C HA P T E R 17 Common Categories of Injury 291 Chapter 3, the muscle damage explanation has a sound the skin, the skin becomes slightly irritated, which causes scientific basis. an increase in blood flow to the area. This produces heat, which relaxes stiff muscles. Some salicylate may enter the Movements that cause muscle soreness have been bloodstream. Because salicylate is the active ingredient in shown to produce localized damage to the muscle fiber aspirin, it also may have some pain-relieving effect. A membranes and contractile elements. Chemical irritants counterirritant action occurs as well. such as histamine are released from damaged muscles and can irritate pain receptors in the muscle. Muscle damage The second type of ointment depends on a substance often causes swelling of the muscle tissue, which creates called capsicum, which is the active ingredient in jalapeño enough fluid pressure to stimulate pain receptors. Swelling and other hot peppers. An extract of this chemical now is has been shown to persist long after muscle soreness has being used as a prescription ointment for arthritis pain, disappeared. Pain receptors gradually adapt to the swelling which is an indication that these ointments really do have or to some other factors present that reduce pain percep- benefit. These hotter ointments have a much stronger irri- tion. Because no effective treatment for muscle soreness tating effect on the skin to stimulate blood flow and give has been identified, training programs should be designed off enough heat that they can cause a burn, so caution is to minimize or prevent soreness. required. Do not allow these preparations to come into contact with any mucous membranes or with the eyes. Typical recommendations for treatment of delayed- onset muscle soreness include gentle stretching, topical Make sure the client has no skin sensitivity to an oint- application of analgesic creams and/or ice, submersion in ment that will cause an allergic reaction. hot baths, hot and cold contrast exposure, Epsom salt soaks, and sauna. Each of these treatments may provide MUSCLE STIFFNESS temporary relief, but none is effective for long. Delayed- onset muscle soreness is common and annoying but not Muscle stiffness is different from muscle pain. Stiffness serious. The athlete can do many things to prevent, avoid, occurs when a group of muscles has been worked hard for and shorten delayed-onset muscle soreness such as: a long time. Fluids that collect in the muscles during and • Warm up thoroughly before activity and cool down after exercise are absorbed into the bloodstream at a slow rate. As a result, the muscle becomes swollen, shorter, and completely afterward thicker and therefore resists stretching. Light exercise, lym- • Use easy stretching after exercise phatic drainage types of massage, and passive mobilization • Start an exercise program with easy to moderate activity assist in reducing stiffness. Stiffness also results in decreased pliability of connective tissue. This occurs when the and build up intensity over time ground substance thickens as part of an enzyme process • Avoid making sudden major changes in the type of during sympathetic dominance. exercise Massage is effective for muscle stiffness, particularly in • Avoid making sudden major changes in the amount of the management of fluid retention. See the discussion on lymphatic drainage in Unit Two. All pain management time spent exercising approaches are appropriate. Massage performed to restore Soreness will go away in 3 to 7 days with no special connective tissue pliability and hydration helps to reduce treatment, and the athlete should avoid any vigorous activ- stiffness. These conditions are not the result of an increase ity that increases pain. The individual should allow the in muscle tone but rather reflect an issue of fluid dynamics. soreness to subside thoroughly before performing any vig- Do not use aggressive massage. orous exercise. Easy, low-impact aerobic exercise will increase blood flow to affected muscles, which may help MUSCLE CRAMPS AND SPASM diminish soreness. Treatment of delayed-onset muscle soreness usually Muscle cramps and spasm can lead to muscle and tendon involves general massage with a lymphatic drainage focus. injuries. A cramp is a painful involuntary contraction of a Muscle soreness can be treated with ice applied within the skeletal muscle or muscle group. Cramps often occur first 48 to 72 hours. because of lack of water or other electrolytes, from muscle Gentle stretching of the affected area with gentle fatigue, and from an interruption of appropriate neurologic massage helps. Do not overmassage, work aggressively, or interaction between opposing muscles. A spasm is a reflex use any methods that would increase swelling or cause reaction caused by trauma to the musculoskeletal system. tissue damage. Almost all professional sports teams use various oint- The two types of cramps or spasms are the clonic type, ments and liniments on sore athletes, but sports medicine with alternating involuntary muscular contraction and doctors may not fully understand how liniments work. The relaxation in quick succession, and the tonic type, with massaging action of rubbing in the liniment and working rigid muscle contraction that lasts for a time. The massage it into muscles may be what actually relaxes the muscle therapist applies compression firmly in the belly of the and may be part of the mechanism of action. cramping muscle and gently massages, moves, and stretches Two basic types of ointments/liniments are available. surrounding joint areas. If cramps recur, send the client for The first typically contains menthol and an aspirin-like hydration and electrolytes. Cramps and spasm respond to chemical, methyl salicylate. When liniment is massaged on proper hydration and rest.
2 92 UNIT THREE Sport Injury MUSCLE GUARDING A bone contusion can penetrate to the skeletal struc- tures, causing a bone bruise. Bone bruises are painful and After injury, muscles that surround the injured area con- require a fairly extensive healing time. tract in effect to splint that area, thus minimizing pain by limiting regional movement. Often this splinting is Symptoms of contusions include the following: referred to incorrectly as a muscle spasm. Muscle guarding • Pain is a more appropriate term for the involuntary muscle • Swelling contractions that occur in response to pain after musculo- • Discoloration skeletal injury. Muscle guarding is appropriate during • Restricted movement acute and subacute healing processes. Massage applica- tion should not attempt to reduce muscle guarding until If after 2 to 3 days the swelling has not gone, an intra- later stages of the subacute phase. Use gentle massage to muscular injury is likely. If bleeding has spread and has reduce pain sensation. caused bruising away from the site of injury, the injury is likely to be intermuscular. Contusions are classified as CONTUSIONS grade 1, 2, or 3, depending on severity (Box 17-1). Objective Caution is necessary when providing massage over con- tusions. Compressive force and depth of pressure need to 1. Describe and apply appropriate massage for the follow- be modified to prevent further injury. Lymphatic drainage ing common syndromes and injury categories: types of applications are usually appropriate. Once bruis- d. Contusions ing dissipates, in all three grades of contusion, kneading is A bruise, or contusion, occurs because of a sudden used to prevent fibrosis. Over the next 3 to 6 months, continue to apply bending and torsion forces of kneading traumatic blow to the body. The severity of a contusion to support the remodeling stage of healing. can range from superficial and minor to extremely serious with deep tissue compression and hemorrhage. BOX 17-1 Contusion Grades The extent to which an athlete may be hampered by GRADE 1 this condition depends on the location of the bruise and the force of the blow. This type of injury is common in Tightness contact sports. An impact to the muscles can cause more Minor swelling damage than might be expected and should be treated Nearly a full range of motion appropriately. The muscle is crushed against the bone, and if the injury is not treated correctly or if it is treated Treatment too aggressively, a condition such as myositis ossificans with calcification of the tissues may result. The speed of Treatment includes PRICE and lymphatic drainage massage with skin drag healing of a contusion, as with all soft tissue injuries, methods only. depends on the extent of tissue damage and internal bleeding. GRADE 2 The three types of contusions are intramuscular, inter- Painful movement muscular, and bone bruise. Swelling Compression causing pain Intramuscular contusions occur as tearing of the muscle Limited range of movement within the sheath that surrounds it. This means that initial bleeding may stop early (within hours) because of increased Treatment pressure within the muscle; however, the fluid is unable to escape because the muscle sheath prevents it. The result is Treatment consists of ultrasound and electrical stimulation, lymphatic considerable loss of function and pain; days or weeks may drainage massage application using skin drag methods only, and a be needed for recovery. The typical bruise discoloration rehabilitation program consisting of stretching, strengthening, and may not appear with this contusion type, especially in the gradual return to full function. early stages. Because a bruise is not seen, the severity of the injury may not be recognized. The typical bruise may GRADE 3 appear finally in the subacute phase and indicates progres- sive healing. Severe pain Immediate swelling Intermuscular contusions consist of tearing of the muscle Isometric contraction will be painful and might produce a bulge in the and part of the sheath surrounding it. The initial bleeding will take longer to stop. Recovery is often faster than with muscle. intramuscular contusions because the blood and fluids can flow away from the site of injury through tears in the Treatment muscle sheath. Bruising discoloration occurs with this type of contusion. Seek medical attention immediately. PRICE: Use ultrasound and electrical stimulation. Perform lymphatic drainage massage using skin drag methods only. Wait at least 48 hours before applying massage. If necessary, relieve pressure.
C H AP T E R 17 Common Categories of Injury 293 WOUNDS Wounds can be classified as follows (Figure 17-1): • Abrasion. In this wound, the outer surface of skin has Objective been scraped away. Usually some minor oozing of 1. Describe and apply appropriate massage for the follow- blood and serum occurs. ing common syndromes and injury categories: Depending on how the injury was obtained, dirt or e. Wounds foreign matter usually is ground into it. To treat an abra- The first concern with any wound is the need to control sion such as a scraped knee, the wound first must be cleaned to remove dirt that could cause an infection and bleeding. In terms of first aid, this usually means use of a therefore impair healing. pressure bandage. The next concern is the need to prevent Once cleaned, the wound should be blotted dry with wound contamination by cleaning the wound and apply- sterile gauze, and pressure should be applied over the ing a sterile bandage and possibly an antibiotic ointment. injured site for a few minutes for the purpose of control- Last, immobilization of the injured part, along with ling bleeding. Application of first aid or antibiotic cream medical intervention, is needed. Many wounds will have to the abrasion could help to prevent infection and keep to be sutured or stitched. the bandage from sticking to the raw wound. For the best protection, the bandage should cover an inch The purpose of suturing is to pull the tissues together beyond the wound. An ice pack over the final bandage just enough that no dead spaces will exist below the skin can serve to reduce swelling and ease some of the where blood and fluid can accumulate. If space is present, discomfort. it eventually could serve as a breeding ground for infec- • Incision. A wound of this kind is made with a sharp, tion. Wounds heal better when the edges are close together. knife-like object that leaves a cut with smooth edges. Incisions are often part of surgical care procedures. Generally speaking, the deeper the wound, the more • Laceration. This wound type is similar to an incision but serious the consequences. With minor wounds, the outer with jagged edges caused by a tear. Because incisions layer of skin, the epidermis, is scraped away or opened up and lacerations go beyond the outer layer of skin and to permit bacteria and materials to enter. With a more into the deeper layers that contain blood vessels, a lot severe wound, the next layer deeper, the dermis, is injured. of bleeding occurs. If the wound is deep enough to cut This contains connective tissue, sweat glands, hair follicles, nerves, and lymph and blood vessels, and the potential for infection to spread increases. AB C DE FIGURE 17-1 Types of wounds. A, Abrasion. B, Laceration. C, Incision. D, Puncture. E, Avulsion. (From Young AP, Kennedy DB: Kinn’s the medical assistant: an applied learning approach, St Louis, 2003, Saunders.)
2 94 UNIT THREE Sport Injury an artery, blood will squirt out with each heartbeat Day 3 because of high pressure in these vessels. Care involves applying pressure dressing and getting the victim to Use bend, shear, and tension forces around the wound medical care, during which sutures usually are needed far enough away to prevent any chance of contamination. to close the wound fully or partially. The goal is to drag the skin gently in multiple directions • Puncture. As its name implies, a puncture occurs when to prevent formation of adhesions. Connective tissue a foreign object is pushed into the skin. The wound can formation is random at this time. Do not disturb the be superficial or deep. Minimal bleeding is evident wound edges. externally, but internal bleeding can occur. A deep puncture wound requires medical care, and a tetanus Increase the intensity and depth of forces in the area injection may be required. Some arthroscopic surgical that has been treated, and move closer to the wound. procedures produce wounds that are more like punc- Decrease intensity and gently apply bend, shear, and tures than incisions. stretch (tension) forces to the tissue. Do not disturb • Avulsion. With this type of injury, the skin is pulled or wound edges. torn off. Severed tissue should be saved and taken to the hospital. A pressure dressing is applied over the Day 7 wound until medical care is received. Once a dressing is applied, leave it alone and do not take it off to check Again, increase intensity in previously treated areas, and the wound. then move closer to the wound. At this point, the wound should be moving a bit from the forces loading adjacent THERAPEUTIC MASSAGE APPLICATION tissue, but the wound edges must not be disturbed. Pro- FOR WOUNDS gressively increase intensity daily by moving closer and closer to the wound. Follow these guidelines when performing therapeutic massage for wounds (Figure 17-2). As soon as the wound is healed completely (14 days is typical, but it can take longer), begin to bend and shear Massage Applied Days 1 to 3 the scar tissue and stretch it with tension. Sanitation and infection prevention are essential. Proceed The wound must be healed completely before you can with caution. work directly on it. Before working on the scar, address the tissue surrounding the wound. Address this tissue after the Avoid the area during massage to protect the wound acute phase has passed. Usually this happens after 2 to 3 from contamination. days. Maintain ongoing attention to the scar for at least 6 months. These methods can be taught to the client or Lymphatic drainage can be used above and below the family member. wound. Do not perform drainage if any signs of infection are present: heat, swelling, red color (especially any type OLD SCARS of red streaking), pus, or sour smell. Old scars that are adhered to underlying tissue can be FIGURE 17-2 Therapeutic massage application for wounds and contusions. softened and stretched. All mechanical forces are used in Wound, subacute early (3 to 5 days). multiple directions on the scar at each session until the scar tissue and tissues at least 1 inch away from the scar become warm and slightly red. The intensity should be enough that the client experiences a burning stretching sensation (Figure 17-3). A small degree of inflammation is desired, and the area may be a bit tender to the touch after the massage but not painful to movement. Ideally, treat- ment should occur every other day, allowing the tissue to recover on alternate days. These methods can be taught to the client or family member. STRAINS Objective 1. Describe and apply appropriate massage for the follow- ing common syndromes and injury categories: f. Strains Note: A specific massage treatment protocol for strain and sprains is provided on p. 299. A strain is a stretch, tear, or rip in the muscle or in adjacent tissue such as fascia or muscle tendons (Figure 17-4). Strains also are called pulls and tears. The cause of
C HA P T E R 17 Common Categories of Injury 295 AB CD FIGURE 17-3 Old scars. A, Skin roll to identify areas of adherence. When found, increase lift and move through bind. B, Pull and twist (tension and torsion forces) adhered tissue. C, Direct tissue stretching. D, Shear force. Shear areas of adhesion work just through the bind. muscle strain is often not clear. Often a strain is produced guarding, and muscle weakness. They also can have local- by an abnormal muscular contraction during reciprocal ized swelling, cramping, or inflammation and, with a coordination of agonist and antagonist muscles. This type minor or moderate strain, usually some loss of muscle of injury often occurs when muscles suddenly and power- function. Clients typically have pain in the injured area fully contract. Possible explanations for the muscle imbal- and general weakness of the muscle when they attempt to ance may be related to a mineral imbalance caused by move it. Severe strains that partially or completely tear the profuse sweating, fatigue, metabolites collected in the muscle or tendon are usually very painful and disabling. muscle itself, or a strength imbalance between agonist and antagonist muscles. A muscle may become strained or GRADES OF MUSCLE STRAIN pulled—or may even tear—when it stretches unusually far or abruptly. A muscle strain may occur while slipping on A grade 1 (mild) strain is accompanied by local pain, which the ice, running, jumping, throwing, lifting a heavy object, is increased by tension of the muscle and minor loss of or lifting in an awkward position. strength. Mild swelling and local tenderness occur. A strain may range from a tiny separation of connective A grade 2 (moderate) strain is similar to the mild strain tissue and muscle fibers to a complete tendinous avulsion but has moderate signs and symptoms, mild bruising, and (breaking away from the bone) or muscle rupture. The impaired muscle function. resulting pathologic condition is similar to that of a contu- sion or sprain, with capillary or blood vessel hemorrhage. A grade 3 (severe) strain has signs and symptoms that Typically, persons with a strain experience pain, muscle are severe, with loss of muscle function and bruising and commonly a palpable defect (small hole) in the muscle. Injuries often occur at the junction where the muscle and
2 96 UNIT THREE Sport Injury Femur Semitendinosus Tear in muscle belly Biceps Semimembranosus femoris muscle muscle GRADE 1 GRADE 2 GRADE 3 FIGURE 17-4 Calf pull with degrees of severity. (From Salvo SG, Anderson SK: Mosby’s pathology for massage therapists, ed 2, St Louis, 2008, Mosby.) the tendon meet, called the musculotendinous junction, or S where the tendon attaches to the periosteum of the bone, called the tenoperiosteal junction. Junction sites of ligament, ML tendon, and joint capsules are relatively vascular and show increased stiffness. These junctions are therefore more I prone to injury. FIGURE 17-5 Muscle strain. This muscle strain is located in the biceps After a tear of the connective tissue of the muscle, femoris muscle of the hamstring group (in this case, a tear in the mid-portion fibroblasts lay down collagen. If the tear is significant, of the belly of the muscle). Arrows show direction of massage stroke. (From adhesions often form in connective tissue layers. Because Thibodeau GA, Patton KT: The human body in health and disease, ed 5, of the development of abnormal cross-links in the collagen St Louis, 2009, Elsevier.) and adhesions within the fascia of the muscle during healing, a muscle that has had a strain injury typically The muscles that have the highest incidence of strain shortens and loses some of its extensibility. After a tear of in sports are the hamstring group, the sacrospinalis group the muscle fiber, satellite cells help myoblasts develop into of the back, the deltoid, and the rotator cuff group of the muscle fibers. The regeneration is usually complete in 3 shoulder. Contact sports such as soccer, football, hockey, weeks. Immobilization causes decreased cellular activity, boxing, and wrestling put athletes at risk for strains. Gym- decreased collagen formation in the fascia, and loss of nastics, tennis, rowing, golf, and other sports that require muscle fibers. Therefore, controlled movement is essential extensive gripping can increase the risk of hand and for optimal healing. forearm muscle strain. Elbow muscle strains sometimes occur in persons who participate in racquet sports, throw- Muscle dysfunctions that contribute to susceptibility to ing, and contact sports. muscle strain include sustained hypertonicity, sustained inhibition, abnormal position, and abnormal torsion in Muscle strain usually causes a protective muscle guard- the soft tissue. These contractions can be caused by the ing response. This guarding should not be reduced by following: massage because it protects the area from further injury. • Poor posture • Static stress (nonproductive isometric contraction) Massage needs to target the following goals during • Muscle injury muscle strain injury repair: • Joint dysfunction • Minimize adhesion formation. • Emotional or psychological stress: anxiety and anger • Promote circulation. • Chronic overuse • Increase lubrication of the tissues. • Disuse-deconditioned syndrome • Promote proper alignment of collagen fibers. • Support movement to stimulate replacement of con- Massage addresses muscle dysfunction by reversing inappropriate soft tissue adaptation in response to these nective tissue and regeneration of muscle fibers. conditions.
C H A P T E R 17 Common Categories of Injury 297 TREATMENT FOR STRAINS is called an inversion injury. One or more of the lateral liga- ments are injured—usually the anterior talofibular liga- Treatment for strains consists of two stages. The goal ment. The calcaneofibular ligament is the second most during the first stage is to reduce swelling and pain. Use frequently torn ligament. A more serious ankle sprain PRICE—protection, rest, ice, compression, and elevation— often is called a high ankle sprain. This happens when the for the first 24 to 48 hours after the injury. Severe strains ankle rolls over the foot, and the membrane between the may require surgery to repair torn muscle or tendons. tibia and the fibula is damaged (Figure 17-7). Surgery usually is performed by an orthopedic surgeon. Gentle massage around the area encourages circulation, The knee is another common site for a sprain. A blow and lymphatic drainage manages swelling and supports to the knee or a fall is often the cause. Twisting also can healing. During acute and subacute phases, the soft tissue result in a sprain. should be massaged in the direction of the fibers and crowded toward the site of injury to promote reconnection Sprains frequently occur at the wrist, typically when of the ends of separated fibers (Figure 17-5). Depth of pres- persons fall and land on an outstretched hand. sure, duration, and intensity need to be adjusted during the various healing phases. Once the acute phase of healing The usual signs and symptoms of a sprain include pain, is complete, methods that support mobile scar formation swelling, bruising, and loss of the ability to move and use can be introduced, including moving the tissue away from the joint (functional ability). These signs and symptoms the injury site and massaging across the fibers. vary in intensity, depending on the severity of the sprain. Sometimes a person feels a pop or a tear when the injury The second stage of treating a strain is rehabilitation, happens. for which the overall goal is to improve the condition of the injured part and restore its function with an exercise In general, a grade 1 or mild sprain causes overstretch- program designed to prevent stiffness, improve range of ing or slight tearing of the ligaments with no joint instabil- motion, and restore normal flexibility and strength. ity. A person with a mild sprain usually experiences minimal pain and swelling, and little or no loss of func- SPRAINS tional ability. Bruising is absent or slight, and the person usually is able to put weight on the affected joint. Persons Objective with mild sprains usually do not need an x-ray examina- tion, but such an examination may be performed if the 1. Describe and apply appropriate massage for the follow- diagnosis is unclear. ing common syndromes and injury categories: g. Sprains A grade 2 or moderate sprain causes partial tearing of Note: A specific massage treatment protocol for strain the ligament and is characterized by bruising, moderate pain, and swelling. A person with a moderate sprain and sprain is found on p. 299 (Figure 17-6). usually has some difficulty putting weight on the A sprain is an injury to a ligament and/or a joint capsule affected joint and experiences some loss of function. An x-ray examination may be needed to determine whether that results in overstretching or tearing. A sprain can result a fracture is causing the pain and swelling. Magnetic res- from a fall, a sudden twist, or a blow to the body that onance imaging is used occasionally to help differentiate forces a joint out of its normal position. Typically, sprains between a significant partial injury and a complete tear occur when persons fall and land on an outstretched arm, in a ligament. slide, land on the side of their foot, or twist a knee with the foot planted firmly on the ground. One or more liga- A grade 3 or severe sprain completely ruptures liga- ments can be injured during a sprain. The severity of the ments. Pain, swelling, and bruising are usually severe, injury depends on the extent of injury to a single ligament and the patient is unable to put weight on the joint. An (whether the tear is partial or complete) and the number x-ray film usually is taken to rule out a broken bone. This of ligaments involved, and if any fractures are involved. injury may be difficult to distinguish from a fracture Effusion of blood and synovial fluid into the joint cavity or dislocation. during a sprain produces joint swelling, local temperature increase, pain or point tenderness, and skin discoloration. When diagnosing any sprain, the doctor will ask the Ligaments and joint capsules heal slowly because of a rela- person to explain how the injury happened and will tively poor blood supply. Nerves in the area often produce examine the affected joint and check its stability and ability a great deal of pain. to move and bear weight. For persons with a severe sprain, particularly of the ankle, a hard cast may be applied. Although sprains can occur in the upper and lower parts of the body, the most common site is the ankle. The talus Rehabilitation includes different types of exercises, bone and the ends of two of the lower leg bones (tibia and depending on the injury. For example, persons with an fibula) form the ankle joint. This joint is supported by ankle sprain may be told to rest their heel on the floor and several lateral and medial ligaments. Most ankle sprains write the alphabet in the air with their big toe. A person happen when the foot turns inward as a person runs, turns, with an injured knee or foot will work on weight-bearing falls, or lands on the ankle after a jump. This type of sprain and balancing exercises. Rehabilitation commonly lasts for several weeks. Another goal of rehabilitation is to increase strength and regain flexibility. Depending on the individual rate of
2 98 UNIT THREE Sport Injury Right Lower Extremity IR Femur internally rotated ER IR Lateral Superficial compartment Posterior cruciate MCL torn usually intact ligament may be torn F Anterior cruciate ligament torn Tibia is Tear of deep portion externally of medial collateral rotated and ligament which is abducted comprised of the ER meniscofemoral A and meniscotibial components Stretching Superficial Superficial Tibial collateral and fraying MCL intact and deep ligament is partially of MCL tibio- or completely Deep tibio- collateral disrupted or avulsed collateral lig. torn lig. torn Flexor hallucis longus Flexor digitorum longus Tear of joint capsule at metatarsal head B Grade 1 Grade 2 Grade 3 C FIGURE 17-6 Examples of sprains. A, Anterior cruciate and medial collateral tear with tibial collateral sprain. B, Medial collateral ligament sprains. C, Turf toe injury in American football player resulting in hyperextension and sprain of the great toe. (From Saidoff DC, McDonough AL: Critical pathways in therapeutic intervention: extremities and spine, St Louis, 2002, Mosby.) recovery, this process begins about the second week after rehabilitation before a person can return to full activity. the injury. During this phase of rehabilitation, the client With a severe sprain, 8 to 12 months may be needed before progresses to more demanding exercises as pain decreases the ligament is healed fully. and function improves. MASSAGE APPLICATION: STRAINS AND SPRAINS The final goal is the return to full daily activities, includ- ing sports when appropriate. Sometimes persons are The following strategies describe how to manage muscle tempted to resume full activity or to play sports despite tears and tendon strains and ligament sprains, as well as pain or muscle soreness. Returning to full activity before incisions and skin wounds, and explain why they are normal range of motion, flexibility, balance, and strength addressed in a similar fashion. are regained increases the chance of reinjury and may lead to a chronic problem. Regardless of the soft tissue type and the area of the injury, these injuries result in tissue and fiber separation. The extent of rehabilitation and the time needed for For treatment purposes, the injured area can be explained full recovery after a sprain depend on the severity of the simply as a hole in the tissue created during the injury. injury and individual rates of healing. For example, a Healing involves closing the hole and restoring moderate ankle sprain may require 3 to 6 weeks of function.
C H AP T E R 17 Common Categories of Injury 299 Splint bone Appropriate massage application occurs after the (fibula) medical team has made a diagnosis. These types of injuries typically are graded as first, second, and third degree, or Tear of the as mild, moderate, and severe. Grade 1 (mild) is a little syndesmosis hole, grade 2 (moderate) is a medium-sized hole, and grade Lateral ligaments 3 (severe) is a big hole. Ankle bone (talus) Other tissue injuries such as punctures, abrasions, cuts, FIGURE 17-7 High ankle sprain. Sprain of the distal tibiofibular syndesmosis, ulcers, and surgical incisions are “holes” as well. Bone injury to the deltoid or lateral ligaments of the ankle joint. (From Peterson L, breaks can be conceptualized in the same simple manner. Renstrom P: Sports injuries: their prevention and treatment, Chicago, 1983, Year Book Medical.) Healing of these injuries follows a typical pattern in terms of acute, subacute, and remodeling phases (Table 17-1). Massage can offer support during all stages of the healing process. Tissue healing involves two main pro- cesses: regeneration and replacement. Regeneration occurs when functional tissue cells regrow. Bone is active regen- erative tissue. “Holes” in the bone heal well if the ends of broken bones are lined up and held in that position. Skin heals well, especially if deep, large wounds are sutured. Muscle tissue does not regenerate well. However, the closer the ends of the breach in the tissue (the hole), the better is the potential for muscle cell regeneration to occur. Most “holes” heal through the replacement process. Connective tissue that fills up an injury is called a scar. The goal of healing is to create an environment where the least amount of scar tissue is needed to repair the injury. Therefore, strategies used to make the “hole” as small as possible are appropriate. Interventions such as sutures, casts, and immobilization accomplish the goal by sewing the ends of the tissue together or by positioning injured tissues so that they approximate (touch). Little TABLE 17-1 Stages of Tissue Healing and Massage Interventions Characteristics Stage 1: Acute Inflammatory Reaction Stage 2: Subacute Repair and Healing Stage 3: Chronic Maturation and Remodeling Vascular changes Growth of capillary beds into area Maturation and remodeling of scar Clinical signs Inflammatory exudate Collagen formation Contracture of scar tissue Massage Clot formation Granulation tissue; caution necessary Collagen aligns along lines of stress forces Phagocytosis, neutralization of irritants Fragile, easily injured tissue intervention Early fibroblastic activity (tensegrity) Inflammation Decreasing Inflammation Pain before tissue resistance Pain during tissue resistance Absence of Inflammation Protection Controlled Motion Pain after tissue resistance Control and support effects of Promote development of mobile scar: Return to Function Increase strength and alignment of scar inflammation: PRICE • Cautious and controlled soft Promote healing and prevent tissue mobilization of scar tissue tissue: along fiber direction toward injury • Cross-fiber friction of scar tissue compensation patterns: • Passive movement mid-range • Active and passive, open- and coupled with directional stroking along • General massage and closed-chain range of motion, lines of tension away from injury mid-range • Progressive stretching, and active and lymphatic drainage with resisted range of motion; full range caution Support healing with full-body massage Support rehabilitation activities with full-body Support, rest with full-body massage 14 to 21 days massage 3 to 7 days 3 to 12 months From Fritz S: Mosby’s fundamentals of therapeutic massage, ed 5, St Louis, 2012, Mosby.
3 00 UNIT THREE Sport Injury surgical “holes” are one of the major benefits of arthroscopic recommendations. If pain medication is prescribed, the and laparoscopic surgical procedures and have represented therapist needs to evaluate and factor into the treatment a major advancement in medical treatment. approach the possible interaction with massage. Pain medi- cation and antiinflammatory drugs alter pain mechanisms. Understanding the tissue regeneration or replacement Therefore, the therapist must monitor pressure levels care- process is important in acute and subacute stages of fully. Massage application must not produce pain in the healing. Any application or activity that brings the ends injured area during this stage. of the healing tissue apart will prolong healing and increase scar formation. Because scar tissue is nonfunctional tissue With medical team approval, massage can be applied that has a tendency to shorten and become nonpliable, to the injured tissue in a specific and precise manner to the smaller the scar, the better the tissue should function approximate (push together) the ends of the torn tissue. after healing is complete. One of the major errors made This method should be applied only to tissue that can be during massage is creating forces that disrupt healing by accessed easily from the body surface around joints, such pulling apart the ends of healing tissue. During any tissue as ankle and knee, or to pulls and tears in surface muscles. breach, the surrounding muscle tissue contracts to pull the The method is ineffective for muscle tears in deeper layers ends of the injured tissue together and prevent the ends and for tendons and ligaments that are deep to surface from separating. This is called muscle guarding. Massage tissue. The approach works because injured tissue is sticky must not interfere with this appropriate protective response. during the first 48 hours after injury. Massage is applied This appropriate guard response often is mistaken for to push the tissue together mechanically with the intention muscle tension or trigger point activity that should be of decreasing the size of the “hole” by approximating the eliminated. To the contrary, reducing muscle activity and injured tissues of the hole to encourage the torn ends to lengthening and stretching the tissue are ineffective and stick together. This should be a beneficial strategy because have the potential to prolong, disrupt, and negatively the smaller the hole, the faster the healing. affect the healing process, thereby increasing the likeli- hood of formation of excessive scar tissue. Identification of the exact location of the injury is nec- essary. This usually is indicated by a painful point, and the The guarding process typically involves co-contractions athlete can best locate this spot if the trainer or other of agonist and antagonist muscle groups around the injured medical personnel have not located it for you. Under- area. This appropriate process further stabilizes the area, standing the anatomic structure of the area is essential protecting the healing area and keeping the torn tissue because a deliberate stroke is applied in the direction of ends close together. The result is a temporary reduction in tendon, ligament, or muscle fibers so that the sticky ends range of motion of the area and the sensation of stiffness of the new injury touch. The application must not be or a knot. Again, this process must not be disturbed during painful, and it must not create additional inflammation or acute and early subacute healing stages. Stretching and specifically touch the injury. This method is repeated for aggressive joint movement techniques are inappropriate at up to 5 minutes and is applied slowly and rhythmically. this time. The hand is lifted and is repositioned for each stroke, allowing crowding together of the tissue ends. This method Frictioning and compressing in the early stages of tissue can be repeated 3 to 4 times per day within the first 3 days healing is inappropriate as well. This approach to massage of the injury. If during the acute injury phase, the area is contraindicated during acute and early subacute stages. surrounding the injury becomes excessively stiff and Errors in massage application include mistaking grade 1 painful, the area can be shaken rhythmically and gently and 2 injury, particularly in deeper layers of the muscle, for up to 10 minutes. This repetitive movement will for trigger point activity, and applying these methods too decrease swelling and guarding just a bit, making the client soon during the healing process. Friction will disturb the more comfortable. formation of healing tissue, and compression into the injured area may spread the fibers and disturb tissue Subacute Phase formation. Massage in the subacute phase is best given every other TREATMENT STRATEGIES day and involves full-body massage to address any com- pensation resulting from the body protecting the injury. Methods that are appropriate during acute and early sub- This can occur as guarding, changes in gait from limping, acute phases of healing include general full-body massage or altered sleep patterns. Applying massage to correspond- as described in this text to support the restorative capacity. ing reflex areas as indicated can help manage pain, normal- Perform massage as often as feasible, with every other day ize some tension, and reduce mild compensation (see being ideal. Include in the general massage the area of the Figure 4-1, p. 47). injury (Figure 17-8). Massage can begin to reduce tension by 50% in muscles Acute Phase that are guarding at the injury site. Work on larger surface muscles in the area. Do not massage deeper stabilizing During the first 24 hours, PRICE should be used. Because groups because these muscles are still providing a protec- it is assumed that the medical team has evaluated tive function. the injury, the massage therapist should follow all
C HA P T E R 17 Common Categories of Injury 301 Continue with strokes at the injury site in the opposite tissue and some tissue regeneration. Muscle guarding is direction, gradually increasing pressure and drag over the still present, particularly in the deep stabilizing muscles, typical 10-day subacute period. Light cross-fiber (bend and but movement in the mid-range with application of a shear) force can be applied 5 to 7 days after injury. This moderate resistance load should not be painful. The intent application should not cause pain. of massage at this point is to encourage strength and func- tion of the new tissue. Gradually, over the next 4 weeks, Remodeling Phase tension in the deep stabilizing muscles should be reduced as muscle strength increases in the injured area. Massage Massage should be performed 2 to 3 times per week. The is applied across the grain of the fibers to encourage scar injured area should be filled completely with connective AB CD EF FIGURE 17-8 Examples of massage of grade 1+ lateral ankle sprain. A, Acute, 24 to 48 hours. Palpate most tender area. B, Manage swelling with lymphatic drain. C, Gently approximate tissues over sprain. D, Subacute: tension force. E, Subacute: reduce guarding general massage. F, Remodeling: reduce guarding, address trigger points.
3 02 UNIT THREE Sport Injury GH IJ FIGURE 17-8, cont’d G, Remodeling: support pliable scar formation using shear force. H, Move tissue into ease. I, Move tissue into bind. J, Massage tissues around fibular head while client moves ankle in slow circles. mobility and to reduce adhesion. This massage application acute phase may last up to a week. Swelling that occurs can be mildly painful but not so intense as to cause flinch- with these types of injuries is managed with lymphatic ing or inflammation. drainage. Surgery creates swelling just as traumatic injury does, but it is much more controlled; therefore, the Massage is applied across fiber direction to the entire actual tissue damage is minimized. Arthroscopic surgery length of the injured structure, be it a ligament or a tendon is a wonderful advancement in joint surgery; however, and attached muscle. Pressure, drag, and force introduced during the procedure, fluid is introduced into the joint to the healing area gradually increase over the 4-week capsule, which helps separate the joint, allowing the pro- interval. The area should not be painful during movement cedure to wash away any debris and keeping the field of the next day. However, it may be a bit sore to touch. This vision clear for the surgeon. The body has to remove massage application is included in the context of full-body any water left in the joint cavity after the procedure is general massage with continued awareness of compensa- complete. Restoring range of motion as quickly as possi- tion patterns. ble helps the body absorb and eliminate the intracapsu- lar fluid, which helps the joint heal after the procedure. By the end of this treatment phase, 6 to 8 weeks has Swelling beyond the acute phase must be managed for passed. It takes up to 6 months for a grade 1 to 2 injury all injuries, and lymphatic drainage massage is one of the to heal fully and 6 to 12 months for a grade 2 to 3 injury most effective methods. Lymphatic drainage is described to heal fully. During this time, the massage therapist in Unit Two. should address the area periodically with the cross-fiber massage process as previously described. With more severe injuries, massage treatment needs to be more focused to manage compensation patterns This procedure sequence can be used for any wound, and edema from body adjustment to the injury and sprain, or strain. The method is most effective for grade rehabilitation activities such as weight training and range- 1 and 2 injuries. Grade 3 injuries take longer to heal and of-motion activities. Scar mobility and return to function may have had some sort of medical intervention such as are the goals. surgery, casting, or other stabilization. Each of the three healing stages is longer with severe injuries, and the
C H AP T E R 17 Common Categories of Injury 303 Log on to your Evolve website to view Video 17-1: Therapeutic Supraspinatus Supraspinatus Massage Application for Wounds, Strains, and Sprains. muscle tendon CHRONIC SOFT TISSUE INJURIES A Objective Gastrocnemius 1. Describe and apply appropriate massage for the follow- Achilles tendon ing common syndromes and injury categories: h. Chronic muscle injury Total rupture of the Chronic soft tissue injuries consist of a low-grade B Achilles tendon inflammatory process with a proliferation of fibroblasts FIGURE 17-9 Tendon injuries. A, Full-thickness tear of the rotator cuff and scarring. An acute injury that is managed improperly tendons. B, Total rupture of Achilles tendon. (A from Saidoff DC, McDonough AL: or an athlete who returns to activity before healing is Critical pathways in therapeutic intervention: extremities and spine, St Louis, 2002, complete can contribute to a chronic injury. Mosby. B from Peterson L, Renstrom P: Sports injuries: their prevention and treatment, Chicago, 1983, Year Book Medical.) MYOSITIS AND FASCIITIS Tendonitis is inflammation or irritation of a tendon. In general, the term myositis means inflammation of muscle Tendonitis is characterized by gradual onset, diffuse ten- tissue. More specifically, it can be considered a fibrositis, derness because of repeated microtraumas, and degen or connective tissue inflammation. Fascia that supports erative changes. Obvious signs of tendonitis are swelling and separates muscle can become chronically inflamed and pain. after a traumatic or repetitive injury. A typical example of this condition is plantar fasciitis. This condition, which causes pain and tenderness just outside a joint, is most common around the shoulders, TENDON INJURIES elbows (tennis elbow), and knees, but it also can occur in the hips and wrists. Tendinopathy describes two conditions that are likely to occur together: tendon inflammation, known as tendon- Tendons usually are surrounded by a sheath of tissue itis, and tiny tears in the connective tissue in or around similar to the lining of the joints (synovium). They are the tendon, known as tendinosis. The tendon contains subject to wear and tear, direct injury, and inflammatory wavy parallel collagenous fibers that are organized in diseases. The most common cause of tendonitis is injury bundles surrounded by a gelatinous material that or overuse. Occasionally, an infection within the tendon decreases friction. A tendon attaches a muscle to a bone sheath is responsible for the inflammation. This condition and concentrates a pulling force in a limited area. When a tendon is loaded by tension, the wavy collagenous fibers straighten in the direction of the load; when tension is released, the collagen returns to its original wavy shape. In tendons, collagen fibers will break if their physiologic limits have been exceeded. A breaking point occurs after a 6% to 8% increase in length. Because a tendon has usually double the strength of the muscle it serves, tears most commonly occur in the muscle belly, the musculotendinous junction, or a bony attachment (Figure 17-9). Tendon injuries usually progress slowly over a long time. Repeated acute injuries can lead to a chronic condi- tion. Constant irritation caused by poor performance techniques or ongoing stress beyond physiologic limits eventually can result in a chronic condition. Repeated microtrauma from overuse can evolve into chronic muscle strain, resulting in reabsorption of collagen fibers and eventual weakening of the tendon or other con- nective tissue structures. Collagen reabsorption also occurs in the early period of sports conditioning. During reab- sorption, collagenous tissues are weakened and are suscep- tible to injury; therefore, a gradually paced conditioning program process is necessary.
3 04 UNIT THREE Sport Injury also may be associated with diseases such as rheumatoid has developed unyielding scar tissue. Whether inflamma- arthritis. Tenosynovitis is inflammation of the synovial tion or fibrosis is present determines the type of massage sheath surrounding a tendon. In its acute stage, pain onset used. Inflammation can be caused by rubbing short struc- is rapid and articular crepitus (crackling noise or vibration tures, and massage should focus on restoring normal produced during joint movement) and diffuse swelling are length to muscles and connective tissue in the area. Thera- noted. In chronic tenosynovitis, the tendons become peutic exercise is necessary to strengthen muscles that have locally thickened, with pain and articular crepitus present been inhibited. If tissue has become fibrotic, connective during movement. tissue methods are used to restore pliability. Tendonitis produces pain, tenderness, and stiffness near Treatment a joint and is aggravated by movement. The type of ten- donitis typically is named for the associated joint. For The goals of tendonitis treatment are to relieve pain instance, tennis elbow causes pain on the outer side of and reduce inflammation. Tendonitis is treated with the forearm near the elbow when the forearm is rotated, PRICE. especially when the hand is gripping, which involves the wrist. Achilles tendonitis causes pain just above the heel. Steroid injection into tissue or around a tendon may be Adductor tendonitis leads to pain in the groin, patellar used to relieve tendonitis. Injections of cortisone reduce tendonitis causes pain just below the kneecap, and biceps inflammation and can help ease pain. These injections tendonitis leads to shoulder pain. If the tendon sheath must be used with care because repeated injections may becomes scarred and narrowed, this may cause locking of weaken the tendon or cause undesirable side effects. Do the tendon, as seen with trigger finger. not massage over an injection site. The steroid works by pooling around the inflamed area. Massage disperses the Risk factors for developing tendonitis include excessive medication. repetitive motions of the arms or legs. For instance, base- ball players, swimmers, tennis players, and golfers are sus- Persons with tendonitis and tendonosis also may ceptible to tendonitis in their shoulders, arms, and elbows. be helped by a program of specific exercise designed Soccer and basketball players, as well as runners and to strengthen the force-absorbing capability of the dancers, are more prone to tendon inflammation in their muscle-tendon unit. When a tendon is torn, a reconstruc- legs and feet. tive operation may be necessary to clean inflammatory tissue out of the tendon sheath or to relieve pressure on Improper technique in any sport is one of the primary the tendon by removing bone. Surgeons can repair tendon causes of overload on tissues such as tendons, which can tears to reduce pain, restore function, and, in some cases, contribute to tendinopathy. prevent tendon rupture. Sometimes the discomfort of tendinopathy disappears To avoid recurrence of tendinopathy, warming up within a matter of weeks, especially if the joint area is before exercising and cooling down afterward is important. rested and iced. In elderly persons and those who continue Strengthening exercises may help prevent further episodes to use the affected area, tendonitis often heals more slowly of tendinopathy. and is more likely to progress to a chronic condition termed tendonosis. Tendonosis often involves a change in BURSITIS, CAPSULITIS, AND SYNOVITIS the structure of the tendon to a weaker, more fibrous tissue. The soft tissues that are an integral part of the synovial joint can develop chronic problems. If tendonitis is severe and leads to the rupture of a tendon, surgical repair may be required. This is almost Bursitis certainly the case if the rupture occurs in the Achilles tendon. Usually, rest and medications to reduce pain Bursae are fluid-filled sacs found in places at which friction and inflammation are the only treatments required. The might occur within body tissues. Bursae provide protec- pain of tendonitis is usually worse with activities that use tion between tendons and bones, between tendons and the muscle that is attached to the involved tendon. ligaments, and between other structures where there is Appropriate massage that can support healing is friction. Sudden irritation can cause acute bursitis. Overuse described on p. 306. of muscles or tendons and constant external compression or trauma can result in chronic bursitis. Atrophy and Contracture Signs and symptoms of bursitis include swelling, pain, Two complications of muscle and tendon conditions are and some loss of function. Repeated trauma may lead to atrophy and contracture. Muscle atrophy is the wasting calcific deposits and degeneration of the internal lining of away of muscle tissue. The main cause of atrophy in ath- the bursa. Bursitis in the knee, elbow, and shoulder is letes is immobilization of a body part, inactivity, or loss common among athletes. Massage can be used to lengthen of nerve stimulation. A second complication is muscle the shortened structures, reducing friction. Use of muscle contracture—an abnormal shortening of muscle tissue with energy methods and inhibiting pressure at the belly or at a great deal of resistance to passive stretch. A contracture muscle attachments can affect muscle tension. Connective is associated with a joint that, because of muscle injury, tissue application is beneficial for increasing pliability. Ice applications and rehabilitative exercise are indicated.
C H AP T E R 17 Common Categories of Injury 305 Short-term use of antiinflammatory medication may be in step 1. These strategies typically are used for 3 to 10 helpful. Steroid injections at the site are a common treat- sessions. ment. Massage is contraindicated in the area of steroid 3. Once no significant improvement is noted, add con- injection until the medication is absorbed completely by nective tissue methods as described in Unit Two. Active the body. A safe waiting period for massage is 5 to 7 days. release and kneading are effective. Do not massage Massage application should not increase inflammation in directly on the specific location of the inflammation. the area. Treatment should be combined with steps 1 and 2 and should span several sessions. Capsulitis 4. If after a reasonable treatment period (6 to 10 weeks) the tendon or bursa remains painful, controlled use of Capsulitis is an inflammation process affecting the joint deep transverse friction can be attempted. Friction capsule. Usually associated with capsulitis is synovitis, would be applied along with the first three steps of this which is inflammation of the synovial membrane. Synovi- protocol and would be repeated every other day for 1 tis occurs acutely, but usually chronic conditions arise with to 2 weeks, then reduced to every third day. Improve- repeated joint injury or with joint injury that is managed ment should be noted in the first 2 weeks to justify improperly. Chronic synovitis involves active joint conges- continued use of deep transverse friction. tion with edema. As with the synovial lining of the bursa, For these massage strategies to be successful, the client the synovium of a joint can undergo degenerative tissue needs to ice the area consistently, be involved in appropri- changes. Several movements may be restricted, and joint ate rehabilitation, and be consistent with massage sessions. noises such as grinding or creaking may be noted. Again, massage is focused on managing pain and supporting CHRONIC JOINT INJURIES mobility without creating irritation. Massage with mechan- ical force application may be used to increase pliability of Objective the joint capsule in these conditions as long as the inflam- matory response is not increased. 1. Describe and apply appropriate massage for the follow- ing common syndromes and injury categories: Acute Synovitis i. Degenerative joint disease j. Dislocation The synovial membrane of a joint can be injured acutely by a contusion or a sprain. Irritation of the membrane DEGENERATIVE JOINT DISEASE causes an increase in fluid production, and swelling occurs in the capsule. The result is joint pain during motion, As with other chronic physical injuries or problems, along with skin sensitivity from pressure at certain points. chronic synovial joint injuries stem from microtrauma and In a few days with proper care, the excessive fluid is overuse. The two major categories are osteochondrosis absorbed, and swelling and pain are diminished. This con- and traumatic osteoarthritis. A major cause of chronic dition is managed best by the athletic trainer. joint injuries is failure of the muscles to control or limit deceleration during eccentric function. Athletes can avoid Massage Strategies for Tendonitis and Bursitis such injuries by avoiding chronic fatigue and training when tired and by wearing protective gear to enhance Observe the following massage strategies for clients with absorption of impact forces (Figure 17-10). tendonitis and bursitis: 1. Initially the inflamed tendon or bursa area is not directly Traumatic arthritis is usually the result of accumulated microtraumas. With repeated trauma to articular joint massaged. Instead the area is iced. Massage is targeted surfaces, the bone and the synovium thicken, and to reducing the reason for inflammation by lengthening pain, muscle spasm, and articular crepitus (grating on the shortened tissue. movement) occur. Joint wear leading to arthritis can result from repeated sprains that leave a joint with weakened Progressively deep gliding is applied from the least ligaments. Joint wear can arise from misalignment of the affected muscle attachment over the muscle belly and musculoskeletal structure, which stresses joints, or it can stops just before the area of inflammation is reached. arise from an irregular joint surface caused by repeated For example, Achilles tendonitis would be treated articular chondral injuries. Loose bodies that have been with gliding beginning at the knee and ending at the dislodged from the articular surface can irritate and Achilles attachment. The depth of pressure and drag produce arthritis. Athletes with joint injuries that are gradually increases, with the method applied up to 10 immobilized improperly or who are allowed to return to times during each massage session. Corresponding activity before proper healing has occurred eventually may reflex areas also are addressed (i.e., ankle, wrist, and be afflicted with arthritis. Massage applications for chronic forearm). joint injury are managed with palliative care to control 2. The next step is to apply sustained compression in the pain, and the following protocol is added during the muscle belly of the inflamed tendon while the client general massage protocol. moves the affected jointed area in a slow range of motion, usually a circle, but sometimes back and forth. This method is followed by gliding as described
3 06 UNIT THREE Sport Injury Bone Sclerotic Osteophytes mobility to encourage synovial fluid production and car- cysts bone tilage health. Co-contraction of the guarding response Bone reduces mobility by increasing muscle shortening in the agonist/antagonist muscles that surround the joint, com- Cartilage pressing the bone ends in the joint capsule. Joint Flexors, internal rotators, and adductor muscle groups capsule exert more pull than extensors, external rotators, and abductors during co-contraction, and joint fit is altered Cartilage Periarticular Calcified because flexors, internal rotators, and adductors are com- fragments fibrosis cartilage pressing the bone ends to a greater degree than extensors, external rotators, and abductors. Anytime the joint does NORMAL OSTEOARTHRITIS OSTEOARTHRITIS - ADVANCED move, the bone end can rub, increasing inflammation and further damaging the cartilage. A • Irregular joint space • Osteophytes Massage can manage the guarding response and encour- • Fragmented cartilage • Periarticular fibrosis age more normal neuromuscular function. Normalizing gate and muscle activator firing pattern sequences is • Loss of cartilage • Calcified cartilage important. Short, tense muscles can be inhibited by muscle energy methods and lengthening. Compression • Sclerotic bone applied at the muscle belly or at the attachments affects muscle spindle cells or Golgi tendon receptors, allowing • Cystic change motor tone to reduce and muscles to lengthen to a more normal resting length. Trigger point activity specifically Loose located in the muscle belly of short muscles can be body addressed with trigger point methods. Do not treat trigger points in a long inhibited muscle. Address reflex areas B in paired joints, such as knee/elbow, ankle/wrist, toes/ fingers, hip/glenohumeral joint, and sacroiliac joint/ C sternoclavicular joint. FIGURE 17-10 Degenerative joint disease. (A from Damjanov I: Pathology Arthritic joints tend to display increased edema. Extra- for health-related professions, ed 2, Philadelphia, 2000, Saunders. B and C from capsular fluid around the joint limits movement and can Saidoff DC, McDonough AL: Critical pathways in therapeutic intervention: extremities inhibit normal muscle function, especially firing patterns. and spine, St Louis, 2002, Mosby.) Lymphatic drainage methods are effective. An increase in intracapsular fluid (effusion) is an attempt to keep bone MASSAGE FOR ARTHROSIS AND ARTHRITIS ends separated, and under most conditions it should be left untreated during massage. If the fluid inside the capsule Repetitive impact and joint trauma predispose the joints becomes excessive, treatment is best left to the doctor. to arthritic development. Therapeutic massage has benefits Needle aspiration can relieve pressure. Synvisc, or artificial as part of a comprehensive treatment program for chronic synovial fluid, can be injected into the joint space if insuf- joint pain and mobility. Neuromuscular involvement is of ficient intracapsular fluid exists. Treatment of arthritis is a two types: guarding response and inhibition. condition management situation because guarding and edema usually recur. Ideally, massage would be given every Guarding is the response of the body to protect the other day, but massage given 2 times per week can be joint. Guarding occurs with an isometric co-contraction of effective in symptom management. the muscles that surround an affected joint. The strategy is a good one if it occurs during the acute phase of an Pain is another issue with arthritic joints. All pain man- injury for a short time but is problematic with chronic agement massage methods are appropriate, with massage problems such as arthritis. Guarding compresses the joint creating counterirritation and hyperstimulation analgesia. space, reduces mobility, and causes an uneven force distri- Use of a counterirritant ointment with capsicum is helpful bution throughout the joint, which over the long term if the skin will tolerate it. aggravates the arthritic condition. An arthritic joint needs Antiinflammatory medications are commonly pre- scribed. Side effects and symptoms affect the heart, kidney, liver, and gastrointestinal system. These medications can thin blood, and bruising is likely. Massage pressure and intensity need to be altered. Make sure compression during massage is broad-based, and avoid friction. Massage methods should not increase inflammation. Antiinflam- matory essential oils mixed in with the massage lubricant are appropriate.
C H AP T E R 17 Common Categories of Injury 307 Hydrotherapy is effective for arthritic joints. (See Unit and immobilizes the joint and may result in sudden and Two.) In general, ice goes on the joint, and heat is applied severe pain. to surrounding soft tissue. Signs and symptoms of a dislocation may include the All methods used to treat degenerative joint disease following: seek to reduce pain and increase mobility, but not reduce • A deformed and immovable joint stability. In the rare situation that steroid injection is used, • Swelling massage is contraindicated in the area. • Intense pain • Tingling or numbness near the injury Note: Rheumatoid arthritis is a systemic disease and is not discussed in this text. At times, x-ray examination of the dislocation, as with a fracture, is the only absolute diagnostic measure. First- DISLOCATION AND DIASTASIS time dislocations or joint separations may result in rupture of the stabilizing ligamentous and tendinous tissues sur- Dislocations are second to fractures in terms of disabling rounding the joint, and in avulsion, or pulling away from the athlete (Figure 17-11). A dislocation is an injury in the bone. Trauma is often so violent that small chips of which the ends of the bones that form a joint are forced bone are torn away with the supporting structures (avulsive from their normal positions. The cause is usually trauma, fracture), or the force may separate growth epiphyses or such as a hard blow to a joint or a fall. In some cases, an cause a complete fracture of the neck in long bones. These underlying disease such as rheumatoid arthritis may cause possibilities indicate the importance of administering dislocation of a joint. complete and thorough medical attention for first-time dislocations. The highest incidence of dislocation involves the fingers and the shoulder joint. Dislocations, which result primarily Two types of diastasis may occur: a disjointing of two from forces causing the joint to go beyond its normal bones parallel to one another, such as the radius and ulna anatomic limits, are divided into two classes: subluxation and tibia and fibula (usually called a high ankle sprain); and and luxation. Subluxations are partial dislocations in the rupture of a “solid” joint, such as the symphysis pubis. which an incomplete separation between two articulating A diastasis commonly occurs with a fracture. bones occurs. Luxations are complete dislocations, pre- senting total disunion of bone apposition between articu- Treatment lating surfaces. Dislocations are common injuries in contact sports, such as football and hockey, and in sports A dislocation requires prompt medical attention, returning that may involve falls, such as downhill skiing, gymnastics, bones to their proper positions without damaging the and volleyball. joint structure. Depending on the amount of pain and swelling, a local anesthetic may be administered before Dislocations may occur in major joints—shoulder, reduction. hip, knee, elbow, or ankle—or in smaller joints, such as a finger, thumb, or toe. The injury temporarily deforms Surgery is required if blood vessels or nerves are damaged, or if the doctor cannot move the dislocated Clavicle bones back into their correct positions. Surgery also may be necessary because lax joint capsules or ligaments Bone displaced stretched during the injury cause predisposition to recur- out of joint ring dislocations. Humerus The doctor may immobilize the joint with a splint or sling and may prescribe a pain reliever and a muscle relax- Scapula ant. After the splint or sling has been removed, a slow and gradual rehabilitation program is provided to restore stabil- FIGURE 17-11 Shoulder dislocation. (From Salvo SG, Anderson SK: ity, range of motion, and strength of the joint. The client Mosby’s pathology for massage therapists, ed 2, St Louis, 2008, Mosby.) should avoid strenuous activity involving the injured joint until full movement is regained and normal strength and stability of the joint are achieved. It often has been said, “Once a dislocation, always a dislocation.” In some cases, this statement is true because once a joint has been partially or completely dislocated, the connective tissues that stabilize and hold it in its correct alignment are stretched to such an extent that the joint will be vulnerable to subsequent dislocations. Chronic, recurring dislocations may take place without severe pain because of the slack condition of stabilizing tissues. The massage practitioner needs to be aware of any history of dislocation. Increased muscle tension and con- nective tissue formations may occur around the dislocated
3 08 UNIT THREE Sport Injury joint as an appropriate stabilization process. The massage PERIOSTITIS therapist needs to take care to maintain joint stability while supporting mobility. Do not lengthen shortened structures An inflammation of the periosteum can result from various to the point that the joint is vulnerable to another sports traumas, mainly contusions or attachments of short dislocation. soft tissue structures. Periostitis often appears as skin rigid- ity of the overlying muscles. It can occur as an acute With a fairly simple dislocation without major nerve or episode or can become chronic. The lymphatic drainage tissue damage, the joint likely will return to a near or fully type of massage is indicated. normal condition. As with most injuries, returning to activity too soon may cause reinjury to the joint or may ACUTE BONE FRACTURES dislocate it again. Massage therapists must acknowledge the instability of dislocated joints. Muscle guarding around A bone fracture can occur as a partial or complete break the joint provides stability. Massage manages muscle of a bone. Fracture can occur without external exposure tension that is excessive without interfering with joint or can extend through the skin, creating an external wound stability. Typically, the massage application is inhibiting (open fracture). Because of normal tissue remodeling, a compression in the belly of the excessively short muscle bone may become vulnerable to fracture during the first without stretching. The lengthening response is enough to few weeks of intense physical activity or training. Weight- reduce pain and increase mobility. If lengthening or bearing bones undergo bone reabsorption and become stretching is necessary, the massage is applied only directly weaker before they become stronger. to the tissue. Movement of the joint to stretch the area is not recommended. Also, massage corresponding reflex Fractures can result from direct trauma, and the bone areas such as shoulder/hip and elbow/knee. breaks directly at the site where a force is applied. A frac- ture that occurs some distance from where force is applied BONE INJURIES is called an indirect fracture. A sudden, violent muscle con- traction or repetitive abnormal stress to a bone also can Objective cause a fracture (Figure 17-12). 1. Describe and apply appropriate massage for the follow- STRESS FRACTURES ing common syndromes and injury categories: k. Bone injury Another type of bone break is a stress fracture. The exact Because of its viscoelastic properties, bone will bend cause of stress fracture is not known, but a number of likely possibilities are known, such as overload caused by muscle slightly. However, bone is generally brittle and is a poor contraction, altered stress distribution in the bone accom- shock absorber because of its mineral content. This brit- panying muscle fatigue, change in ground traction force tleness increases under tension forces more than under such as movement from a wood surface to a grass surface, compression forces. Bone injuries generally can be classi- or performance of a rhythmically repetitive stress such as fied as periostitis, acute bone fractures, and stress distance running. fractures. Early detection of the stress fracture may be difficult. Because of their frequency in a wide range of sports, stress fractures always must be suspected in susceptible body Closed Transverse Oblique Spiral Comminuted fracture fracture fracture fracture fracture with hematoma Open Intraarticular fracture fracture with with hemarthrosis bleeding Segmental fracture Impacted Avulsion (greater Compression fracture fracture tuberosity of Greenstick Torus (buckle) humerus avulsed fracture fracture by supraspinatus m.) Pathologic fracture (tumor or bone In children disease) FIGURE 17-12 Fracture types. (Netter illustration from www.netterimages.com. © Elsevier Inc. All rights reserved.)
C H AP T E R 17 Common Categories of Injury 309 areas that fail to respond to usual treatment. The most occurs around the fracture area. This tension pattern will common sites of stress fracture are the tibia, fibula, meta- not shift while the area is in acute and subacute healing tarsal shaft, calcaneus, femur, lumbar vertebrae, ribs, and phases. General pain control measurements are used to humerus. help the client be more comfortable. Avoid any deep or aggressive methods. Repetitive light stroking or gentle Major signs of a stress fracture include swelling, focal holding of tissues that are aching in response to guarding tenderness, and pain. In early stages of the fracture, the can generate hyperstimulation analgesia. Massage in the athlete complains of pain when active but not at rest. corresponding reflex areas can increase comfort. For Later, the pain is constant and becomes more intense at example, if the break occurs in the right lower leg (fibula), night. Percussion by light tapping on the bone at a site massage the left forearm. other than the suspected fracture will produce pain at the fracture site. Once the immobilization (cast or other) is removed and with approval from the medical team, soft tissue mobiliza- Management of stress fractures varies with the indi- tion around the break can begin. The forces used are vidual athlete, the injury site, and the extent of injury. applied so as not to disturb the healing bone. Instead, the Stress fractures that occur on the concave side of bone heal tissues generally are moved around the bone. Tension and more rapidly and are managed more easily compared with torsion forces are used to increase soft tissue pliability in those on the convex side. A stress fracture on the convex the area of immobilization, where tissue often becomes side can rapidly become a complete fracture. atrophied and dense. The process is gentle at first, moving tissues into and out of bind. Drag is increased over the Treatment following weeks of rehabilitation. Therapeutic exercises will reverse the atrophy of surrounding muscles. If surgical Bone is an active tissue that regenerates well. It heals com- areas exist, the same approach is used in the specific inci- pletely as long as initial treatment is appropriate. Treat- sion areas and for scar tissue management. ment of fractures typically involves realignment of the broken segments of bone (reduction). Some fractures, such NERVE INJURIES as stress fractures, do not require reduction. Simple frac- tures can be treated with closed reduction and immobiliza- Objective tion (cast). More complicated fractures may require more complicated surgical repair involving use of various pins, 1. Describe and apply appropriate massage for the follow- screws, and plates. Infection is a great concern if the bone ing common syndromes and injury categories: penetrates the skin. The massage practitioner needs to be l. Nerve injury aware of the potential for stress fractures and must refer The two main forces that cause major nerve injury are the client if necessary. compression and tension. As with injuries to other tissues Complete fracture healing takes a minimum of 6 weeks in the body, nerve injury may be acute or chronic. Injured and much longer if the injury is complex. Bone heals well peripheral nerve tissue can heal over time (Figure 17-13). if conditions are present that support healing such as proper nutrition, appropriate rehabilitation from qualified Any number of traumas directly affecting nerves can medical professionals, stress management, and restorative produce a variety of sensory responses, including pain. For sleep. example, a sudden nerve stretch or pinch (burners, stingers) can produce muscle weakness and a sharp burning pain Massage Application to Support Fracture Healing that radiates down a limb. Neuritis, a chronic nerve problem, can be caused by a variety of forces that usually Massage application does not address bone fractures have been repeated or continued for a long time. Symp- directly. Instead massage supports general healing and any toms of neuritis can range from minor nerve problems to compensation from changes resulting from use of various paralysis. types of immobilization or crutches, changes in gait, or postural stabilization. Pain felt at a point of the body other than its actual site of origin is known as referred pain. Another potential cause When applying massage during the first 1 or 2 weeks, of referred pain is a trigger point, which occurs in the completely avoid the area of the fracture, and as always be muscular system. Massage applications for nerve injuries attentive to sanitation during the massage. The massage are palliative to reduce pain. If the nerve is being impinged should be relaxing, nonpainful, and focused to support by short muscles and fascia, massage can be used to restore parasympathetic dominance. Sufficient pressure needs to normal length of these tissues and reduce pressure on the be used during the general massage to generate a serotonin nerve. and endorphin response to aid in pain management. NERVE IMPINGEMENT As the client becomes more mobile, compensation develops in response to the fracture, treatment, and reha- Nerve impingement commonly is called a pinched nerve. bilitation. General massage can be expanded to address Two types of impingement exist: entrapment and neighboring areas that are sore and aching. These adapta- compression. tions often occur in the neck, shoulder, and low back areas in the postural muscles. Muscle guarding commonly
3 10 UNIT THREE Sport Injury Neuron The brachial plexus is situated in the neck and the axilla cell body and consists of virtually all nerves that innervate the upper limb. Any imbalance that increases pressure on this complex Axon of nerves can result in pain in the shoulder, chest, arm, wrist, and hand. The muscles most often responsible for Schwann impingement on the brachial plexus are the scalenes, pec- cells toralis minor, and subclavius muscles. The muscles of the arm also occasionally impinge on branches of the brachial Cut plexus. Brachial plexus impingement is responsible for thoracic outlet symptoms, which often are misdiagnosed Muscle as carpal tunnel syndrome. Whiplash injury, stingers, and cell burners often cause impingement on the brachial plexus. A B CD Carpal tunnel syndrome is caused by compression of the median nerve as it passes under the transverse carpal FIGURE 17-13 Repair of a peripheral nerve fiber. A, Injury results in a cut ligament at the palmar aspect of the wrist. The syndrome nerve. B, Immediately after the injury occurs, the distal portion of the axon can occur when fluid retention causes swelling of the hand degenerates, as does its myelin sheath. C, The remaining neurilemma tunnels from and wrist. The syndrome is common in persons who use the point of injury to the effector. New Schwann cells grow within this tunnel, their hands in repetitive movements, usually resulting maintaining a path for regrowth of the axon. Meanwhile, several growing axon from inflammation that leads to compression on the sprouts appear. When one of these growing fibers reaches the tunnel, it increases nerve. The symptoms are palmar by pain and numbness its growth rate, growing as much as 3 to 5 mm per day. (The other sprouts in the first three digits. Sometimes surgically opening the eventually disappear.) D, The connection of the neuron with the effector is transverse carpal ligament can help relieve the pain. reestablished. (From Thibodeau GA, Patton KT: Anatomy and physiology, ed 7, St Louis, 2009, Elsevier.) Impingement on the lumbar plexus gives rise to low back discomfort, which is marked by a belt-like distribu- Entrapment results when soft tissue (e.g., muscles, liga- tion of pain and by pain in the lower abdomen, genitals, ments) exerts inappropriate pressure on nerves; compres- thigh, and medial lower leg. The main muscles that impinge sion occurs when hard tissue (e.g., bone) exerts inappropriate on the lumbar plexus are the quadratus lumborum, mul- pressure on nerves. Regardless of what is impinging (press- tifidi, and psoas. Shortening of the lumbodorsal fascia ing) on the nerve, the symptoms are similar; however, the exaggerates a lordosis and can cause vertebral impinge- therapeutic intervention varies. Therapeutic massage is ment on the lumbar plexus. beneficial in entrapment but less so with compression. The sacral plexus has about a dozen branches that Tissues that can bind and impinge on nerves are the innervate the buttock, lower limb, and pelvic structures. skin, fascia, muscles, ligaments, and bones. Shortened The main branch is the sciatic nerve. Impingement on this muscles and connective tissue (fascia) often impinge on nerve by the piriformis muscle is a cause of sciatica. Short- major and minor nerves, causing discomfort. Because of ened ligaments that stabilize the sacroiliac joint can affect the structural arrangement of the body, these impinge- the sacral plexus. Pressure on the sacral plexus can cause ments often occur at major nerve plexuses. The specific pain in the gluteal muscles, leg, genitals, and foot. nerve root, trunk, or division affected determines the con- dition, producing disorders such as thoracic outlet syn- Various forms of massage reduce muscle spasm, lengthen drome, sciatica, and carpal tunnel syndrome. shortened muscles, and soften and stretch connective tissue, restoring a more normal space around the nerve and If the cervical plexus is impinged, the person most likely alleviating impingement. When massage is combined with will have headaches, neck pain, and breathing difficulties. other appropriate methods, surgery is seldom necessary. If The muscles most responsible for pressure on the cervical surgery is performed, the massage practitioner’s role is to plexus are the suboccipital and sternocleidomastoid manage adhesions to prevent reentrapment of the nerve in muscles. Shortened connective tissue at the cranial base the future and to maintain soft tissue suppleness around also presses on these nerves. Many cutaneous (skin) the healing surgical area. As healing progresses, extend the branches of the cervical plexus transmit sensory impulses focus of therapeutic massage to deal with the forming scar from the skin of the neck, ear area, and shoulder. Motor more directly. Before doing any work near the site of a branches innervate muscles of the anterior neck. Impinge- recent incision, the practitioner must obtain the physi- ment causes pain in these areas. cian’s approval. In general, work close to the surgical area can begin after the stitches have been removed and all inflammation has dissipated. Follow the massage strategies for wounds. NERVE ROOT COMPRESSION Many different conditions can result in compression of the nerve root, including tumors, subluxation of vertebrae,
C HA P T E R 17 Common Categories of Injury 311 and muscle spasms (entrapment) and shortening. Disk stabilize bony structures and prevent further compression degeneration is a common cause. As degeneration pro- on the nerve. Massage application addressing the soft gresses and the fluid content of the disk decreases, the disk tissue, combined with repositioning of the underlying becomes narrower. As a result, the amount of space structure with manipulation and therapeutic exercise, is between vertebrae is reduced. Because spinal nerves exit required for effective treatment. and enter in the spaces between the vertebrae, this situa- tion increases the likelihood of nerve root compression. Massage methods used to treat entrapment vary depend- The condition most commonly occurs in the areas where ing on what is impinging the nerve: the spine moves the most: C6 to C7, T12 to L1, L3 to Muscle shortening: Use muscle energy methods such as L4, and L5 to S1 (C, cervical; T, thoracic; L, lumbar; S, sacral). The result is radiating nerve pain often associated positional release and lengthening. Direct inhibiting with protective and stabilizing muscle guarding, weakness, pressure at the spindle cell and/or Golgi tendon organs or both. combined with application of tension and bend force will lengthen the muscle. DISK HERNIATION Connective tissue: Mechanical force, bend, torsion, and compression force increase ground substance pliability. Disk herniation occurs when the fibrocartilage surround- Adhesion/fibrosis can be addressed with bend, shear, ing the intervertebral disk ruptures, releasing the nucleus torsion, and tension force to encourage more appropri- pulposus. Resultant pressure on spinal nerve roots may ate fiber alignment. cause pain and may damage surrounding nerves. This con- Fluid: Lymphatic drainage combined with passive and dition most often occurs in the lumbar region and involves active joint movement. the L4 or L5 disk and L5 or S1 nerve roots. This particular Bone: Compression usually is managed best by the back pain radiates from the gluteal area down the lateral trainer, physical therapist, physician, or chiropractor. side or back of the thigh to the leg or foot. Back strain or In simple situations, joint play and indirect functional injury often causes disk herniation, but occasionally methods may help. The body area is placed in an ease coughing and sneezing may precipitate the condition. position, and the client exerts muscle force to pull the Improper form during weight lifting is a common source body back into the neutral position (described in Unit of injury in the athlete. Two). The pull of the muscle on the bone can help the structure to reposition, thus reducing nerve The symptoms of herniation are similar to those pro- compression. duced by a compressed disk but often are more severe. In The location of the nerve entrapment is identified with extreme cases, surgical intervention may be necessary; palpation. When the area is located, the symptoms will otherwise, conservative care is used. Conservative treat- be reproduced. If the nerve is irritated in this location, ment consists of rest, exercise, and other methods, includ- sustained compression or intense stretching only increases ing massage to reduce spasm. Traction can be beneficial. the irritation. Once the impingement is located, next identify the nature of the impingement—muscle tension, Massage Treatment connective tissue bind, fluid buildup, or structural misalignment—and then treat accordingly. When in Various forms of massage are important for managing the doubt, apply all methods but do not overwork the area. muscle spasm and pain associated with nerve irritation Begin with general massage around the area before target- from the herniated disk. The muscle spasm/guarding ing the actual impingement site. response serves a stabilizing and protective function. In athletes with muscle bulk and dense tissues, actually Without some protective muscle guarding, the nerve could reaching the area of impingement is often difficult. In this be damaged further, but too much muscle contraction case, use muscle energy methods, especially positional increases the discomfort. Therapeutic intervention seeks to release. Normalization of firing patterns and gait reflexes reduce pain and excessive tension and to restore moderate is usually necessary. If the impingement is the result of mobility while supporting resourceful compensation pro- muscle spasm, short-term use of muscle-relaxing medica- duced by the muscle tension pattern. tion is effective. Athletes often experience nerve impingement, and SUMMARY physical rehabilitation exercises are used to treat nerve impingement in the general population. Repetitive strain, This chapter categorized injury types and explained the posture changes, and compensation from traumatic injury commonalities of these injuries. are common causes. The elderly are prone to cervical and lumbar nerve impingement because of age-related tissue The strategies were described for beneficial and safe and bone changes. Nerve pain usually radiates in a line therapeutic massage application. These conditions use following the tract of the nerve. Massage applied to reduce treatment assessment procedures described in Unit Two soft tissue binding on the nerve needs to address the soft and usually are treated in the context of full-body massage, tissue effectively but not irritate the underlying nerve. If which also is described in Unit Two. the impingement consists of entrapment and compression, muscle tension actually may be protective, attempting to
3 12 UNIT THREE Sport Injury WORKBOOK Visit the Evolve website to download and complete the following exercises. 1 List the general injury categories that have lymphatic 4 List the common injuries that usually are caused by drainage as the major intervention. a traumatic event. 2 List the general injury categories that have scar tissue 5 List the common injuries that have repetitive strain management as a portion of the recommended treat- as the major causal factor. ment strategies. 3 List the general injury categories that would indicate appropriate application of muscle energy methods and lengthening.
CHAPTER 18Medical Treatment for Injury OUTLINE OBJECTIVES Surgery After completing this chapter, the student will be able to perform the following: 1 Explain the importance of appropriate use of surgery and medication to treat injury. Arthroscopy 2 List indications and contraindications for massage. Massage Application 3 Perform appropriate presurgical and postsurgical massage application. Regenerative Therapy and Joint 4 Alter massage to interact appropriately with use of medication and injected substances. Replacement Steroid Injections (Cortisone) KEY TERMS Pharmacology Presurgical Viscosupplementation Arthroscopic Surgery Postsurgical Steroid Injections Platelet-Rich Plasma (PRP) Injections Muscle Relaxers Pharmacology Nonsteroidal Antiinflammatory Summary Drugs (NSAIDs) Advances in surgical techniques, rehabilitation, treat- most common arthroscopic procedures include removal ment, and pharmacology have prolonged the of loose bodies, trimming of articular cartilage flaps and careers of many athletes and have improved the meniscal tears, and débridement of scar tissue. Arthroscopic quality of life for the general public. Sport medicine pro- procedures can also be used to obtain a more accurate fessionals now can treat and rehabilitate patients with inju- diagnosis through visual inspection of the joint. Although ries and illnesses that in the past could end a career or many of today’s magnetic resonance images are of very cause permanent disability. This chapter describes current high quality, at times a visual inspection through arthros- approaches to treatment and explains how massage can copy is needed to make an accurate diagnosis. In particu- support successful outcomes. lar, arthroscopy can be used to diagnose the size, depth, and condition of articular cartilage lesions. SURGERY The technique of arthroscopic surgery involves the Objectives placement of three to four small incisions (portals) around the joint. Standard arthroscopic incisions create small, 1. Explain the importance of appropriate use of surgery approximately 1 to 2 cm, portals. Fluid is introduced in and medication to treat injury. the joint to allow better visualization and separation of structures and to remove any blood that might be present 2. List indications and contraindications for massage. from surgical incisions or injuries. 3. Perform appropriate presurgical and postsurgical The portals are used for placement of the arthroscopic massage application. camera to visualize the work inside the joint. A beam of light and a small camera are used to project an image of ARTHROSCOPY the interior of the joint onto a video monitor. Arthroscopic surgery involves the use of fiberoptic Sterile fluid is used to expand the joint, and a probe is cameras and small surgical instruments to visualize and frequently used to manipulate and investigate joint struc- treat intraarticular structures of the joint (Figure 18-1). The tures. Because the portal incisions are so small, stitches 313
3 14 UNIT THREE Sport Injury 2 problems in the shoulder, elbow, wrist, hip, and ankle. 13 Whether joint problems are the result of an acute event, such as a sports injury, or a chronic condition, such as FIGURE 18-1 Arthroscopic portals. Posterior (1), anterior (2), and lateral arthritis, arthroscopy has improved the quality of patient (3). (From Miller MD, Cole BJ: Textbook of arthroscopy, Philadelphia, 2004, care and can be performed on individuals of all ages. Saunders.) Arthroscopy not only makes joint surgery less invasive, FIGURE 18-2 Arthroscopy. (From Miller MD, Cole BJ: Textbook of arthroscopy, it also reduces recovery time. Because less disruption of Philadelphia, 2004, Saunders.) joint structures occurs, pain and swelling to surrounding usually are not required to close the surgical wounds structures are lessened. This can allow earlier return to (Figure 18-2). range-of-motion and strengthening exercises. Arthroscopy can be used to examine and repair the Although some complex procedures still require tradi- damaged joint in a single operation. First used primarily tional open surgery, many procedures can be performed on the knee joint, arthroscopy now can diagnose and treat by using arthroscopy. As with any surgical procedure, risks are associated with arthroscopy, including the following: • Nerve injury • Infection • Bleeding • Stiffness Almost all arthroscopic surgeries now are performed on an outpatient basis. Steri-Strips are frequently used to close the arthroscopic portals, allowing skin incisions to heal and minimizing scarring. A loose, sterile dressing is applied for 3 to 4 days. Depending on the procedure, patients may be allowed to bear weight as tolerated with the use of crutches and may wean off the crutches when they can walk without a limp. Rehabilitation should begin as soon as the surgeon permits so that the joint does not lose range of motion and so that muscle atrophy can be reduced. Showers generally are allowed at 3 or 4 days after surgery. Most patients recover fully. MASSAGE APPLICATION Before Surgery (24 to 48 Hours) The goals of presurgical massage are to reduce anxiety and support restorative sleep. A rested, calm person requires less anesthesia and copes better with the stress of the surgical procedure. Do not work directly on targeted surgical areas with deep pressure, intense drag, or any methods with the potential for tissue damage. Use a pallia- tive approach. Target breathing function, parasympathetic dominance, and neurochemical balance. After Surgery (24 to 48 Hours) The goals of postsurgical massage include pain control, reduction of anxiety, and restoration of sleep. Additional benefits can include wound and pain management, as well as lymphatic drainage. Depending on the procedure, massage can begin within 24 to 48 hours. The massage focus targets pain management, reduced anxiety, and sleep support. The duration is short and more frequent, such as 2 times per day. Target areas may include tissue other than the surgical site. Often the neck, shoulders, and low back are sore from bed rest or positioning during surgery. Massage of the head, face, hands, and feet is usually effec- tive in calming the client. Do not use methods that cause pain. Do not apply massage near the surgery site. Some
C H A P TE R 18 Medical Treatment for Injury 315 outpatient procedures allow the client to return home the BOX 18-1 Examples of Massage After day of the surgery or the next day. Infection control is important; therefore, maintain meticulous sanitation. Surgery 3 Days After Surgery EXAMPLE 1: ARTHROSCOPIC KNEE SURGERY ON THE LEFT KNEE The goals of massage are to improve lymphatic drainage, to manage postsurgical edema, and to manage pain. For Reflexive massage would be targeted to the right elbow including the most surgical procedures involving arthroscopy, the patient biceps to influence the hamstring reflexively, the triceps to influence the will be home and ambulatory. Work on the surgical site quadriceps, and the wrist and finger flexors at the elbow to influence should be avoided, but careful and gentle work around the the calf. Lymphatic drainage is promoted and circulation is supported for joint may be appropriate. (See the discussion of wounds the entire arm. Then massage application moves to the left elbow and in Chapter 17.) This is considered acute care, and the surgi- is targeted to influence the right hamstring and the left quadriceps cal sites are wounds. Sanitation and infection control con- reflexively. Wrist extensors at the elbow target the calf. Then move to tinue to be top priorities. If the patient has been instructed the right leg. The hamstrings on the left are influenced reflexively by to do range-of-motion exercises, massage supports the massage of quadriceps on the right. The quadriceps on the left is influ- movement pattern. Work with reflex patterns. Paired func- enced by massage of the hamstring on the right. tional areas include the following: • Right shoulder, left hip, and vice versa EXAMPLE 2: SPORTS HERNIA IN • Right elbow, left knee, and vice versa THE RIGHT GROIN • Right wrist, left ankle, and vice versa • Right hand, left foot, and vice versa Reflexive massage is applied to the left anterior and lateral neck, the pectoralis major and pectoralis minor on the left, the region of the scapula Functional muscle units are as follows: on the right, and the neck extensor on the right. • Flexors with opposite side flexors and same-side incision. Use gentle bending and shear force to increase extensors tissue pliability. Intensity increases each day, and by 14 • Extensors with opposite side extensors and same-side days, if the incision is fully healed, tension force is added. At 18 to 20 days, add torsion force and work directly on flexors the incision unless a contraindication, such as delayed • Internal rotators with opposite side internal rotators and healing, exists. same-side external rotators Continue to promote lymphatic drainage of the area, • External rotators with opposite side external rotators and reset all firing patterns and gait reflexes. Support all rehabilitation exercises prescribed and monitored by the and same-side internal rotators physician, physical therapist, and athletic trainer. Massage • Adductors with adductors and abductors with the client 3 to 4 times per week if possible. abductors Remodeling Stage: 3 to 4 Weeks After Surgery Trunk paired patterns are as follows: • Neck flexors with trunk flexors The goals of massage are to improve lymphatic drainage, • Neck extensors with trunk extensors to manage postsurgical edema, to manage pain, and to • Neck lateral flexors with trunk lateral flexors support pliable scar formation and rehabilitation proce- These relationships are especially helpful in the treat- dures. Resume use of a full-body general protocol as pre- ment of acute tissue inflammation that can be the result sented in Unit Two. Continue to manage edema and of surgical procedures. Because massage on the surgical muscle activation patterns and reflex patterns. Address scar area is contraindicated, paired areas can be addressed to tissue each massage. Normalize all residual muscle guard- create beneficial reflex responses (Box 18-1). ing. Continue this focus for at least 6 months. Massage 2 The effect of massage is increased if the client can move times per week if possible. the area gently while the targeted reflex areas are massaged. Intentional and deliberate focus is important. For the first Total joint replacement surgery follows the same post- example, in Box 18-1, when massaging the right biceps, be surgical patterns, but each healing phase will take longer, thinking about the left hamstring. Using these reflexes especially in the elderly. does not mean that you are massaging the arm for the benefit of the arm. The arm is massaged to influence the REGENERATIVE THERAPY AND leg. Continue to promote lymphatic drainage and massage JOINT REPLACEMENT daily if possible. Advances are occurring in the treatment of joint injury and Subacute Phase: 7 Days After Surgery deterioration. Tissue engineering is a new treatment strat- egy. Tissue engineering uses a person’s own tissues or cells The goals of massage are to improve lymphatic drainage, to help heal injuries (Fosang and Beier, 2011). Stem cell to manage postsurgical edema, to manage pain, and to support mobility. Stitches (if present) should be removed, and gentle scar tissue work can begin in the surgical area. Use strategies for wound healing but avoid pull on the
3 16 UNIT THREE Sport Injury research has been ongoing, and mesenchymal stem cells • Plantar fasciitis (MSCs) have the ability to differentiate into various cell • Carpal tunnel syndrome types, including osteoblasts, chondrocytes, and myocytes. • Herniated disk and other back pain MSCs can be isolated from various tissues such as bone marrow, adipose tissue, skeletal muscle, synovium, pla- Steroid injections cannot cure any of these conditions centa, and teeth. Treatment typically involves introducing and are targeted to symptom management. They generally the regenerative substance into the target area and allowing are used as a last resort after antiinflammatory drugs and repair to occur. For massage therapists, recommendations physical therapy have been tried and have failed to provide include avoidance of the area until the physician indicates relief. Steroid injections may help with chronic, painful that it is appropriate for the patient to receive massage inflammation and may reduce recovery times, but unless therapy to address joint function. Tissues around the joint the underlying cause is determined and treated, injections can be treated, but aggressive movement methods should will provide only temporary relief. More than three to four be avoided. injections within a year in the same area of the body are not recommended because glucocorticoids can result in Advancements are also being made in joint replacement the following potentially serious adverse effects: technology. The goal of replacement surgery is to replace • Weight gain damaged and deteriorating joint structures to decrease pain • High blood pressure and restore function. New technology for imaging and • Cataracts computer-assisted implant placement has been developed, • Diabetes allowing more precise reconstruction of damaged joints • Puffy face instead of total replacement. New implant designs and • Osteoporosis (thinning of the bones) materials are being developed to facilitate surgery and • Reduced immunity and increased risk of infection prolong the life span of replacements, for example, a • Long-term joint and tendon damage “partial” knee replacement essentially caps the damaged • Ulcers area and preserves the integrity of the joint itself. Adverse effects are more likely to occur with steroid STEROID INJECTIONS (CORTISONE) pills than injections, but research indicates that as few as four injections per year can damage a joint permanently Objectives or introduce risk of tendon rupture. 4. Alter massage to interact appropriately with use of Because cortisone needs to surround the area of inflam- medication and injected substances. mation to work successfully, massage in the area of the Steroid injections are a common and effective treat- injection is contraindicated for at least a week. ment for a variety of conditions in which inflammation VISCOSUPPLEMENTATION causes pain, swelling, and other problems. Glucocorti- coids, particularly prednisone and cortisone, are used in 4. Alter massage to interact appropriately with use of injections for inflammation and pain. These hormones medication and injected substances. help reduce inflammation and pain in the body. Cortisone Synovial fluid is necessary for joint function. Hyal- is the most well-known injectable steroid, and it has a proven antiinflammatory effect on tissues, particularly uronic acid is a naturally occurring substance found in the joints and tendons. This family of steroids is not the same synovial (joint) fluid. Synovial fluid acts as a lubricant to as anabolic steroids, which are used to enhance muscular enable the articular surfaces to move smoothly over each development and are largely illegal in the United States other; it also serves as a shock absorber for joint loads. and in international athletic competition. Viscosupplementation injects a preparation of hyaluronic acid into the joint when a lower-than-normal concentra- Glucocorticoids are thought to interfere with immune tion of hyaluronic acid is found in the joint fluid. People system processes that result in inflammation, but the exact with osteoarthritis/osis (“wear-and-tear”) may benefit. It is method by which they do this is not known. Injections of most effective if arthritis is in its early stages (mild to glucocorticoids are known to target the area of pain and moderate). The long-term efficacy of viscosupplementa- inflammation better and faster than orally ingested forms. tion is not yet known, and research continues in this area Cortisone injections typically result in pain relief in a (Carulli et al., 2012). The knee is commonly treated with matter of days, which may last up to a month. this method. Hyaluronic acid does not have an immediate pain-relieving effect; a local reaction such as pain, warmth, Some common conditions that can be treated by steroid or slight swelling may be noted immediately after the shot. injections include the following: These symptoms generally do not last long, and an ice pack • Tennis elbow (lateral epicondylitis) is appropriate. For the first 48 hours after the injection, • Golfer’s elbow (medial epicondylitis) excessive weight bearing on the leg should be avoided. • Joint pain of varying nature (osteoarthritis) Multiple injections may be used. Hyaluronic acid • Bursitis of the shoulder, hip, or knee does seem to have antiinflammatory and pain-relieving • Frozen shoulder
C H A P T E R 18 Medical Treatment for Injury 317 properties, and the effects may last for several months Common NSAIDs and analgesics available over the (Schiavinato and Whiteside, 2012). counter include ibuprofen (Advil, Motrin IB), ketoprofen (Actron, Orudis-KT), and naproxen (Aleve). Related drug The massage therapist should adapt massage in the classes include aspirin (Genuine Bayer Aspirin, Bufferin, treatment area and avoid aggressive methods. Ecotrin). Acetaminophen (Tylenol) is an analgesic that does not have antiinflammatory properties. A common PLATELET-RICH PLASMA (PRP) INJECTIONS prescription antiinflammatory drug, celecoxib (Celebrex), is a cyclooxygenase (COX)-2 inhibitor that is thought to Objectives be easy on the stomach. However, it does produce cardio- vascular adverse effects. 4. Alter massage to interact appropriately with use of medication and injected substances. In general, NSAIDs may increase the potential for Platelet-rich plasma, or PRP, injection is used to treat bruising, so the massage therapist needs to monitor pres- sure during the massage. Maintain broad-based contact, soft tissue injury by supporting natural healing processes. and do not poke, probe, or dig on the tissues. This therapy is most beneficial when the injury is in the acute or early subacute phase (Bava and Barber, 2011; NSAIDs act therapeutically by inhibiting prostaglandin Sampson et al., 2008). Platelets contain growth factors that synthesis, thereby reducing pain and inflammation. Exces- are responsible for the proliferative healing phase of an sive NSAID use may increase the potential for renal prob- injury. The body’s first response to soft tissue injury is to lems. This potential is magnified if prolonged exercise is deliver platelet cells to trigger repair and attract stem cells combined with severe heat stress and/or dehydration. to the injured area. PRP injection therapy supports natural Proper hydration before and throughout exercise can mini- healing processes by delivering a higher concentration of mize the damage that NSAIDs can cause to the kidneys platelets. To create PRP therapy, a small sample of blood (Wharam et al., 2006; Popkin et al., 2010). is drawn from the recipient, and the platelets are separated from other components in the blood. The concentrated Muscle relaxers reduce motor tone in muscle, altering PRP is then injected into and around the injured tissue, normal protective mechanisms for overstretching and jump-starting and supporting the body’s natural healing overcontracting. Massage and various muscle energy process. lengthening and stretching methods may be contraindi- cated to prevent tissue damage. This procedure takes approximately 1 to 2 hours, includ- ing PRP preparation and recovery time, and can be per- Common muscle relaxers include the following: formed safely in a medical office. Typically, up to three • Cyclobenzaprine (Flexeril) injections may be given within a 6-month period, usually • Metaxalone (Skelaxin) 2 to 3 weeks apart. The need for surgery can be greatly • Carisoprodel and aspirin (Soma) reduced by treating injured tissues before damage pro- • Tizanidine (Zanaflex) gresses and the condition becomes irreversible. SUMMARY PRP injections work at the area of injury; therefore, do not massage over the injection site within 5 days of the Advances in surgical and pharmacologic treatment of procedure. physical exercise–related injuries have allowed individuals to compete and perform daily life activities with signifi- PHARMACOLOGY cantly less pain. These advances will continue as medical technology progresses. Objectives Athletic clients and those in physical rehabilitation 4. Alter massage to interact appropriately with use of may be taking medication for non–exercise-related condi- medication and injected substances. tions. A thorough clinical history including all medication The main pharmacologic agents used for sport injuries supplements and herbal remedies is necessary. Massage needs to be altered on an individual basis to consider the are nonsteroidal antiinflammatory drugs (NSAIDs) and patient’s medication use. Refer to the Evolve website that steroidal antiinflammatory drugs, muscle relaxers, and accompanies this book for a list of medications for pain control medication. Antibiotics are commonly used massage. to prevent and treat infection. REFERENCES Massage application needs to be altered to support the effects of medications without causing tissue damage Bava ED, Barber FA: Platelet-rich plasma products in sports medicine, because pain perception is altered. Massage may be sub- Phys Sportsmed 39:94, 2011. stituted for muscle relaxers and pain medication, but this must be a medical decision directed by the physician. Carulli C, Civinini R, Martini C, et al: Viscosupplementation in haemophilic arthropathy: a long-term follow-up study, Haemophilia NSAIDs are prescribed for competitive athletes and 18:e210, 2012. other physically active individuals because of their anal gesic (pain reduction) and antiinflammatory benefits.
3 18 UNIT THREE Sport Injury Fosang AJ, Beier F: Emerging frontiers in cartilage and chondrocyte Schiavinato A, Whiteside RA: Effective lubrication of articular cartilage biology, Best Pract Res Clin Rheumatol 25:751, 2011. by an amphiphilic hyaluronic acid derivative, Clin Biomech (Bristol, Avon) 27:515, 2012. Popkin BM, D’Anci KE, Rosenberg IH: Water, hydration and health, Nutr Rev 68:439, 2010. Wharam PC, Speedy DB, Noakes TD, et al: NSAID use increases the risk of developing hyponatremia during an Ironman triathlon, Med Sampson S, Gerhardt M, Mandelbaum B: Platelet rich plasma injection Sci Sports Exerc 38:618, 2006. grafts for musculoskeletal injuries: a review, Curr Rev Musculoskelet Med 1:165, 2008. WORKBOOK Example: Client not comfortable on massage table at massage office. Will need to work with client in Visit the Evolve website to download and complete the following exercises. a reclining chair or at client’s home. 1 Prepare a letter to an orthopedic surgeon explaining the benefits and risks of massage before and after surgery. 2 List and explain at least 10 adaptations for massage application if surgery and medication are provided.
Systemic Illness CHAPTER and Disorders 19 OUTLINE OBJECTIVE After completing this chapter, the student will be able to perform the following: Immune Function 1 Apply appropriate massage interventions for clients with infections, inflammation, cardiovascular/ Immunity in Athletes respiratory disease, thermoregulating disorders and heat-related illnesses, and breathing pattern Massage Implications disorder. Inflammation KEY TERMS Dehydration Heat Syncope (Heat Collapse) Massage Implications Bacterial Infection Frostbite Hyperthermia Cardiovascular/Respiratory Illnesses Breathing Pattern Disorder Fungal Infection Hypothermia Cardioprotection Heat Cramps Immune Function Massage Implications Cardiovascular/Respiratory Heat Exhaustion Inflammation Heat-Related Illnesses Heat Rash Disease Heatstroke Heat Rash Cerebrovascular Constriction Heat Syncope (Heat Collapse) Coronary Artery Disease (CAD) Heat Cramps Heat Exhaustion Therapeutic Massage for Breathing Assessment Procedures Breathing Retraining Program Heatstroke Disorders Treatment Procedures Summary Dehydration Treatment Cold-Related Illness Breathing Pattern Disorders Sleep-Disordered Breathing Orthopedic injuries most commonly are associated and multiple sclerosis. Illness can be caused by a body with sports; however, infectious diseases also system failure as occurs in cardiovascular disease, kidney cause problems for athletes. Return to play issues failure, and diabetes. Systemic and local inflammatory and prevention of infection are especially important in response is an underlying factor in immune function and athletes. Illness is different from injury. Illness involves the dysfunction. Acute inflammation is necessary for healing, whole body; injury is more local. Both illness and injury but chronic inflammation is the underlying factor in many can involve the inflammatory response. Various illnesses autoimmune diseases. can target a body system. For example, a cold is an upper respiratory infection. This is different from a localized Disorders occur when the body’s homeostatic regula- bruise on the quadriceps. Illness can be the result of infec- tions are unable to adapt in response to internal or external tion by a pathogen—bacteria, viruses, or fungi—in which influences. Examples are thermoregulating disorders and the immune system is unable to stop the progression of breathing pattern disorder, which is extremely common invasion. Illness can also be autoimmune, such as systemic and is discussed extensively in this chapter. lupus erythematosus (SLE), or it may be the result of an overreaction of the immune response as occurs in allergies Athletes, like other people, have allergies and systemic disease, and these conditions must be factored into the focused treatment plan. Cardiovascular/respiratory 319
3 20 UNIT THREE Sport Injury disease rehabilitation is a major reason for therapeutic depression, poor performance, and muscle soreness. Para- exercise. sympathetic dominance is a very important area of thera- peutic massage intervention for stress management and IMMUNE FUNCTION immune system function. In addition, several lifestyle practices may be beneficial. The athlete needs to eat a Objective well-balanced diet, keep other life stresses to a minimum, avoid overtraining and chronic fatigue, obtain adequate 1. Apply appropriate massage interventions for clients sleep, and space vigorous workouts and competitive events with infections. as far apart as possible (Box 19-1). Overtraining and aggressive physical activity can sup- MASSAGE IMPLICATIONS press the immune system, predisposing to infection. Illness should be diagnosed and treated by the physician. If When an athlete is ill, DO NOT overmassage. Regardless bacterial infection is detected, antibacterial medication of the ongoing treatment plan, back off and apply general, may be prescribed. Digestive upset including diarrhea is nonspecific massage for no longer than 45 to 60 minutes common. Fever below 102° F (39° C) is usually productive with a relaxation/palliative outcome, and encourage rest, during infection (often referred to as a low-grade inflam- sleep, proper fluid intake, and nutritional support. If low- matory response) and should not be reduced unless com- grade productive fever is present, the client may benefit plicating factors are present. Sanitation is always important, more from sleep than from massage. The presence of a but even more so during illness. The main target of massage fever indicates caution for massage application. If massage intervention is immune function support. The basic treat- is provided when low-grade fever is present, the duration ment plan consists of reducing the stress response, sup- and intensity of the massage should be adjusted to porting parasympathetic dominance, managing pain, and support comfort care only. promoting sleep. If massage is indicated, it would be palliative and tar- IMMUNITY IN ATHLETES geted to support parasympathetic dominance, sleep, and reduction of general aching. Do not massage if fever is In the resting state, the adaptive immune system appears above 100° F (38° C), or if the client is fatigued. In general, to be largely unaffected by intensive and prolonged exer- if symptoms are manifested primarily above the shoulders, cise training. However, the innate immune system, which it is acceptable to massage the client. If symptoms involve consists of those immune cells that act as a first line of the whole body, then massage could strain adaptive capac- defense against infectious agents, appears to respond dif- ity. Ask whether the client has any sort of skin infection, ferentially to the chronic stress of intensive exercise. and be aware of skin changes. Avoid local areas where Natural killer cell activity tends to be enhanced and neu- suspected infection is present. Hand hygiene is the single trophil function suppressed. most important practice in reducing the transmission of infectious agents. Cleaning and disinfection are primarily In general, when analyzed in resting individuals, the important for frequently touched surfaces. Follow all Stan- immune systems of athletes and nonathletes appear to be dard Precautions from the Centers for Disease Control. more similar than different. Of various immune function Remember that athletes may be immunosuppressed. Do tests that show some change with athletic activity, only not expose athletes to illness. If the massage therapist is salivary immunoglobulin (Ig) A has emerged as a potential ill, he or she should avoid working until no longer marker of infection risk. It is possible that each bout of contagious. prolonged exercise leads to short-term but clinically sig- nificant changes in immune function. Altered immunity INFLAMMATION may last between 3 and 72 hours. During this time, viruses and bacteria may gain a foothold, increasing the risk for Objective both subclinical and clinical infection. 1. Apply appropriate massage interventions for clients Taken together, the data suggest, but do not prove, that with inflammation. the immune system is suppressed and stressed for a short Within limits, inflammation is a valuable aspect of the time after prolonged endurance exercise. If this is so, infec- tion risk may be increased when the endurance athlete immune response. Inflammation is the body’s normal goes through repeated cycles of heavy exertion, especially protective response to infection and injury. Antigens are if the athlete is experiencing other stressors of the immune molecules, usually protein, that are on the surfaces of system such as lack of sleep, mental stress, malnutrition, pathogens such as bacteria or viruses. Our bodies attack and weight loss. such foreign materials using white blood cells, which can produce antibodies. These antibodies help the immune Athletes resist reducing training workloads. Improper system destroy antigens. nutrition and psychological stress can compound the nega- tive influence that heavy exertion has on the immune Inflammation triggered by injury operates slightly dif- system. Indicators of overtraining include immunosup- ferently from an infection. When tissues are damaged, they pression, loss of motivation for training and competition,
C H A P T E R 19 Systemic Illness and Disorders 321 BOX 19-1 Common Infections MRSA infection more difficult to treat. MRSA is especially troublesome for athletes because they are in close physical contact and may have open MONONUCLEOSIS wounds and weakened immune systems. Mononucleosis is a disease that is most commonly caused by the Epstein- HERPES SIMPLEX Barr virus; it causes lack of energy and stamina. Significant complications of mononucleosis include enlargement of the spleen. In extreme cases, the Herpes infection is caused by the herpes simplex virus (HSV). After an spleen may rupture, causing sharp, sudden pain in the left side of the upper incubation period of 3 to 10 days, symptoms are similar to those of viral abdomen. Occasionally, a streptococcal (strep) infection accompanies the influenza–like illness; the difference noted is that fluid-filled lesions sore throat of mononucleosis, and antibiotics are prescribed for these usually surround the mouth and the nose. HSV is a painful, often recur- infections. ring, infection seen as clusters of small, fluid-filled sacs on a base of red skin. Viruses may remain dormant in the body for years, manifesting FLU themselves in situations of depressed immunity and stress. The outbreak is usually preceded by symptoms that can include irritability, headache, The influenza virus is generally passed from person to person by airborne tingling, and burning or itching of the skin at the site of recurrence. Recur- transmission (i.e., by sneezing or coughing). It may also be spread by rent HSV labialis (fever blisters or cold sores) can shed the virus intermit- touching something that has been handled by someone infected with the tently between episodes and in the absence of lesions. Treatment of virus and then touching your own mouth, nose, or eyes. Fever, headache, primary HSV is most effective with antiviral drugs such as acyclovir or and body aches usually last for 3 to 5 days, but upper respiratory symp- valacyclovir. toms and fatigue may last for 2 weeks or longer. FUNGAL INFECTIONS COLDS Infections involving fungi may occur on the surface of the skin, in skin A cold is a viral infection of the upper respiratory system. A cold usually folds, and in other areas kept warm and moist by clothing and shoes. begins with fatigue, a feeling of being chilled, sneezing, and a headache, Candida is a yeast—similar to a fungus. It most often affects the skin followed in a couple of days by a runny nose and a cough. Symptoms around the nails or the soft, moist areas around body openings. typically peak 2 to 3 days after onset of infection and usually resolve in • Tinea capitis: a common fungal infection of the scalp manifested by 7 to 10 days. Cold viruses are spread by personal contact and by breathing the air near people with colds. Therefore, if at all possible, athletes should gray scaly patches accompanied by mild hair loss in many cases avoid being around sick people before and after important events. • Tinea corporis: a fungal infection on the body commonly referred to GASTROENTERITIS as “ringworm”—a name gleaned from its characteristic ring-like appearance Gastroenteritis (also known as gastric flu, stomach flu, or gastro and • Tinea cruris: a fungal infection in the groin area, commonly referred stomach virus) is inflammation of the gastrointestinal tract involving both to as “jock itch” the stomach and the small intestine and resulting in diarrhea, vomiting, • Tinea pedis: the most common fungal infection that affects the feet; and abdominal cramps. it is commonly referred to as “athlete’s foot.” Fungal infections may be treated initially with topical preparations for Most cases are caused by rotavirus or norovirus. Less common causes 2 to 4 weeks. More widespread, inflammatory, or otherwise difficult-to- include bacteria or their toxins, as well as parasites. Transmission may occur treat cases may require the use of systemic antifungal drugs. as the result of improperly prepared foods, contaminated water, or close contact with those who are infectious. COMMON AND PLANTAR WARTS The foundation of management is adequate hydration. For mild or Warts are epithelial tumors caused by several types of human papilloma moderate cases, this typically can be achieved via oral rehydration solution. virus. Common warts present as cauliflower-shaped, raised lesions. Plantar warts occur as flat lesions with pinpoint bleeding on weight-bearing sur- STAPH faces; they can be debilitating in athletes because of the pain. Transmission occurs by direct skin-to-skin contact, by contact with floors, or by cryo- Staphylococcus is a bacterium that can cause a wide variety of infections, therapy with liquid nitrogen. from minor skin infections, such as impetigo, boils, cellulitis, carbuncles, and abscesses, to life-threatening diseases such as pneumonia, meningitis, osteomyelitis, endocarditis, and sepsis. Methicillin-resistant Staphylococcus aureus (MRSA) is responsible for several difficult-to-treat infections in humans. Antibiotic resistance makes release chemicals, such as histamine and serotonin. These • Swelling chemicals attract white blood cells. This natural “defense” • Pain process brings increased blood flow to the area, resulting • Heat in an accumulation of fluid. As the body mounts this • Redness protective response, symptoms of inflammation develop. These include the following: Inflammation can be acute or chronic. When it is acute, inflammation occurs as an immediate response to trauma
3 22 UNIT THREE Sport Injury or infection. The inflammatory response supports the Exercise is a necessary part of the rehabilitation and treat- removal of cellular debris caused by trauma and any patho- ment plan for these conditions. gens present, but if excessive, it causes damage to sur- rounding tissues. Cardiovascular disease is the number one cause of death in the United States; coronary artery disease (CAD) Chronic inflammation is a perpetuating factor in many is the number one cause of death due to cardiovascular chronic conditions. Chronic inflammation is a factor in disease. CAD is caused by the collection of plaque (i.e., disorders such as asthma, lupus, and rheumatoid arthritis, buildup of cholesterol, calcium, and fibrous tissue) inside as well as in tendinopathies caused by microdamage in the a coronary vessel, resulting in a narrowing of coronary collagen fibers, followed by an acute inflammation, which arteries (stenosis) that decreases the delivery of oxygen to can evolve to chronic inflammation if healing processes the heart owing to reduced coronary blood flow. are disrupted (Solomonow, 2012). Events leading to cardiac injury during a heart attack Overuse tendinopathies are a common cause of pain begin with a transient blockage of coronary blood vessels and disability in athletes. These conditions occur as failed that is usually caused by a blood clot that has broken loose healing responses to overuse tendon injury (Battery and from an area of coronary stenosis. This reduction in blood Maffulli, 2011; Del Buono et al., 2011). Substance P (SP) flow to the heart is called ischemia and is typically followed is a neurotransmitter involved in the transmission of pain by restoration of blood flow (reperfusion) when the clot impulses from peripheral receptors to the central nervous dissolves. Commonly known as a heart attack, the overall system. process of ischemia followed by reperfusion results in cardiac injury and is technically referred to as ischemia- Substance P may be produced by primary fibroblastic reperfusion (I-R) injury. tendon cells called tenocytes (Backman et al., 2011). When tendons are submitted to mechanical loading, substance The magnitude of cardiac injury that occurs during an P production is increased. Massage may suppress sub- I-R insult is a function of the duration of ischemia—that stance P levels (Field et al., 2002). If this is the case, then is, a longer period of ischemia results in greater cardiac massage might be beneficial in the reduction of pain injury. For example, a relatively short duration of isch- perception. emia (e.g., 5 minutes) does not result in permanent cardiac damage but may depress cardiac function for 24 Having a massage after strenuous exercise appears to to 48 hours after the event. In contrast, a long duration reduce inflammation in muscles at the cellular level. of ischemia (20 minutes or longer) promotes permanent Massage may reduce the activity of inflammation-inducing cardiac injury (muscle cell death), resulting in a myocar- proteins called cytokines in muscle cells. Massage may alter dial infarction. The severity of a myocardial infarction is genes, thus reducing inflammation and supporting muscle significant because cardiac muscle cells are not easily adaptation to exercise (Crane et al., 2012). capable of regeneration; therefore, after myocardial infarc- tion, the pumping capacity of the heart is permanently MASSAGE IMPLICATIONS diminished. Inflammation in the body has a variety of causes; when Regular exercise lowers the risk of developing CAD the inflammatory response is triggered at a cellular level, and reduces the risk of cardiac injury during a heart attack. cellular damage along with resultant release of inflamma- The mechanism of exercise-induced protection against tory mediators such as cytokines may occur. Tenocyte cardiac injury (called cardioprotection) is unknown but cells within tendons, when mechanically loaded to the may be linked to increases in “heat-shock” proteins (dis- point of microdamage, result in increased levels of sub- cussed later) and antioxidants in the heart. Animal research stance P, which not only increase pain transmission but suggests that supplementation with nutritional antioxi- also increase cell proliferation; this can support healing if dants reduces I-R–induced cardiac injury and disease. cells are damaged, or overgrowth if excessive. It may be Additional research is required to determine whether possible for massage to then reduce the inflammatory dietary antioxidants can provide myocardial protection in response by decreasing the response of cytokines, and to humans. reduce pain transmission by decreasing the level of sub- stance P. Finding ways to reduce the mortality of cardiovascular disease remains an important public health goal. In this CARDIOVASCULAR/RESPIRATORY regard, numerous studies reveal that regular exercise is ILLNESSES cardioprotective. For example, epidemiologic studies indi- cate that compared with sedentary individuals, physically Objective active people have a lower incidence of heart attack. These investigations also demonstrate that the survival rate of 1. Apply appropriate massage interventions for clients heart attack victims is greater in physically active individu- with cardiovascular/respiratory disease. als than in their sedentary counterparts. The most common reason for mature people to be Numerous epidemiologic studies indicate that regular in rehabilitation is cardiovascular/respiratory disease. physical activity reduces the risk of cardiovascular
C H A P T E R 19 Systemic Illness and Disorders 323 mortality independent of other lifestyle modifications client, as well as the client’s age and general adaptive capac- such as diet or smoking. ity. Otherwise, the methods discussed in Unit Two are appropriate. The biological mechanism responsible for exercise- induced protection against cardiovascular disease contin- HEAT-RELATED ILLNESSES ues to be investigated. In this regard, it is clear that regular exercise reduces several cardiovascular risk factors, includ- Objective ing hypertension, diabetes mellitus, obesity, blood lipids, risk of thrombosis (blood clotting), and endothelial (blood 1. Apply appropriate massage interventions for clients vessel) dysfunction. Therefore, it appears that the relation- with thermoregulating disorders and heat-related ship between exercise and reduced cardiovascular mortal- illnesses. ity rates is due to the reduction of one or more risk factors. The body’s ability to maintain a constant internal tem- Although it is clear that regular exercise reduces the risk perature is called thermoregulation (Box 19-2). If the internal of developing cardiovascular disease, it is also well estab- temperature drops significantly below normal, this is called lished that exercise training improves myocardial tolerance hypothermia. If the internal temperature rises significantly to I-R injury. Endurance exercise training reduces myocar- above normal, this is called hyperthermia. The body’s dial injury resulting from an I-R insult. inability to maintain a steady temperature is a thermoregu- lating disorder that can result in various illnesses. The most At present, the mechanisms behind the exercise-induced common problems are heat-related. myocardial protection against I-R injury are unknown. However, at least three primary mechanisms may explain Exercising in a hot, humid environment can cause this effect: (1) improved collateral circulation; (2) induc- various forms of heat-related illness, including heat rash, tion of myocardial heat-shock proteins; and (3) improved heat syncope, heat cramps, heat exhaustion, and heat- myocardial antioxidant capacity. stroke. Athletes cannot safely exercise at full capacity in the heat. Proteins play an important role in maintaining homeo- stasis in cardiac and other cells. Damage to existing pro- HEAT RASH teins or impaired protein synthesis during I-R injury results in disturbed cellular homeostasis. To combat this type of Heat rash, also called prickly heat, is a benign condition disturbance, cells respond by synthesizing a group of pro- associated with a red, raised rash accompanied by sen teins called heat-shock proteins. These proteins are induced sations of prickling and tingling during sweating. It by a variety of stressful conditions, including elevated usually occurs when the skin is continuously wet with body temperature and prolonged exercise. BOX 19-2 What to Watch for: Improved protection against free radical–mediated Signs of Heatstroke cardiac injury is another possible mechanism of exercise- induced cardioprotection during an I-R insult. Free radi- FUZZY THINKING cals are highly reactive molecules with available incomplete bonds on their surface that are produced during myocar- Cannot follow the plays dial I-R injury. Antioxidants are molecules that can remove Seems confused free radicals by filling their incomplete bonds and forming Suddenly forgetful a new, less reactive molecule, thereby preventing free radical–mediated cellular injury. One can make this BIZARRE BEHAVIOR analogy: rust is the free radical, and Rustoleum paint is the antioxidant that stops the spread of rust when applied. Runs the wrong way Talks nonsense Cells contain several naturally occurring enzymatic and Blank stare nonenzymatic antioxidants. Primary enzymatic antioxi- Laughs or cries at the wrong time dant defenses include superoxide dismutase, glutathione Yells in rage at coach or peers peroxidase, and catalase. Important nonenzymatic defenses Wants to fight for no good reason are provided by compounds such as glutathione, the trace mineral selenium, and vitamins A, E, and C. Each of these PHYSICAL DECLINE antioxidants is capable of quenching radicals and prevent- ing cellular injury. Begins to lose coordination Sudden or unusual fatigue MASSAGE IMPLICATIONS Nausea and vomiting Chills and goose bumps Massage supports the necessary exercise program involved Overbreathing, tingly fingers with cardiofitness and rehabilitation by managing muscle Wobbles or staggers, collapses soreness and joint aching. Massage contributes to increased Seizure or coma compliance with exercise programs. Procedures need to be altered to account for medications being taken by the
3 24 UNIT THREE Sport Injury unevaporated sweat. The rash is generally localized to areas are not necessary; eating salty pickles is a good of the body covered with clothing. Massage is regionally alternative. contraindicated. When cramps strike an athlete during a workout or competition, take immediate action with the following: HEAT SYNCOPE (HEAT COLLAPSE) 1. Stretch. Because cramps are often related to a change in weight bearing, stretching and non–weight-bearing exer- Heat syncope, or heat collapse, is associated with rapid cises are effective treatments. physical fatigue during overexposure to heat. It usually 2. Massage the area. Rubbing the cramped muscle may occurs after standing in heat for long periods or in persons help alleviate pain and stimulate blood flow and fluid not accustomed to exercising in the heat. It is caused by movement into the area. Ice massage can also be used. peripheral vasodilation of superficial vessels, hypotension, 3. Stimulate recovery. Rest and adequate rehydration with and/or pooling of blood in the extremities, which result fluids containing electrolytes, particularly sodium, will in dizziness, fainting, and nausea. Heat syncope is quickly bring quick improvement. relieved by laying the individual down in a cool environ- ment and replacing fluids. HEAT EXHAUSTION HEAT CRAMPS Heat exhaustion results from inadequate replacement of fluids lost through sweating. Clinical symptoms include Heat cramps are extremely painful muscle spasms that collapse, profuse sweating, pale skin, mildly elevated tem- occur most commonly in the calf and abdomen, although perature (102° F [39° C]), dizziness, hyperventilation, and any muscle can be involved. The occurrence of heat rapid pulse. cramps is related to electrolyte balance. Profuse sweating results in loss of water and small quantities of electrolytes; It is sometimes possible to spot athletes who are having this upsets the balance in concentration of these elements problems with heat exhaustion. They may begin to develop in the body. This imbalance will ultimately result in painful heat cramps and become disoriented and lightheaded; muscle contractions and cramps. their physical performance will not be up to their usual standards. In general, persons in poor physical condition The person most likely to get heat cramps is someone who attempt to exercise in the heat are most likely to suffer in fairly good condition who simply overexerts in the heat. from heat exhaustion. An athlete who experiences heat cramps generally will not be able to return to practice or competition that day Immediate treatment of heat exhaustion requires inges- because cramping is likely to recur. tion or intravenous replacement of large quantities of water. Although muscle cramps have many causes, large losses of sodium and fluid can be key factors that predispose HEATSTROKE athletes to run-of-the-mill muscle cramps. Sodium is an important mineral in initiating signals from nerves and Unlike heat cramps and heat exhaustion, heatstroke is a actions that lead to movement in the muscles, so a deficit serious, life-threatening medical emergency. The specific of this element and of fluid may make muscles “irritable.” cause of heatstroke is unknown. Heatstroke can occur Under such conditions, a slight stress such as a tensing when there is a combination of hot environment, strenu- movement may cause the muscle to contract and twitch ous exercise, clothing that limits evaporation of sweat, uncontrollably. Massage does not help these cramps and inadequate adaptation to the heat, too much body fat, may actually cause them. Only fluids and electrolytes will and/or lack of fitness. stop the cramping. During exercise, body heat is generated primarily in the Diabetes, neurologic disorders, or vascular problems active muscles. Transport mechanisms, which include the may be a factor in cramping episodes. Also, anecdotal circulating blood and conduction between body tissues, reports indicate that the use of certain dietary supplements bring heat to the skin. At the skin, evaporation, convec- such as creatine may increase the risk of muscle cramps. If tion, radiation, and—far less important—conduction can cramps suddenly occur in a client without a prior history, transfer heat from the skin to the environment. Certain referral to a physician should be made to rule out more situations can impede heat release. For example, when the serious causes. air temperature is higher than the skin temperature, con- vection, radiation, and conduction will result in transfer Preventing and Managing Cramping of heat from the air to the body. 1. Drink plenty of fluids to stay hydrated during Evaporation of sweat is decreased when the humidity exercise. of the air is high. To maintain a body temperature that is within a safe range, the following factors are important: 2. Replenish sodium levels during times of heavy exercise 1. The intensity and duration of exercise and the body’s and profuse sweating with a diluted sports drink or other electrolyte solutions. Dilute 50% sports drink to efficiency for the effort being performed—this ratio 50% water. establishes the amount of heat released by the body. 2. Blood circulation and blood volume—these determine 3. Ensure adequate nutritional recovery (particularly for the transport of heat from muscles to skin. salt) and rest of muscles after hard training. Salt pills
C H A P T E R 19 Systemic Illness and Disorders 325 3. The amount of sweat produced and the temperature • A rapid, strong pulse and a core temperature of 106° F and humidity of the environment—these factors deter- (41° C) or higher mine how much heat can be given off to the The heatstroke victim experiences a breakdown of the environment. thermoregulatory mechanism caused by excessively high 4. The capability of the body to make other physiologic body temperature, and the body loses its ability to dissi- adjustments to continue regulating the temperature. pate heat through sweating. Heatstroke is always a risk in summer sports. Victims of Stimulants speed heat buildup, so products that speed heatstroke are described as “the hardest worker” or “deter- players up heat them up. Amphetamine and cocaine are mined to prove himself.” During hard practice on a hot the most dangerous, but ephedra is the most prevalent. day, the never-quit mentality can work against a player. Many dietary supplements claim ephedra benefits of weight loss or quick energy. However, ephedra poses many In summer sports, it is not the heat but the combination health risks, including heatstroke, and should not be used. of heat and humidity that predisposes to heat illness. Excessive caffeine use can also pose a problem. Heatstroke Getting heat-fit takes time. Lack of acclimation is a predic- risk is compounded by drugs that impair sweating, such as tor of heatstroke in football. Triathletes unacclimated to some antihistamines, antispasmodics, and certain medica- tropical heat also suffer. Acclimation, much of which tions for depression. occurs in a week or two, leads to drinking more fluids; also, the body holds onto water and salt, increasing blood Heatstroke is often slow to evolve, and the vigilant volume so the heart pumps more blood at a lower rate. observer can detect early warning signs. Heatstroke is Heat-fit athletes sweat sooner, in greater volume, and over always a threat during hard drills on hot days, especially a wider body area, so they stay cooler. in hefty players in full gear. Heatstroke can occur suddenly and without warning. The athlete usually will not experi- During physical training, the athlete who is disabled ence signs of heat cramps or heat exhaustion. Athletes with a spinal cord injury faces the same risks of heat who sleep poorly and those who are ill, especially with stress as the able-bodied athlete. However, the spinal cord vomiting, diarrhea, or fever, are more prone to heatstroke. injury also affects the disabled athlete’s circulating blood The same applies to athletes taking diuretics or drinking volume, sweat production, and temperature regulation, alcohol. and therefore can adversely influence thermoregulatory capabilities. Early warning signs of impending heatstroke may include irritability, confusion, apathy, belligerence, emo- Opportunities to compete in the Paralympics, advances tional instability, and irrational behavior. The coach may in medical treatment and therapies for functional recovery be the first to notice a player who is heating up and can of the disabled, and the recognition that physical activity no longer think clearly. Giddiness, undue fatigue, and is beneficial for the health of everyone, abled or disabled, vomiting can be early signs. Paradoxical chills and goose have contributed to increased participation of disabled bumps signal shutdown of skin circulation, resulting in a individuals in regular physical exercise. As with able- faster rise in temperature. The player may hyperventilate— bodied athletes, disabled athletes face limitations to just as a dog pants—to shed heat; this can cause tingling performance—fatigue, nutrition and fluid needs, and the fingers and face before collapse. Lack of coordination and possibility of heat exhaustion. The greatest risk for heat staggering—“running like a puppet on a string”—are late stress is seen in individuals with spinal cord injury above signs, followed by collapse with seizure and/or coma. At the sixth thoracic vertebra because they are unable to this stage, core body temperature can be 108° F (42.2° C) increase heart rate to sustain cardiac output when blood or higher. must flow to both the muscle and the skin, and because they have a reduced sweating capacity. The possibility of death from heatstroke can be signifi- cantly reduced if body temperature is lowered to normal Preventing heatstroke hinges on heat acclimation, within 45 minutes. The longer the body temperature is hydration, pacing, cooling, and vigilance. Physical fitness, elevated to 106° F (41° C) or higher, the higher is the mor- especially aerobic fitness, provides some of the same physi- tality rate. ologic benefits as heat acclimation. Fitness also makes workouts less taxing. In contrast, lack of fitness increases DEHYDRATION risk of heat illness. Athletes in the heat can lose 1 to 2 liters of water in an The prime time for heatstroke is the day after an exhaust- hour through sweating, and most athletes drink less fluid ing and dehydrating day in the heat. The misconception than they lose in sweat. The result is dehydration. Dehy- is that hydration prevents heatstroke. The truth is that drating only 2% of body weight—that’s just 5 pounds in hydration is critical but is not sufficient to prevent a 250-pound athlete—can impair physical performance. heatstroke. Dehydration increases heart rate and decreases cardiac output. Dehydration drains mental sharpness and will- Heatstroke symptoms include the following: power along with muscle power and endurance, so that • Sudden collapse with loss of consciousness the same level of activity seems as if it requires more • Flushed, hot skin with less sweating than would be seen effort. with heat exhaustion • Shallow breathing
3 26 UNIT THREE Sport Injury Hydration helps prevent heatstroke, but consuming an environment that easily predisposes the athlete to fluid in excess of sweat loss provides no advantage. Like- hypothermia. wise, it is not necessary to overhydrate the night before or during the hours before a long run or practice. During A relatively small drop in body core temperature can training, the athlete should weigh in before and after a induce shivering sufficient to materially affect an athlete’s workout and should learn to adjust fluid intake to mini- neuromuscular coordination and performance. Shivering mize weight loss. If weight loss does occur, rehydration ceases when the body temperature is 85° F to 90° F (29.4° C after activity is critical. The athlete should drink 20 to 24 to 32.2° C). Death is imminent if the core temperature rises ounces of fluid for every pound of weight loss and should to 107° F (41.6° C) or falls to between 77° F and 85° F (25° C eat foods with high water content (fruits and vegetables). and 29° C). TREATMENT Treatment consists of warming and drying the athlete. Cool First Frostbite No faster way to cool is known than placing the athlete in an ice-water tub. Submerge the trunk—shoulders to Frostbite is local tissue destruction resulting from exposure hip joints. Research suggests that ice-water immersion to extreme cold; in mild cases, it results in superficial, cools runners twice as fast as air exposure with the reversible freezing, followed by erythema and slight pain. runner wrapped in wet towels. The U.S. Marines use ice- In severe cases, it can be painless or paresthetic and may water cooling, and recent field research with volunteer result in blistering, persistent edema, and gangrene. runners suggests that cold water may cool as fast as ice water. Do not massage any areas with frostbite. Transport Second IN MY EXPERIENCE This is a medical emergency. BREATHING Some research suggests that heatstroke patients may Breathing pattern disorder is extremely common in competing have brief or lasting heat intolerance, but whether this is athletes. This tendency occurs because of extremes in activity level. innate or is a result of the heatstroke is unclear. Most Running around while breathing heavily is perfectly normal during heatstroke sufferers have normal heat tolerance within 2 many sports activities. Yet this same breathing pattern at home with months. It seems likely that most athletes treated early for the family can lead to disrupted interaction. heatstroke and educated about prevention can return safely to their sport within weeks (see Box 19-2). I recall an athlete with multiple stressors as the result of a nagging injury that was compromising performance, who would go home to After an episode of major heat exhaustion, an athlete is a young family with a 3-year-old son and 1-year-old twin girls. His allowed to return to play when his or her weight has nor- breathing was just stuck in the upper chest, perpetuating sympathetic malized and symptoms are gone—usually within 48 hours. arousal patterns. On the playing field, the result was too much “fight.” At home, it seemed that everything irritated him. Obviously, Massage Implications this athlete needed help that went beyond massage strategies and that targeted normal relaxed breathing. As is often the case, the Massage is not applicable for heat-related illnesses except massage therapist may be the first to notice the cumulative strain. for temporary management of muscle cramps. Refer all Sensitivity to noise is a common symptom of sympathetic dominance clients with suspected heat-related illness to the trainer or that is caused by, or perpetuated by, upper chest breathing. to appropriate medical personnel. I asked this client if he was having trouble with the “kid” noise. COLD-RELATED ILLNESS He looked at me and began to tear up. Then I asked if he was yelling at the kids, and he just hung his head and began to sob. The head Cold weather is a frequent adjunct to many outdoor coach, a great guy, was able to intervene, and the athlete was given sports in which the sport itself does not require heavy help on multiple levels. Both massage to manage breathing dysfunc- protective clothing; consequently, the weather becomes tion and help for the nagging injury were included in the intervention a pertinent factor in injury susceptibility. In most plan. I often wonder what might have happened to this young family instances, the activity itself enables the athlete to increase if the coach had not been so supportive. the metabolic rate sufficiently to function normally and dissipate resulting heat and perspiration through usual BREATHING PATTERN DISORDERS physiologic mechanisms. If an athlete fails to warm up sufficiently or becomes chilled because of relative inac- Objective tivity for varying lengths of time, he or she is more prone to injury. 1. Apply appropriate massage interventions for clients with breathing pattern disorder. Dampness or wetness further increases the risk of hypo- The massage therapist working with athletes as well as thermia. Air at a temperature of 50° F (10° C) is relatively comfortable, but water at the same temperature is intoler- with other clients involved in physical exercise needs to able. The combination of cold, wind, and dampness creates
C H A P T E R 19 Systemic Illness and Disorders 327 BOX 19-3 Signs and Symptoms of Breathing Pattern Disorder Increased ventilation is a common component of fight-or-flight responses, due to aerophagia (air swallowing), nausea, flatulence, belching, abdomi- but when our breathing increases and our actions and movements are nal discomfort, and bloating. restricted or do not increase accordingly, we are breathing in excess of our metabolic requirements. Blood levels of carbon dioxide fall, and many of MUSCULAR the following signs and symptoms can occur. Muscular symptoms include cramps and pain, particularly in the occipitals, CARDIOVASCULAR neck, and shoulders, and between the scapulae, and less commonly in the lower back and limbs. Tremors, twitching, weakness, stiffness, or tetany Cardiovascular symptoms include palpitations, missed beats, tachycardia, (seizing up) may also occur. sharp or dull atypical chest pain, “angina,” vasomotor instability, and cold extremities. Raynaud’s phenomenon, blotchy flushing of the PSYCHOLOGICAL blush area, and capillary vasoconstriction (face, arms, hands) may also be seen. Individuals with breathing pattern disorder may complain of tension, anxiety, “unreal feelings,” and “out of body” feelings. Other psychic NEUROLOGIC symptoms include depersonalization, panic, phobias, and agoraphobia (fear of being in open spaces). Neurologic symptoms include dizziness, unsteadiness or instability, sensa- tion of giddiness, feelings of faintness (rarely actual fainting), visual dis- GENERAL turbances (blurred or tunnel vision), headache (muscle tension and vascular migraine), and paresthesias (numbness, uselessness, heaviness, pins and Other symptoms include feelings of weakness; exhaustion; impaired con- needles, burning), commonly of hands, feet, or face, but sometimes of centration, memory, and performance; disturbed sleep, including night- the scalp or whole body. Limbs may feel “out of proportion,” or as if they mares; emotional sweating (axillae, palms, sometimes whole body); and “don’t belong.” Hypersensitivity to noise or light may be noted, and the a “thick-headed” sensation. pupils may be dilated (wearing dark glasses on a dull day). Cerebrovascular constriction, a primary response to disordered breath- RESPIRATORY ing, can reduce by about one half the amount of oxygen available to the brain. Among resulting symptoms are dizziness, blurring of consciousness, Respiratory symptoms include shortness of breath (typically after exertion), and possibly, because of a decrease in cortical inhibition, tearfulness and irritable cough, tightness or oppression of chest, difficulty breathing, emotional instability. “asthma,” air hunger (inability to take a satisfying breath), and excessive sighing, yawning, and sniffing. Other effects that therapists should watch for include generalized body tension and chronic inability to relax. Persons with breathing pattern dis- GASTROINTESTINAL order are particularly prone to spasm (tetany) of muscles involved in the “attack posture”—they hunch the shoulders, thrust the head and neck Gastrointestinal symptoms include difficulty in swallowing, dry mouth and forward, scowl, and clench the teeth. throat, acid reflux (heartburn), exaggeration of symptoms of hiatal hernia be able to address the mechanism of breathing both to and anatomy and physiology are normal, it is consid- help correct dysfunction and to support optimal function. ered a functional syndrome. The breathing pattern is Persons in pain, including athletes, are prone to breathing inappropriate—a situation resulting in confused signals pattern disorder (Box 19-3). Those with any sort of respira- to the central nervous system, which sets up a whole tory disease are especially susceptible to breathing dysfunc- chain of events. tion. Increased upper chest breathing results in biochemical changes that may temporarily reduce pain but in the long SLEEP-DISORDERED BREATHING run may make the situation worse. Respiratory illness such as a cold can shift the breathing function to an upper chest Obstructive sleep apnea is the most common disorder of pattern, and then it may not reverse. Chronic respiratory breathing. During sleep, breathing efforts persist, but the disease such as asthma perpetuates breathing dysfunction. upper airway is obstructed. Symptoms include excessive Persons with anxiety and depression often display breath- snoring, daytime sleepiness, headache, impaired thinking ing difficulties. and irritability. Athletes can get “stuck” in the breathing rate required Continuous positive applied pressure (CPAP) prevents for practice and competition and may not be able to airway collapse and is effective in long-term treatment. reverse the breathing to a resting phase. This interferes with mood, recovery, and further performance. THERAPEUTIC MASSAGE FOR BREATHING DISORDERS Breathing pattern disorder consists of a complex set of behaviors that lead to overbreathing without evident If accessory muscles of respiration, such as the scalenes, pathology. Because no specific pathology is known sternocleidomastoid, serratus posterior superior, pectoralis
3 28 UNIT THREE Sport Injury Muscles of Inspiration Muscles of Expiration FIGURE 19-1 Muscles used during breathing. (Netter illustration from www.netterimages.com. © Principal Accessory Quiet Active Elsevier Inc. All rights reserved.) Sternocleido- breathing breathing mastoid Expiration (elevates results from sternum) passive recoil of lungs Scalenus anterior Internal middle intercostals, posterior except interchondral (elevate and part fix upper ribs) Abdominal External muscles intercostals (depress (elevate ribs) lower ribs, Interchondral compress part of internal abdominal intercostals contents) (also elevates ribs) Rectus abdominis Diaphragm External (domes oblique descend, Internal increasing oblique longitudinal Transversus dimension of abdominis chest and elevating lower ribs) minor, levator scapulae, rhomboids, abdominals, and qua- Observe and palpate for overuse of upper chest breath- dratus lumborum, are constantly being activated for breath- ing muscles during normal relaxed breathing. ing when forced inhalation and expiration are not called for, dysfunctional muscle patterns will result (Figure 19-1). Stand behind the client and place your hands or the client’s hands over the upper trapezius area, so that the Therapeutic massage can assist in normalizing these tips of the fingers rest on top of the clavicles. As the client conditions and supporting more effective breathing. It is breathes, determine whether he or she is using accessory very difficult to breathe well if the mechanical mechanisms muscles during relaxed breathing. are not working efficiently. Many who have attempted breathing retraining have become frustrated with their If the shoulders move up and down as the client breathes, inability to accomplish the change in breathing pattern it is likely that accessory muscles are being recruited. In because these muscle patterns are not changed. They may normal relaxed breathing, the shoulders should not move find more success once the muscles of the body and the up and down. The client is using accessory muscles to mechanism of breathing are normalized. breathe if the chest movement is concentrated in the upper chest instead of in the lower ribs and abdomen. Use of any The massage therapist influences breathing in two dis- of the accessory muscles for breathing causes increased tinct ways: tension and a greater tendency toward the development of 1. Supporting balance between sympathetic and parasym- trigger points. These situations can be identified by palpa- tion. Connective tissue changes are common because this pathetic autonomic nervous system function. (This is condition is often chronic. The connective tissues are pal- generally accomplished with a relaxation focus in the pated as thick, dense, and shortened in this area. general protocol.) 2. Normalizing and then maintaining effective thoracic Have the client naturally inhale and exhale, and observe and respiratory muscle function. for a consistent exhale that is longer than the inhale. The following assessment and treatment procedures Normal relaxed breathing consists of an inhalation phase specifically target these areas. The applications should be that is shorter than the exhalation phase. The ratio of integrated into the general protocol to work more specifi- inhalation time to exhalation time is 1 count inhale to 4 cally with breathing function if assessment indicates a counts exhale. The reverse of this pattern serves as the basis tendency toward breathing pattern dysfunction. Again, it for breathing pattern disorder. is strongly recommended that the reader study Multidisci- plinary Approaches to Breathing Pattern Disorders (Chaitow The ideal pattern ranges from 2 to 4 counts during the et al., 2002). inhale, and from 8 to 16 counts for the exhale. Targeted massage and breathing retraining methods can be used to ASSESSMENT PROCEDURES restore normal relaxed breathing. During each massage session, the client should be moni- Have the client hold the breath without strain, to assess tored continually for symptoms related to breathing for tolerance to carbon dioxide levels. The client should pattern disorder. be able to comfortably hold the breath for at least 15 seconds; 30 seconds is much better.
C H A P T E R 19 Systemic Illness and Disorders 329 Deep neck Trapezius and Erector Abdominals flexors weak levator scapula spinae weak tight Tight Tight tight iliopsoas pectorals Weak gluteus maximus Weak rhomboids and serratus anterior AB FIGURE 19-2 A, Upper crossed syndrome (after Janda). B, Lower crossed syndrome (after Janda). (From Chaitow L, DeLany J: Clinical applications of neuromuscular techniques, vol 1, The upper body, Edinburgh, 2001, Churchill Livingstone.) Palpate and gently mobilize the thorax to assess for rib are difficult to assess with movement and strength testing. mobility. This is done with the client in the supine, prone, Palpation will be more accurate. Typical patterns of the side-lying, and seated positions. The ribs should have a upper and lower crossed syndromes are often involved springy feel and should be a bit more mobile from the 6th (Figure 19-2). to the 10th rib. Muscles assessed as short need to be lengthened. If the TREATMENT PROCEDURES primary cause of the shortening is neuromuscular, then inhibitory pressure should be used at the muscle belly and The following muscles are specifically targeted by massage lengthening should be performed by moving adjacent because they tend to shorten during breathing dysfunction joints or, more likely, by introducing tension, bend, or (see Chapter 13): torsion force directly on the muscle tissues. For scalenes • Scalenes and for sternocleidomastoid, serratus anterior, pectoralis • Sternocleidomastoid minor, latissimus dorsi, psoas, quadratus lumborum, dia- • Serratus anterior phragm, rectus abdominis, and pelvic floor muscles, • Serratus posterior superior and inferior follow recommendations in the specific release section of • Levator scapulae Chapter 13. • Rhomboids • Upper trapezius Work with each area as needed, as it becomes conve- • Pectoralis major and minor nient during the general massage session. Use the least • Latissimus dorsi invasive measure possible to restore a more normal muscle • Psoas resting length. • Quadratus lumborum • All abdominals If breathing has been dysfunctional for an extended • Pelvic floor muscles period (longer than 3 months), connective tissue changes • Calf muscles are common. Focused connective tissue massage applica- tion is effective (see Unit Two). The intercostals and the diaphragm, which are the main breathing muscles, also will be addressed. Once the soft tissue is more normal, gentle mobiliza- tion of the thorax is appropriate. If the thoracic vertebrae All of these muscles should be assessed for shortening, and ribs are restricted, chiropractic or other joint manipu- weakness, and agonist/antagonist interaction. Muscles that lation methods may be appropriate and referral is indi- orient mostly transverse, such as serratus anterior and ser- cated. The massage therapist can use indirect functional ratus posterior, superior, and inferior, are rhomboids and techniques to increase the mobility of the area as well. These methods are described in Unit Two.
3 30 UNIT THREE Sport Injury Methods and sequences used to address the breath- • Give increased attention to general massage of the ing function need to be integrated into a full-body thorax; posterior, anterior, and lateral access to the approach because breathing is a whole body function thorax is used to primarily address general tension or (Figure 19-3). dysfunctional patterns in the respiratory muscles of this area. Address scalenes, psoas, quadratus lumborum, and A possible protocol to add to the general massage legs, especially the calves. session would consist of the following: AB CD EF FIGURE 19-3 Assessment and treatment of breathing function. A, Assess shoulder movement. Shoulders should not move up and down in normal relaxed breathing. B, Assess rib mobility. Lower ribs should move out not up during normal relaxed breathing. C, Watch client breathe. Hand on abdomen should move out. Hand on chest should not move during normal relaxed breathing. D, Assess rib mobility, anterior. Gentle compression on the ribs should feel springy with slightly more movement on ribs lower than 1 through 4. E, General massage accesses the posterior thorax. F, General massage accesses the lateral thorax.
GH IJ KL M FIGURE 19-3, cont’d G, General massage accesses the shoulder and pectoral muscles. H, Compression/kneading/ mobilization treatment, rib mobility, anterior. I, Identify trigger/ tender point (drag palpation). Then use positional release. J, Stretch tissues directly and with movement. K, Relief position 1: lifts lower ribs to support diaphragm function. L, Relief position 2: opens chest and fixes shoulders so the accessory muscles cannot be used for breathing. M, Self-help 1: breathing retraining. Have client loosely interlace fingers. N, Then have client press fingers tightly together as when making a fist with both hands. Client breathes normally while fingers are pressing. This method makes breathing with accessory muscles more difficult and supports more normal breathing function. Maintain position as long as is comfortable. Relax and repeat. O, Self-help 2: instruct client to bend elbows to 90 degrees, and hold against lateral side of the body. Then have client press forearms down into the therapist’s hands. This method is practiced N O by pushing into the arms of a chair or simply down toward the floor. This maneuver does not allow shoulders to move during breathing.
3 32 UNIT THREE Sport Injury • Use appropriate muscle energy techniques to lengthen Use positional release to treat these points by moving and stretch shortened muscles of the cervical, thoracic, the client or having the client move into various and lumbar regions, as well as the legs. positions until pain in the tender point decreases. • As a reminder, the procedure for positional release is as • Gently move the rib cage with broad-based com follows. pression. Assess for areas that move easily and those • Locate the tender point. that are restricted. Assess the anterior, lateral, and • Gently initiate the pain response with direct posterior areas. pressure. (Remember that the sensation of pain is a guide only.) The pain point is not the point of • Identify the amount of rigidity in the ribs with the client intervention. supine by applying bilateral compression to the thorax, • Slowly position the client’s body, actively or pas- beginning near the clavicles and moving down toward sively, until the pain subsides. This position can be the lower ribs, while maintaining compressive force focal and can be accomplished by moving the near the costal cartilage. client’s ribs, arm, or head, or it can be a whole body process involving many different areas to • Identify rigidity in the ribs with the client prone bilater- achieve the position in which pain is decreased. ally (on both sides of the spine) at the facet joints, • Have the client maintain the position for up to 30 beginning near the 7th cervical vertebrae and moving seconds, or until the client feels the release; while down toward the lower ribs, while maintaining com- encouraging the client to breathe from the dia- pressive force near the facet joints. phragm, lightly monitoring the tender point with palpation. • Use compression against the lateral aspect of the thorax • Slowly reposition the client to neutral, and then into with the client in a side-lying position to assess rib a stretch position for the tender point. Direct tissue mobility in both facet and costal joints. Begin by apply- stretching is usually most effective. ing compression near the axilla and then moving down toward the lower ribs. Sufficient force needs to be used BREATHING RETRAINING PROGRAM while applying compression to feel the ribs spring, but not so much as to cause discomfort. Normal response Once the thorax and breathing function begin to is a feeling of equal mobility bilaterally. A feeling of normalize—usually after four to six focused sessions—a stiffness or rigidity indicates immobility. breathing retraining program can be taught to clients. The main focus of a breathing retraining program is the exhale • Identify the area of greatest mobility and the area of process. Do not even address the inhale. When the exhale greatest restriction. pattern normalizes, the inhale pattern will normalize as well. Three common activities can normalize a breathing • Position the client so that a broad-based compressive pattern: yelling, crying, and laughing. Each of these activi- force can be applied to areas of ease—the most mobile. ties sustained for 3 to 5 minutes can be valuable in any breathing retraining program. • Gently and slowly apply compression until the area begins to bind. Hold this position and have the client Pursed lip exhale is helpful. The client inhales normally, cough. Coughing will act as a muscle energy method holds the breath for 1 or 2 seconds, and then slowly and will support mobility of the joint through activa- exhales (as if gently trying to make a candle flame flicker tion of the muscles. Repeat 3 or 4 times. about 1 foot away) by blowing the air through pursed lips. • If areas of rigidity remain, the following intervention Blowing up balloons can be a good exercise for support- may be useful. ing exhale function, as is playing a horn, a flute, or a • Apply broad-based compression to the area of immo- similar musical instrument. Singing or chanting and simply bility, using the whole hand or forearm. toning the vowel sounds (a, e, i, o, u) are variations that • Have the client exhale, and then increase the inten- support exhale function. sity of the compressive force while following the exhale. It is helpful for the client to combine a slow breathing • Hold the ribs in this position. pattern with a stretching/flexibility program that targets • Have the client push out against the compressive the short muscle areas. The client can practice breath pressure. holding until the breath can be held comfortably for 30 • Instruct the client to inhale while continuing to hold seconds. Relief positions place the thorax in such a way as the compressive focus against the ribs. to support normal, relaxed breathing or inhibit muscle • Have the client exhale while following the action of function (see Figure 19-3). the ribs. Mobility should be increased. • Gently mobilize the entire thorax with rhythmic SUMMARY compression. • Reassess the area of greatest bind/restriction. If the Illnesses and disorders are typically systemic and affect treated area has improved, locate a different area and multiple body systems. Injury is more local. Injury, repeat the sequence. It is appropriate to do three or four areas in a session. • Next, palpate for tender points in the intercostals, pectoralis minor, and anterior serratus. (Clients are not very tolerant of this, so be direct and precise.)
C H A P T E R 19 Systemic Illness and Disorders 333 illness, and disorders interact. Clients who are injured are Battery L, Maffulli N: Inflammation in overuse tendon injuries, Sports more apt to become ill. Those who have been or are ill Med Arthrosc 19:213, 2011. are more susceptible to injury and to thermoregulation problems. Those with disordered breathing are more Chaitow L, Bradley D, Gilbert C: Multidisciplinary approaches to prone to both injury and illness. Strain on adaptive capac- breathing pattern disorders, Philadelphia, 2002, Churchill Livingstone. ity is the common thread here, and effective massage can at least temporarily reduce adaptive strain. Caution is Crane JD, Ogborn DI, Cupido C, et al.: Massage therapy attenuates necessary, however. Massage that is excessive for an indi- inflammatory signaling after exercise-induced muscle damage, Sci vidual client with a specific condition can add to adaptive Transl Med 4:119, 2012. strain. The skilled massage therapist should be able to balance the dynamics of appropriate and inappropriate Del Buono A, Battery L, Denaro V, et al.: Tendinopathy and inflamma- massage application. tion: some truths, Int J Immunopathol Pharmacol 24(1 Suppl 2):45, 2011. REFERENCES Field T, Diego M, Cullen C, et al.: Fibromyalgia pain and substance P Backman LJ, Fong G, Andersson G, et al.: Substance P is a mechanore- decrease and sleep improves after massage therapy, J Clin Rheumatol sponsive, autocrine regulator of human tenocyte proliferation, PLoS 8:72, 2002. ONE 6:e27209, 2011. Solomonow M: Neuromuscular manifestations of viscoelastic tissue degradation following high and low risk repetitive lumbar flexion, J Electromyogr Kinesiol 22:155, 2012. WORKBOOK c. A 19-year-old cheerleader with mononucleosis d. A 27-year-old marathon runner, 24 hours post Visit the Evolve website to download and complete the following exercises. event 1 Describe a massage treatment plan that would be e. A 38-year-old deconditioned client playing tennis appropriate if the client had a viral respiratory infection. in heat and humidity f. A 44-year-old client with generalized anxiety 2 Describe a massage treatment plan that would NOT be appropriate if a client had suppressed immunity. and disrupted breathing, who is using exercise for both weight management and anxiety 3 Write a treatment plan for each of the following management. clients: a. A 23-year-old basketball player with a sinus infection b. A 67-year-old male who has recently had a mild heart attack
CHAPTER 20 Injury by Area OBJECTIVES OUTLINE After completing this chapter, the student will be able to perform the following: The Head 1 Identify specific injuries based on location. 2 Develop and implement appropriate treatment plans for massage application for a specific injury. Concussion Skull Fracture KEY TERMS Buttock Pull Jammed Finger Broken Nose Calf Cramps Jumper’s Knee Broken Cheekbone Achilles Bursitis Calluses Leg Muscle Pulls and Tears Blowout Fracture Achilles Tendinopathy (Tendonitis, Carpal Tunnel Syndrome Little League Elbow Scratched Cornea Cauliflower Ear Loose Body Cauliflower Ear Tendonosis) Cervical Stenosis Lumbar Pain Broken Jaw Achilles Tendon Rupture Cluster Headaches Mass Reflex TMJ Injury and Pain Arthritis of the Shoulder Compartment Syndrome Metatarsal Stress Fracture Headache Baker’s Cyst (Popliteal Cyst) Concussion Metatarsalgia Biceps Tendonitis Cracked Back Mid-Back Pain The Neck Black Toenails Cracked Wing Migraine Headache Blisters Cruciate Ligament Injury Morton’s Foot Sprained Neck Blowout Fracture Dislocated Finger Morton’s Syndrome Whiplash Bo Jackson Injury (Avascular Dislocated Knee Osgood-Schlatter Disease Pinched Nerve Dislocated Patella Osteitis Pubis Broken Neck Necrosis) Dislocated Shoulder Osteoarthritis/Arthrosis Cervical Stenosis Bone Chips Dislocation of the Fibularis Pain on the Outside of the Leg “Burner,” “Stinger,” and Stretched Boxer’s Wrist Femur Fracture Partial Dislocation of the Shoulder Nerves Broken Ankle Fracture of the Shoulder Patellofemoral Syndrome Spastic Torticollis Broken Cheekbone Frozen Shoulder (Adhesive Pes Cavus (Claw Foot) Trapezius Triggers Broken Collarbone Pinched Nerve Spinal Cord Injuries Broken Finger Capsulitis) Pitcher’s Elbow Broken Hand “Funny Bone” Syndrome Plantar Fasciitis The Anterior Torso Broken Hip Ganglion Prepatellar Bursitis Broken Jaw Golfer’s Wrist Pro’s Rotator Cuff Injury Bruised Ribs Broken Neck Groin Pull Pronating Foot Separated Ribs Broken Nose Hamstring Pull Psoas Low Back Pain Broken Ribs Broken Patella Headache Quadratus Lumborum Pain Rib Muscle Pulls and Tears Broken Rib Heel Spur Quadriceps Pull or Tear Broken Toe Heel Stress Syndrome Quadriplegia The Back Bruised Collarbone Hip Pointer Racquet Wrist Bruised Quadriceps Hyperextended Elbow Rib Muscle Pull or Tear Back Pain Bruised Ribs Iliotibial Band Syndrome Rib Separation Bulging Disk Bulging Disk Impingement Syndrome Ruptured Disk Bunion/Hallux Valgus Cracked Back “Burner” (“Stinger”) Cracked Wing Bursitis Short-Leg Syndrome Sciatica Massage Protocols for Treatment of Pain Associated With Back Disorders The Shoulder Dislocated Shoulder 334
C H A P T E R 20 Injury by Area 335 K E Y T E R M S — continued Broken Patella Loose Body in the Knee Rotator Cuff Tear Sprained Knee Tibialis Posterior Syndrome Osgood-Schlatter Disease Ruptured Disk Sprained Neck TMJ Injury Iliotibial Band Syndrome Scaphoid Fracture Sprained Thumb Toe Tendinopathy (Tendonitis, Osteoarthritis/Arthrosis Sciatica Sprained Wrist Prepatellar Bursitis Scratched Cornea “Stinger” (“Burner”) Tendonosis) Torn Cartilage Shin Splints Stress Fracture Torn Biceps Baker’s Cyst (Popliteal Cyst) Short-Leg Syndrome Stretched Nerve Torn Cartilage (in the Knee) Massage for Knee Injury and Pain Shoulder Muscle Pulls (Strains) Supinating Foot Torn Tendon Shoulder Separation Tarsal Tunnel Syndrome Trapezium Fracture The Leg Shoulder Sprains Tendonitis of the Shoulder Trapezius Triggers Ski Pole Thumb Tennis Elbow Triceps Tendinopathy (Tendonitis, Shin Splints Skull Fractures Tennis Leg Tibial Stress Syndrome Spastic Torticollis Tension Headache Tendonosis) Pain on the Outside of the Leg Spinal Cord Injuries Terrible Triad of O’Donohue Trigger Finger Compartment Syndrome Spondylolysis Tibial Stress Syndrome Turf Toe Leg Muscle Pulls and Tears/Strains Sports Hernia/Athletic Pubalgia Tibialis Anterior Tendon Sheath Weight Lifter’s Shoulder Calf Cramps Sprained Finger Whiplash Achilles Tendinopathy (Tendonitis, Inflammation Wryneck Tendonosis) Achilles Bursitis Sprains Biceps Tendinopathy (Tendonitis, Lower Abdomen and Groin Achilles Tendon Rupture Shoulder Separation Tendonosis) Tennis Leg Shoulder “Pops”: Partial Dislocation Torn Biceps Sports Hernia/Athletic Pubalgia Fractures Tendonitis, Bursitis, and Impingement Osteitis Pubis Stress Fractures Syndrome The Wrist Groin Pull Tibialis Anterior Tendon Sheath The Pro’s Rotator Cuff Injury Inflammation Rotator Cuff Tear Sprains The Hip Frozen Shoulder (Adhesive Capsulitis) Trapezium Fracture The Ankle Fracture Scaphoid Fracture Osteoarthritis/Arthrosis Arthritis Golfer’s Wrist Bo Jackson Injury Sprains Weight Lifter’s Shoulder Lunate Injury Broken Hip Broken Ankle Shoulder Muscle Pulls (Strains) Racquet Wrist Buttock Pull Tibialis Posterior Syndrome Tendinopathy (Tendonitis, Tendonosis) Iliotibial Band Syndrome Dislocation of the Fibularis (Peroneal) The Collarbone (Clavicle) Ganglion Hip Pointer Tendons Chronic Osteoarthritis/Arthrosis Bruised Collarbone Carpal Tunnel Syndrome The Thigh The Foot Broken Collarbone The Hand Hamstring Pull/Tear/Strain Pronating Foot The Elbow Bruised Quadriceps Supinating Foot Broken Hand Quadriceps Pull or Tear/Strain Morton’s Foot Tennis Elbow Broken Finger Femur Fracture Metatarsalgia Pitcher’s Elbow Dislocated Finger Metatarsal Stress Fracture Little League Elbow Jammed Finger The Knee Broken Toe “Funny Bone” (Cubital Tunnel) Tendon Tears Black Toenails Syndrome Ski Pole Thumb Patellofemoral Syndrome Turf Toe Hyperextended Elbow Trigger Finger Jumper’s Knee Plantar Fasciitis Bone Chips Blisters Sprained Knee Morton’s Syndrome Triceps Tendinopathy (Tendonitis, Calluses The Terrible Triad of O’Donohue Heel Spur Tendonosis) Sprained Thumb Anterior and Posterior Cruciate Heel Stress Syndrome Sprained Finger Ligament Injury Toe Tendinopathy (Tendonitis, Dislocated Knee Tendonosis) Dislocated Patella Tarsal Tunnel Syndrome and Entrapment of the Medial Calcaneal Nerve Pes Cavus (Claw Foot) Bunion/Hallux Valgus Summary
3 36 UNIT THREE Sport Injury repeated concussions (even if mild) can result in minimal brain damage. The previous chapters have prepared the reader to assess the indication (or contraindication) for A serious aftermath of a concussion is a condition massage therapy in cases of injury, illness, and dis- known as second impact syndrome. This can occur when a orders, and to provide appropriate intervention. Typically, person who is still recovering from a concussion returns the client will come to the massage therapist with an to a contact sport or activity or has recurrent head trauma. injury diagnosis. A massage treatment plan is then devel- A seemingly minor trauma or bump on the head in these oped as part of a multidisciplinary care approach. This individuals can lead to devastating swelling of the brain, chapter enables the massage therapist to understand the which may prove fatal. physician’s diagnosis, provides guidance for effective treatment, and discusses the injury in relation to its body Head trauma can result in various types of closed head region. injuries. Impaired functions depend on the area of brain injury. Any change in typical behavior or ability in a If massage therapy is appropriate as treatment or as an person who has suffered head trauma should be closely adjunct to treatment, the reader is referred to a section in monitored. a previous chapter outlining appropriate procedures. Occasionally, a more expansive discussion is presented More than 300,000 athletes suffer concussions each here, along with specific strategies for the particular year. There is no way to predict which athletes are likely injury. to suffer concussions. The severity of a concussion depends on how much force is applied to the head and whether It is the responsibility of the massage therapist who is the blow is head-on or glancing. treating a client with an injury to thoroughly research the specific injury, understand the treatments being used by People who wear helmets, which absorb shock, proba- the medical team, and provide appropriate supportive bly will have milder concussions than those who do not. care during the healing and rehabilitation process. How Advances in the design of protective headgear are helping injuries cluster in relation to common sports is found in to prevent head trauma and reduce the severity of a con- Table 20-1. cussion. Although protective equipment continues to improve in quality, many athletes participate in high- Massage applications recommended for a specific con- impact sports activities, such as soccer, or sports in which dition can be incorporated into the general massage session head trauma can result from falling, such as gymnastics, protocol. or the many other sports in which head protection is not required. Therefore, concussions are an ongoing concern, THE HEAD and repeated head trauma can have cumulative effects. Previous head trauma seems to make a person more pre- Objectives disposed to future problems. 1. Identify specific injuries based on location. Signs and symptoms of concussions can be subtle and 2. Develop and implement appropriate treatment plans may not appear immediately. Once present, symptoms can last for days, weeks, or longer. The severity and side effects for massage application for a specific injury. of a head injury depend greatly on which area of the brain Because the head houses all of the body’s vital control was most affected. centers, any injury to the head other than a mild bump or scrape should be seen by a physician. Head injuries Immediate signs and symptoms of a concussion may should be monitored for at least 2 weeks because some include the following: conditions worsen slowly. Consider ALL head injuries • Confusion to be serious until proven otherwise because they can be • Amnesia life-threatening. • Headache • Loss of consciousness after injury CONCUSSION • Ringing in the ears (tinnitus) • Drowsiness A concussion is any disorientation or loss of conscious- • Nausea ness, even for a moment, after a blow to the head. The • Vomiting brain floats within the skull surrounded by cerebrospinal • Unequal pupil size fluid, which cushions it from the light bounces of every- • Unusual eye movements day movement. However, the fluid is not able to absorb • Convulsions the force of a sudden blow or a quick stop, and the brain • Slurred speech slides forcefully against the inner wall of the skull and becomes bruised. This can result in bleeding in or around Delayed signs and symptoms may include those listed the brain and tearing of nerve fibers. It is common for a here: person who suffered a concussion to not remember events • Irritability just before, during, and immediately after the injury. • Headaches Memory of these events may return. After recovery, cogni- • Depression tive function almost always returns to normal, although • Sleep disturbances
C HA P T E R 20 Injury by Area 337 TABLE 20-1 Common Injuries by Sport Athletic Sport Definition Common Injuries Baseball/Softball Shoulder tendinopathy (tendonitis, tendonosis), bursitis, Bat and ball game: A game played with a bat and ball by two teams of nine players on a field with impingement syndrome, muscle sprains and strains, rotator four bases marking the course the batters must take cuff, frozen shoulder, wrist sprains, tennis elbow, anterior to score runs. cruciate ligament (ACL) and posterior cruciate ligament (PCL) injuries, medial collateral ligament (MCL) and lateral collateral Basketball Ball game played on a court: A game played by two ligament injuries. teams of five players, who score points by throwing ACL and PCL injuries, ankle sprain, Achilles tendinopathy Bicycling a ball through a basket mounted at the opponent’s (tendonitis, tendonosis), rotator cuff tendinopathy (tendonitis, Boxing end of a rectangular court. tendonosis), injuries to the meniscus, wrist sprain, finger Canoe/Kayaking fractures, Achilles tendon rupture, hamstring pull or tear, Football The act or sport of riding or traveling by bicycle or muscle sprains and strains. motorcycle. Neck pain, neck strain, knee pain, patellofemoral pain, chondromalacia, osteoarthritis of the knee, Achilles Sport of fighting with fists: The sport of fighting with tendinopathy (tendonitis, tendonosis), plantar fasciitis. the fists with the objective of knocking out the Facial lesions, rotator cuff injury, inflammation, impingement opposing boxer, or inflicting enough punishment to syndrome. cause the other boxer to quit or be judged defeated. Shoulder strain, wrist/hand and elbow/forearm sprains. Sports canoe: A lightweight plastic- or fiberglass- covered canoe propelled by a double-bladed paddle, Anterior and posterior cruciate ligament injuries, meniscus injury, used for leisure and in competitive sport. groin pull; hamstring pull, tear, sprain, or strain; iliotibial band syndrome, shin splints, concussion, shoulder fracture, torn Game played with an oval ball: A game in which two rotator cuff, shoulder separation, shoulder dislocation, teams of 11 players score points by carrying an whiplash, neck strain, Achilles tendinopathy (tendonitis, oval ball across their opponents’ goal line, or by tendonosis), turf toe, back muscle strains, low back pain, kicking the ball through the opponents’ goal posts. herniated disks. Gymnastics A competitive sport in which individuals perform Muscle back strain, spondylolysis, bruises, contusions, muscle Hockey optional and prescribed acrobatic feats mostly on soreness, overtraining syndrome, ankle sprains. special apparatuses to demonstrate strength, Golf balance, and body control. Lacerations, knee sprains, medial collateral and capsular ligaments, acromioclavicular joint separation, shoulder Ice skating Team sport played on ice: A game played on ice dislocation, gamekeeper’s thumb, fracture of the hand and Running between two teams of six, using long sticks with wrist, bruises and contusions, muscle cramps, lumbosacral curved ends. The objective is to hit a small hard pain. rubber disk into the opposing goal. Muscle back strain, low back pain, herniated disks, shouder Game with ball and clubs: An outdoor game in which tendinopathy (tendonitis, tendonosis), bursitis, impingement an array of special clubs with long shafts are used syndrome, torn rotator cuff, frozen shoulder, rotator cuff to hit a small ball from a prescribed starting point tendonitis, shoulder instability, golfer’s elbow, bursitis of the into a series of holes. elbow, tennis elbow. Skating on ice as a sport or pastime. Sprained wrist, plantar fasciitis, MCL injury, low back injury. The exercise or sport of someone who runs. Shin splints, runner’s knee, ankle sprain, foot arch pain and strain, Achilles tendinopathy (tendonitis, tendonosis), blisters, delayed-onset muscle soreness, groin pull, heel spur; hamstring pull, tear, or strain; iliotibial band syndrome, muscle cramps. Continued
3 38 UNIT THREE Sport Injury TABLE 20-1 Common Injuries by Sport—cont’d Athletic Sport Definition Common Injuries Anterior and posterior cruciate ligament injuries, meniscus injury, Snow skiing/Snowboarding Activity of gliding over snow using skis or a flat board (originally wooden planks, now usually made from concussion, knee pain, low back pain, skier’s thumb, wrist fiberglass or related composites) strapped to the arthritis pain, shoulder fracture, torn rotator cuff, shoulder feet. separation or dislocation, neck strain, shoulder fracture. Hamstring pull, ankle sprain, Achilles tendinopathy (tendonitis, Soccer Ball game using no hands: A game in which two tendonosis), cruciate ligament tears, concussion, groin pull, Swimming teams of 11 players try to score by kicking or iliotibial band syndrome, ACL and MCL injuries, meniscus Tennis butting a round ball into the net goals on either end injuries. of a rectangular field. Swimmer’s shoulder (shoulder joint pain), inflammation, impingement, rotator cuff pain, eye irritation. Moving through water: The action or activity of making progress unsupported through water using Tennis elbow, bursitis of the elbow, rotator cuff tendonitis, the arms and legs, whether for pleasure, exercise, shoulder tendinopathy (tendonitis, tendonosis), frozen or sport. shoulder, shoulder joint pain, inflammation, ankle sprain, torn rotator cuff, wrist tendinopathy (tendonitis, tendonosis), Game with ball, racquets, and net: A game played on Achilles tendinopathy (tendonitis, tendonosis), iliotibial band a rectangular court by two players or two pairs of syndrome, osteoarthritis. players, who use racquets to hit a ball back and forth over a net stretched across a marked-out Shin splints, runner’s knee, shoulder inflammation and pain, court. Achilles tendinopathy (tendonitis, tendonosis), plantar fasciitis. Triathlon Athletic contest with three events: An athletic Shoulder joint pain, inflammation, impingement syndrome, Volleyball competition in which the contestants compete in rotator cuff pain, tendinopathy (tendonitis, tendonosis), tennis three different events and are awarded points for elbow, bursitis of the elbow, glenohumeral arthritis, wrist each to find the best all-around athlete. tendinopathy (tendonitis, tendonosis), Achilles tendinopathy (tendonitis, tendonosis), osteoarthritis of the knee, low back A sport in which two teams hit a large ball over a pain, ankle sprain. high net using their hands, played on a rectangular court. Strained lower back injury, shoulder joint inflammation, tendinopathy (tendonitis, tendonosis). Weight training Training using weights: Physical training using weights to strengthen the muscles. • Fatigue Rest is the best recovery technique. Some over-the- • Personality changes counter and prescription drugs may be taken for headache • Poor concentration pain. Aspirin and other nonsteroidal antiinflammatory • Trouble with memory drugs (NSAIDs) usually are not recommended because • Getting lost or becoming easily confused they could contribute to bleeding. The healing process • Increased sensitivity to sounds, lights, and distractions takes time—sometimes several months—and includes the • Loss of sense of taste or smell following: • Difficulty with gait or in coordination of the limbs • Plenty of sleep at night, and rest during the day • Gradual return to normal activities When diagnosing a concussion, the doctor may ask • Avoiding activities that could result in a second head questions about the accident and may conduct a neuro- logic examination to assess memory, concentration, vision, injury hearing, balance, coordination, and reflexes. Depending After a concussion, some symptoms may persist, includ- on the results of the neurologic examination, the doctor ing headache, dizziness, loss of memory of the event, may request a computed tomography (CT) scan or a mag- fatigue, and general weakness. This is called postconcussion netic resonance imaging (MRI) scan. syndrome. In some people, these symptoms clear up and
C H A P T E R 20 Injury by Area 339 they feel fine, but the symptoms recur when they become causing bleeding on the brain. Pressure and bleeding can active again. If these symptoms persist, the athlete should cause coma and even death if not relieved. be reevaluated by the physician. No athlete should return to heavy physical activity until the symptoms clear Massage Strategies completely. Massage is contraindicated in these cases. Returning to athletic activity depends on the cumula- tive effects of the concussions. The following time frames BROKEN NOSE are typical: First concussion—7 days or until all postconcussion symp- A blow to the nose can fracture the nasal bones or the cartilage of the septum. A broken nose appears flattened toms clear, whichever is longer. or crooked; there is copious bleeding from the nose, and Second concussion—3 weeks or until symptoms cease. breathing is difficult. Third concussion—up to 6 months. If a broken nose is suspected, it should be iced down The effect of multiple concussions can result in long- to limit swelling and bruising. The nose needs to be exam- term neurologic and functional deficits, including changes ined and x-rayed by a physician. If the broken bone has in emotional behavior. been displaced, this can cause later breathing problems if not repaired. After treatment, the nose should be protected Massage Strategies with a splint and/or a face guard until it heals completely, which can take 4 to 6 weeks. Massage, if approved by the physician, should be general and nonspecific. Avoid any abrupt movements of the Massage Strategies head. The focus of the massage should be sleep support and recovery (parasympathetic dominance). Once the Massage is general and nonspecific, avoids injured areas, athlete is allowed to practice, gait patterns and ocular manages pain, and promotes healing. The prone position reflexes need to be reset. The massage therapist should may need to be avoided. Because of disrupted breathing, maintain vigilant observation for any postconcussion auxiliary breathing muscles may become strained. Include symptoms and should urge the athlete to see the physician focus on normalized breathing in the general massage for even minor symptoms. protocol. Use general procedures for fractures, broken bones, breathing support, and pain management. SKULL FRACTURE BROKEN CHEEKBONE A hard blow to the head can fracture the bones of the skull (Figure 20-1). Although not common, skull fractures A hard blow to the cheek can fracture the bone. The same occur, and a severe blow to the head can cause a fracture. athletes who are prone to a broken nose may also be prone Blood or clear fluid leaking from the ear or nose may be to a broken cheekbone (Figure 20-2). Treatment includes a sign of a skull fracture. This is a medical emergency—refer icing the cheek and possibly surgery. Healing may take the client to a physician immediately. several weeks. A depressed skull bone from a fracture may put pressure Massage Strategies on the brain or tear blood vessels in the lining of the skull, Do NOT massage the area. Focus on pain management Compound depressed and support healing by encouraging parasympathetic dom- skull fracture. Note hair inance. The prone position should be avoided. See general impacted into wound procedures for fractures (page 309). FIGURE 20-1 Skull fractures. (Netter illustration from www.netterimages. BLOWOUT FRACTURE com. © Elsevier Inc. All rights reserved.) A blow to the eye or cheek can fracture the bones sur- rounding the eyeball. A blowout fracture is easy to spot because the orbit connects to one of the sinuses. When the client blows hard through the nose, the eye will sud- denly swell shut as air gets into the tissues right under the eye. As with any fracture, the victim of a blowout fracture must see a doctor for treatment, which may include surgery. If the fractured orbit is displaced, as often happens, one of the eye muscles may be trapped, and the eye will not move properly, causing double vision, unless surgically corrected. Massage Strategies Massage avoids the area, and the prone position is not used. See general procedure for broken bones and pain
3 40 UNIT THREE Sport Injury Lowered lateral portion of palpebral fissure Subconjunctival hemorrhage Flattened Lateral canthal lig. displaced downward cheekbone with dislocation of zygomatic bone Ecchymosis Dislocated zygomatic bone Displaced segment Fracture at zygomaticofrontal suture line Displaced segment Fracture at zygomaticomaxillary suture line FIGURE 20-2 Zygomatic fractures. (Netter illustration from www.netterimages.com. © Elsevier Inc. All rights reserved.) management. Once the athlete has recovered, eye reflexes Massage Strategies may need to be addressed. General massage that supports healing mechanisms and SCRATCHED CORNEA avoids the area is indicated. Once healing is in the sub- acute phase, scar tissue management can begin. A scratched cornea commonly occurs when a person gets poked in the eye. Direct blows to the eye from a ball in BROKEN JAW sports such as racquetball can cause a scratched cornea, as well as a variety of other injuries. This is an extremely Symptoms of a broken jaw include pain on one side of painful injury. If severe, it can lead to loss of vision. Every the jaw and pain inhibiting the ability to clench the jaw. eye injury must be considered serious. Treatment includes If the jaw can be closed, the teeth will not meet properly. covering the eye with a patch and examination by a physi- cian as soon as possible. A broken jaw must be wired shut by a dental surgeon to allow it to heal, which typically takes about 6 weeks. To guard their eyes, many athletes now wear protective Many athletes can compete with their jaws wired shut, but gear, especially if they have already had an eye injury. their diet is limited to liquids taken through a straw, which can result in weight and strength loss. Massage Strategies Massage Strategies Massage supports pain management and healing by encouraging parasympathetic dominance. Use massage strategies for fractures. CAULIFLOWER EAR TMJ INJURY AND PAIN If an unprotected ear is bent over, punched, or caught in A blow to the jaw can injure the temporomandibular joint a wrestling hold, the cartilage in the ear can break. Bleed- (TMJ). The ligaments may become torn, causing the joint ing occurs under the skin, and if the blood is not drained, to slide into and out of place. The jaw may become stuck scar tissue will form and the ear will look somewhat like a in an open position, requiring manipulation by an oral cauliflower—hence the name cauliflower ear. surgeon to close it. This injury usually heals within 6 to 8 weeks, but a mouthpiece may be necessary to hold the jaw Medical treatment includes ice and compression to the in position until the ligaments heal. ear to limit bleeding, and drainage of excess blood from the ear by a physician. Preventing TMJ injury is one of the reasons athletes wear mouthpieces. The mouthpiece protects the jaw and
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