SPORTS INJURIES AND MICRO-TRAUMAS OF ATHLETES

By Othon Molina, PhD(c), LMT

Athletes live and breathe by one thing – optimal performance. What stops them on this quest are injuries. Thus, preventing injuries in the first place becomes important. However, some athletes seem to always push the envelope, and inevitably, for those athletes, injuries do occur, and very frequently they are repetitive injuries. This is what I call the VIP cycle: Vicious Injury and Pain. With this in mind, it is crucial to be familiar with important techniques and approaches to help heal athletic injury quickly and completely.

I have worked with athletes and dancers for more than 40 years, and even the legends often succumb to injury. Today, there is a real need for Sports Rehabilitation Massage, and it is becoming increasingly more popular. However, many therapists who say they do this therapy are actually not trained in it. The approach to the rehabilitation of sports injuries and the techniques that are used are not part of regular massage.

ACUTE INJURY (24-48h)

For any acute injuries, the first treatment option is RICE: Rest, Ice, Compression, and Elevation. Never use heat for acute injuries! The therapist can use mild heat later to relax muscles but not for the treatment of acute cases. If heat is used for treatment of acute injuries, it creates more swelling and makes the initial trauma worse.

REST

Rest is necessary because continued exercise or other activity could extend the injury and the length of healing time. The athlete should stop using the injured part the minute it is traumatized.

I have spent much time working with elite athletes. Some of the marathon runners I’ve worked with are the worst! I finally came up with a way for them to rest and still get a workout. My solution was running underwater, some swimming and intense exercise of unaffected parts of the body. Since anaerobic conditioning is very easy to lose without regular training, the exercise of the unaffected areas becomes a really helpful tool to rest the injured area without compromising conditioning. To do so, my clients used a hand-cycling machine for lower body injuries, and a regular bicycle would do the same for upper body injuries. Make sure that the athlete is well advised and informed. Don’t do what a bunch of crazy athletes and some therapists do and say that stupid saying, “NO PAIN NO GAIN.”

ICE

Ice decreases bleeding from injured blood vessels by triggering local vasoconstriction, and it reduces further inflammation. The more blood accumulates in a hematoma, the longer it takes to heal. Ice on and off prevents blood leaking into the tissue. It helps the future cleansing process in the injured area, creates conditions for the restoration of the capillary networks in the injured tissues, and it acts as a natural analgesic.

I continue to use ice if the athlete still feels pain even after the initial period. If pain and swelling persist past forty-eight hours after the injury, apply ice alternately: 30 min. on, then 5 min. off. Do this three to four times a day. A neck injury is more delicate, since ice can produce vasoconstriction in the pool of the vertebral (posterior neck injury) or carotid arteries (anterior neck injury) and trigger headaches.

COMPRESSION

Compression limits swelling. For compression, wrap an ace bandage firmly over the ice, around the injured part. You may have noticed in football games that when players get hurt, they walk around with an ice bag strapped on them. Be careful not to completely shut off the blood supply by wrapping the area too tightly.

Sometimes an injured athlete may complain about a muscle spasm or cramping. If either of these happens, unwrap the area immediately. Otherwise, leave the ice pack and bandage in place for at least 30 to 40 minutes. After that, unwrap the area for ten minutes to allow the skin to re-warm and the blood to re-circulate. Repeat this procedure for at least three to four hours. If the area continues to swell or the pain increases, check immediately with a physician.

ELEVATION

Elevation of the injured part above the level of the heart uses the force of gravity to assist drainage from the injured area, preventing swelling and accelerating recovery. Elevation takes pressure off the injured area and relaxes the body considerably.

Following the initial trauma, blood from the damaged capillaries leaks into the soft tissues, dramatically increasing interstitial pressure (i.e., pressure between cells). This swelling is the initial protective reaction to the trauma, and it helps the future cleaning and repair forces that are mobilizing during this initial period. However, when swelling is too great, it becomes an obstacle to recovery since it now decreases oxygenation of the injured tissues, slows repair of the capillary network and delays restoration of normal blood flow through the tissue. These processes contribute to the tension buildup in the traumatized tissue, with eventual scarring and restriction of ROM.

Since swelling usually starts within seconds of an injury, RICE needs to be employed as soon as possible. If the injury is severe, you can follow the RICE program for up to 48 hours.

Any injury that involves more than a minor tear should be referred to an appropriate sports medicine physician. A tear can be serious enough to bench an athlete or even ruin his or her entire professional career. Believe me, it takes a lot for them to stop. They are used to pushing through the pain! That’s our greatest task: educating athletes about their bodies.

The best doctors for sports injuries are:

• Physiatrists (physical medicine and rehab specialists)
• Physical therapist doctors (some PTs have a PhD)
• Orthopedic doctors
• DOs (Doctors of Osteopathy)
• General practitioners with a sports medicine fellowship

SPORT INJURIES

Here are the three most common types of injuries in athletes:

Contact Injury

A contact injury is the result of a direct blow, a fall or any kind of impact. Of course, this can happen to anyone, not just athletes. However, an athlete’s contact injury has a twist ordinary people don’t have.

If an ordinary person experiences a contact injury, he or she immediately stops the task or activity he or she was doing. The problem with athletes is that they continue to push through, playing the rest of the football, hockey or basketball game. They realize the extent of the injury only when the competition is over. This has a devastating impact on the injured area, since while muscles contract, the blood continues to leak through the damaged capillary network, dramatically increasing the extent of hematoma.

This initial swelling is composed primarily of fluids containing white corpuscles and erythrocytes. I have seen huge bruises on hamstrings, and believe me, they can take some serious time to heal. Fortunately, with the proper RICE treatment and Deep Transverse Friction (DTF), often called Cyriax’s friction massage, you can accelerate the healing process.

Muscle Strains and Ligament Sprains

These injuries occur during running, lifting too much weight, improper body mechanics, etc. Although muscle strains and ligament sprains are injuries of the same nature – overstretching of the tissues – they are quite different. The difference lies in the fact that small local damage to the muscle fibers is always accompanied by bleeding into the muscle tissue, while in the case of ligament sprains, bleeding is not a factor, since ligaments are avascular structures. In other words, ligaments don’t need blood flow to function since they get oxygen by diffusion from the surrounding tissues.

For muscle injuries, ice is a critical treatment that may extend well beyond 48 hours. However, for a ligament sprain, a long application of ice is counterproductive, since it decreases blood flow in the tissue around the injured ligament, practically stops the diffusion of oxygen into the ligament and slows the recovery process.

Overuse

This type of trauma is the result of overtraining or just hard training. The micro-tears are the ones we seem to deal with more often. They’re what I call the “Overuse Syndrome.” This is the ache and pain that athletes complain about when they come into my clinic for therapy. For many of these athletes, pain is especially intense in the morning. The pain may seem to subside when they work out, then it may come back when they’re done training, and it often gets worse at night and especially in the mornings when they just start to move.

Intense pain and tension in the mornings is a very important sign for the therapist. If it’s present, it means that muscles are running on their last stretch and now they are very vulnerable to injury.

Each muscle contraction and relaxation pushes used blood out of the muscle and sucks in the oxygenated blood. This process is called the muscle pump. Normally, during the night, the muscle pump, which supports muscles’ oxygenation during the day, doesn’t work. However, intense training increases the resting muscle tone, and the muscles at night never completely relax and start to resist the normal blood flow. As a result, oxygen can’t be delivered to the muscle tissue at night and it greatly diminishes the synthesis of ATP by mitochondria during resting hours. ATP is the fuel that supports the muscle contraction/relaxation cycle.

The athlete will feel this significant depletion of ATP storage needed for normal muscle contraction as pain and tightness in the morning. After a shower, light movements, etc., the muscle pump kicks in, stimulating blood perfusion and restoring the level of badly needed ATP, relieving the morning’s pain and tension.

This is why the therapist can indirectly measure the level of tension the athlete has developed by evaluating the intensity of the morning’s pain and discomfort. The more pronounced the symptoms, the more residual tension has accumulated and the greater the chance that the athlete will suffer an injury.

GENERAL EVALUATION OF SPORTS INJURIES

To determine the extent of the injury, you need to look at the muscles, tendons, ligaments and attachments surrounding the injured site. Pain and alterations of ROM are usually two main keys to any assessment of sports injury. Healthy soft tissues will function well with no pain, weakness or restrictions. The pain level should be measured during inactivity, movement, or during the motion that hurts the most, as well as during resistance.

Manually examining tension developed in the injured muscle will increase pain. This should be done very carefully using palpation and resistance to the muscle contraction. The latter component of evaluation should be last and the therapist must know muscle function. This is why at least basic knowledge of kinesiology is so critical for the therapist.

We can separate soft tissues into two major groups:

Contractile tissues are muscles, tendons and, as was recently discovered, fascia. They are the engines of our locomotion.

Inert tissues are ligaments, joint capsules, cartilage, and bursae. These inert tissues move with the joints, and because they have limited blood supply and are dense, they are slower to heal.

For information about the palpatory evaluation of the soft tissues, I will refer readers to the four-part article “Science of Palpation” published by the Journal of Massage Science THE SCIENCE OF PALPATION. PART I; THE SCIENCE OF PALPATION. PART II: SKIN AND CONNECTIVE TISSUE ZONES, THE SCIENCE OF PALPATION. PART III: PALPATION OF THE SOFT TISSUE IN THE MIDDLE LAYERS and THE SCIENCE OF PALPATION. PART IV: DEEP PALPATION OF THE SOFT TISSUES 2016.

Here are general guidelines for the dynamic soft tissue evaluation after sports injury:

1. Passively bring the joint to mid-range, ask the athlete to hold it there and slowly withdraw the support. There are two possible outcomes of this simple test:

The athlete can’t support the extremity at the middle range by himself or herself. Most likely, you are dealing with a significant acute injury, which may even be a tissue rupture.

The athlete can hold the segment at the middle point but with pain and sometimes with a little support from you. This is a much better prognosis, since it means that the tissue has sustained a less extensive injury.

2. Ask the athlete to slowly conduct movement supported by the evaluated muscle and stop as soon as he or she feels any discomfort.

Here is a clinical example of the test conducted to evaluate abduction in the shoulder joint. The athlete feels pain as soon as he attempts active abduction. In such a case, the therapist is dealing with an injury to the supraspinatus muscle. In another scenario, the athlete is able to abduct the arm at the right shoulder joint to 80 degrees, and pain starts at this level. In this case, the therapist is dealing with an injury to the deltoid muscle or with compression of the subacromial bursa.

3. Have the athlete slowly contract the muscle that is being evaluated, starting gradually from a mild power of contraction, and ending with an 85% contraction while you resist it. Notice when the athlete starts to feel discomfort. If the athlete immediately reports pain as soon as the muscle contracts against resistance, it means that a very large number of fibers are affected. If the athlete reports pain at 80-90% of contraction it means that only a small number of fibers are compromised.

In Part II of this article we will discuss basic principles of soft tissue rehabilitation after sports trauma.

ABOUT THE AUTHOR

Category: Sport Massage

Tags: JMS 2016 Issue #4