Sport Injuries
Individual SportsMuscle Strains & Contusions
Muscle strains and contusions are some of the most frequent injuries occuring in sports. A muscle strain comes from an excessive stretch applied to a muscle-tendon unit and may also be called a muscle pull, muscle tear, or muscle rupture. Biarticular muscles (muscles spanning two joints) tend to be strained more frequently than uniarticular muscles. Compared to the information available for treating bone, cartilage, and ligament injuries, however, relatively little information is available on the basic-science mechanisms associated with muscle strains. Most muscle strains are associated with microtears in the muscle and should be distinguished with pure tendinous injuries. Microtears, or microtrauma, result from multiple submaximal loadings of the tissues. A contracting muscle can absorb more energy than a passively stretched muscle, and generally, stronger muscles can absorb greater energy than weaker muscles. When a muscle is fatigued, it is less able to absorb energy.
When a muscle strain occurs, an inflammatory response develops, with more edema than bleeding. After the inflammatory changes occur, there is a general clearing of necrotic muscle fibres, a proliferation of granulation tissue, increased capularization, and muscle regeneration gradually occurs.
In the immature skeleton, the immature epiphyseal region is less able to resist tensile loads, and a portion of bone (avulsion fracture) may be pulled away rather than a tensile lesion occurring in either tendon or muscle.
Muscle strains can be graded from I - III.
Grade I involves a small number of muscle fibres being crushed or torn with the surrounding fascia remaining intact. Some swelling or ecchymosis may be found during the first day post-injury.
Grade II strains involve the tearing of a large number of fibres. Fascia may also be involved, and there may also be a partial tear or rupture of the musculotendinous junction. A palpable defect in the muscle tendon unit may be found.
A complete rupture of the muscle tendon unit is a Grade III. Muscle function is lost, and the defect is clearly palpable.
For most muscle strains, ice and compression wraps are useful immediately following injury to control edema and bleeding. Non steroidal anti-inflammatory drugs can be effective for controlling the inflammatory response during the first few days. Immobilization can be useful for providing comfort and protection for the first day or two after injury. Nevertheless, passive gentle remobilization through a range of motion should be started soon after the injury and followed by active motion and stretching. Some muscle tendon ruptures, particularly those in the Grade III range, will require surgical repair.
Muscle soreness, related to physical excursion and exercise, is commonly associated with instances where muscles have been forcibly lengthened. Exercise-related muscle soreness typically occurs between 12-24 hours after the exercise. This kind of muscle soreness is relatively common and, generally, does not have any lasting, adverse affects on the muscle.
"Warming up" before entering into physical activity can help prevent muscle strains. Generally, slow stretching appears to be more beneficial than ballistic (rapid bouncing) stretching. Ten to fifteen minutes of relatively slow stretching and easy range-of-motion activities can be particularly useful for reducing the incidence in muscle strains.
A muscle contusion results from a blow or impact to a muscle. After the impact, there can be a haematoma formation and an initial inflammatory process. A dense connective tissue scar may then replace the haematoma; appropriate immobilization following the injury can lead to the formation of less scar tissue.
Immediate treatment of a muscle contusion should include the application of ice during the first day, to minimize and control bleeding. Before returning to participation the individual should have a painless full range of motion.
With severe contusions at the site of the haematoma, ossification can occur (myositis ossificans). Myositis ossificans can usually be observed in radiographs 2-4 weeks after the injury. After approximately six months, its size typically stabilizes. Recovery from myositis ossificans is relatively long in duration, but usually surgical removal is not necessary, unless pain and motion restriction extends beyond one year. The proper use of protective padding and equipment can greatly reduce the incidence of muscle contusions. Although protective equipment is standard in sports such as football, soccer, lacrosse, and hockey, it is important in emphasize to the players, coaches, and parents this equipment must always be worn during practice and in games.
Sports Injuries & Sport Psychology
It is important to realize "the body has a head". This is a cliche, of course, but many times sports injuries in athletes are treated without acknowledging the psychological and psychosocial aspects associated with injuries and sport participation. Psychological stress can accompany sport activity, and depending upon the individual, how stress is handled can be quite different and have quite different effects on health and the probability of injury. "Optimal stress" is important for peak performance, but excessive stress can lead to "burn out", overuse injuries, or substance abuse. Pressure from parents, coaches, teachers, and peers at times can be too much for a young athlete. Even though the pressures may only be "perceived" by the athlete the perception itself creates a significant stress.
Burn Out
Burn out is when a participant or athlete feels emotional exhaustion, fatigue, and frustration as a result of a great effort that has failed to produce the expected result. The addition of a physical injury to a frustrating experience in sports is a classic way in which burn out can develop.
Overuse Syndrome
By the time youngsters reach their teenage years, it is not unusual for them to have suffered from "overuse" injuries. It is important to be alert to signs indicating a young athlete is predisposing himself or herself to over use injuries. Some of those signs include the following:
very high levels of commitment and dedication to the sport
perfectionism
belief that working harder, practicing longer, and playing through pain will achieve success
excessive need of constant approval from coaches
It is important the athlete, parents and physician realize when an overuse syndrome is developing and take active steps to intervene. An injury can have significant disruptive and disorganizing effects for someone who regularly participates in sports. There is a sequence of "denial-distress-determination" that characteristically can occur with such injuries. Denial, generally, is a lack of recognition of the severity of the injury. Distress corresponds to the emotional and psychological response that may be either appropriate or inappropriate, depending on the severity of the injury. Determination is the motivation to recover, be rehabilitated and return to activity. When an injury occurs requiring long-term rehabilitation or permanently restricts a persons activity, there is a tremendous challenge to a person's psychological state. Strong "goal orientation" or "reorientation" may be very important in this instance. Here the coordination of efforts parents, coaches, physician, and trainer are important.
Drug Use
Recreational drug use, as well as the use of some ergogenic aids, can have a significant impact on the psychological character of sports participants. Anabolic steroids can have a potent effect on an individuals psyche. For more information related to this topic, see "Ergogenic Aids".
Eating Disorders
Abnormalities in eating behavior, or eating disorders, are prevalent in many sports. Anorexia nervosa and bulimia are two conditions existing in various sports, including gymnastics, distance running, ballet, and wrestling. An individual who has an eating disorder is more likely to experience a weakening of musculoskeletal tissue, and therefore be more prone to overuse or fatigue-related injuries.
Treatment & Rehabilitation
The rehabilitative care of athletic injuries is aimed at reducing the inflammation resulting of an injury to a joint or tissue. The inflammation can lead to joint pain and reduced motion accompanied by muscle atrophy.
Cryotherapy
Cryotherapy, or cold therapy, includes a host of techniques for decreasing the temperature of tissues, including cold compresses, ice packs, ice towels, cooling sprays and ice baths. The cooling effect used in the therapy is a result of either conduction or evaporation. The greater the discrepancy between the temperature of the tissue and the cooling agent, the greater the tissue change in temperature. Although the skin may be rapidly cooled during cryotherapy, the temperature of subcutaneous tissues in muscle requires 20-30 minutes of exposure. Evaporation, with the use of the vapocoolant sprays, can remove heat from superficial tissues, but little change occurs in subcutaneous or muscle tissues. Physiologically, when the temperature is reduced vasoconstriction of arterioles occurs as well as reduced inflammation, muscle spasms, and pain. Applications of cold are advised in the following acute and chronic injury situations:
| sprains | strains |
| contusions | fractures |
acute phase of:
inflammatory bursitis
tendinitis
tenosynovitis
Cooling agents should not be applied continuously to the skin for more than 30 minutes. Typically ice packs (e.g., a towel filled with crushed ice) can be applied directly to the skin overlying the injured region, or "gelpacks" consisting of silica gel mixture in a heavy vinyl bag can be applied to the area. The advantage of a gel pack is that it can be reused, but care should be taken to prevent cold injury to the underlying skin. Massaging an affected area with ice can also be effective. The skin overlying the injured area is massaged for a period of 10-15 minutes, and with this technique the risk of tissue damage is minimal. When extremities have been injured, immersing the limb in a bucket of water and crushed ice (13-18C) for approximately 5-15 minutes can be particularly effective.
Thermotherapy
Thermotherapy, the application of heat to an injured area, can help to relieve pain, increase blood flow, facilitate tissue healing, and get joints and muscles prepared for vigorous activity. The heat can be applied either superficially or deeply, and in wet, dry, or chemical form. The form in which the heat energy is provided can be through conduction, convection, radiation, or conversion. Deep heat is transmitted through conversion, and superficial heat is transmitted through radiation, conduction or convection. Conduction occurs when heat is conveyed from a warm object to a cooler object by direct contact (moist hot packs, heating pads, or paraffin baths). Convection indicates the transfer of heat via the movement of fluids or gases (whirlpool baths). Radiation involves the transmission of heat through space by electromagnetic waves (infra-red or ultra-violet light). Conversion is related to the generation of heat from a source such as sound, chemical agents, or electrical agents. With ultrasound, mechanical energy from the sound waves is converted to heat energy at interfaces between tissues.
The application of heat can be useful in the following situations:
musculoskeletal pain
muscle spasm
joint stiffness
after the acute phases of:
| contusions | strains |
| bursitis | tendonitis |
| tenosynovitis | capsulitis |
Superficial heating should not be used when there is a loss of sensation, within the first 48-72 hours after an injury if there is reduced arterial circulation, directly over the eyes or genitals, or over the abdomen during pregnancy. Typically the application of thermotherapy is with moist hot packs, whirlpool baths, or ultrasound.
Hydrotherapy
Hydrotherapy, or water therapy, has been used for many years. It is advocated for joint stiffness, painful scars, adhesions, arthritis, and as an adjunct for stretching and warm up. The most common forms for hydrotherapy include a whirlpool for the arm or leg, the Hubbard tank, or a therapeutic pool. Whirlpools can provide an effective means of applying circumferential heat or cold while allowing relatively free movement of the injured part. One of the primary reasons of using hydrotherapy is to effectively enhance the therapeutic value of either heat or cold; the greater exposure of the body parts to the different temperatures will have a systemic influence on the cardiovascular and other organ systems as well as having a local effect at the injured site. Hydrotherapy can be very useful with chronic traumatic injuries, inflammation, joint stiffness and pain, adhesions, arthritis, or tenosynovitis. However, application of either heat or cold through complete immersion should be avoided for cardiac patients, and extreme temperature should be avoided for patients with peripheral vascular disease.
Electrical stimulation
Many types of electrical stimulation can be used in the treatment of sports injuries. The stimulations can be administered through high-volt pulsed galvanic stimulation, microcurrent electrical neuromuscular stimulation (MENS), transcutaneous nerve stimulation (TENS), or diathermy. The effects of the different forms of electrical stimulation are typically similar. Generally, the stimulation has been shown to produce a reduction in atrophy of the injured part, acceleration of healing, reduction of edema, muscle relaxation, and pain reduction. The application of high-volt pulsed galvanic stimulation is typically indicated for the following: acute pain, post-surgical pain, post-traumatic edema, muscle spasm, joint contracture, and disuse atrophy. The high-voltage pulsed galvanic stimulation is, to a greater and greater extent, becoming a preferred treatment for acute pain, post-operative pain, and reduction of muscle spasms.
Transcutaneous nerve stimulation (TENS) involves sending an electrical stimulation across the skin to relieve pain. The analgesia is produced, most likely, via a "gate control" mechanism and/or the stimulation of release of endorphins and enkephalins. TENS units are readily available commercially.
Microcurrent electrical neuromuscular stimulation (MENS) has gained proponents in the past few years because of its effective relief of pain, restoration of function, and enhancement of wound healing. The current (200-300 microamperes) involved in MENS (4) is very low, with a long pulse duration. Wound healing can be dramatically enhanced with the use of MENS.
Iontophoresis is a method by which ions are passed into tissues via a low-voltage electrical current. The ions transmitted into the tissue produce a therapeutic effect. Because like charges repel and unlike charges attract during iontophoresis, ions of medication with similar charge to the source electrode are driven into the skin. In this way, anti-inflammatory drugs are introduced into the region of inflammation. Iontophoresis is non-invasive, is less painful than a local injection, and is recommended for the treatment of fascitis, bursitis, tendonitis, and epicondylitis.
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