SPORTS INJURIES AND MICRO-TRAUMAS OF ATHLETES
By Othon Molina PhD, 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 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 rehabilitation of sports injuries and 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 treatment of acute cases. If heat is used for treatment of acute injuries, it creates more swelling and makes the initial trauma worse.
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 under water, 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 decreases the bleeding from injured blood vessels triggering local vasoconstriction and it reduces further inflammation. The more blood accumulated in hematoma, the longer it takes to heal. Ice on and off prevents blood leaking into the tissue. It helps 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 alternatively for 30 min. on then 5 min. off. Do this three to four times a day. The neck injury is more delicate since it can produce vasoconstriction in the pool of vertebral (posterior neck injury) or carotid arteries (anterior neck injury) and trigger headaches.
Compression limits swelling. For compression, wrap an ace bandage firmly over the ice, around the injured part. You may have noticed in football games, 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 any of these happen, 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 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 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 future cleaning and repair forces which are mobilizing during this initial period. However, when swelling is too large 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 build up in the traumatized tissue with eventual scarifications 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 carrier. 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
Here are three types of the most common injuries with athletes:
Contact injury is result of direct blow, falls 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 they were doing. The problem with athletes is 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 creates a devastating impact to 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 it 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 Sprains and Ligament Sprains.
These injuries occur during running, lifting too much weight, improper body mechanics, etc. Despite that muscle sprains and ligament sprains are injuries of the same nature – overstretching the tissues – they are quite different. This difference is in the fact that small local damage of the muscle fibers is always accompanied by the bleeding into the muscle tissue and 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 injures the ice is critical treatment which may extend way beyond 48 hours However for the ligament sprain a long application of ice is counterproductive since it decreases blood flow in the tissue around the injured ligament and it practically stops diffusion of oxygen into the ligament and it slows the recovery process.
This type of trauma is result of over-training, 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 a therapy. For many of these athletes pain is especially intense in the morning. The pain may seem to subside when they workout, 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 muscle pump. Normally during the night, muscle pump which supports muscles’ oxygenation during the day, doesn’t work. However, the 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 the oxygen can’t be delivered to the muscle tissue at night and it greatly diminishes synthesis of ATP by mitochondrias during resting hours. ATP is fuel which supports muscle contraction/relaxation cycle.
The athlete will feel this significant depletion of ATP storage needed for the normal muscle contraction as pain and tightness in the morning. After taking a shower, light movements etc., muscle pump kicks in stimulating blood perfusion and restoring the level of badly needed ATP, taking off 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 morning’s pain and discomfort. More expressive symptoms and more residual tension is accumulated and there are more chances that the athlete will suffer 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 alternations 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 later 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 it was recently discovered, fascia. They are engines of our locomotion.
Inert tissues are ligaments, joint capsules, cartilage, and bursa. These inert tissues move with the joints, and because they have limited blood supply and are dense, they are slower to heal.
For the info about palpatory evaluation of the soft tissues I will send readers to the three part article in “Science of Palpation” published by The Journal of Massage Science Issue #4, 2015; Issues #1, #2 and #3 2016.
Here are general guidelines for the dynamic soft tissue evaluation after sports injury:
- Bring the joint passively at 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 him or herself. More likely you are dealing with significant acute injury which very well may be even tissue rupture.
The athlete can hold the segment at the middle point but with pain and sometimes your little support. It is a much better prognosis since it means that there is less extent of injury and tissue sustained.
- 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 the clinical example of the test conducted for the evaluation of the abduction in the shoulder joint. The athlete feels pain as soon as he makes an attempt of active abduction. In such case the therapist is dealing with injury of the supraspinatus muscle. In another scenario the athlete is able to abduct the arm in the right shoulder joint to 80 degrees and pain starts on this level. In this case the therapist is dealing with injury to the deltoid muscle or with compression of subacromial bursa.
- 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.
Professor Othon Molina, Ph.D, LMT has been involved in the health field as an athlete, a massage therapist and a nutritional and personal trainer since 1970. He was the first licensed massage therapist in Hawaii to teach massage and license other massage therapists in his own school. Also in 1979 he was the first therapist to teach massage and holistic health at the University of Hawaii.
He sat on the Board of Massage for the State of Hawaii as well as the Board of Health for the Governor of the State of Hawaii. He is working on finishing his Ph.D in sports medicine and rehabilitation, and is presently living in Tucson, Arizona.
He has studied with some of the top doctors and healers of our time, working for several years and learning Kinesiology at The Touch for Health foundation, Pasadena with John Thie, DC and Master Kinesiologist, George Goodheart and Bernard Jensen DC, the father of Iridology and nutrition. Also John Christopher, ND, a great herbalist, Evarts Loomis, MD, the father of Holistic Health, a Quaker with great love for mankind andfounder of Medowlark, one of the first healing centers in California. Also trainers Like Terry Albriton, UH strength coach and former Olympic shot putter, who is always on the cutting edge of sports medicine science. Also Dr. Bernard Portner in Honolulu as a team member of his physical therapy clinic, and too many more to list here.
Dr. Molina’s tools are Medical/Sports Massage, Kinesiology, Polarity Therapy, Reflexology, Iridology, Nutrition, Rehabilitation, Neuro-Lynguistics and sports medicine with an emphasis in body mechanics. His specialty is treating sports injuries, auto injuries, back/neck problems and teaching others how to improve their health or athletic competition using nutrition and other fitness technologies. His clients have been some of the top athletes of Hawaii, Outrigger Canoe (World Champions 84), the professional German Triathlon team, Nike pro runners, for whom he was a trainer and therapist. University teams came to his clinic as well as professional dancers like the San Francisco Ballet, Honolulu Ballet and celebrities including Bob Hope, Jane Seymore, Essam Kashoggi, Jim Nabors, Carol Burnett and Tony Robbins.
Category: Sport Massage
Tags: Issue #4 2016