Sports Rehabilitation and Injury Prevention Edited by Paul Comfort

TREATMENT PLANS FOR NERVE INJURY 129 the plexus region (Weinstein 1998; Reid and Trent pression within this area. Restriction of space for the 2002). neurovascular structures to pass through within the thoracic outlet can cause compression of the neural Symptoms reported for Stinger Syndrome gen- and/or vascular structures, subsequently resulting in erally involve a single upper extremity (Dimberg symptoms (Crosby and Wehbe´ 2004). Compression and Burns 2005; Wilbourn 2007) with sharp, burn- of one or more of the structures can lead to the ing pain and numbness accompanied by short-lived diagnosis of thoracic outlet syndrome (TOS). weakness down the arm (Weinstein 1998; Aldridge The clinical presentation of TOS can be variable, et al. 2001). Patients who report bilateral or lower presenting as either a neurological or a vascular con- extremity symptoms should be treated with caution dition, or both. However, with Brantigan and Roos as spinal cord injury is a potential injury (Dimberg (2004) reporting 98% of cases to be neurological and Burns 2005). An important finding with Stinger in origin and Crosby and Wehbe´ (2004) agreeing Syndrome is that symptoms are unilateral (Wilbourn that the majority of patients have neurogenic 2007) and short-lived. Neuropraxia and axontmesis symptoms, for the purpose of this section, TOS will are typically associated with this type of injury. be discussed in relation to the brachial plexus only. If the symptoms resolve within minutes and there TOS can develop insidiously, or as a consequence is no evidence of reduced strength or disrupted move- of a previous traumatic injury, such as whiplash ment of the neck, the athlete can be considered for or a similar such trauma, which ultimately causes return to play in the same competition (Dimberg and chronic muscle spasm within the neck or shoulder Burns 2005). However, the player should be contin- (Brantigan and Roos 2004). Whilst the initial injury uously monitored during the remainder of the com- may be considered to be relatively minor, the resul- petition and re-assessed over the subsequent weeks. tant effect of the injury on the brachial plexus may Cervical spine rehabilitation should be undertaken be delayed and the condition may take considerable in the Stinger Syndrome patient, aiming to protect time to develop. The patient may complain of arm the injured structures and control pain and inflam- elevation exacerbating symptoms, such as shoulder mation in the initial stages, following which flexi- press or serving in tennis, whilst exercise can in- bility and strength imbalances and deficits should be duce a similar response, but only following cessation addressed (Weinstein 1998). Postural abnormalities of the exercise, rather than during it (Brantigan and should also be considered over the course of treat- Roos 2004). Neck stiffness may also be evident in pa- ing patients with cervical spine and nerve injuries. tients with suspected TOS, and therefore the physical A treatment strategy for Stinger Syndrome can in- examination should include a comprehensive assess- clude NSAIDs, modification of activity, neurody- ment of the neck, shoulder and the upper extremity. namic sliding techniques in the acute stage, manual Typically evident in patients with neurogenic TOS, therapy of the cervical spine, range of movement is the reproduction of symptoms when the clinician activities for the shoulder and strengthening of the places mild to moderate pressure over the brachial shoulder and neck muscles. plexus in the supraclavicular fossa of the symp- tomatic side (Brantigan and Roos 2004). Branti- Thoracic outlet syndrome gan and Roos (2004) recommend incorporating the EAST (elevated arm stress test) into the clinical ex- The thoracic outlet region in the upper extremity amination to diagnose TOS as few individuals with contains three structures; the subclavian artery, this condition are actually able to complete the test. subclavian vein and the brachial plexus, all of which pass under the clavicle and subclavius muscle, In the majority of cases, conservative treatment before then travelling beneath the pectoralis minor will alleviate symptoms and address the cause muscle close to its insertion point at the coracoid of TOS unless there is significant neural loss or process, whereafter, the structures enter the axilla vascular compression (Crosby and Wehbe´ 2004). space (Atasoy 2004). These neurovascular structures Incorporation of NSAIDs, postural control including pass through the interscalene triangle; comprising during sleep, manual therapy such as thoracic and of the anterior and middle scalene muscles and the first rib mobilisation and muscle and nerve gliding first rib, whilst en-route to the axilla (Brantigan and exercises into the treatment plan should be under- Roos 2004) and are considered vulnerable to com- taken for patients with TOS (Crosby and Wehbe´

130 PERIPHERAL NERVE INJURIES 2004). Exercise therapy such as neck side flexion, 1998). A well-defined patch of sensory loss over the neck rotation, chin tucks, shoulder shrugs and lateral shoulder, in addition to weakness in shoulder shoulder circles to name but a few, can also be ben- abduction (deltoid) and external rotation (teres eficial for this condition (Crosby and Wehbe´ 2004). minor) are typical clinical reporting for axillary Crosby and Wehbe´ (2004) present a comprehensive neuropathy (Perlmutter and Apruzzese 1998; Goslin overview of treatment strategies for TOS. and Krivickas 1999). Neurological complications following shoulder dislocation, of the brachial Axillary nerve plexus and axillary nerve are enhanced in patients >50 years or if the shoulder remains dislocated for The axillary nerve is the terminal branch of the greater than 12 hours (Pratt 2005). posterior cord of the brachial plexus, receiving its contributions from C5 and C6 nerve roots (Bencar- Restoring full range of motion at the shoulder is a dino and Rosenberg 2006). Axillary nerve injury is a priority in the conservative treatment for the axillary well-known complication of anterior glenohumeral nerve (Perlmutter and Apruzzese 1998; Goslin and dislocation (Perlmutter and Apruzzese 1998; Goslin Krivickas 1999. NSAIDs and analgesics will assist and Krivickas 1999) evident in 9–18% of this with pain and inflammation control during the acute injury (Perlmutter and Apruzzese 1998). The close stage. Strengthening exercises for the rotator cuff proximity of the anatomical course of the axillary and periscapular muscles should also be undertaken nerve to the shoulder joint increases its susceptibility (Aldridge et al. 2001) in addition to nerve gliding to injury, secondary to shoulder dislocation. The exercises. nerve travels inferior to the humeral head before passing through the quadrangular space, where Long thoracic nerve it then wraps horizontally around the posterior aspect of the surgical neck of the humerus (Pratt The long thoracic nerve arises from the ventral rami 2005). It then enters the deltoid muscle which it of C5–C7 spinal nerves (Goslin and Krivickas 1999) innervates, along with teres minor (Goslin and and innervates exclusively the serratus anterior mus- Krivickas 1999). cle (Goslin and Krivickas 1999; Aldridge et al. 2001; Pratt 2005). The relative immobility of the long Glenohumeral dislocation typically occurs in thoracic nerve is a primary factor in the occurrence an inferior-anterior direction (Owens and Itamura of injury to this structure, as it is anchored at regular, 2000) whereby on dislocation, the humeral head short intervals throughout it’s anatomical course moves into the infra-articular fossa (Pratt 2005). (Pratt 2005), particularly at the scalene medius and As a consequence of the forced, abrupt movement serratus anterior muscles (Goslin and Krivickas of the humeral head, a traction force is placed 1999). Consequently, traction or stretch of the long on the axillary nerve (Perlmutter and Apruzzese thoracic nerve, such as with extreme excursion of 1998) resulting in stretching of the nerve around the the shoulder girdle, is a common mechanism of humeral head and tension propagating to the infra- injury for this structure (Goslin and Krivickas 1999; clavicular brachial plexus (Pratt 2005); the overall Pratt 2005). Palsy of this nerve has been associated outcome resulting in nerve injury (Pratt 2005). Blunt with repetitive motion or muscular hypertrophy in trauma to the anterior/lateral aspect of the shoulder, sport (Toth et al. 2005). One case reported an elite typically seen in tackling during rugby, whereby a marksman presenting with long thoracic neuropathy, compressive force is applied to the axillary nerve due, according to the author, to the positional stress is another common mechanism of injury for this imposed during repetitive shooting postures whilst structure (Perlmutter and Apruzzese 1998). holding the gun (Woodhead 1985). Maintaining static postures that keep the shoulder girdle elevated Injury to the axillary nerve with shoulder dis- for long periods is an alternate way in which injury to locations may go unnoticed initially as the bony the long thoracic nerve occurs (Goslin and Krivickas injury may dominate the clinical picture (Perlmutter 1999; Pratt 2005). This is evident in patients with and Apruzzese 1998) and consequently for an Saturday night palsy (Pratt 2005), which originates athlete participating in contact sports, a thorough from patients falling asleep on a chair with the neurological examination with shoulder dislocation shoulder draped over the back of a chair, thereby should be undertaken (Perlmutter and Apruzzese,

TREATMENT PLANS FOR NERVE INJURY 131 subjecting the long thoracic nerve to prolonged 2001). Repetitive scapular motion, such as that stretching. Due to the relative superficiality of the which occurs during overhead activities in tennis nerve, it is also susceptible to external compression or badminton can stretch and compress the supras- (Pratt 2005). capular nerve and induce entrapment neuropathy (Bencadino and Rosenberg 2006). Patients with Scapula winging is the most prevalent clinical suprascapular neuropathy may complain of pain finding associated with injury to the long thoracic at the superior border of the scapula (Goslin and nerve (Aldridge et al. 2001; Goslin and Krivickas Krivickas 1999), which may co-exist with impinge- 1999) as a result of weakness of the serratus ante- ment signs and symptoms (Owens and Itamura rior muscle (Owens and Itamura 2002). This clinical 2002) or weakness (Goslin and Krivickas 1999). finding is best demonstrated by having the patient Weakness and pain during shoulder abduction and perform a push-up against a wall (Owens and Ita- lateral rotation may be evident, due to dennervation mura 2002). An ache or burning pain in the posterior of the supraspinatous and infraspinatous muscles shoulder with associated weakness in arm elevation respectively (Goslin and Krivickas 1999; Aldridge and abduction is an early finding in patients with et al. 2001). Point tenderness over the area of nerve long thoracic nerve pathology (Owens and Itamura compression is evident in patients with entrapment 2002), in addition to them having difficulty perform- of the nerve whilst horizontal adduction of the ing overhead activities (Aldridge et al. 2001), possi- shoulder may elicit patient symptoms as the tension bly due to serratus anterior being unable to efficiently on the nerve is increased with this manoeuvre laterally rotate the scapula during shoulder elevation. (Aldridge et al. 2001). Treatment strategies for long thoracic neuropathy The management for injury to the suprascapular involve rest and avoidance or modification of the nerve should involve modifying or ceasing the aggravating activity (Goslin and Krivickas 1999), aggravating activity (Goslin and Krivickas 1999; NSAIDs and physical therapy. Exercises aiming to Aldridge et al. 2001), whilst incorporating NSAIDs fix the scapula against the thorax are advised to pre- and scapular stabilisation exercises into the rehabil- vent further overstretching of the nerve or scapula itation programme (Aldridge et al. 2001). Restoring winging (Goslin and Krivickas 1999). Maintaining full range of motion at the shoulder, increasing shoulder range of motion (Aldridge et al. 2001) and strength of the scapular stabilisers and rotator cuff increasing the strength of trapezius and the rhom- muscles (Goslin and Krivickas 1999) are additional boids (Goslin and Krivickas 1999) should be addi- aims for a treatment programme for this neuropathy. tional aims for the treatment plan. Suprascapular nerve Ulnar nerve The suprascapular nerve originates from the su- The ulnar nerve is the end point of the medial cord perior nerve trunk (C5–C6 nerve roots) at Erbs’ of the brachial plexus, composed of fibres from C8 point (Aldridge et al. 2001; Pratt 2005; Bencardino and T1 nerve roots (Rokito et al. 1996; Aldridge and Rosenberg 2006) and is responsible for inner- et al. 2001; Bencardino and Rosenberg 2006) and vating supraspinatous and infraspinatous muscles, is extremely mobile at the elbow joint. It is there- which abduct and laterally rotate the shoulder re- fore susceptible to direct trauma, compression and spectively (Goslin and Krivickas 1999; Pratt 2005). traction; to name but a few causes of injury to this The suprascapular nerve is vulnerable to entrapment structure (Izzi et al. 2001). (Goslin and Krivickas 1999) as it passes through the suprascapular foramen before curving around the Cubital tunnel syndrome spinoglenoid notch; both anatomical points of nerve entrapment (Pratt 2005). Cubital tunnel syndrome is the second most com- mon neuropathy in the upper extremity (Bencardino Injury to this structure can occur as a result of and Rosenberg 2006) and the commonest entrap- acute stretching, a blow to the superior aspect of the ment neuropathy at the elbow (Salama and Stanley shoulder (Owens and Itamura 2001) whereby the 2008), being responsible for entrapment of the ul- shoulder is forcibly depressed (Goslin and Krivickas nar nerve. The potential for ulnar nerve compression 1999), or can be of insidious onset (Aldridge et al.

132 PERIPHERAL NERVE INJURIES at the cubital tunnel is unsurprising considering its of the forearm, due to subluxation of the ulnar nerve, anatomical arrangement (Pratt 2005). The arcuate may also be reported (Aldridge et al. 2001). ligament and medial collateral ligament of the elbow form the roof and floor aspect of the tunnel respec- In the early stages of nerve compression, provoca- tively (Pratt 2005; Bencardino and Rosenberg 2006). tive testing may be the only positive finding (Novak During elbow flexion the points of attachments for and Mackinnon 2005). A positive Tinel’s sign should the structures of the cubital tunnel are pulled further be performed at the entrapment site and along the apart, resulting in tightening of both the floor and course of the nerve whereby reproduction of patient roof of the tunnel. In addition, during forearm flex- symptoms in the relevant neural distribution consti- ion, the trochlea of the humerus rotates under the tutes a positive test. Tapping the ulnar nerve behind medial collateral ligament and elevates the floor of the medial epicondyle is a Tinel’s test for the ulnar the tunnel, culminating in decreased space for the ul- nerve at the elbow (Salama and Stanley 2008). Po- nar nerve to glide and move (Pratt 2005). Therefore, sitional and provocation tests should also be under- it is unsurprising that this syndrome is prevalent in taken in potential entrapment neuropathy, whereby throwing athletes (Izzi et al. 2001), many of whom each test is held for one minute, and are deemed pos- undertake repetitive elbow joint movements, with itive if there is alteration in sensations in the correct forced extension, such as seen in pitching a baseball. neural distribution (Table 8.3) (Novak and Mackin- During repetitive, high-velocity throwing, athletes, non 2005). It is important in cubital tunnel syndrome particularly in those who demonstrate excessive lax- to differentially diagnose the possibility of thoracic ity at the elbow (Badia and Stennett; Rokito et al. outlet syndrome, lower cervical neuropathy or com- 1996), increased traction is placed on the nerve dur- pressive ulnar neuropathy at the wrist (Bencardino ing the movement, all of which culminates in an and Rosenberg 2006). Medial epicondylitis, medial increased susceptibility to ulnar neuropathy (Rokito ligament laxity and ulnar neuritis all require differ- et al. 1996). ential diagnosis by the clinician (Rokito et al. 1996). Clinically, patients with cubital tunnel syndrome Conservative treatment of cubital tunnel syn- may present with diminished sensation in the drome can include avoidance of the aggravating ulnar aspect of the fourth finger and all of the fifth activity (Badia and Stennett 2006), NSAIDs, finger (Izzi et al. 2001; Salama and Stanley 2008) altering throwing technique, manual therapy, nerve and elbow pain radiating to the hand with sensory gliding (Kostopoulos 2004) and exercise therapy symptoms, particularly at night, when the elbow is such as a progressive strengthening exercise pro- maintained in flexion for long periods of time during gramme (Badia and Stennett 2006). A night splint sleep (Bencardino and Rosenberg 2006). Weakness may be indicated in early cases, particularly if the in the finger abductors, and thumb adductor or strug- patient sleeps prone, with the elbow tucked under gling to maintain a powerful grip may be additional a pillow whereby local pressure can be placed on clinical complaints (Izzi et al. 2001; Shapiro and Pre- the ulnar nerve. In this position, traction can also ston 2009). In the overhead athlete, pain along the be placed on the nerve, if the elbow remains flexed medial joint line may be the first clinical sign of ulnar and shoulder abducted during the sleeping posture neuropathy or complaints of a popping or snapping (Izzi et al. 2001; Salama and Stanley 2008). sensation at the elbow during flexion and extension Night splints should only be utilised if the patient complains of symptoms whilst sleeping. Table 8.3 Positive tests for nerve compression in the upper extremity Nerve Site of entrapment Provocation test Radial nerve Distal forearm Forearm pronation with wrist ulnar deviation. Pressure over tendinous junction of extensor carpi radialis and brachioradialis Ulnar nerve Cubital tunnel Median Nerve Proximal forearm Elbow flexion and pressure on ulnar nerve at the cubital tunnel region Carpal tunnel Forearm supination with pressure in the region of pronator teres Wrist flexion and/or extension with pressure proximal to carpal tunnel Adapted from Novak and Mackinnon (2005).

TREATMENT PLANS FOR NERVE INJURY 133 Radial nerve Management of radial tunnel syndrome should in- corporate pain-relieving modalities such as NSAIDs The radial nerve is the larger branch of the pos- (Izzi et al. 2001; Salama and Stanley 2008), nerve terior cord of the brachial plexus (Bencardino and gliding exercises (Badia and Stennett 2006), activity Rosenberg 2006), with part of its anatomical course modification and splinting (Izzi et al. 2001; Salama running obliquely around the posterior shaft of the and Stanley 2008). humerus in the spiral groove (Pratt 2005), making it therefore very vulnerable to injury following Median nerve fracture of the humerus. Radial nerve injury can occur secondary to humeral shaft fracture, as a result The median nerve is formed by contributions from of the inappropriate use of axillary crutches or due to the medial and lateral cords of the brachial plexus entrapment at the elbow (Bencardino and Rosenberg (Pratt 2005; Bencardino and Rosenberg 2006) con- 2006). The radial nerve also has the potential to taining motor and sensory fibres from the C5–T1 become entrapped in callus formation during the nerve roots (Bencardino and Rosenberg 2006). healing process following humeral fracture (Pratt Whilst carpal tunnel syndrome is the most common 2005). nerve entrapment of the upper extremity (Bencardio and Rosenberg 2006), it is more common in the gen- Radial tunnel syndrome eral population as opposed to athletes, as the latter typically suffer from nerve compression at the elbow Compression of the radial nerve at the elbow is (Izzi et al. 2001). referred to as radial tunnel syndrome and more commonly affects the posterior interosseus nerve Pronator teres syndrome (Bencardino and Rosenberg 2006). It is commonly seen in racquet sport athletes or swimmers where Pronator teres syndrome is compression of the me- repetitive pronation and supination occurs (Izzi et al. dian nerve (Izzi et al. 2001; Kostopoulos 2004) and is 2001; Bencardino and Rosenberg 2006). The poste- the most common cause of median nerve entrapment rior interosseus nerve is vulnerable to compression at the elbow (Bencardino and Rosenberg 2006). It is at various sites within the radial tunnel (Bencardino more prevalent in athletes as opposed to the general and Rosenberg 2006), of which the arcade of Frohse population (Badia and Stennett 2006) with hyper- is one of the hazardous anatomical structures that trophy of the pronator teres cited as one of the po- can compress the nerve at the elbow (Pratt 2005). tential inflictors of compression on the nerve (Izzi The arcade of Frohse is a fibrous arch formed by et al. 2001). External compression on the forearm the proximal portion of the superficial head of muscles is another source of medial neuropathy dis- the supinator muscle (Pratt 2005; Bencardino and cussed by Badia and Stennett (2006) whereby one of Rosenberg 2006) and under which the radial nerve the authors reported medial nerve compression in an passes (Bencardino and Rosenberg 2006). acrobat who wrapped a curtain of material around the forearm as part of an acrobatic routine during Clinically, a patient with compression of the numerous performances, thereby repetitively com- radial nerve at the elbow will present with poorly pressing the median nerve and ultimately inflicting localised pain to the antero-lateral aspect of the injury. elbow, which can be provoked by manoeuvers that stretch or compress the nerve (Izzi et al. 2001). The clinical features of pronator teres syndrome Tenderness over the radial nerve along the radial are often vague (Kostopolous 2004). However, pa- tunnel, pain on resisted supination and a positive tients with this syndrome may complain of volar Tinels’ sign over the radial forearm are factors arm pain, with or without hand pain, which may that may be present on physical examination be exacerbated by repeated forearm pronation and (Bencardino and Rosenberg 2006). Differential wrist flexion (Izzi et al. 2001). Numbness in the diagnosis for lateral epicondylitis of the elbow is median nerve distribution with repetitive pronation vital as radial tunnel syndrome can masquerade and supination, but not elbow flexion and extension, as or co-exist with this condition (Bencardino is another indicator of this neuropathy (Bencardino and Rosenberg 2006; Salama and Stanley 2008). and Rosenberg 2006). Weakness in resisted forearm

134 PERIPHERAL NERVE INJURIES pronation, wrist flexion and radial deviation are ad- et al. 2001) in addition to reporting nocturnal pain ditional clinical presentations with this condition, in (Aldridge et al. 2001; Izzi et al. 2001). In chronic additional to thenar atrophy and an inability to op- conditions, symptoms may be reported above the pose or flex the thumb (Bencardino and Rosenberg carpal region, as far distal as the cervical spine 2006). Tenderness on palpation can be evident over (Kostopoulos 2004). Abductor pollicis weakness is the pronator muscle (Izzi et al. 2001). the most common motor weakness associated with CTS (Izzi et al. 2001) and a diminished grip strength Patients with pronator teres syndrome are advised may be evident when compared to the asymptomatic to abstain from the aggravating activity or mod- side (Aldridge et al. 2001). A positive Tinel’s sign ify their choice of equipment or technique (Badia or Phalens test is indicative of CTS (Aldridge et al. and Stennett; Salama and Stanley 2008). NSAIDs, 2001; Shapiro and Preston 2009) and thenar atrophy rest (Salama and Stanley 2008), nerve gliding exer- may be observed in advanced cases of CTS (Aldridge cises and stretching of the pronator teres muscle are et al. 2001). Symptoms can be exacerbated during some of the treatment strategies available to clini- sleep if the wrist is maintained in a flexed or extended cians for this neuropathy. Splinting is another option position (Shapiro and Preston 2009). presented by Salama and Stanley (2008) for treat- ment of this condition. Conservative treatment of CTS can include NSAIDs, active rest, modification of the aggravat- Carpal tunnel syndrome ing activity, tendon and nerve gliding (Aldridge et al. 2001; Izzi et al. 2001; Kostopoulos 2004) and Carpal tunnel syndrome (CTS) is the most common exercise therapy. Splinting of the wrist is another entrapment neuropathy in the upper body (Shapiro treatment option for clinicians for CTS management. and Preston 2009), involving compression of the me- dian nerve as it traverses through the wrist at the Lower limb nerve injuries carpal tunnel (Rempel and Diao 2004) and presents relatively frequent in athletes (Aldridge et al. 2001). Comprising of the lumbar and sacral plexuses, the The carpal tunnel is composed of the stiff carpal lumbosacral plexus originates from L1, L2, L3 and, bones of the wrist, which make up the floor and walls in part, L4 anterior primary rami (APR) (Wilbourn of the tunnel and the flexor retinaculum, which acts 2007). The remaining APR of L4 fuses with L5 APR as the roof of the tunnel (Kostopoulos 2004). Nine to form the lumbosacral trunk, which subsequently tendons, the medial nerve, synovium and radial and contributes to the formation of the sacral plexus; an ulnar bursae occupy the carpal tunnel (Rempel and entity responsible for providing sensation to the ma- Diao 2004). It is therefore quite apparent how this jority of the lower limb (Wilbourn 2007). The lower particular area may be subjected to entrapment neu- branch of L2, all of L3 and the upper branch of L4 ropathy due to the limited space within the tunnel, terminate by dividing into anterior and posterior divi- and the high volume of structures occupying this sions; the former forming the obturator nerve and the space. latter forming the femoral nerve. The superior and inferior gluteal nerves are formed by the posterior CTS is considered to develop as the result of repet- divisions of L4, L5 and S1, and the posterior divi- itive wrist use and commonly presents in gripping sions of L5, S1 and S2, respectively (Figure 8.13). athletes, such as archery, racquet and throwing ath- The sacral plexus provides sensation to the gluteal re- letes (Izzi et al. 2001). The syndrome, according gion and, with the exception of the anterolateral thigh to Kostopoulos (2004) is defined by the signs and and a lengthy strip of medial leg, the lower limb. symptoms of the median nerve at the wrist, as sen- It innervates the pelvic floor muscles, gluteals and sory loss and parasthesia are commonly present in tensor fascia latae, hamstrings and all the muscles the distribution of the median nerve with this condi- of the leg and foot (Wilbourn 2007). Lumbosacral tion (Shapiro and Preston 2009). A thorough inves- plexopathies are infrequent, compared to brachial tigation of the wrist and cervical spine should be un- plexus injury, possibly due in part to the protec- dertaken to eliminate the potential for double crush tive anatomical arrangement of the pelvis and sur- syndrome (Kostopoulos 2004). Clinically, patients rounding musculature, in addition to the nerves be- complain of pain in the wrist and hand with parasthe- ing associated with less mobile structures (Wilbourn sia evident in the lateral three and a half fingers (Izzi

LOWER LIMB NERVE INJURIES 135 Iliohypogastric n. L1 trochanter of the femur (Papadopoulos and Khan Ilio-inguinal n. 2004). It traverses to its insertion, via the sciatic L2 notch; a point where all neurovascular structures Lateral cutaneous n. which enter the buttock from the pelvis descend, of thigh L3 either superior or inferior to piriformis; the sciatic nerve, being one such structure, exits the pelvis be- Genitofemeral n. L4 low the muscle (Papadapoulous and Khan 2004). Lumbosacral Piriformis syndrome arises from the belief that a hy- truck L5 pertrophied piriformis muscle compresses the sciatic Femoral n. nerve causing pain in the nerve’s distribution (Tiel S1 2008), a theory which is plausible considering the Super & Interior S2 intimate anatomical arrangement between these two gluteal n’s S4 structures. The resultant effect of this nerve com- pression is symptoms indicative of proximal sciatic Posterior cutaneous nerve dysfunction, a neuropathy that has become n. of thing known as piriformis syndrome (Shapiro and Preston Common peraneal n. 2009). Tibial n. A patient presenting with suspected piriformis Obturator n. syndrome generally complains of pain and ten- Great Sciatic derness in the buttock region at the sciatic notch, particularly during prolonged sitting on hard Figure 8.13 Lumbosacral plexus. surfaces (Shapiro and Preston 2009). Complaints of buttock pain, with or without accompanying 2007). The anatomical arrangement of the sciatic, ipsilateral radiating pain in the sciatic nerve’s distri- tibial and peroneal nerves can be viewed from Fig- bution, is common; symptoms may be exacerbated ure 8.14 and are subsequently discussed in relation by stretching the piriformis via adduction and to injury and treatment, particularly in sporting pop- medial rotation of the hip joint (Papadapoulous ulations. and Khan 2004; Shapiro and Preston 2009). The clinical assessment should include a comprehensive Sciatic nerve neurological examination inclusive of motor, sensory and reflex tests (Papadapoulous and Khan Originating from L4, L5, S1 and S2 nerve roots and 2004). Palpation of the sciatic notch should also consisting of a peroneal and tibial division, which be undertaken as this can reproduce symptoms are encased in a common sheath, the sciatic nerve (Papadapoulous and Khan 2004; Shapiro and is formed (Katirji 1999). The sciatic nerve exits the Preston 2009). However, the intolerance to pro- pelvis via the greater sciatic notch before traversing longed sitting on hard surfaces is probably the most into the posterior thigh where approximately mid- prominent sign of this condition (Papadapoulous thigh; it splits into the tibial nerve and common per- and Khan 2004); and therefore this condition may be oneal nerve (Yuen and So 1999). The tibial nerve is commonly seen in rowers. The noticeable difference responsible for innervating the majority of the ham- between piriformis syndrome and L5 radiculopathy strings; the short head of biceps femoris being the is the latter presents with back pain, altered reflexes, exception as it is innervated by the common peroneal sensory loss and muscle weakness of the hamstrings nerve (Katirji 1999; Yuen and So 1999). and gastrocnemius (Shapiro and Preston 2009). Piriformis syndrome Treatment options for piriformis syndrome should include NSAIDs, physical therapy, neurodynamic The piriformis muscle originates from the anterior treatment techniques and stretching of the muscle surface of the sacrum, inserting into the greater (Papadapoulous and Khan 2004; Shapiro and Pre- ston 2009). Should conservative treatment fail, in- jection or surgical release are more advanced options according to the same authors.

136 PERIPHERAL NERVE INJURIES Intercostal nerve (T11) Anterior division T12 Posterior division Subcostal nerve (T12) Sympathetic trunk Iliohypogastric nerve (T12, L1) L1 Ilioingguinal nerve (L1) Rami communicantes To psoas major and psoas minor muscles Genitofemoral nerve (L1, 2) Lateral cutaneous nerve L2 of thigh (L2, 3) Lumbar plexus Genital branch and L3 Femoral branch of genitofemoral nerve L4 To psoas major and iliacus muscles Anterior branches and Lateral branches of subcostal and iliohypogastric nerves Lumbosacral trunk Nerve to quadratus L5 femoris (and inferior gemellus) (L4, 5, S1) Sacral plexus S1 Nerve to obturator internus (and superior S2 gemellus) (L5, S1, 2) Superior gluteal nerve (L4, 5, S1) Nerve to piriformis (S1, 2) S3 Obturator nerve (L2, 3, 4) S4 Accessory obturator nerve S5 Coccygeal plexus (L3, 4) (inconstant) Co Inferior gluteal nerve (L5, S1, 2) Pelvic splanchnic nerves Femoral nerve (L2, 3, 4) Perforating cutaneous Sciatic nerve nerve (S2, 3) Nerve to levator ani Posterior cutaneous and coccygeus (S3, 4) nerve of thigh (S1, 2, 3) Perineal branch of Pudendal nerve (S2, 3, 4) 4th sacral nerve Anococcygeal nerves Sciatic Common fibular nerve (peroneal) nerve Obturator nerve (L4, 5, S1, 2) Posterior Inferior anal Tibial nerve cutaneous (rectal) nerve (L4, 5, S1, 2, 3) nerve of thigh Dorsal nerve of penis/clitoris Perineal nerve and Posterior scrotal/labial branches Figure 8.14 Nerve pathways for lower limb. Posterior thigh injury in the posterior thigh (Verrall et al. 2001). The conse- quences of such findings for clinicians is such that, in In athletes presenting with an injury to the posterior a patient presenting with posterior thigh pain, where thigh there is not automatically an injury to the there is difficulty identifying by palpation the painful hamstrings (Woods et al. 2004). For example, almost site, lack of bruising, a vague mechanism of injury 20% of Australian Football League (AFL) players or complaints of spinal pain, mechanosensitivity of had a normal Magnetic Resonance Imaging (MRI) the neural system should be suspected (Butler 1991). scan of the hamstrings, despite presenting with pain The nervous system may incur injury as a direct or

LOWER LIMB NERVE INJURIES 137 indirect result of hamstring muscle injury; the latter thigh before traversing the popliteal fossa, whereby of which may occur as a consequence of the natural it then wraps around the fibular neck before passing formation of scar tissue during the healing process through the fibular tunnel (Katirji 1999), following (Shacklock 1995). Fibrosis, lesions or intermuscular which the nerve divides into the superficial and deep adhesions following muscle injury can reduce the peroneal nerve (McKean 2009; Shapiro and Preston fluidness of movement between the muscle and the 2009). The fibular tunnel is a tendinous tunnel be- nerve, and thereby lead to secondary nerve damage tween the peroneus longus muscle and the fibula (Turl and George 1998; Shacklock 2005). Consid- (Katirji 1999) and it is therefore a common site of erable overlap in terms of clinical features exist be- compression for this nerve. tween Grade 1 or minor hamstring muscle strains and injuries involving referred pain (Verrall et al. 2003). Peroneal neuropathy is prevalent in individuals Considering that the clinical signs associated with who repetitively squat (Shapiro and Preston 2009), Grade 2 and 3 muscle strains, such as swelling and such as a catcher in baseball, as this position can bruising, are typically absent from Grade 1 strains induce prolonged stretching of the nerve. However, (Kornberg and Lew 1989; Turl and George 1998), it also occurs in individuals with minimal body fat, differentiation of Grade I hamstring injury from due to the minimal amount of adipose tissue avail- referred pain is difficult (Kornberg and Lew 1989). able to surround and protect the nerve from external forces or compression (Shapiro and Preston 2009). Suspicion of sciatic nerve involvement in ham- An acute injury to the CPN may occur in runners, string strains is warranted, particularly considering whereby the nerve is forcibly stretched as the result how one in five athletes will have an absence of of a severe ankle inversion injury (Shapiro and Pre- muscle pathology on MRI scan (Verrall et al. 2001), ston 2009), whilst fracture to the fibular head or knee despite presenting clinically as a muscle strain. As an dislocation can also injury this nerve (Katirji 1999). MRI scan is not an easily accessible diagnostic tool to many clinicians working in sport, neurodynamic Typically patients complain of pain, burning or testing, via the slump test is often the clinical test numbness down the anterolateral aspect of the lower used to differentially diagnose posterior thigh pain. leg with a loss in sensation evident in the dorsum of the foot (Katirji 1999; McKean 2009; Shapiro Whilst the treatment of posterior thigh pain, if and Preston 2009). Clinical examination can reveal considered to be muscular, should focus on return- weakness in the ankle evertor muscles (McKean ing the muscle to pre-morbid abilities, the sciatic 2009), the ankle and toe dorsi-flexors (Shapiro and nerve should not be ignored. Whilst slump stretch- Preston 2009), the resultant effect being foot-drop ing, used in conjunction with traditional treatment (Katirji 1999). As a consequence of foot-drop, sus- (not mobilisation) modalities, has been shown to ceptibility to falls is increased in patients as the foot significantly decrease the recovery period from ham- may get trapped due to the inability to dorsi-flex string injury in professional AFL players (Kornberg the foot when walking (Katirji 1999). A positive and Lew 1989); no research has evaluated the effect Tinel’s sign may be present at the fibular neck (Katirji sliding or tensioning techniques has on the return to 1999; McKean 2009; Shapiro and Preston 2009) and play. However, as with all the aforementioned neu- pain can also be reported at the lateral fibular neck ropathies, sliding or tensioning neurodynamic tech- (Shapiro and Preston 2009). niques should be included in the treatment of pos- terior thigh injury; the selected technique dependant Conservative treatment for non-traumatic per- on the irritability of the patient’s condition. Slid- oneal neuropathy should include NSAIDs, active ing techniques should be considered in the acute rest, physical therapy and neurodynamic sliding or stage management, progressing to the more aggres- tensioning techniques, such as the SLR with plantar- sive tensioning techniques in the latter stages of re- flexion and inversion and manual therapy. In thin habilitation. athletes, padding on the fibular head may be recom- mended to protect the peroneal nerve from external Peroneal nerve injury compressive forces. Avoidance of crossing the legs is also advised and ankle bracing should be consid- The common peroneal nerve (CPN) originating from ered in patients presenting with foot-drop to prevent the sciatic nerve, descends through the posterior ankle inversion sprains (Katirji 1999; Shapiro and Preston 2009).

138 PERIPHERAL NERVE INJURIES Tibial nerve injury Preston 2009). These symptoms may increase dur- ing running, subsequently decreasing with rest The tibial nerve originates from the ventral divisions (KcKean, 2009). The two most prominent clinical of the L5, S1 and S2 nerve roots and is the largest of signs are a positive Tinel’s test and sensory impair- the two major divisions of the sciatic nerve (Oh and ment of the terminal branches of the plantar nerve. Meyer 1999), traversing through the popliteal fossa, Percussion over the tibial nerve proximal to the upper entering the lower leg between the medial and lateral border of the tarsal tunnel behind the medial malleo- head of gastrocnemius (Franson and Baravarian lus is the best location for the Tinel’s test. Evaluating 2006), before passing on the medial aspect of the sensory impairment, via pin-pricking, and compar- ankle and entering the foot via the tarsal tunnel (Oh ing to the non-involved foot is recommended by Oh and Meyer 1999). The tarsal tunnel is a fibro-osseous and Meyer (1999). It is vital to differentially diag- tunnel comprising of the flexor retinaculum as the nose TTS from L5 or S1 radiculopathy and sensory roof of the tunnel and the medial wall of the talus peripheral neuropathy. Lumbosacral radiculopathy and calcaneus and distal medial aspect of the tibia generally presents with a positive straight leg raise as the floor of the tunnel (Oh and Meyer 1999; (SLR), weakness of the calf muscles, pain radiat- Franson and Baravarian 2006; McKean 2009). ing from the lower back and a negative Tinel’s sign, Numerous anatomical structures course through the whereas distal sensory peripheral neuropathy, has tarsal tunnel, such as the tibialis posterior tendon, an objective stocking distribution sensory loss in the posterior tibial nerve and flexor hallucis longus foot, including the dorsum and lateral aspects, and an and flexor digitorum tendons, along with numerous absent Tinel’s sign (Oh and Meyer 1999; Oh 2007). blood vessels (Franson and Baravarian 2006). One In TTS there should be no objective sensory loss over of the most common entrapment neuropathies of the dorsum of the foot, although it may be evident the lower limb is tarsal tunnel syndrome involving on the dorsum of the toes (Oh 2007). Bilateral TTS the tibial nerve (Oh and Meyer 1999). rarely occurs; however, if suspected, the presence of a distal sensory neuropathy must be considered (Oh Tarsal tunnel syndrome 2007). Plantar fasciitis is another condition requiring consideration during the diagnosing process in pa- Tarsal tunnel syndrome (TTS) is a compression tients with suspected TTS. Plantar fasciitis generally neuropathy of the posterior tibial nerve as it presents with localised pain, which is absent of sen- passes through the tarsal tunnel at the ankle on the sory abnormalities; two factors not evident in TTS. medial side (Franson and Baravarian 2006). The diagnosis of TTS is based on the subjective history As with all the previously mentioned neu- and objective examination of a patient (Franson ropathies, conservative treatment can include and Baravarian 2006). Patients can present with NSAIDs, active rest, manual therapy, neurodynamic numerous symptoms such as tingling, numbness or siding or tensioning techniques and exercise therapy. pain at the toes, through the arch of the foot or the An additional treatment option to consider is using heel. Prolonged standing or walking may exacerbate orthotics or modify footwear to correct any excessive symptoms (Franson and Baravarian 2006) and pronation, to minimise the stress placed on the tibial therefore this is an injury that may be prevalent nerve (McKean 2009; Shapiro and Preston 2009). in hikers or runners, the latter of which may be vulnerable to TTS (Shapiro and Preston 2009) due to Summary the repetitive ankle dorsi-flexion and plantar flexion which occurs whilst running (McKean 2009). The upper limb, being more mobile than the lower extremity is more susceptible to nerve injury and An insidious onset of TTS is often reported therefore the clinicians working in sport should ex- (Shapiro and Preston 2009) and symptoms can vary pect a higher incidence of upper limb neuropathies depending on the location of the tibial nerve and than lower limb, particularly in athletes participating its branches (McKean 2009). Patients may com- in contact sports such as rugby union. Not all neural plain of numbness or tingling and pain in the me- injuries in the sporting population will be traumatic dial heel, arch of the foot or the sole, particularly in nature, particularly for those semi-professional or on the medial aspect (McKean 2009; Shapiro and

REFERENCES 139 recreational athletes, who are in employment and treatment strategy utilised over the course of reha- may be susceptible to chronic neuropathies of the bilitation was the use of neural sliding techniques upper limb. In this particular cohort, whereby diver- during the slump test. Considering the acuteness sity exists in the type of employment, the clinician and irritability of the condition and the fact neural needs to be aware of neuropathies that can present symptoms had been experienced for three weeks as a consequence of occupation; such as CTS and prior to hamstring injury onset, sliding techniques TOS. Rather than being blinkered by neuropathies were deemed the most appropriate neurodynamic that typically occur in sport, the clinician who has a treatment tool. The patient was instructed to execute vast array of knowledge of various conditions will the sliders as frequently as possible, particularly not only aid the athletes in their sporting activity, but if he had been driving for a significant period also their activities of daily living. of time. Manual therapy and a home exercise programme of stabilisation exercises were also Case study implemented into the patient’s treatment plan to address the underlying lumbar spine problem. A 30-year-old male football player, who competed Finally, a progressive rehabilitation programme once a week, reported sustaining a left hamstring for the hamstrings was also implemented. Three injury during a game, three days prior to initial weeks following injury, the patient returned to assessment, whereby he felt an “electric” pulse shoot competition. into the ischial tuberosity region and had to stop playing immediately. The patient reported lumbar References spine stiffness and a feeling of being unable to straighten the knee whilst walking. He first noticed Aldridge, J.W., Bruno, R.J., Strauch, R.J. and Rosen- discomfort in the gluteal area approximately three wasser, M.P. (2001) Nerve entrapment in athletes. weeks prior to assessment, which was exacerbated Clinics in Sports Medicine, 20, 95–122. whilst driving, particularly whilst resting the left foot on the foot pedal. However, over the three-week pe- Atasoy, E. (2004) Thoracic outlet syndrome: anatomy. riod the symptoms gradually increased, whereby the Hand Clinics, 20, 7–14. patient reported a feeling of tightness in the buttock and hamstring during competition and training. Babbage, C.S., Coppieters, M.W. and McGowan, C.M. (2007) Strain and excursion of the sciatic nerve in the During the physical assessment, the patient dog: Biomechanical considerations in the development reported stiffness in the lumbar spine and hamstring of a clinical test for increased neural mechano sensi- during lumbar flexion. No abnormalities were re- tivity. Veterinary Journal, 174, 330–336. ported in the sacroiliac joint. All passive and resisted hip movements were negative. Resisted knee flexion Badia, A. and Stennett, C. (2006) Sports-related Injuries was weak but pain free, whilst all other resisted of the Elbow. Journal of Hand Therapy, 19, 206– movements for the knee were normal. No bruising 227. was apparent in the gluteal or posterior thigh region. The patient reported reproduction of symptoms Bencardino, J.T. and Rosenberg, Z.S. (2006) Entrapment during the Straight Leg Raise ankle dorsi-flexion, neuropathies of the shoulder and elbow in the athlete. which was relieved with the release of dorsi-flexion. Clinics in Sports Medicine, 25, 465–487. Likewise, a positive slump test, in terms of symptom reproduction and decreased knee ankle, was also Bove, G.M., Zaheem, A. and Bajwa, Z.H. (2005) Sub- observed in both the right and left limb. The jective nature of lower limb radicular pain. Journal patient experienced pain on palpation, with central of Manipulative and Physiological Therapeutics, 28, posterior-anterior pressure on L4, L5 and S1 12–14. vertebrae, which were found on palpation to be hypomobile. Brantigan, C.O. and Roos, D.B. (2004) Etiology of neu- rogenic thoracic outlet syndrome. Hand Clinics, 20, It was apparent the hamstring strain occurred 17–22. as a bi-product of lumbar spine pathology. A core Butler, D. (1991) Functional Anatomy and Physiology. Melbourne: Churchill Livingstone. Butler, D. (2000) The Sensitive Nervous System. Adelaide: NOIGroup Publications. Campbell, W.W. (2008) Evaluation and management of peripheral nerve injury. Clinical Neurophysiology, 119, 1951–1965.

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Part 4 Effective clinical decision making



9 An introduction to periodisation Paul Comfort and Martyn Matthews University of Salford, Greater Manchester Periodisation through phases (meso-cycles), each of which targets a specific fitness attribute, but which is planned such Probably the most influential factor behind recent that the intensity and specificity advances from phase advances in sports performance is the greater un- to phase and culminates in the athlete reaching their derstanding shown by coaches, athletes and sports peak of sport-specific fitness at the exact time of scientists of Training Theory. Central to this is key competitions. For example, subsequent phases the concept of periodisation, or the structured may focus on basic anatomical and functional adap- and sequential planning of training to allow the tations (increased range of motion, increased tendon athlete to make optimal gains in sports perfor- strength, improved co-ordination and increased sta- mance and produce their best performances in bility), strength endurance, maximal strength, power key competitions, with minimal risk of overtrain- and, ultimately, sport-specific speed and power. Such ing or injury. Previous research has also demon- a progression requires appropriate adjustments in the strated that compared to non-periodised training frequency, intensity and duration of individual train- programmes, periodised training programmes result ing sessions and the appropriate selection of exer- in greater increases in strength, power and sports cises, sets and repetitions within each session. (For performance (Fleck 1999; Fleck 2002; Rhea and more detail on recommended sets, repetitions and Alderman 2004). loads see Chapter 13 Strength and Conditioning.) With this in mind, periods of training are divided Specifically, periodisation involves the planned into smaller, more manageable chunks that allow the and structured variation in training type, volume athlete to maintain both physical and mental input (intensity and duration), and rest to achieve sport- throughout. specific goals. This is achieved via the periodical progression of specific aspects of fitness within a This chapter will focus on training cycles and their specified time frame. This style of programme al- specific goals, and will consider how best to integrate lows for gradual and progressive overload, ensuring these into performance, injury prevention and reha- an optimal stimulus for adaptation whilst allowing bilitation goals, with specific emphasis on ensuring adequate time for recovery and adaptation. the athlete’s readiness to perform. Progressive overload is essential in all aspects of By the end of this chapter the reader should have physical training, whether the aim is to optimise per- a better knowledge of periodisation, and its differ- formance, improve body image, or rehabilitate an ent phases, an understanding of the application of injury. In a periodised model, the athlete progresses periodisation to injury prevention and rehabilitation Sports Rehabilitation and Injury Prevention Edited by Paul Comfort and Earle Abrahamson C 2010 John Wiley & Sons, Ltd

146 AN INTRODUCTION TO PERIODISATION Table 9.1 Training phase descriptions Cycle Size Example Macro-cycle Meso-cycle Large block. Represents several months The training year; a whole Olympiad or even years Often with a specific focus such as strength endurance, Medium block. Usually consisting of a maximal strength, power, peaking, active rest, number of weeks or months of training aerobic endurance, or anaerobic threshold Micro-cycles Smaller blocks of time Individual training day/week programmes, and the integration of this into the ath- threshold), interspersed with periods of reduced lete’s strength and conditioning programme. training to facilitate rejuvenation. In this way, meso-cycles can be structured to maximise the recu- Training cycles perative effects of the recovery periods and minimise the risk of overtraining. Micro-cycles are smaller Most effective training programmes break training blocks such as an individual training day/week. down into cycles. This allows athletes to focus on different attributes at different times, helps with Many coaches use a 4-week cycle where the train- the prevention of overtraining, and is convenient as ing load increases up to week three, followed by an training can be made to coincide with our own cycles easier (unloading) week to allow full recovery (usu- (for example, weeks, seasons, years and Olympiads). ally a decrease in volume but not intensity). This is Training cycles can last from days to years and, a basic form of shock training with the four weeks depending on their length, are termed macro-cycles, termed ordinary, development, shock and recovery meso-cycles and micro-cycles (Table 9.1). A (Matveyev 1981). A meso-cycle typically consists of macro-cycle represents several months or years, for one or two full 4-week cycles. A 4-week meso-cycle example, the general conditioning period, the whole may look like Figure 9.1. An 8-week meso-cycle training year, or the four years of an Olympiad. A may look like Figure 9.2. meso-cycle is a smaller block, usually consisting of a number of weeks or months of training (usually pri- Meso-cycles that use such a 4-week training block oritised towards a particular training outcome, such place a great deal of short-term accumulative stress as strength endurance, maximal strength, power, on the body. It is possible that full recovery between peaking, active rest, aerobic endurance, or anaerobic sessions or even micro-cycles is not achieved until week four. Prior to this the athlete will accumulate fatigue as the overall training load increases. This in Training load/volume Figure 9.1 An example of a 4-week Week 1 Week 2 Week 3 Week 4 meso-cycle. Micro–cycles

TRAINING CYCLES 147 Training load/volume Week1 Week2 Week3 Week4 Week5 Week6 Week7 Week8 Figure 9.2 An example of a 8-week Micro–cycles meso-cycle. turn can have implications for the trainability of par- depending on the competition schedule of each par- ticular fitness attributes (Balyi 2001). For example ticular sport. the training of speed, maximal strength, technique and the learning of new skills should be emphasised The preparation phase itself may be considered during the early weeks of each four-week cycle, in greater detail and further divided into a general when the athlete is relatively fresh and receptive to preparation period, a specific preparation period such methods. During later weeks the most trainable and a pre-competition period (Matveyev 1965). attributes will be cardiovascular endurance, anaer- This gives a training year with five distinct phases: obic power, local muscular endurance and speed general-conditioning period; specific-conditioning endurance. The improvements in fitness from such period; pre-competition period; competition (or a pattern of training are illustrated in Figure 9.3. performance) period; transition (or recuperation) period (see Table 9.2). Figure 9.5 shows Bompa’s The training year (1999) representation of the annual training plan. The most common macro-cycle is the training year, General conditioning period which in turn consists of a number of meso-cycles and micro-cycles. Every training year consists of a The aim of the general conditioning period is to de- preparation phase, a performance phase and a re- velop a broad base of fitness that acts as a foundation cuperation phase (Figure 9.4), which vary in length Adaptation pattern from traditional train–recover cycle Adaptation pattern from a shock training pattern Figure 9.3 A comparison of traditional and shock train- Figure 9.4 Example of macrocycle phases. ing adaptations.

148 AN INTRODUCTION TO PERIODISATION Table 9.2 Training phases Aim Phases of the training year To develop a broad base of fitness involving strength, power, local muscular (Matveyev 1965) endurance, cardiovascular fitness and flexibility General conditioning period To provide a progressive transition from the broad general fitness towards the highly specific fitness required by competition Specific conditioning period and pre-competition period To maintain their hard earned fitness, remain injury free and peak for key competitions Competition (or performance) period To achieve full recuperation in readiness for the general preparation period Transition (or recuperation) period ahead for the high-intensity, sport specific training that fol- Specific conditioning and pre-competition lows. This period predominantly focuses on strength period endurance (8–20 repetitions, 3–5 sets, 3–4 days per week) (Plisk and Stone 2003), but also includes The aim of this phase is to provide a progressive some power exercises, cardiovascular fitness, flex- transition from the broad general fitness towards ibility training and technique work. This phase is the highly specific fitness required by competition. characterised by a progressive increase in both vol- It can last from a few weeks (English Premiership ume (primary aim) and intensity (secondary aim) of football) through to two or three months (sprinters) training. and consists of a progressive increase in intensity and decrease in volume of training with a greater Note: Although this period is about general emphasis of sports specific activities and skills, func- preparation, athletes should not neglect their tional speeds and actual sports practices. Strength practice of sport specific skills. These skills should training focuses on basic strength (4–6 repetitions, be incorporated into the training via dedicated, 3–5 sets, 3–5 days per week) (Plisk and Stone 2003). short duration, high quality practices, or included as part of a functional dynamic warm-up. This will Competition period help ensure that athletes maintain the skills and coordination required in competition. For example, The length of the competition period varies for dif- during this period sprinters may be focusing many ferent sports (soccer — 9 months, athletics — 3–4 of their track sessions on speed endurance, rather months, cricket — 5 months); however the aims re- than pure speed. This, however, does not preclude main the same. Athletes need to maintain their hard the athletes performing short bursts of maximum earned fitness, optimise performance, remain injury speed running, or quick feet coordination drills, as free, and peak for key competitions. This phase part of their warm-up. Phases of The annual plan Competitive Transition training Preparatory Transition Pre– Competitive Aim General Specific competitive preparation preparation Meso cycles Figure 9.5 Annual training plan Micro (after Bompa 1999). cycles

usually focuses on lower volume strength and power TRAINING CYCLES 149 based activities (2–3 repetitions, 3–5 sets, 3–6 days per week depending on frequency of competition) r Hypertrophy (strength endurance) – high volume (Plisk and Stone 2003). (repetitions of 8–20 at 50–80% –1RM, for 4–6 Transition/recuperation period/active rest sets). This period usually lasts around a month, depending r Strength – which can be subdivided into maximal on the sport, the stresses of the previous compet- itive season and the timing of the next one. The strength (repetitions of 3–6 at 80–90% –1RM, for aims are to achieve full recuperation in readiness 4–8 sets), speed strength (repetitions of 8–15 at for the general preparation period ahead. This pe- <70% –1RM, for 3–4 sets) and strength endurance riod allows any injuries to heal and a period of re- (repetitions of 20–30 at 30–40% –1RM, for 2–3 habilitation to occur so that the athlete is ready to sets) (Plisk and Stone 2003). resume full training. It is also a time of relaxation and enjoyment. The stresses of competitive sport are r Power – can be trained via two primary methods; far more than just physical. Athletes need time to un-wind and relax. Rest should be taken from the plyometrics and variations of the ‘Olympic lifts’. hard training and competition but athletes must also However, it is worth noting that few athletes ‘natu- remain active and partake in activities unrelated to rally’ have the attributes to perform ‘Olympic lifts’ their sport. This helps with weight management but safely and effectively and therefore this needs to be also enables the athlete to maintain a degree of gen- developed in the early stages of training (McGill eral fitness going into the general preparation phase. 2006). It is also important to select the component The activities should be novel and fresh and not too of the lift that is most suitable for the training goal, demanding (low volume: 1–3 repetitions, 1–3 sets, for example lower limb biomechanics during the ∼3 days per week) (Plisk and Stone 2003). A similar second pull is similar to the mechanics of a vertical strategy can be adopted when peaking/tapering for jump. During ‘Olympic lifts’ and their variations it competition. is not necessary to use maximal load as Kawamori et al. (2005) showed that lighter loads (50–70% There are specific goals for each meso-cycle of –1RM) resulted in a greater power output due to training (usually completed in the order below) as a higher velocity. Cormie et al. (2007a, 2007b) proposed by Bompa (1999). These phases include: also demonstrated that when performing activities (such as jump squats) optimal loading, to achieve r Anatomical adaptation – the development of tech- peak power, is achieved using only body mass, with no additional external resistance. nique and preparation of the musculoskeletal sys- tem (including connective tissues) for the heavier These phases, but especially the anatomical adap- loads used in the following stages (these are usu- tation phase, need to take into account the ‘laws of ally addressed in the general conditioning phase). strength training’ and the principles of ‘functional training’ (Table 9.3) to ensure that the individual is appropriately conditioned to perform the more Table 9.3 Functional Training (McGill 2006) Laws of Strength Training (Bompa 1999) Develop intra-muscular co-ordination of fibres within a muscle (fast and slow twitch) Develop joint flexibility (active ROM) Develop inter-muscular co-ordination between muscle groups (efficiency Develop tendon strength of movement) Develop core strength Develop facilitatory and inhibitory reflex pathways (optimal efficiency Develop stabilisers and fixators (balance through the kinetic chain, affected by balance and posture) between agonists and antagonists) Motor learning (optimal efficiency of specific movement) Train movements not muscles

150 AN INTRODUCTION TO PERIODISATION intense phases of training that follow. This approach til the complete lifts (snatch and clean and jerk) can will not only reduce the risk of injury, but also be performed (Table 9.4). See Appendix 1 and 2 for ensure that each phase of training is as productive illustrations of the clean and snatch. as possible/intended. By the end of the first macro-cycle, the athlete Differences between sports should be confident/competent at performing each of the primary lifts, but should have also developed The length of the preparation, competition, transi- a considerable level of strength in the key exercises tion periods and associated meso-cycles, changes (back squat, front squat, overhead squat, deadlift, from sport to sport and athlete to athlete. For Romanian deadlift, see Figures 9.6–9.10). During example, a track and field athlete may have two or the next macro-cycle, the athlete can focus on devel- three key competitions throughout the course of a oping additional strength in each of the key exercises three-month competitive season. The rest of the year of the individual lifts, while progressively increasing is effectively preparation for these key competitions. load on the ‘Olympic lifts’. This allows the athlete In contrast, an English Premiership football team to perform the primary lifts with additional weight may only have a six- or seven-week preparation whilst maintaining good technique at high velocities period preceding a nine-month competitive season, to ensure the development of power. during which players are expected to compete on a weekly or a twice-weekly basis. Swimmers often The next macro-cycle should place greater em- have major competitions arranged on 13- or 14- phasis on the loads lifted during the clean and jerk week cycles. Professional boxers may have between and the snatch. The previous phase should have en- three and four fights a year, with their training sured adequate anatomical adaptations during each always geared towards preparation for the next of the components of the lifts to ensure adequate fight. Despite the different conditions encountered conditioning for the lifts to be performed at higher during the preparation for these sports, the following loads. To ensure that the client can decelerate during general principles still apply. A gradual build-up in the catch phase of the snatch, initial deceleration volume (and intensity) early on; as the competition training begins with drop jumps and then progresses approaches the intensity or quality increases further, to snatch balances, which mimic the catch phase whilst the volume tapers off. of the snatch (Figure 9.11) and develop adequate trunk strength to decelerate the torso and bar during Application to sports performance the rapid decent to the catch phase; a similar progression can also be seen for the clean (drop For athletes with limited training experience the in- jumps, clean balance) (Figure 9.12) and the split jerk corporation of a periodisation plan provides an excel- (split squat, overhead split squat), (Figure 9.13). It lent framework to develop an athlete’s lifting skills, is also essential that the velocity of each movement as well as their strength and power. For example, if is trained in a progressive manner, as can be seen an individual wishes to compete in Olympic weight- in the progression from military press to push lifting but has never actually completed a structured press. resistance training programme, they need to start with the basic components of the ‘Olympic’ lifts, Olympic lifts are commonly used within strength and progress to the point where they are as strong and conditioning program, due to the fact that in- as possible in each of these components, while they creases in performance in these lifts has been shown learn the complete ‘Olympic’ lifts. Each meso-cycle to increase athletic performance (Hori et al. 2005; should teach progressively more complex compo- Tricoli et al. 2005; Hori et al. 2005; Channell and nents of the lifts to ensure correct technique and to Barfield, 2008). Appropriate conditioning and prepa- allow for the appropriate anatomical and functional ration for these athletes is essential to ensure that adaptations (neuromuscular control, active range of these athletes are adequately prepared to perform motion, joint stability, tendon strength) to occur un- these types of exercises. As mentioned above, each phase has a specific role, which ensures that the athlete is appropri- ately conditioned for the subsequent phase. Anatom- ical adaptation focuses on the development of

APPLICATION TO REHABILITATION 151 Table 9.4 Example of a macro-cycle 1: weight lifting Meso-cycle 1 Meso-cycle 2 Meso-cycle 3 Meso-cycle 4 Meso-cycle 5 Training day 1 Overhead squat Overhead squat Overhead squat Overhead squat Back squat Back squat Back squat Overhead squat Back squat Romanian seadlift∗ Romanian deadlift∗ Romanian deadlift∗ Romanian seadlift∗ Power snatch Hang snatch Snatch Back squat Power shrug∗ Snatch balance Snatch balance Romanian deadlift∗ Front squat Barbell shrug∗ Snatch balance Front squat Clean balance (Drop Deadlift# Drop jump landings and catch) Clean Training day 2 Front squat Front squat Deadlift# Split jerk Front squat Clean balance (Drop Clean balance (Drop Overhead split squat Leg flexion/glute Drop jump landings Hang clean and candatch) and candatch) Split jerk ham raise Deadlift# Deadlift# Deadlift# Leg flexion/glute Split squat Split squat Overhead split squat Barbell shrug# Power shrug# Power clean ham raise Military press Push press Jerk Leg flexion/glute Leg flexion/glute Leg flexion/glute ham raise ham raise ham raise ∗Using snatch grip Anatomical Adaptations / Technique #Using clean grip Hypertrophy / Strength Endurance Strength Key: Maximal Strength 15 × 2–3 @ 60%1RM Power 8–12 × 3–4 @ 65–80% 1RM Maintenance 3–6 × 4–6 @ 85–95% 1RM 1–3 × 4–6 @ 95–100% 1RM 3v–5 × 3–5 @ 75–85% 1RM 3–4 × 2 @ 85–95% 1RM technique and preparation of the musculoskeletal sist with initial acceleration and maximal velocity system (including connective tissues) for the heav- sprinting, respectively. Table 9.5 illustrates a generic ier loads used in the following stages in the strength periodised programme for a Sprinter. This only de- phase. Hypertrophy (strength endurance) in this ex- scribes the gym based conditioning programme, ample is not a specific goal; therefore this is used which would require amendments based on addi- as a transition phase between anatomical adapta- tional sports specific/technique training and manip- tions and strength. The focus of the strength train- ulation of volume and intensity near periods of com- ing phase is to maximise the loads that the ath- petition. lete can use during the power phase. The strength phase is subdivided into two phases: strength and Application to rehabilitation maximal strength, which allows appropriate pro- gression of loads through to near maximal loads An understanding of periodisation is essential for (>90% –1RM). The power phase incorporates two complete and effective rehabilitation. This applies primary methods: plyometrics and variations of the both to the phases of progression through rehabil- ‘Olympic lifts’, which provide the opportunity for itation, but also to an understanding of the train- the athlete to develop near maximal force at high ing year of the particular sport to which the athlete velocity (Olympic variations), and near maximal ve- is returning. For example, a multiple sprint sport locity high force production (plyometrics) that as- athlete (football, rugby, hockey) has had their ACL

152 AN INTRODUCTION TO PERIODISATION Figure 9.6 Back Squat. Figure 9.8 Overhead squat (Snatch Catch Position). Figure 9.7 Front Squat (Clean Catch Position). Figure 9.9 Deadlift & Clean Start.

APPLICATION TO REHABILITATION 153 Figure 9.10 Romanian (Stiff Leg) Deadlift. Figure 9.11 Overhead Squat (Snatch Catch Position). reconstructed, has regained ‘normal’ ROM and can cle imbalance between hamstring and quadriceps perform activities of daily living without any prob- (h:q ratio <0.6) (Li et al. 1999; Ahmed 2006) or an lems or pain. The athlete wants to begin training with eccentric hamstring to concentric quadriceps ratio the squad and playing in matches. However, most <1.0 (Holcomb et al. 2007); delayed activation of non-contact ACL injuries occur during rapid deceler- the hamstrings, especially in females (Hewett et al. ation and cutting manoeuvres (Agel 2005) or during 1996; Malinzak et al. 2001; Zazulak et al. 2005), both landing (Boden et al. 2000a, 2000b), which both of which can result in an increased knee valgus dur- involve high velocity, high force eccentric loading. ing eccentric loading (Markolf et al. 1995; Malinzak ‘Normal’ ACL rehabilitation does not appropriately et al. 2001; Ford et al. 2003; McLean 2004; Hewett condition the athlete for such demands, therefore it is et al. 2005a). essential that the rehabilitation process is specific to the demands of the sport. To achieve this, it is essen- Therefore, to reduce the risk of non-contact ACL tial to understand the mechanisms of ACL injury. Re- injuries and their recurrence, it is essential that the cent evidence suggests that decreased activation and athlete is appropriately conditioned to cope with possible inadequate strength in the gluteus medius, rapid deceleration (high velocity eccentric loading) especially in female athletes, can lead to increased and changes in direction (high velocity eccentric knee valgus (Zazulak et al. 2005; Hanson et al. 2008), loading followed immediately by high velocity con- which is a common factor in acute ACL injury. Other centric muscle actions – plyometric movements). As causative factors are poor/inappropriate technique, females, generally, appear to be quadriceps domi- with limited knee flexion during deceleration; mus- nant during deceleration in landing and cutting ma- noeuvres (Hanson et al. 2008), it is essential that adequate guteus medius and maximus strength is developed (this must be developed in a functional

154 AN INTRODUCTION TO PERIODISATION Figure 9.12 Catch position for the clean, and bottom of the front squat and front squat drop jumps. manner, not via isolation of the gluteal muscles), Figure 9.13 Split Jerk Catch Position & Overhead along with adequate hamstring strength to re- Lunge. duce anterior translation of the tibia during knee flexion. Eccentric hamstring exercises, such as Nordic hamstring lowers, are more effective than con- centric training (Kaminski et al. 1998; Mjolsnes et al. 2004; Kilgallon et al. 2007), improving the hamstring: quadriceps ratio, especially at higher velocities (Mjolsnes et al. 2004; Holcomb et al. 2007). This type of activity will also condition the muscles for the specific eccentric component required during deceleration, albeit at a slower velocity. Based on the periodisation model, and taking into account the current research and guidelines on plyo- metric training, there are a number of phases (meso- cycles) required to train the athlete to a point where they are appropriately conditioned for return to their sport. The end stage for the athlete is to be able to perform high-intensity plyometric movements; however, in order for them to be able to per- form high-intensity plyometrics safely it is recom- mended that the athlete is sufficiently conditioned

Table 9.5 Example 2: Periodised programme for a sprinter General preparation Specific preparation Pre-Competition Anatomical Hypertrophy Strength Maxí Strength Power Speed adaptation/endurance (Transition) Meso-cycle 7 Meso-cycle 1 Meso-cycle 3 Meso-cycle 4 Meso-cycle 5 Meso-cycle 6 Back Squat Complex (5 reps, 1 set, @ Training day 1 90% –1RM); 4 mins rest THEN: Back Squat (10–20 × 3 Back Squat (8–12 × 4 Back Squat (4–6 × 4–5 Back Squat (2–4 × 5–6 Back Squat Complex @ 80–90%) @ 90–95%) (5 reps, 1 set, @ Jump Squats (2–3 × 4 @ 50–60%) @ 65–80%) 90% –1RM) 4 mins @ Body Mass)∗1. Jump Squats (5–6 × Jump Squats (5–6 × rest THEN: Jump Squats (5–6 × 3 Jump Squats (5–6 × 4 4–5 @ Body Mass ⇓ 5–6 @ Body Mass ⇓ Mid-Thigh Power 5–10%) 10–20%) Jump Squats (3–5 × 5 Snatch (2–3 × 3 @ Body Mass) @ Body Mass) @ Body Mass)∗1 Low resistance Stiff Leg Deadlift (6–6 Linear Box Jumps (5–6 60–70%; emphasise Stiff Leg Deadlift (8 – Stiff Leg Deadlift × 3 – 4 @ 80–90%) × 3 @ Body Mass Linear Box Jumps speed); 4 mins rest 10 × 3 @ 50–60%) (8–12 × 3 @ (8–10 × 3 @ Body THEN: 65–80%) Stiff Leg Deadlift (2–4 Mass ⇓ 5–10%) × 4 –5 @ 90–95%) Linear Box Jumps Stiff Leg Deadlift (4 (10–15 × 3 @ Body reps, 2 sets, @ 90% Mass∗4 –1RM) (Continued) Mid-Thigh Power Mid-Thigh Power Hang-Clean (4–6 × 3 Hang-Clean (6–10 × 3 Hang Power-Clean Shrug (Snatch-grip) Shrug (6–10 × 3 @ Technique, low medium resistance (2–3 × 3 @ 70%)∗3 (10 × 3 @ 60–70%) 70–80%) resistance ∼40%) ∼60%) Mid-Thigh Power Mid-Thigh Power Mid-Thigh Power Snatch (2–3 × 3 @ Shrug (4–6 × 3 Snatch (6–10 × 3 60–70%) @80–90%) low/medium resistance 50–60%; emphasise speed)

Table 9.5 (Continued) General preparation Specific preparation Pre-Competition Anatomical Hypertrophy Strength Max’ Strength Power Speed adaptation/endurance (Transition) Meso-cycle 4 Meso-cycle 5 Meso-cycle 6 Meso-cycle 7 Meso-cycle 1 Meso-cycle 3 Training Day 2 Deadlift (8–12 × 3–4 Deadlift (4 @ 80–90%) Deadlift (2–4 × 4 @ Deadlift (4 reps, 2 sets, Deadlift (4 reps, 1 set, Deadlift (15 × 2–3 @ @ 65–75%) 90–95%) @ 90% –1RM) @ 90% –1RM) Mid-Thigh Power 50–60%) Mid-Thigh Power Shrug (4 × 4 @ Mid-Thigh Power Mid-Thigh Power Mid-Thigh Power Mid-Thigh Power Shrug (8–12 × 3–4 80–90%) Shrug (2–4 × 4–6 @ Shrug (6 × 6 @ Shrug (3 × 4 @ 65–75%) 90–95%) 80%)∗2 @80%)∗2 Shrug (2nd Pull) (15 Walking Lunges × 2–3 @ 50–60%) Walking Lunges Walking Lunges (4–6 Walking Lunges (5 Walking Lunges (5 Walking Lunges Alternate Split Jump × 4 @ 85–90% reps/leg, 2 sets, @ reps/leg, 2 sets, @ Lunge (4 – 6/leg × 3 –1RM) 85–90% –1RM), 4 85–90% –1RM) 4 Split Jump Lunge Alternate Split Jump @ Body Mass ⇓ mins rest THEN: mins rest THEN: (8–12 × 2 @ Body Lunge (6 – 8 /leg × Weighted Vest) Alternate Leg Bounds Mass 3 @ Body Mass ⇓ (10/leg × 2 @ Body Alternate Leg Bounds Alternate Leg Bounds Weighted Vest) Nordic Hamstring Mass) (15/leg × 2 @ Body (10/leg × 2 @ Body Nordic Hamstring Lowers (6 × 3 @ Mass ⇓ Weighted Mass) Lowers (4 × 3 @ Nordic Hamstring Body Mass) Nordic Hamstring Vest) Body Mass) Lowers (4 × 4 @ Lowers (6 × 3 @ Body Mass) Body Mass ⇓ Nordic Hamstring Weighted Vest) Lowers (6 × 3 @ Body Mass ⇓ Weighted Vest)

Calf Raises (15 × 2–3 Calf Raises (8–12 × Calf Raises (4 @ Calf Raises (2–4 × 4 Calf Raises (4 reps, 2 80–90%) @ 90–95%) sets, @ 90% –1RM) @ 50–60%) 3–4 @ 65–75%) 4–5 mins rest Double Leg Hops (30 Double Leg Hops (50 THEN: × 2 @ Body Mass) × 2 @ Body Mass) Single Leg Hops (10 × Single Leg Hops (15 × 2 @ Body Mass) 2 @ Body Mass) Key : Anatomical Adaptations / Technique / Muscular Endurance General Preparation Hypertrophy / Transition Strength SpecificPreparation Maximal Strength Pre–Competition Power Maintenance Peaking/CompetitionPhase Maintenance (Prevention of Detraining) Notes: ∗1Cormie et al. (2007a, 2007b) demonstrated that peak power was achieved during jump squats when body mass alone was used as resistance, when taking body mass into account. Stone et al. (2003) had previously reported peak power to be achieved using 10% 1–RM squat, during a jump squat, however, they did not assess peak power during an unloaded jump squat. Their results demonstrated a decrease in peak power in direct relationship with an increase in load. ∗2Cormie et al. (2007a, 2007b) also demonstrated that peak power, during power cleans, is achieved at 80% 1–RM. ∗3Kawamori et al. (2005) demonstrated that a load of 70% or 1–RM during a hang power – clean results in the greatest peak power output. Hori et al. (2008) have also shown a significant relationship (p<0.05) between hang power clean performance and 20m sprint performance, therefore increasing performance in the hang power clean may result in improved acceleration over the initial 20m. ∗4Rest for 5–10 seconds between each repetition to prevent fatigue and maintain velocity. Cormie et al. (2007a) demonstrated that combining lower body strength and power training is more effective than power training alone, at increasing power especially against additional resistance. Therefore the example programme above combines both strength and power based activities, but alters the focus from maximising strength, in the general preparation phases, to optimising power during the pre-competition phase. Peak power during the jump squat (50–70% 1–RM) and split jump squat (30–60% 1–RM) are related initial acceleration during sprints, as assessed by 5-m sprint times (Sleivert and Taingahue 2004). Thomas et al. (2007) showed a gender effect on optimal power load during the jump squat, with 30–40% 1–RM as the optimal load for females and 30–50% 1–RM as the optimal load for males.

Table 9.6 Example macro-cycle for ACL rehabilitation Meso-cycle 1 Meso-cycle 2 Meso-cycle 3 Meso-cycle 4 Meso-cycle 5 Meso-cycle 6 10–15 reps, 2–3 Sets, 15–20 reps, 2 Sets 8–12 reps, 4 sets 4–6 reps, 5–6 Sets 2–4 reps, 6 sets 10 reps, 4 sets 50% –1RM 55–60% –1RM 65–75% –1RM 80–90% –1RM 90–95% –1RM 40% –1RM Training Day 1 Split Squats Bulgarian Split Squats Single Leg Squats∗1 Single Leg Squats Single Leg Squats Single Leg Squats (10 reps, 3 sets) (5 reps, 3 sets) (8 reps, 3 sets) (10 reps, 3 sets) (12–15 reps, 3 sets) (10 reps, 3 sets) Back Squat∗1 Back Squat Back Squat Back Squat Back Squat Back Squat Romanian Deadlift Romanian Deadlift Romanian Deadlift Romanian Deadlift Romanian Deadlift Romanian Deadlift Drop Jumps∗3 Drop Jumps Drop Jumps Drop Jumps Drop Jumps Training Day 2 Deadlift∗2 (5 reps, 2 sets) (5 reps, 3 sets) (8 reps, 2 sets) (10 reps, 2 sets) (10 reps, 3 sets) Leg Flexion / Glute Nordic Hamstring Nordic Hamstring Nordic Hamstring Nordic Hamstring Ham Raise Lowers Lowers Lowers Lowers (3 reps, 2 sets) (3 reps, 3 sets) (5 reps, 3 sets) (5 reps, 3 sets) Split Squats Double Leg Hops Double Leg Hops Single Leg Hops Single Leg Hops (10 reps, 3 sets) (10 reps, 2 sets) (15 reps, 3 sets) (10 reps, 2 sets) (10 reps, 3 sets) Calf Raises Deadlift Deadlift Deadlift Deadlift Deadlift Leg Flexion / Glute Leg Flexion / Glute Leg Flexion / Glute Leg Flexion / Glute Leg Flexion / Glute Ham Raise Ham Raise Ham Raise Ham Raise Ham Raise Nordic Hamstring Nordic Hamstring Nordic Hamstring Nordic Hamstring Drop Jumps∗3 (5 reps, 2 sets) Lowers Lowers Lowers Lowers (3 reps, 2 sets) (3 reps, 3 sets) (5 reps, 3 sets) (5 reps, 3 sets) Bulgarian Split Squats Drop Jumps Drop Jumps Drop Jumps Drop Jumps (10 reps, 3 sets) (5 reps, 3 sets) (8 reps, 2 sets) (10 reps, 2 sets) (10 reps, 3 sets) Single Leg Squats Single Leg Squats Single Leg Squats Single Leg Squats Calf Raises (5 reps, 3 sets) (8 reps, 3 sets) (10 reps, 3 sets) (12–15 reps, 3 sets) Double Leg Hops Double Leg Hops Single Leg Hops Single Leg Hops (10 reps, 2 sets) (15 reps, 3 sets) (10 reps, 2 sets) (15 reps, 3 sets) Calf Raises Calf Raises Calf Raises Calf Raises ∗1 During the initial introduction of the single leg squat and back squat it is essential that the exercise is performed within a pain free ROM, which may initially be limited. If this is the case it is essential to continue to develop active ROM in the joint. ∗2 During the initial introduction of the Deadlift it is essential that the exercise is performed within a pain free ROM, which may initially be limited and require the bar to be elevated on to blocks to initially decrease the level of knee flexion required. If this is the case it is essential to continue to develop active ROM in the joint. ∗3 Drop jump landings should focus on force acceptance (deceleration), while focussing on the correct landing technique. This can be progressed in terms of intensity from increasing the height of the step / platform from which the exercise is performed. Alternatively the intensity and difficulty of the movement can be increased by progressing to single leg drop jump landings.

SUMMARY 159 Table 9.7 Progression of example programme Meso-Cycle Aim Meso-cycle 1: Anatomical Adaptations Develop ROM and technique in each exercise, including split squats Meso-cycle 2: Strength Endurance as a unilateral exercise, with low level deceleration Meso-cycle 3: Hypertrophy Meso-cycle 4: Strength Increase muscular endurance, improve technique, introduce correct Meso-cycle 5: Maximal Strength landing technique and higher speed deceleration training Meso-cycle 6: Speed Strength (High Velocity) Transitional phase from strength endurance to strength phase Increase strength introduce focussed eccentric loading of hamstrings to further improve H:Q ratio Optimize strength prior to speed strength development, in preparation for plyometric training Progressively decrease loading from 90–95% –1RM down to 40% –1RM while progressively increasing velocity of movements, in preparation for full integration of plyometric training to achieve the following stages (see also Table 9.6 It is essential that during a conditioning pro- and 9.7): gramme (such as the previous example Tables 9.6 and 9.7) the athlete still addresses other issues, such r Developing lower limb control during bilateral and as ensuring restoration of adequate range of motion for their sport, whilst prioritising the training of cor- then unilateral exercises rect landing, cutting and deceleration strategies to minimise the risk of recurrence of ACL injury dur- r Developing pain-free ROM for a full-depth squat, ing their skill training (Ford et al. 2003, Hewett et al. 2005a; Hanson et al. 2008). while addressing the hamstring to quadriceps ratio As long as the athlete exhibits all of the pre- r Developing strength in squatting movements, pro- requisites for plyometric training identified above, by the end of micro-cycle 5, they should be able to gressing to the point that the athlete can correctly progress to full plyometric training programme, after squat 1.5 × body mass, pain free, through a full micro-cycle 6. ROM (Holcomb et al. 1998; Bompa 1999), prior to high intensity plyometrics (depth jumps). It is Plyometric training should also be progressive and essential that the hamstrings are not neglected at periodised to allow improvement in terms of increas- this stage as squatting is not a sufficient training ing velocity of movement or deceleration forces, de- stimulus to ensure their development (McCaw and pending on the aims of the athlete and the require- Melrose 1999; Escamilla et al. 1998, 2001; Ander- ments of the sport. At the same time, it is essential son et al. 2006) to continue with some strength training to prevent a detraining effect and therefore a loss of strength. Pro- r Low intensity plyometric movements, such as low- gression for sport specific activities should develop from unidirectional, to bidirectional, to multidirec- level drop jumps should be practiced to ensure that tional movements (Heidt et al. 2000). the athlete has the appropriate foot placement, limb movement, balance and posture (McGill Summary 2006), while developing strength Although periodisation has previously been used r Plyometric movements should be integrated be- primarily by strength and conditioning coaches to optimise performance for specific competitions, ginning with primarily vertical movements, fol- the same approach can be used in the develop- lowed by forward momentum, then lateral move- ment of both rehabilitation programmes and injury ments finally progressing to multidirectional prevention programmes. This approach ensures that movements which gradually become more sport specific.

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10 Management of acute sport injury Jeffrey A. Russell University of California, Irvine Introduction and aims the United Kingdom in activities classified as sport (excluding in educational venues), running, cycling The experience of acute injury can be devastating to or riding (Royal Society for the Prevention of Ac- an athlete. Catastrophic injury is an obvious exam- cidents 2009). The UK’s Leisure Accident Surveil- ple, but even less severe occurrences can adversely lance System (LASS) estimated that the total number affect an athlete because of fears and thoughts of of sport injuries occurring in the United Kingdom in the unknown: How severe is it? Can I carry on play- 2002 (the last year for which data are available) was ing? What if I have to sit out – for how long? Will 824,182 (Department of Trade and Industry 2003). I lose my place on the team? All of these and many More than 525,000 of these occurred in ball sports more can negatively impact a situation that is al- where implements (e.g., sticks, bats) were not used. ready antithetical to sport “activity.” Thus the sport This reflects the immense popularity – and the high rehabilitator and the rest of the healthcare team must injury rates – of football and rugby. Football injury ensure that the management of acute injury creates rates have been reported to be 25.9 per 1000 player- the best environment possible for a successful return match hours (i.e. injuries occurring in matches) and of the athlete to full function. With this as the ul- 3.4 per 1000 player-training hours (i.e. injuries oc- timate goal, the aims of the chapter are to describe curring in training) in England’s Premiership and the nature and occurrence patterns of acute sport in- First and Second professional divisions (Hawkins jury, to present a general plan for assessing acute and Fuller 1999). Rugby’s injury rate is even higher: sport injury, to recommend appropriate methods for in preparation for and participation in the Rugby managing acute sport injury; and to provide a foun- World Cup by the England national team, injury rates dation on which to base more detailed presentations were reported as 218 per 1000 player-match hours of specific injuries in various body regions. and 6.1 injuries per 1000 player-training hours, with an overall rate of 17 injuries per 1000 hours (Brooks Common acute injuries in sport et al. 2005). In the 2007 Rugby World Cup epidemi- ology study, injury rates for all teams taken together Injury epidemiology were reported at 83.9 injuries per 1000 player-match hours and 3.5 injuries per 1000 player-training hours Intuitively it is not possible to eliminate injuries in (Fuller et al. 2008). sport, however, the incidence of injuries can be re- duced. For the year 2002 the Royal Society for the Sadly LASS only offer raw statistics without Prevention of Injuries reported 710,018 injuries in epidemiological interpretation; research studies add Sports Rehabilitation and Injury Prevention Edited by Paul Comfort and Earle Abrahamson C 2010 John Wiley & Sons, Ltd

164 MANAGEMENT OF ACUTE SPORT INJURY clarity to the data. However, it is clear that all sports Any pain or disability that occurs during participa- carry inherent risk of injury for participants. It is tion in rugby league match or training activities that therefore important to understand the epidemiolog- is sustained by a player, irrespective of the need for ical terms related to injury. Incidence is the number match or training time loss or for first aid or medical of new occurrences of an injury or illness in a given attention. An injury that results in a player requir- time period and prevalence is the number of injuries ing first aid or medical attention is referred to as a that are present in a given population at a specified “medical attention injury” and an injury that results time (Anonymous 2005; Caine et al. 2006). Three in the player being unable to partake in full part of specific terms have been presented in the context future training and/or match activities is referred to of analysing sport injury incidence (Knowles et al. as a “time loss” injury. (p. 13) 2006): incidence proportion, incidence rate and clin- ical incidence. Incidence proportion is the number of The dissimilarity with the ISS definition is obvi- injured athletes divided by the number of athletes at ous and substantial. Analogous variation exists, as risk and represents the average risk of injury for an well, between the ISS and King et al. definitions athlete (Knowles et al. 2006). Incidence rate refers of exposure. An “athlete exposure” is the ISS’s ba- to the number of injuries in a given quantity of time. sic measure of risk, being defined as one athlete Clinical incidence is the overall number of injuries participating in one training session or one compe- that occur in a given group of athletes, a number tition in which they are exposed to the potential for important to those responsible for decisions about being injured (National Collegiate Athletic Associ- how to allot clinical resources to healthcare settings ation 2008). The definition provided by King et al. (Knowles et al. 2006). (2009) is: One of the key factors of any systematic injury [For matches] The product of the number of players, survey that provides data about acute injury epi- the number of matches between two different teams, demiology is the definition of injury and related pa- and the match duration for the period that the study rameters (van Mechelen et al. 1996; Ekstrand and is being conducted. The recommended recording of Karlsson 2003; Brooks and Fuller 2006; Hodgson exposure time is the duration of the matches being et al. 2007). The National Collegiate Athletic As- studied in hours. (p.14) sociation’s Injury Surveillance System (ISS) has recorded injuries in university athletes in America [For training] The product of the number of players, since 1982 (National Collegiate Athletic Association the number of training sessions, and the training du- 2008). A reportable injury is defined in this database ration for the period that the study is being conducted. as one that: The recommended recording of exposure time is the duration of the training sessions being studied in Occurs as a result of participation in an organized hours. (p. 14) intercollegiate [i.e. inter-university] practice or com- petition; requires medical attention by a [healthcare In a study of the ISS for the years 1988–2004 professional]; and results in restriction of the student- (Hootman et al. 2007), injuries are statistically more athlete’s participation or performance for one or likely to occur during competitions than during train- more days beyond the day of injury. (p. 109) ing (13.8 versus 4.0 injuries per 1,000 athlete expo- sures). Also, injuries during pre-season training were In other words, an episode is not considered an significantly higher (6.6 injuries per 1,000 athlete injury until, at a minimum; it compromises an ath- exposures) than injuries occurring during a sport’s lete’s ability to participate in their sport on the day season (2.3 injuries per 1,000 athlete exposures) following the episode. and after the season (1.4 injuries per 1,000 athlete exposures). The general tendencies of these results – This definition is not universal, however. Hodgson if not the injury rates – are similar to observations et al. (2007) recommend a much more encompass- made about rugby injuries in England (Brooks ing definition. Contrast of the foregoing classifica- et al. 2008) and Australia (Gabbett 2004). Another tion with the following underscores the difficulty in interesting finding is that across all sports, university comparing injury rates among research articles. King male athletes are 3.5 times more likely to suffer a et al. (2009) recommended this definition of injury non-time-loss injury than a time-loss injury (Powell for the entirety of rugby league: and Dompier 2004). This ratio is even higher in

INITIAL ASSESSMENT OF ACUTE SPORT INJURY 165 Table 10.1 Injury risk data for selected sports (National Athletic Trainers’ Association 2007) Sport Time-loss injuries per Injury risk1 Health Care Index2 1,000 athlete exposures Basketball, men 5.5 7 2.4 Basketball, women 5.1 5 4.0 Football, men 7.8 4 2.8 Football, women 7.4 5 3.6 Gymnastics, men 6.8 8 3.7 Gymnastics, women 7.8 8 4.0 Hockey, women 4.7 4 2.8 Ice hockey, men 7.3 6 1.8 Ice hockey, women 4.9 5 1.0 North American football, men 8.7 8 3.1 Outdoor athletics, men 3.7 2 1.1 Outdoor athletics, women 3.1 2 1.1 Volleyball, men 7.5 5 4.0 Volleyball, women 4.4 5 3.5 1Catastrophic and non-catastrophic risks combined; higher number indicates greater relative risk. 8 is maximum 2Higher number indicates more healthcare required; 4.0 is maximum female athletes: they are over 5 times more likely to Countless articles offer reports about injuries in cer- suffer a non-time-loss injury. tain sports, but assessing these systematically is a monstrous task. In addition, the types of injuries The relative need for healthcare delivery to par- sustained by children, adolescents, young adults, ticipants of a given sport is a pertinent topic in any middle-aged adults and senior adults likely differ, discussion about sport injury incidence. A very use- as do injuries encountered in recreational sport, ful tool for determining the healthcare requirements competitive sport and sport training. Combine these of a variety of sports has been proposed and is based diversities with the variety in sports, rules, equip- on injury incidence rate and the relative personnel ment, venues, training regimens and healthcare ac- load of providing care for injuries incurred in uni- cess across the globe and the task of assessing versity sports (National Athletic Trainers’ Associ- sport injury epidemiology appears overwhelming at ation 2007). Injury rate index is based on risk of best. The USA’s National Collegiate Athletic Asso- injury combined with risk of catastrophic (brain and ciation maintains excellent data for university ath- spine) injury. Table 10.1 summarises relevant data. letes that offer some insight into those body regions A higher Health Care Index suggests that a sport that are most affected and those injuries that oc- requires more medical attention. While comparable cur most commonly in certain sports (Hootman et data for cricket and rugby could not be found, the al. 2007). Selected data are provided in Tables 10.2 information presented is helpful for the sport reha- and 10.3. bilitator’s understanding about the nature of injury in sport and the demand for healthcare each sport Initial assessment of acute sport injury engenders. Assessment of all injuries in sport participants Specific injuries encountered should follow the standard history, inspection (obser- vation), palpation, and special testing paradigm com- It is surprisingly difficult to locate summary data monly applied by healthcare professionals. These on the incidences of specific injuries in sport. Apart steps can be summarised as follows (for greater de- from the epidemiological challenges previously out- tail read Chapter 11:Musculoskeletal Assessment). lined, there are some practical reasons for this.

166 MANAGEMENT OF ACUTE SPORT INJURY Table 10.2 Injury incidence by body region for uni- r How did the injury occur? versity athletes from 1988 through 2004 (Hootman et al. 2007) r Did you hear or feel a pop, crack, snap, or other Percent of all injuries unusual sensation? Body region Matches Training r Have you injured this area previously? Lower extremity 53.8 53.7 r How does it feel now compared to when the injury Upper extremity 18.3 21.4 Trunk/back 13.2 10.0 first occurred? Head/neck 12.8 Other 9.8 2.2 r How is the injury limiting your activity? 4.9 History Inspection (observation) This first step in injury evaluation is fundamental to This step requires a careful visual analysis of the in- success. It entails a series of questions directed to jured area and adjacent regions. Several pieces of in- the athlete that are designed to elicit the factors sur- formation are collected before the examiner touches rounding the injury and any corollary findings (such the injured area. The contralateral limb should be as previous history of injury) that may be important used for comparison as long as it does not exhibit in arriving at a diagnosis. The exact questions are atypical characteristics because of a prior injury or modified depending on the situation, but some sam- other reason. Examples of observational information ple queries for athletes with acute injuries are given to gather about the type and extent of injury include: below. r Deformity (e.g. joint incongruity, limb angula- r When did this happen? tions, anatomical landmark displacement) r What were you doing at the time of the injury? r Swelling Table 10.3 Incidence of common injuries in university athletes, by sport, from 1988 through 2004 (Hootman et al. 2007) Ankle ligament sprains Anterior cruciate ligament Concussions injuries Sport Percent of Injury rate per Percent of all Injury rate per Percent of all Injury rate per all injuries 1000 exposures injuries 1000 exposures injuries 1000 exposures Basketball, men 26.6 1.30 1.4 0.07 3.2 0.16 Basketball, women 24.0 1.15 4.9 0.23 4.7 0.22 Football, men 17.2 1.24 1.3 0.09 3.9 0.28 Football, women 16.7 1.30 3.7 0.28 5.3 0.41 Gymnastics, women 15.4 1.05 4.9 0.33 2.3 0.16 Hockey, women 10.0 0.46 1.6 0.07 3.9 0.18 Ice hockey, men 0.23 1.2 0.06 7.9 0.41 Ice hockey, women∗ 4.5 0.14 0.7 0.03 18.3 0.91 North American 2.8 0.83 3.0 0.18 6.0 0.37 13.6 football, men 1.01 2.0 0.09 2.0 0.09 Volleyball, women 23.8 ∗ Data collection began in the academic year 2000−2001

INITIAL ASSESSMENT OF ACUTE SPORT INJURY 167 r Discolouration (e.g. pallor, ecchymosis, ery- important caveats for the examiner. First, the unin- jured limb should be tested before the injured one thaema) in order to familiarise the athlete with the evalua- tion procedures and to allay their apprehensions. If r Gait discrepancies or difficulties the athlete cannot relax, muscle guarding will com- promise the testing. Second, a previously injured r Difficulties climbing to the examination couch contralateral joint may not be a suitable “normal” standard against which to judge the currently injured r Reduction in joint range of motion. joint. Third, a systematic method for evaluating each region of the body is most effective and efficient for Palpation completing the examination process without missing important diagnostic details. This is the first instance when the examiner actu- ally touches the injured athlete. A systematic prob- Serving as one common example that will be en- ing of the injured area and surrounding tissues gain countered by virtually all sport rehabilitators, the important details and may help the clinician iden- evaluation of an acute knee injury includes special tify pathologies that accompany the primary injury. tests such as: Once again the contralateral limb is used as a refer- ence. Examples of findings from effective palpation r Apprehension sign for patellar dislocation/ include: subluxation r Localisation of pain and tenderness (including de- r Lachman’s test for anterior cruciate ligament in- ciding which structures are painful and which are tegrity not as part of a differential diagnostic process) r Anterior drawer test for anterior cruciate ligament r Atypical anatomical contours integrity r Crepitus r Posterior gravity sign for posterior cruciate liga- r Effusion and oedema. ment integrity Special testing r Pivot shift test for anterolateral rotary instability Following completion of the history, inspection and r McMurray’s test for meniscal damage palpation steps the examiner conducts a series of as- sessments to gather further insight into the nature r Apley’s grind test for meniscal damage and severity of the injury. These vary widely de- pending on the body region being evaluated and the r Ottawa Knee Rules (Stiell et al. 1995, 1996; Tigges diagnostic clues gained in the first portion of the ex- amination. (Magee (2008) provides an excellent and et al. 1999) to rule out fracture. comprehensive handbook of musculoskeletal exami- nation that the sport rehabilitator will find invaluable Assessment case study: ankle sprain as a reference in addition to the present text.) They may include manual tests performed by the examiner One of the most common injuries in sport is ankle to identify joint instability or certain functional ac- sprain (Garrick 1977; Yeung et al. 1994; Fong et al. tivities that the examiner asks the athlete to perform. 2007; Hootman et al, 2007), so it will serve as an The results of this analysis add to the diagnostic example of how acute injury evaluation is applied. process and help broaden the information on which The sport rehabilitator confronted with this type of clinical decision making is based. ankle injury will assign a severity grade to the sprain based on the results of the clinical examination (see Once again, testing the contralateral extremity is Table 10.4). A partially torn ligament – categorised important as a comparison. However, there are three as a grade 2 sprain – can encompass a wide range of damage, whilst a grade 3 sprain is a complete rupture

168 MANAGEMENT OF ACUTE SPORT INJURY Table 10.4 Summary of ligament injury severity grading Injury grade Ligament damage Sensation to examiner with stress exam Associated pain for patient Grade 1 None to minimal (stretched) No instability Mild to moderate Grade 2 Partially torn Mild to moderate instability; endpoint Moderate Grade 3 Completely torn (ruptured) is present Moderate to severe Moderate to severe instability; soft or indistinct endpoint of a ligament. The determination by the examiner of Examiner: What happened to your ankle? a limit – or an endpoint – to their stress exam of the Player: I jumped up for a rebound and when I came joint is important. The endpoint is created by any remaining intact ligament restricting the movement. down, my foot landed on top of Ian’s and it rolled A grade 3 sprain does not exhibit such a limit; rather, over. an indistinct, soft endpoint is present because the Examiner: When did this occur? torn ligament cannot oppose the stress the examiner Player: Yesterday afternoon during training. places on the ankle. Examiner: What did you feel when it happened? Player: It hurt a lot, and I felt it pop. However, the examiner must remember that many Examiner: Has it been painful since the injury oc- subjective subtleties exist in evaluating ligament curred? damage because there are virtually infinite ways that Player: It hurt loads when it happened, but I just ligaments supporting a joint can be injured. The walked it off. Later it felt better and I’ve been able amount of joint instability may be graded instead to carry on with life OK. of the degree of injury to a specific ligament (Hilde- Examiner: How does it feel now? brand et al., 2007). For instance, a grade 2 instabil- Player: It still hurts, but not as much. ity may be present when one ligament is completely Examiner: Have you ever hurt this ankle before? torn and the others around a joint are not. But, partial Player: No. tears to two or more ligaments about the joint may Examiner: How about the other one? also result in the same type of instability. This under- Player: No, not at all. scores the need for the sport rehabilitator to practise Examiner: OK, I’m going to examine it now. a systematic method of ligament injury evaluation. Acute ankle injury: inspection The following section outlines the stages of injury assessment carried out by a sport rehabilitator. An At this point the examiner looks carefully at both the injured basketball player presents to the sport injury injured and uninjured ankles to assess swelling, ec- clinic to be evaluated by a member of staff. He is chymosis (bluish discolouration), and other visible wearing shorts and walks with a limp. He climbs onto signs that may add information to the assessment. the examination couch and the sport rehabilitator The athlete’s ankle exhibits an area of swelling an- begins the assessment. terior to the lateral malleolus that is approximately the size of a table tennis ball. Acute ankle injury: history Examiner: Where would you say it hurts the most? There are certain customary questions to ask an Can you place one finger at that spot? injured athlete, and some of these depend on the The player points to a location about 1.5 cm an- body region involved. A framework of “What, When, Where, How?” may be helpful. It is ideal to develop terior to the lateral malleolus; this is an area over a routine examination methodology in order to fa- the anterior talofibular ligament and the spot where cilitate the process and ensure one does not miss the swelling is located. There are no other areas of important diagnostic clues. swelling nor are there other outward signs of injury.

INITIAL ASSESSMENT OF ACUTE SPORT INJURY 169 Examiner: Can you show me the way your ankle ◦ peroneal tendons, extending up the leg to their and foot turned when you landed on Ian’s foot? muscles The player demonstrates an inversion movement ◦ tibialis anterior tendon of the foot with slight plantar flexion. ◦ tibialis posterior tendon. Acute ankle injury: palpation The examiner does not note any pain or crepitus on bony structures, so the suspicion for fracture is First the examiner palpates the uninjured extrem- low. Palpating the soft tissue structures does not elicit ity in order, again, to familiarise the player with the pain except for the anterior talofibular ligament; this process and to reduce his apprehension. Then the ex- is accompanied by a sensation of ballottement as the aminer begins to gently palpate various places about examiner presses over the swollen tissue. the foot, ankle and leg of the player’s injured limb, starting with areas that are not likely to be painful Acute ankle injury: special testing in order to keep the player at ease. It is crucial that the clinician be well versed in clinical anatomy for Now the examiner proceeds to the final phase of the this portion of the injury examination. Locations and injury evaluation. Once again, the contralateral side structures the examiner palpates are: receives attention first; the player reported no history of injury to this side so it will serve as “normal” for r Ligaments (to investigate possible sprains) comparison purposes. The following tests are per- formed there and then repeated on the injured limb. ◦ deltoid ligament (For more specific detail regarding special testing for the ankle please see Chapter 22) ◦ anterior talofibular ligament r Eversion (varus) stress test to evaluate the deltoid ◦ calcaneofibular ligament ligament ◦ anterior tibiofibular ligament r Forcing the foot into dorsiflexion to evaluate the ◦ calcaneocuboid ligament anterior tibiofibular ligament (this forces slight r Bones (to investigate the possibility of associated separation of the tibiofibular syndesmosis) fractures) r Twisting the foot in the ankle mortise to evaluate ◦ base of the 5th metatarsal, to assess an avulsion the anterior tibiofibular ligament (this also sepa- fracture rates the syndesmosis) ◦ metaphysis and diaphysis of the 5th metatarsal, r Inversion (valgus) stress test in anatomical posi- to assess a shaft fracture or Jones (proximal di- aphyseal/metaphyseal) fracture tion (ankle neutral) to evaluate the calcaneofibular ligament ◦ lateral malleolus r Inversion stress test in plantar flexion to evaluate ◦ fibula, extending up the leg to the fibular neck in order to assess a Maisonneuve fracture the anterior talofibular ligament ◦ dorsal talus r Anterior drawer test with the ankle in neutral po- ◦ navicular sition to evaluate the anterior talofibular ligament. ◦ calcaneus The examiner must be careful to not fall into the trap of finalising an injury diagnosis without gather- r Tendons and muscles (to investigate possible ing all potentially useful information with a thorough history, inspection, palpation and special testing strains) protocol. Many inexperienced clinicians have been ◦ Achilles tendon

170 MANAGEMENT OF ACUTE SPORT INJURY Table 10.5 Ottawa Ankle Rules (see Figure 10.1 also) (Stiell et al. 1992, 1994; Leddy et al., 2002; Nugent 2004) Ankle should be X-rayed if. . . . . .the posterior half of the distal AND . . .the patient cannot bear weight 6 cm of the fibula or tibia or tip for 4 steps on the injured limb at of the lateral malleolus is painful the time of injury and at the time to palpation. . . of the evaluation (limping is irrelevant) Midfoot should be X-rayed if. . . . . .the base of the 5th metatarsal or AND the navicular bone is painful to . . .the patient cannot bear weight palpation. . . for 4 steps on the injured limb at the time of injury and at the time of the evaluation (limping is irrelevant) distracted from a proper diagnostic conclusion be- ◦ Impression: grade 1 or 2 anterior talofibular lig- cause they did not assess an injury carefully enough. ament sprain That being said, however, there are certainly natural tendencies that are anticipated when the mechanism r Anterior drawer test: moderate pain that worsens of an injury is known. In the case of our basket- ball player here, we are aware that he inverted and at end of range of movement and slight instability plantar flexed his ankle when he landed on another compared to contralateral player’s foot. This mechanism is very typical of an ◦ Impression: grade 2 anterior talofibular ligament anterior talofibular ligament sprain (Garrick 1977), but completing the battery of tests listed above will sprain. help identify other potentially injured structures. Parenthetically, as part of an acute ankle assess- Our basketball player exhibits the following re- ment the Ottawa Ankle Rules (Stiell et al. 1992, sults of ligament testing: 1994) should be applied. These rules (Table 10.5 and Figure 10.1) have greatly reduced the unnecessary r Eversion stress: not painful and no instability (firm X-rays previously associated with ankle injury man- agement in the A&E department and other healthcare endpoint) compared to contralateral Figure 10.1 Pictorial representation of the Ottawa An- ◦ Impression: deltoid ligament intact kle Rules showing the locations – the shaded areas – where bony tenderness indicates the advisability of obtaining an- r Forced dorsiflexion: no pain elicited kle X-rays. Reproduced, with permission, from Figure 1 from Russell, J.A., ‘Acute Ankle Sprain in Dancers’ Jour- ◦ Impression: anterior tibiofibular ligament intact nal of Dance Medicine and Science, 14, 2010 © J. Michael Ryan Publishing, Inc. r Twisting foot in the mortise: no pain elicited ◦ Impression: anterior tibiofibular ligament intact r Inversion stress test in anatomical position: very slightly painful anterior to the lateral malleolus at end of range and no instability compared to contralateral ◦ Impression: calcaneofibular ligament intact; based on its location, the mild pain is likely em- anating from the anterior talofibular ligament r Inversion stress test in plantar flexion: moderate pain that worsens at end of range of movement and questionable slight instability compared to con- tralateral

FIRST AID AND INITIAL THERAPEUTIC MEASURES 171 settings (Milne 1996; Leddy et al., 1998; Bachmann Certainly injury examination is very subjective, al- et al., 2003; Nugent 2004). The rules provide guid- though a systematic evaluation scheme helps reduce ance for clinical personnel in determining when an- variability in the assessment process. Nonetheless, kle injuries require radiography for suspected frac- there is no substitute for the experience of exam- ture, and they are appropriate and effective for sport ining as many injuries as possible in order to gain medicine settings (Leddy et al., 1998; Papacostas the ability to discern subtleties present in the wide et al., 2001; Leddy et al., 2002). Implementing the variety of cases. Both proper clinical education and rules for sport ankle injuries prevented missed frac- clinical experience are essential for effective injury tures, decreased X-ray exposure, saved unnecessary care. healthcare expenditures and fostered patient satisfac- tion (Leddy et al., 2002). The Ottawa Ankle Rules First aid and initial therapeutic measures appear to be most useful when applied by health- care workers, as patients may not be able to apply The acronym PRICE is the standard for acute care of them accurately to their own ankle injuries (Black- sport injury. This is a reminder of five steps: applica- ham et al., 2008). Sport rehabilitators and other allied tion of Protection, Rest, Ice, Compression and Ele- health professionals should familiarise themselves vation (Flegel 2008). An alternative, RICES – Rest, with these important adjuncts to ankle injury evalu- Ice, Compression, Elevation, Stabilisation – has been ation. proposed (Knight 2008; Knight and Draper 2008), but portrays the same basic meaning. The generally Acute ankle injury: information collating and accepted period for the acute treatment described be- decision making low is the first 48–72 hours after the injury. Knight (2008) suggests for clarity’s sake that acute care be After executing the history, inspection, palpation and subdivided into three phases: emergency (encom- special testing steps, the sport rehabilitator arrives at passing CPR or urgent transport to A&E), immedi- the clinical impression of a grade 2 sprain of the an- ate (from time of injury to 12 hours post-injury) and terior talofibular ligament. Following is a summary transition care (from 12 hours to 4 days post-injury). of the examination details that led to this decision. No matter how the initial period of time following an injury is apportioned, the success of follow-up treat- r Mechanism of injury: inversion with plantar flex- ment depends substantially on the initial treatment that is applied. ion, a movement that places the anterior talofibular ligament under tension Protection by bracing, splinting, or non-weight bearing transport of an injured athlete is under- r Location of swelling and pain: anterior to the lat- taken when necessary to minimise the risk of further trauma to an injured area. Proper first aid techniques eral malleolus, which is the anatomical location of at this initial stage are crucial to the athlete’s well- the anterior talofibular ligament being. Rest from the activity that caused the injury, or similar activities, is warranted when the opportunity r Pain and slight laxity in the ankle: occurs dur- exists for reinjury or further injury. ing inversion and plantar flexion testing that place In the last several years, the “gold standard” of tension on the injured ligament, suggesting that a cold – or cryotherapy – as an injury treatment has portion of the ligament is disrupted; note that in been analysed for its efficacy in evidence-based prac- this case there is an equivocal impression when tice (Ernst and Fialka 1994; Lessard et al. 1997; considering only the inversion exam with plantar Bleakley et al. 2004; Hubbard and Denegar 2004; flexion – the anterior drawer test result adds clini- Collins 2008). In spite of questions raised about the cal information therapeutic effects of cold treatment, it is helpful for pain reduction (Hubbard and Denegar 2004; Algafly r Associated fracture likelihood: not likely, as the and George 2007). Other reasons for applying cold to acute sport injuries include minimising oedema player arrived at the clinic with full weight bearing and effusion (Merrick 2007) and controlling sec- ambulation and palpation of the bony structures ondary cellular hypoxia (Dale et al., 2004) and the did not reveal pain; thus, the Ottawa Ankle Rules broader secondary metabolic injury (Merrick et al. suggest no fracture.

172 MANAGEMENT OF ACUTE SPORT INJURY 1999; Knight and Draper 2008) in the injured re- Figure 10.2 The shaded areas denote the shape and lo- gion. Whilst cold slows oedema formation, it does cation for placement of a foam or chiropody felt horse- not reduce oedema that is already present (Knight shoe pad as a compressive element in treating acute ankle and Draper 2008). sprain. Reproduced, with permission, from Figure 1 from Russell, J.A., ‘Acute Ankle Sprain in Dancers’ Journal A typical application of therapeutic cold should of Dance Medicine and Science, 14, 2010 © J. Michael last no longer than 20 minutes (Bleakley et al. 2006; Ryan Publishing, Inc. Flegel 2008); approximately one hour should elapse before another cold treatment in order to allow the adjacent to the malleoli without sufficient external tissue to rewarm. As with all treatment procedures pressure. Horseshoe shaped pads cut from 1 cm (3/8 there are important caveats. More body tissue heat inch) foam or chiropody felt and positioned under- is given off (resulting in lower tissue temperature) neath the bandage during wrapping – as shown in to a 10◦ cold pack than to a 20◦ cold pack (Knight Figure 10.2 – may improve elimination of oedema and Draper 2008) and by body regions with a thinner in these areas (Wilkerson and Horn-Kingery 1993; insulating fat layer (Otte et al. 2002) or a larger sur- Merrick 2004). face area covered by the treatment modality (Knight and Draper 2008). Therefore, longer treatment times Elevation of the injured extremity so the ankle or more intense forms of treatment further increase is positioned above the level of the heart is an- heat loss and can instigate tissue damage (Knight other technique that promotes a decrease in swelling 1995; Knight and Draper 2008). Moreover, research (Rucinkski et al. 1991). Gravity assists venous re- suggests that muscular power and functional per- turn, as well as lymphatic drainage of fluid collected formance are reduced even after a 10 minute ice in the interstitial spaces (Dale et al. 2004). However, application (Fischer et al. 2009). a return of the limb to the non-elevated, or gravity- dependent, position may reverse the oedema reduc- Circumferential compression in an injured ex- tion gained by elevation (Tsang et al. 2003). Thus, tremity enhances control of oedema by increasing elevation for as much time as possible is important the external tissue pressure to promote lymphatic during the period of acute injury management. drainage in the region of the injury and by assist- ing venous return (Wilkerson 1991; Wilkerson and Pain management in acute Horn-Kingery 1993; Delis et al. 2000; Mora et al. musculoskeletal sport injury 2002; Vanscheidt et al. 2009). Application of an elastic or crepe bandage provides some compression A number of therapeutic modalities are available to- and a general reassurance to the athlete, although a day for treatment of various aspects of sport injury. pneumatic stirrup-type of brace has been shown to be The presentation of these will be confined to those more effective in treating ankle sprains (Boyce et al. categorised as physical agents (Merrick 2007) or 2005). Intermittently applied compression may be pharmacological agents that are designed to control beneficial, as well, especially when applied in con- junction with cryotherapy (Starkey 1976; Quillen and Rouillier 1982; Mora et al. 2002). Research in this area related to patients with chronic oedema- tous pathology is instructive (Delis et al. 2000; Van- scheidt et al. 2009) as significant improvements in swelling have been shown and a dose-response rela- tionship has been reported (Vanscheidt et al. 2009). Of concern in the common sport injury of an- kle sprain are the contours of the medial and lateral malleoli. This topology about the ankle may pre- vent the areas anterior and posterior to the malleoli from receiving adequate compression by an elas- tic or crepe bandage. This is because the bandage bridges across from the anterior and posterior an- kle surfaces to the malleoli, thus leaving the spaces

PAIN MANAGEMENT IN ACUTE MUSCULOSKELETAL SPORT INJURY 173 pain in the acute stage of injury. It is important in Transcutaneous electrical nerve stimulation applying any type of modality to a patient or client (TENS) is an electrotherapy modality shown to be that the clinician has an appropriate aim for such effective for musculoskeletal pain (Hsueh et al. 1997; application as well as an understanding about the Bertalanffy et al. 2005). It electrically stimulates sen- physiology of the modality and its effects on the sory nerves around an injured body region to in- body. terfere with pain stimuli. The gate control theory (Melzack and Wall 1965; Dickenson 2002) defines Physical agents how high-frequency TENS mediates the sensation of pain. Pain impulses on α-δ and C nerve fibres The two traditional physical agents best suited in the spinal cord are interrupted by sensory infor- to successful management of acute injury pain mation transmitted via α-β afferent nerves (Mer- are cryotherapy and electrotherapy (Merrick 2004). rick 2004). Thus, if the TENS signal stimulates the There are many methods of cryotherapy (Swenson α-β fibres to a great enough degree, those nerve et al. 1996; Bleakley, et al. 2004), though not all are signals will close a “gate” in the spinal cord for equivalent in their efficacy (Bleakley et al. 2004). the pain stimuli and be perceived instead of the As previously mentioned, cold treatment is effec- pain. tive for ameliorating pain among other therapeu- tic effects like slowing development of haematoma Although it has been applied to acute muscu- and oedema, decreasing nerve conduction velocity, loskeletal pain scenarios, systematic review of the reducing muscle spasm (Swenson et al. 1996), re- research is inconclusive about the efficacy of TENS ducing local blood flow in the injured area (Knight (Walsh et al. 2009), and a lack of randomisation in and Londeree 1980) and minimising secondary clinical trials leads to over-estimation of the posi- metabolic injury (Merrick et al. 1999; Knight and tive effects of the treatment (Carroll et al. 1996). In Draper 2008). acute low back pain patients, therapeutic exercise with TENS was not assistive to patient recovery in In terms of method of application, it is somewhat comparison to exercise alone (Herman et al. 1994). difficult to make a recommendation because tech- Neither was it a benefit for patients with acute post- niques and published findings are so varied (Bleak- operative pain following lumbar surgery (McCallum ley et al. 2004, 2007). A simple ice bag is usually the et al. 1988). However, in a randomised, double-blind most expeditious and inexpensive means of apply- study of trauma patients at A&E TENS was as effec- ing cold. It has many proponents (McMaster et al. tive as oral medication for analgesia (Ordog 1987). 1978; Merrick 2004; Bleakley, et al. 2006; Knight There are several different TENS units on the market, and Draper 2008), although it has been shown that a myriad of musculoskeletal injuries and numerous a 20 minute cold whirlpool bath procured a longer protocols with which TENS can be applied to these tissue temperature reduction than did a 20 minute injuries. Discussing all of these variations is beyond crushed ice pack treatment for the leg (Myrer et al. the scope of this chapter; but, because TENS is a rela- 1998). A protocol of a 10 minute ice pack appli- tively safe modality, there is minimal risk to utilising cation, 10 minutes without ice and then another 10 it for management of acute pain in sport injuries and minutes of ice pack lowered tissue temperature better discontinuing it if it proves ineffective for a given than a single 20 minute ice pack treatment (Bleakley athlete. et al. 2006). The effective cooling by ice is related to the phase change that it undergoes from a solid to a High-voltage, low-frequency electrical stimula- liquid as it melts (Merrick et al. 2003). The combina- tion also can be useful for managing acute pain tion of therapeutic cold and exercise, or cryokinetics (Merrick 2004). The intention for this modality is (Hayden 1964; Knight 1995; Bleakley et al. 2007; to elicit release of an opioid substance called beta- Knight and Draper 2008), is especially beneficial be- endorphin that naturally occurs in the body (Hughes cause of the way early motion promotes subsequent et al. 1984; Bender et al. 2007); beta-endorphin is rehabilitation. In this technique pain is managed by a powerful mediator of pain (Bender et al. 2007). the cold treatment and then the athlete undertakes The treatment may be somewhat uncomfortable to a controlled exercise regimen, followed by another the patient because of the waveform and frequency, cycle of cold. but this stimulation is what makes the technique ef- fective in bringing forth release of beta-endorphin

174 MANAGEMENT OF ACUTE SPORT INJURY and consequent pain relief after treatment (Merrick Over-the-counter oral analgesics 2004). Paracetamol (acetominophen) is the most widely A final type of electrotherapy that often is effective used analgesic compound in the world (Jalan et al. for acute pain management is interferential current 2007). It is generally thought to be a safe and ef- (Merrick 2004; Jorge et al. 2006). This technique’s fective medication (Graham et al. 2003; Kehlet and name is derived from its two electromagnetic fields Werner 2003), although some concern exists that that cross each other; at their point of intersection liver toxicity is possible even at commonly used non- is a localised field of interference caused by their prescription doses (Jalan et al. 2007). Paracetamol competing current phases. The current in this field also has been shown to be as efficacious in acute mus- continually changes, a property that precludes ac- culoskeletal pain as non-steroidal anti-inflammatory commodation by the nerves in the treatment area and drugs (Woo et al. 2005; Gøtzsche 2006). Nonetheless which yields analgesia via the gate control mecha- the drug is not without side-effects and controversy nism (Merrick 2004). Whilst interferential current (Moynihan 2002; Ahmad 2007); and, assuredly it has been shown to be similarly effective compared must not be offered nor ingested indiscriminately. to TENS, research about it is scant (Johnson and The sport rehabilitator has a role and responsibility Tabasam 2003). Certainly its usage is confined to in properly advising athletes, patients and clients in a clinical setting, perhaps making TENS preferable the approved use of this and other medicinal prepa- simply because of easier device portability and the rations. ability of patients to operate the equipment. Compared to Paracetamol, NSAIDs are much Pharmacological agents more likely to elicit unfavourable reactions. They are well known for adversely affecting the gastrointesti- Topical analgesics nal system (McCarthy 2001), and more recent evi- dence has associated adverse cardiovascular effects Topical methods of analgesia are enjoying renewed with cyclo-oxygenase 2 (COX-2) inhibitor NSAIDs interest in healthcare because of the challenges in- (Ju¨ni et al. 2004; Vardeny and Solomon 2008). As- herent with administering pain medications via other sessing the risks and benefits of this class of phar- routes (Stanos 2007). Among the non-prescription maceuticals can be complex (Patrono and Rocca compounds available, counterirritants are one of the 2009). As mentioned above, some studies suggest oldest and most widely used. They are marketed that for typical pain from acute musculoskeletal in- under such brand names as Sports Muscle Rub, jury, NSAIDs and Paracetamol are similarly effec- Muellergesic, BioFreeze, Tiger Balm and Deep Heat tive. Unquestionably, administration of prescription Cream. These preparations contain capsaicin, men- NSAIDs or over-the-counter NSAIDs (e.g. ibupro- thol, camphor, garlic and other ingredients that pos- fen) at prescription strength doses is unethical with- sess both distinct aromatic properties and an ability out the care of a GP or consultant. The sport re- to act on the nociceptors of the skin. Their charac- habilitator must adhere to approved applications of teristic “counterirritation” reduces the perception of NSAIDs and discourage improper NSAID use when the musculoskeletal pain “irritation.” advising individuals under their care. NSAID topical ointments, especially those con- Concussion taining ibuprofen or diclofenac, show promise as satisfactory alternatives to oral NSAIDs. A double- An understanding of concussion as an acute injury is blind study of the effects of oral versus topical gel crucial to the sport rehabilitator. Whilst it is not the ibuprofen reported no difference between the two de- typical musculoskeletal injury, it can be considerably livery methods for all therapeutic measures (White- more serious and troublesome to manage. Concus- field et al. 2002). Other studies corroborate the ef- sion is defined as “a trauma-induced alteration in ficacy of topical NSAIDs (Dominkus et al. 1996; mental status that may or may not involve loss of Rovensky´ et al. 2001; Banning 2008); but, this de- consciousness” (American Academy of Neurology pends on the relative depth (e.g. superficial versus 1997, p. 582). It has gained increasing attention in re- intra-articular) of the pain’s origin (Dominkus et al. cent years because – in addition to its trauma-induced 1996; Miyatake et al. 2009).

CONCUSSION 175 Table 10.6 Neurological injuries to participants in a variety of sports (NA = not available) (adapted from Toth 2008) Sport Acute neurological injury rate Incidence of mild traumatic brain per 100 athlete-exposures injury per 1,000 athlete-exposures Basketball, males 18–23 yrs 1.0 0.3 Basketball, males 22–39 yrs 1.9–6.4 NA Basketball, females 18–23 yrs 0.4 0.5 Basketball, females 22–39 yrs 2.5–6.7 NA Boxing, amateur 14–20 11–77 Boxing, professional 21–45 186–251 Cricket <0.1 <0.1 Football, males 18–23 yrs 18.8 1.1 Football, males 22–35 yrs 105 NA Football, females 18–23 yrs 16.4 1.4 Football, females 22–35 yrs 109 NA Football, North American, 18–23 yrs 1.5–4.0 2.3–6.1 Hockey, males 17–23 yrs 12.6 1.1 Hockey, females 17–23 yrs 7.9 0.5–0.7 Ice hockey, males 18–23 yrs 0.5 1.5–4.2 Ice hockey, females 18–23 yrs 1.3 2.7 Ice hockey, males 20–36 yrs 11.9 6.6 Snowboarding 0.4 6.1 Taekwondo 6.3 NA Wrestling, males 17–23 yrs 7.3 1.3 metabolic compromise of the brain (Katayama et al. in sport and recreation. Table 10.6 summarises his 1990; Giza and Hovda 2001) – insidious sequelae analysis. Collision sports (e.g. rugby, North Ameri- often are associated with it in the form of associ- can football), sports where the participants or projec- ated pathologies such as subdural hematoma (Kersey tiles move at high velocity (e.g. alpine skiing, motor- 1998; Mori et al. 2006) or post-concussion syndrome sports, skateboarding, cricket, baseball, ice hockey) (Fazio et al. 2007; Yang et al. 2009). and pugilistic sports (e.g. boxing, martial arts) are particularly prone to injuries of the head and neck. Whilst the basic steps of acute injury evaluation Certainly protective headgear are helpful against di- presented earlier apply to concussion, this injury is rect blows in some sports, but they do not prevent all being treated separately herein because of its im- head injuries and concussion can occur with or with- portance and the special techniques necessary for out helmets (American College of Sports Medicine successfully handling it. Several medical associa- 2006). In football, headgear does not offer protec- tions have published position papers outlining proper tion against ball contact head injuries, but it does ap- management of concussion (American Academy of pear to reduce the severity of head-to-head contact Neurology 1997; Guskiewicz et al. 2004; American injuries (Withnall et al. 2005). Of particular conse- College of Sports Medicine 2006; McCrory et al., quence in sport-related brain injuries are rapid accel- 2009) in order to help decrease the morbidity and eration or deceleration of the head or high velocity mortality of this injury. The sport rehabilitator who angular head motion (Holbourn 1945; Ommaya and attends pitchside must be well versed in manage- Gennarelli 1974). Concussions are usually graded 1 ment of concussion and related conditions as catas- through 3 according to severity (American Academy trophic injury can be more alarming and potentially of Neurology 1997; Randolph 2001), as outlined in deadly than most other situations that confront sport Table 10.7. medicine workers. Athletes who experience concussion can safely Toth (2008) comprehensively reviewed the liter- resume sport participation if the return to play ature to identify neurological injury rates sustained

176 MANAGEMENT OF ACUTE SPORT INJURY Table 10.7 Characteristics of concussion grades Table 10.8 University of Pittsburgh’s signs and symp- (American Academy of Neurology 1997; Randolph 2001) toms of concussion (Lovell et al. 2004) Concussion Signs observed Appears to be dazed or stunned grade Identifying characteristics by medical staff Is confused about assignment Forgets plays 1 Transient confusion Is unsure of game, score, or opponent No loss of consciousness Concussion symptoms or mental status Moves clumsily abnormalities resolve in less than 15 minutes Answers questions slowly 2 Transient confusion Loses consciousness No loss of consciousness Concussion symptoms or mental status Shows behaviour or personality change abnormalities last more than 15 minutes Forgets events prior to play 3 Any loss of consciousness (retrograde) Forgets events after hit (post-traumatic) Symptoms Headache reported by Nausea athlete Balance problems or dizziness Double or fuzzy/blurry vision decisions are carefully made by healthcare pro- Sensitivity to light or noise fessionals using appropriate individualised clinical guidelines (Randolph 2001; Lovell et al. 2004; Feeling sluggish or slowed down American College of Sports Medicine 2006; Alla et al. 2009; Makdissi et al. 2009). However, such Feeling “foggy” or groggy evaluations are complex. Evidence suggests that athletes who sustain multiple concussions exhibit Concentration or memory problems cumulative neurological effects (Collins et al. 2002; Iverson et al. 2004), experience a substantial Change in sleep pattern (appears later) reduction in memory ability (Iverson et al. 2004) and demonstrate several pitchside neurological Feeling fatigued examination abnormalities (Collins et al. 2002) when compared to athletes with no history of the athlete from participation until concussion is dis- concussion. Moreover, return to participation prior proven or completely resolved because there is a risk to resolution of head injury symptoms heightens of cumulative neurological deficits in athletes who susceptibility to further concussive episodes, even sustain subsequent concussions, especially before if the subsequent trauma is relatively minor (Kersey resolution of the antecedent episode (Cantu 1988; 1998; Lovell et al. 2004; Mori et al. 2006). McCrory and Berkovic 1998). Prudence indicates that the sport rehabilitator and other healthcare pro- Acute evaluation of concussion fessionals maintain an emergency action plan that can be implemented as required when they are con- Concussion is not an easy diagnosis in the sport fronted with a head injured athlete. Consciousness, environment. The precipitating event may be asso- airway integrity, breathing and circulation are fun- ciated with neither direct head trauma nor loss of damental diagnostic signs to assess and act on. consciousness (Lovell et al. 2004). Players usually are anxious to return to the match/competition; thus, Presuming a non-emergency episode of potential they may not report a head injury or they may at- concussion, the sport rehabilitator should embark tempt to evade examination in favour of resuming on the history, inspection, palpation and special play. A wide variety of signs and symptoms must testing paradigm described previously. Appropriate be assessed, many of which are presented in Tables modification of these is warranted. For example, an 10.8 and 10.9. A consultant neurologist is invalu- athlete’s mental status may preclude their ability to able in this instance, and conservative management offer satisfactory answers to injury history questions. is paramount at all times. When in doubt, exclude (This substantiates the value of qualified pitchside healthcare practitioners for firsthand observation of an injury episode that provides key information to the evaluation.) The observation step coincides heav- ily with the special testing phase of the examination because so many of the special tests require visual

CONCUSSION 177 Table 10.9 American Academy of Neurology’s (1997) signs and symptoms of concussion. Reproduced, with permis- sion, from Table 1 and 2 from ‘Practice Parameter: the management of concussion in sports’ © American Academy of Neurology. Features of concussion Vacant stare (befuddled facial expression) frequently observed Delayed verbal and motor responses (slow to answer questions or follow Symptoms of concussion instructions) Confusion and inability to focus attention (easily distracted and unable to follow through with normal activities) Disorientation (walking in the wrong direction, unaware of time, date and place) Slurred or incoherent speech (making disjointed or incomprehensible statements) Gross observable incoordination (stumbling, inability to walk tandem/straight line) Emotions out of proportion to circumstances (distraught, crying for no apparent reason) Memory deficits (exhibited by the athlete repeatedly asking the same question that has already been answered, or inability to memorise and recall 3 of 3 words or 3 of 3 objects in 5 minutes) Any period of loss of consciousness (paralytic coma, unresponsiveness to arousal) Early (minutes to hours): Headache Dizziness or vertigo Lack of awareness of surroundings Nausea or vomiting Late (days to weeks): Persistent low grade headache Light-headedness Poor attention and concentration Memory dysfunction Easy fatigability Irritability and low frustration tolerance Intolerance of bright lights or difficulty focusing vision Intolerance of loud noises, sometimes ringing in the ears Anxiety and/or depressed mood Sleep disturbance interpretation by the examiner. Palpation in this because of the higher stakes for participants (e.g. instance is usually utilised to determine cranial stature, salary, importance of a given competition). or facial tenderness associated directly with the He offers a model for neuropsychological evaluation offending blow or muscular tenderness that results that is customised for each level and also recom- from reflexive contraction of the neck musculature mends baseline evaluations be collected from every when the head is struck. Table 10.10 outlines player, something which is clearly more feasible for diagnostic criteria for assessing concussion; this the professional clubs. information provides an excellent pitchside guide for the sport rehabilitator. Concussion case study There are important cautions for the sport reha- An 18-year-old North American football player ar- bilitator when evaluating the athlete with a closed rived at his university for the beginning of pre-season head injury. In his report of neuropsychological test- training. A typical training schedule was followed ing algorithms for suspected concussion in high with the players wearing only T-shirts, shorts and school, university and professional athletes, Ran- headgear for two days and then wearing headgear dolph (2001) identifies the increased sophistication and shoulder pads for the next few days in order necessary for each subsequent sport proficiency level

178 MANAGEMENT OF ACUTE SPORT INJURY Table 10.10 Pitch side evaluation of suspected concussion (adapted from the American Academy of Neurology 1997) Mental status testing Orientation Report time, place, person and situation External provocative (circumstances of injury) tests Concentration Count presented digits backward (e.g. 3-1-7, Neurologic tests 4-6-8-2, 5-3-0-7-4) Name months of the year in reverse order Memory Name the teams in prior match Recall 3 words and 3 objects at 0 and 5 minutes Recall recent newsworthy events Recall details of the match (plays, moves, strategies, etc.) Any appearance of associated symptoms is Complete 35 metre sprint abnormal, e.g. headaches, dizziness, Complete 5 push-ups nausea, unsteadiness, photophobia, blurred Complete 5 sit-ups or double vision, emotional liability or Complete 5 knee bends mental status changes Pupils Observe symmetry and reaction Coordination Touch finger to nose Touch right finger to left finger Observe tandem gait Sensation Touch finger to nose (eyes closed) Balance in Romberg test to acclimatise to the workload and environmental abnormal signs; otorrhea, rhinorrhea and Battle’s conditions. On the second day of training with the sign were all absent. No signs of serious injury were full complement of equipment the player partici- outwardly apparent. pated in a tackling drill and received a blow to the head that was hard, but not extreme. He was obvi- Concussion: palpation ously shaken by the play, and he came off the field to be evaluated by the medical staff. The player’s skull, cervical spine and neck muscula- ture were systematically palpated for areas of point Concussion: history tenderness that could indicate pathology. There was some tenderness in his right trapezius muscle along The player denied loss of consciousness – which was the neck, but all other areas were non-tender. corroborated by the medical staff who witnessed his collision and the events immediately subsequent – Concussion: special testing but he did report a mild instance of “seeing stars.” He was oriented to his surroundings and able to ac- The player’s vital signs were within normal limits at curately relate the circumstances of the injury. On baseline and continued so. Evaluations of the cranial questioning he indicated that his head felt “a little nerves were normal. Ocular tracking was normal, al- foggy.” He was slightly disoriented and his vision though the player mentioned needing to concentrate was unfocused for a few seconds. These symptoms to complete the task. His visual acuity was normal. resolved in less than five minutes. A mild headache He completed the Romberg test for balance success- was the player’s one enduring symptom. fully with his eyes closed. Motor coordination testing was normal. The player’s neck soreness was accen- Concussion: inspection tuated slightly by active resistive muscle testing for right lateral flexion and hyperextension of the cervi- The player’s pupils were of appropriate and equal cal spine. size and responsive to light. He did not exhibit any