Sports injuries are NOT inevitable but, sadly, they are common. All athletes should have a basic knowledge of first aid but, even more important, they should understand and follow the relatively simple guidelines for injury management when, and if they occur.
A small amount of early care can significantly reduce your recovery time. Appropriate treatment in the first 48 hours will limit the damage to the tissues and reduce the swelling, bleeding and pain that hinders your recovery. Ultimately, this will result in less time spent away from your sport.
A recent study by Bleakley, Glasgow and MacAuley 2012 in the British Journal of Sports Medicine has suggested that the PRICE Guidelines (Protect, Rest, Ice, Compression, Elevation) for dealing with acute injuries are now outdated, and have suggested using the acronym POLICE for the early management of injuries. This stands for:
P – Protect
OL – Optimal Loading
I – Ice
C – Compression
E – Elevation
Protect
Support the injured part using the likes of tape, strapping, crutches, casts or braces to help protect it against further damage. This is particularly useful if you are having problems weightbearing, in which case you will need to get a medical professional to assess your injury. Take care with self strapping as poorly applied tape can make your injury worse!
Optimal Loading
This is the major change in the protocol suggested by Bleakley et al. So why do they suggest replacing rest with optimal loading? While rest may be helpful in the short term, continued rest may lead to joint stiffness, muscle weakness and tightness and reduced proprioception (control and balance). Optimal loading will stimulate the healing process as bone, tendon, ligament and muscle all require some loading to stimulate healing. Also, the appropriate amount of activity can actually reduce swelling. For example, with an ankle injury, walking around will cause the calf muscles to contract, pumping the swelling up the leg against gravity. With complete rest the swelling may pool in the ankle.
Obviously there are some injuries that do require complete rest, such as unstable fractures or complete tendon ruptures, so optimal loading in these situations would be no loading at all. If there is excessive swelling or pain with your injury, or if you are in any doubt about weightbearing, contact a health professional and they will be able to assess your injury and advise you on how to proceed. As a rule of thumb you should begin weightbearing if you are able to walk without limping and the pain is tolerable.
Ice
The application of ice immediately after injury reduces the amount of pain, bleeding and swelling. Ice can be applied in a number of ways:
Crushed ice (or frozen peas) wrapped in a damp towel
Frozen gel packs
Instant ice packs
Immersion of part in ice and water
Never apply ice directly to the skin as this may cause a burn.
Placing a damp towel or cloth between the skin and the ice will help prevent this.
Ice should be applied as soon as possible after the injury. The ice pack should be applied for 20 minutes every 2 hours. Although rare, leaving the pack on for longer than 20 – 30 minutes may cause an ice burn. The skin should be checked under the ice pack after 2 or 3 minutes to make sure there are no signs of an ice burn (blistering).
Ice should not be applied in the following cases:
Raynaud’s disease
Poor tissue circulation
Poor tissue sensation
Compression
Compression of the injured area with a firm bandage will help reduce swelling around the injury. The bandage needs to be stretchable and should be applied firmly, but not so tightly as to cause pain, and should be applied both during and after ice application. Bandaging should be started just below the injury, with each layer of the bandage overlapping the underlying layer by half, and should extend to at least one hand’s breadth above the injury. Ensure there is good circulation distal to the bandage (i.e. in the toes if the ankle is compressed).
Elevation
Elevation of the injured part is very effective in reducing swelling and pain. It can be achieved by using a sling for upper limb injuries and by resting lower limbs on a chair or pillows. It is important to ensure that the lower limb is above the level of the pelvis.
What to Avoid in the First 48 Hours:
Hot baths
Hot packs
Alcohol
Massage
Exercise (remember optimal loading!)
When to Apply Heat
Heat can promote healing by increasing blood flow to the injured area, however, in the first 48 hours this will increase swelling and slow your recovery. Heat treatments can be started once swelling has subsided, usually after 48 – 72 hours.
Early Injury Management: Summary
Minor sprains and strains can be treated using the POLICE protocol, however, if the symptoms persist for more than a few days, or the injury is more serious, you should contact a physiotherapist for further assessment and treatment.
Remember – the sooner you start treatment after injury, the sooner healing can begin, and the sooner you’ll be back playing sport.
The Gluteus Medius is an often overlooked muscle that plays a vital role in maintaining normal function of the lower limb and pelvis. A weakness in this muscle will not only adversely affect your performance (an unstable pelvis will lead to an inefficient running style), but has also been implicated as a major contributing factor in many lower limb injuries.
The Role of Gluteus Medius
The actions of Gluteus Medius are abduction, internal rotation and external rotation of the hip, however, it’s most important function is as a dynamic stabilizer of the pelvis and lower limb. The role of Gluteus Medius during activities such as walking or running is to stabilize and hold the pelvis in a neutral position during single leg stance. Any weakness of this muscle will cause a dropping of the hip to the opposite side (Trendelenberg sign). For example, if the right Gluteus Medius is weak, when standing on the right leg, the left hip will drop (see diagram below).
Athletes may be able to compensate for this weakness in a couple of ways:
By adducting and internally rotating their hip on the weak side (this is seen during running as the knee drifting in towards the midline of the body).
By leaning their body towards the same side as the weakness.
How do I Strengthen the Gluteus Medius?
I have described below some of the basic Gluteus Medius exercises. Strengthening this much overlooked muscle should not only improve your performance, but also reduce your chances of developing many lower limb injuries.
Clamshells
Lie on your good side with your knees bent to 90 degrees and your heels, hips and shoulders in a line. Lying with your back against a wall may help you maintain your form. Raise your top knee toward the ceiling rotating at the hip and keeping your heels stationary. Hold for 3 to 5 seconds and do 10 to 20 repetitions.
Lying Wall Angel
Lie on your good side, against a wall, with your shoulders, hips and heels all touching the wall. Turn the toes of your top leg slightly upwards and lift your leg as high up the wall as it will reach. Hold your leg at the top of its arc for a second and then slowly lower it to the starting position.
Side Lying Leg Swing
Lie on your good side with your shoulders, pelvis and ankles all in line. Lift your top leg a few inches away from your bottom leg. Slowly extend your hip to bring your top leg behind your body. Next slowly flex your hip to bring your top leg in front of your body. Do not lower your top leg but continue extending and flexing your hip for the desired number of repetitions. Your upper body should remain stationary throughout this exercise.
Hip Hike
Stand sideways on a step with one leg held free over the edge. Keep both hips squared forward and shoulders level. Keeping your standing leg (the one on the step) straight (no knee bending!), raise your free hip directly upward and then drop the leg down so that your beltline alternately tilts up and down.
Step Down
Stand on your affected leg on a 2-4 inch step. Slowly lower your opposite leg down until it barely touches the floor and then return to start position. Ensure that your pelvis stays level and that the knee of your affected leg passes directly over your toes.
Single Leg Squat – Leg Behind Body
Stand on your affected leg and perform a single leg squat with your opposite leg passing behind your affected leg.
Side Stepping
Flex your knees and hips slightly and start to walk sideways with small controlled steps. Hips and shoulders should remain parallel to the floor with only the lower limbs moving. Repeat in both directions.
Monster Walk
Place the rubber band around your ankles. Get into the athletic position with bent knees, neutral lower back and looking forward. Walk forward with small steps, about 3-6 inches. Make sure your hips and chest are facing forward, don’t rotate your entire pelvis while you walk. After 20-30 steps, reverse the movement and walk backwards. As you get stronger you can bend your knees deeper.
Management of injuries after the first 48 hours is a complex procedure that can encompass a variety of different treatment techniques. The type of treatment required depends on the type, severity and stage of injury. If rehabilitation is inadequate the athlete may be:
Prone to re-injury of the affected area
Incapable of performing at pre-injury standard
Predisposed to injuring another part of the body
The following treatment techniques may be used in the management of injuries.
Muscle Strengthening
After injury, there is rapid muscle wasting due to pain, inflammation and immobility. Muscle strength decreases after relatively short periods of immobilization and shows increased fatigability, therefore less endurance.
Muscle weakness is a contributing factor in many acute and chronic soft tissue injuries. It is important to recognize these weak muscles either as a cause, or as a consequence of the injury. For recovery to be successful, rehabilitation must include careful assessment, strengthening and re-education of the affected muscle groups.
Joint Mobilization/Manipulation
These are techniques applied to a spinal or peripheral joint in order to restore full, pain-free range of movement. Mobilization is a passive oscillatory movement that is performed within the control of the patient, who can stop the movement at any time. Manipulation is a sudden movement or thrust of small amplitude, performed at high speed such that the patient is unable to prevent the movement. It can be a very effective form of treatment, however, it is associated with more risk than mobilization.
Massage
Massage involves direct manual manipulation of the soft tissues of the body and has an important role to play in the prevention and treatment of injuries. It can be used to:
Promote efficient scar formation
Reduce muscle tension
Reduce excessive adhesion and scar formation
Reduce pain
Reduce muscle spasm
Promote healing by increasing blood flow
Help recovery after exercise by promoting lymphatic drainage
Reduce swelling
Deactivate trigger points
Neural Stretching
Tension and restricted range of movement can occur in the nervous system just as it can in the muscles. These abnormalities may make a significant contribution to the signs and symptoms in certain injuries and unless they are corrected, full recovery may not occur.
Stretching the nerves (Neural Stretching) is an effective method of treating these abnormalities by restoring normal neural tension and normal mechanics of the nervous system.
Flexibility
Immediately following injury, flexibility of the muscles is reduced due to spasm of the surrounding muscles. Also, if joint range of movement is restricted due to the injury, the muscles very quickly begin to lose their extensibility. This tightness in the muscles causes an abnormal force to act at the surrounding joints, changing the biomechanics of the body. If full flexibility is not regained, injury may occur to the restricted muscles or to the surrounding joints and soft tissues. Normal flexibility is regained by passive or static stretching.
Proprioception
Proprioception is the body’s ability to sense position, motion and pressure in the joints. With injury, proprioception may be altered resulting in impaired balance, decreased co-ordination and a tendency for joints to give way. Impaired proprioception is a common sequel to lower limb injuries. Proprioceptive training should begin as early as possible in the rehabilitation program and may include exercises such as balancing on one leg, using wobble boards, hopping, or running drills.
Cardiovascular Fitness
It is essential that cardiovascular fitness be maintained during rehabilitation in order to minimize the time away from sport. With most injuries it should be possible to design an exercise program to include some form of cardiovascular training.
For instance, a runner with an Achilles tendinopathy may require a period of restricted weight-bearing activity. Cardiovascular fitness may be maintained by performing activities such as cycling, swimming or aqua jogging.
Functional Exercise
Once a reasonable level of strength, power, endurance, flexibility and proprioception has been achieved, functional activities can be introduced. These are movements that form the basis of the sport to be played and prepare the athlete physically and mentally for the demands of that sport.
Functional training begins with basic exercises such as walking, jogging and striding, and progressed to eventually include agility and team drills. The exercises should be progressed slowly and under careful supervision, as too fast a progression will result in re-injury.
Correction of Biomechanical Abnormalities
Biomechanical abnormalities are common predisposing factors to injury, especially overuse injuries. Full biomechanical analysis is essential in the case of recurrent or overuses injuries and, if treatment is to be successful, any abnormalities found must be addressed in the rehabilitation program.
Core Stability
With some sports injuries, poor core stability may be one of the contributing factors. To prevent re-occurrence of the injury, specific core stability training must be included in the rehabilitation program. The most common methods of training your core are with swiss ball exercises or pilates.
Electrotherapy
A large number of different electrotherapeutic modalities are available for the treatment of injuries, and the extent of their use varies widely between therapists. The modalities most often used are Laser, Ultrasound, Interferential, TENS, Neuromuscular Electrical Stimulation (NMES), and Short Wave Diathermy.
The effect of the treatment depends on modality and its parameter settings. Electrotherapy is often used to:
Reduce pain
Increase blood flow
Reduce inflammation
Promote healing
Reduce muscle spasm
Muscle stimulation
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