment of injury: Chemicals are released from damaged cells, triggering a process called inflammation. Blood vessels at the injury site become dilated; blood flow increases to carry nutrients to the site of tissue damage.
Within hours of injury: White blood cells (leukocytes) travel down the bloodstream to the injury site where they begin to tear down and remove damaged tissue, allowing other specialized cells to start developing scar tissue.
Within days of injury: Scar tissue is formed on the skin or inside the body. The amount of scarring may be proportional to the amount of swelling, inflammation, or bleeding within. In the next few weeks, the damaged area will regain a great deal of strength as scar tissue continues to form.
Within a month of injury: Scar tissue may start to shrink, bringing damaged, torn, or separated tissues back together. However, it may be several months or more before the injury is completely healed.
Who Should I See for My Injury?
Although severe injuries will need to be seen immediately in an emergency room, particularly if they occur on the weekend or after office hours, most sports injuries can be evaluated and, in many cases, treated by your primary health care provider.
Depending on your preference and the severity of your injury or the likelihood that your injury may cause ongoing, long-term problems, you may want to see, or have your primary health care professional refer you to, one of the following:
How Are Sports Injuries Treated?
Although using the RICE technique described previously can be helpful for any sports injury, RICE is often just a starting point. Here are some other treatments your doctor or other health care provider may administer, recommend, or prescribe to help your injury heal.1
1All medicines can have side effects. Some medicines and side effects are mentioned in this publication. Some side effects may be more severe than others. You should review the package insert that comes with your medicine and ask your health care provider or pharmacist if you have any questions about the possible side effects.
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)
The moment you are injured, chemicals are released from damaged tissue cells. This triggers the first stage of healing: inflammation (see the box “The Body’s Healing Process”). Inflammation causes tissues to become swollen, tender, and painful. Although inflammation is needed for healing, it can actually slow the healing process if left unchecked.
The moment you are injured, chemicals are released from damaged tissue cells. This triggers the first stage of healing: inflammation (see the box “The Body’s Healing Process”). Inflammation causes tissues to become swollen, tender, and painful. Although inflammation is needed for healing, it can actually slow the healing process if left unchecked.
To reduce inflammation and pain, doctors and other health care providers often recommend taking an over-the-counter (OTC) nonsteroidal anti-inflammatory drug (NSAID) such as aspirin, ibuprofen (Advil,2 Motrin IB, Nuprin), ketoprofen (Actron, Orudis KT), or naproxen sodium (Aleve). For more severe pain and inflammation, doctors may prescribe one of several dozen NSAIDs available in prescription strength.3
2Brand names included in this booklet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.
3Warning: NSAIDs can cause stomach irritation or, less often, they can affect kidney function. The longer a person uses NSAIDs, the more likely he or she is to have side effects, ranging from mild to serious. Many other drugs cannot be taken when a patient is being treated with NSAIDs because NSAIDs alter the way the body uses or eliminates these other drugs. Check with your health care provider or pharmacist before you take NSAIDs. Also, NSAIDs sometimes are associated with serious gastrointestinal problems, including ulcers, bleeding, and perforation of the stomach or intestine. People age 65 and older, as well as those with any history of ulcers or gastrointestinal bleeding, should use NSAIDs with caution.
Though not an NSAID, another commonly used OTC medication, acetaminophen (Tylenol), may relieve pain. It has no effect on inflammation, however.
Immobilization
Immobilization is a common treatment for sports injuries that may be done immediately by a trainer or paramedic. Immobilization involves reducing movement in the area to prevent further damage. By enabling the blood supply to flow more directly to the injury (or the site of surgery to repair damage from an injury), immobilization reduces pain, swelling, and muscle spasm and helps the healing process begin. Following are some devices used for immobilization:
Surgery
In some cases, surgery is needed to repair torn connective tissues or to realign bones with compound fractures. The vast majority of sports injuries, however, do not require surgery.
Rehabilitation (Exercise)
A key part of rehabilitation from sports injuries is a graduated exercise program designed to return the injured body part to a normal level of function.
With most injuries, early mobilization—getting the part moving as soon as possible—will speed healing. Generally, early mobilization starts with gentle range-of-motion exercises and then moves on to stretching and strengthening exercise when you can without increasing pain. For example, if you have a sprained ankle, you may be able to work on range of motion for the first day or two after the sprain by gently tracing letters with your big toe. Once your range of motion is fairly good, you can start doing gentle stretching and strengthening exercises. When you are ready, weights may be added to your exercise routine to further strengthen the injured area. The key is to avoid movement that causes pain.
As damaged tissue heals, scar tissue forms, which shrinks and brings torn or separated tissues back together. As a result, the injury site becomes tight or stiff, and damaged tissues are at risk of reinjury. That’s why stretching and strengthening exercises are so important. You should continue to stretch the muscles daily and as the first part of your warm-up before exercising.
When planning your rehabilitation program with a health care professional, remember that progression is the key principle. Start with just a few exercises, do them often, and then gradually increase how much you do. A complete rehabilitation program should include exercises for flexibility, endurance, and strength; instruction in balance and proper body mechanics related to the sport; and a planned return to full participation.
Throughout the rehabilitation process, avoid painful activities and concentrate on those exercises that will improve function in the injured part. Don’t resume your sport until you are sure you can stretch the injured tissues without any pain, swelling, or restricted movement, and monitor any other symptoms. When you do return to your sport, start slowly and gradually build up to full participation. For more advice on how to prevent injuries as you return to active exercise, see the box “Tips for Preventing Injury.”
Rest
Although it is important to get moving as soon as possible, you must also take time to rest following an injury. All injuries need time to heal; proper rest will help the process. Your health care professional can guide you regarding the proper balance between rest and rehabilitation.
Other Therapies
Other therapies used in rehabilitating sports injuries include:
Most of these therapies are administered or supervised by a licensed health care professional.
Who Is at Greatest Risk for Sports Injuries?
If a professional athlete dislocates a joint or tears a ligament, it makes the news. But anyone who plays sports can be injured. Three groups—children and adolescents, middle-aged athletes, and women—are particularly vulnerable.
Children and Adolescents
Although playing sports can improve children’s fitness, self-esteem, coordination, and self-discipline, it can also put them at risk for sports injuries: some minor, some serious, and still others that may result in lifelong medical problems.
Young athletes are not small adults. Their bones, muscles, tendons, and ligaments are still growing and that makes them more prone to injury. Growth plates—the areas of developing cartilage where bone growth occurs in growing children—are weaker than the nearby ligaments and tendons. As a result, what is often a bruise or sprain in an adult can be a potentially serious growth-plate injury in a child. Also, a trauma that would tear a muscle or ligament in an adult would be far more likely to break a child’s bone.
Because young athletes of the same age can differ greatly in size and physical maturity, some may try to perform at levels beyond their ability to keep up with their peers.
Contact sports have inherent dangers that put young athletes at special risk for severe injuries. Even with rigorous training and proper safety equipment, youngsters are still at risk for severe injuries to the neck, spinal cord, and growth plates. Evaluating potential sports injuries on the field in very young children can involve its own special issues for concerned parents and coaches. Some helpful hints are presented in the appendix.
Adult Athletes
More adults than ever are participating in sports. Many factors contribute to sports injuries as the body grows older. The main one is that adults may not be as agile and resilient as they were when they were younger. It is also possible that some injuries occur when a person tries to move from inactive to a more active lifestyle too quickly.
Women
More women of all ages are participating in sports than ever before. In women’s sports, the action is now faster and more aggressive and powerful than in the past. As a result, women are sustaining many more injuries, and the injuries tend to be sport-specific.
Female athletes have higher injury rates than men in many sports, particularly basketball, soccer, alpine skiing, volleyball, and gymnastics. Female college basketball players are about six times more likely to suffer a tear of the knee’s anterior cruciate ligament (ACL) than men are, according to a study of 11,780 high school and college players. Information on injuries collected since 1982 by the National Collegiate Athletic Association shows that female basketball and soccer players have a much higher incidence of ACL injuries than their male counterparts.
Previous assumptions that methods of training, risks of participation, and effects of exercise are the same for men and women are being challenged. Scientists are working to understand the gender differences in sports injuries.
Although poor conditioning has not been related to an increased incidence of ACL injuries specifically, it has been associated with an increase in injuries in general. For most American women, the basic level of conditioning is much lower than that of men. Studies at the U.S. Naval Academy revealed that overuse injuries were more frequent in women; however, as women became used to the rigors of training, the injury rates for men and women became similar.
Aside from conditioning level, other possible factors in women’s sports injuries include structural difference of the knee and thigh muscles, fluctuating estrogen levels caused by menstruation, the fit of athletic shoes, and the way players jump, land, and twist. Also, “the female triad,” a combination of disordered eating, curtailed menstruation (amenorrhea), and loss of bone mass (osteoporosis), is increasingly more common in female athletes in some sports.
What Can Groups at High Risk Do to Prevent Sports Injuries?
Anyone who exercises is potentially at risk for a sports injury and should follow the injury prevention tips in the box “Tips for Preventing Injury.” But additional measures can be taken by groups at higher risk of injury.
Children
Preventing injuries in children is a team effort, requiring the support of parents, coaches, and the kids themselves. Here’s what each should do to reduce injury risk.
What parents and coaches can do:
What children can do:
Tips for Preventing Injury
Whether you’ve never had a sports injury and you’re trying to keep it that way or you’ve had an injury and don’t want another, the following tips can help.
Adult Athletes
To prevent injuries, adult athletes should take the following precautions:
Women
Increased emphasis on muscle strength and conditioning should be a priority for all women. Women should also be encouraged to maintain a normal body weight and avoid excessive exercise that affects the menstrual cycle. In addition, women should follow precautions listed above for other groups.
More information on research is available from the following websites:
For More Information
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Information Clearinghouse
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
Phone: 301-495-4484
Toll Free: 877-22-NIAMS (877-226-4267)
TTY: 301-565-2966
Fax: 301-718-6366
Email: NIAMSinfo@mail.nih.gov
Website: http://www.niams.nih.gov
Bethesda, MD 20892-3675
Phone: 301-495-4484
Toll Free: 877-22-NIAMS (877-226-4267)
TTY: 301-565-2966
Fax: 301-718-6366
Email: NIAMSinfo@mail.nih.gov
Website: http://www.niams.nih.gov
Other Resources
American Academy of Orthopaedic Surgeons
Website: http://www.aaos.org
American Academy of Pediatrics (AAP)
Website: http://www.aap.org
American College of Sports Medicine
Website: http://www.acsm.org
American Medical Society for Sports Medicine (AMSSM)
Website: http://www.amssm.org
American Orthopaedic Society for Sports Medicine (AOSSM)
Website: http://www.sportsmed.org
American Physical Therapy Association (APTA)
Website: http://www.apta.org
National Athletic Trainers Association (NATA)
Website: http://www.nata.org
Appendix
Traumatic Brain and Spinal Cord Injuries
Traumatic brain injury (TBI) occurs when a sudden physical assault on the head causes damage to the brain. A closed injury occurs when the head suddenly and violently hits an object, but the object does not break through the skull. A penetrating injury occurs when an object pierces the skull and enters the brain tissue.
Several types of traumatic injuries can affect the head and brain. A skull fracture occurs when the bone of the skull cracks or breaks. A depressed skull fracture occurs when pieces of the broken skull press into the tissue of the brain. This can cause bruising of the brain tissue, called a contusion. A contusion can also occur in response to shaking of the brain within the confines of the skull. Damage to a major blood vessel within the head can cause a hematoma, or heavy bleeding into or around the brain. The severity of a TBI can range from a mild concussion to the extremes of coma or even death.
What to do: For anything more than the most superficial injury, call for emergency medical assistance immediately. Observe symptoms so that you can report when help arrives. Do not allow the person to continue the activity. In more serious cases, do not move the person unless there is danger.
Spinal cord injury (SCI) occurs when a traumatic event results in damage to cells in the spinal cord or severs the nerve tracts that relay signals up and down the spinal cord. The most common types of SCI include contusion (bruising of the spinal cord) and compression (caused by pressure on the spinal cord). Other types include lacerations (severing or tearing of nerve fibers) and central cord syndrome (specific damage to the cervical region of the spinal cord).
What to do: In some cases, drugs called corticosteroids can minimize cell damage from a spinal cord injury. To be effective, they must be given within 8 hours of the injury. For this reason, it is important to call for emergency medical assistance immediately. Any person suspected of sustaining such a spinal cord injury should not be moved unless it is absolutely essential to keep the airway open so the person can breathe or to maintain circulation.
For more information on traumatic brain injury and spinal cord injury, visit the website of the National Institute of Neurological Disorders and Stroke (NINDS) at www.ninds.nih.gov/health_and_medical/disorders/sci.htm or call 800–352–9424.
Bruises
A bruise, or muscle contusion, can result from a fall or from contact with a hard surface, a piece of equipment, or another player while participating in sports. A bruise results when muscle fiber and connective tissue are crushed; torn blood vessels may cause a bluish appearance. Most bruises are minor, but some can cause more extensive damage and complications.
What to do: Put the muscle in a gentle stretch position and begin using the RICE method (see the section “When and How to Treat at Home”) to start the healing process. For more severe bruises, consult a doctor.
For more information on bruises, visit the website of the National Library of Medicine’s MedlinePlus atwww.nlm.nih.gov/medlineplus.
Sports Injuries in Young Children: Tips for Caregivers
Here are some “on-the-field” tips for helping a young child who has been injured:
Acknowledgments
The NIAMS gratefully acknowledges the assistance of the following individuals in the preparation and review of the original version of this publication: American Academy of Orthopaedic Surgeons, Rosemont, IL; the American Physical Therapy Association, Alexandria, VA; William E. Garrett, Jr., M.D., Ph.D., University of North Carolina, Chapel Hill, NC; Jo A. Hannafin, M.D., Ph.D., Hospital for Special Surgery, New York, NY; Lynne Haverkos, M.D.,Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH; Cato T. Laurencin, M.D., Ph.D., University of Virginia, Charlottesville, VA; Gayle Lester, Ph.D., NIAMS/NIH; National Institute of Neurological Disorders and Stroke, NIH; and James S. Panagis, M.D., M.P.H., NIAMS/NIH. Special thanks also go to the individuals who reviewed this publication and provided valuable assistance. Mary Anne Dunkin was the author of this publication.
The mission of the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), a part of the U.S. Department of Health and Human Services’ National Institutes of Health (NIH), is to support research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases; the training of basic and clinical scientists to carry out this research; and the dissemination of information on research progress in these diseases. The NIAMS Information Clearinghouse is a public service sponsored by the NIAMS that provides health information and information sources. Additional information can be found on the NIAMS website atwww.niams.nih.gov. Information on bone and its disorders can be obtained from the NIH Osteoporosis and Related Bone Diseases ~ National Resource Center by calling toll free at 800–624–BONE (2663) or by visitingwww.nih.bones.gov.
For Your Information
This publication contains information about medications used to treat the health condition discussed here. When this publication was developed, we included the most up-to-date (accurate) information available. Occasionally, new information on medication is released.
For updates and for any questions about any medications you are taking, please contact
U.S. Food and Drug Administration
Toll Free: 888–INFO–FDA (888–463–6332)
Website: http://www.fda.govFor additional information on specific medications, visit Drugs@FDA atwww.accessdata.fda.gov/scripts/cder/drugsatfda. Drugs@FDA is a searchable catalog of FDA-approved drug products.
For updates and questions about statistics, please contact
Centers for Disease Control and Prevention’s National Center for Health Statistics
Website: http://www.cdc.gov/nchs
This publication is not copyrighted. Readers are encouraged to duplicate and distribute as many copies as needed.
Additional copies of this publication are available from:
National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS)
Information Clearinghouse
National Institutes of Health1 AMS Circle
Bethesda, MD 20892-3675
Phone: 301-495-4484
Toll Free: 877-22-NIAMS (877-226-4267)
TTY: 301-565-2966
Fax: 301-718-6366
Email: NIAMSinfo@mail.nih.gov
Website: http://www.niams.nih.gov
NIH Publication No. 13–5278
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