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Understanding & Managing Bone, Muscle, and Joint Trauma
By Shihan Don Corrigal
What is a contusion?
A contusion (bruise) is an injury to the soft tissue often produced by a blunt force such as a kick, fall, or blow. The immediate result will be pain, swelling, and discoloration.
What is a sprain?
A sprain is a wrenching or twisting injury to a ligament. Sprains often affect the ankles, knees, or wrists.
What is a strain?
A strain is an injury to a muscle or tendon, and is often caused by overuse, force, or stretching.
Other conditions commonly seen with sports and athletics include the following:
Lateral epicondylitis
Lateral epicondylitis, also known as tennis elbow, is characterized by pain in the back side of the elbow and forearm, along the thumb side when the arm is alongside the body with the thumb turned away. The pain is caused by damage to the tendons that bend the wrist backward away from the palm. A tendon is a tough cord of tissue that connects muscles to bones.
Medial epicondylitis
Medial epicondylitis, also known as golfer's elbow, baseball elbow, suitcase elbow, or forehand tennis elbow, is characterized by pain from the elbow to the wrist on the palm side of the forearm. The pain is caused by damage to the tendons that bend the wrist toward the palm. A tendon is a tough cord of tissue that connects muscles to bones.
Lumbar strain
A lumbar strain is an injury to the lower back, which results in damaged tendons and muscles that spasm and feel sore. Trauma of great force can injure the tendons and muscles in the lower back. Pushing and pulling sports, such as weight lifting or football, can lead to a lumbar strain. In addition, sports that require sudden twisting of the lower back, such as basketball, baseball, and golf can lead to this injury.
Patellar tendonitis
Patellar tendonitis, also known as Jumper's knee, is a condition characterized by inflammation of the patellar tendon, which connects the kneecap to shin bone (tibia). The condition may be caused by overuse of the knee joint, such as frequent jumping on hard surfaces.
Patellofemoral stress syndrome
Patellofemoral stress syndrome, also known as Runner's knee, is a condition characterized by the kneecap rubbing against the thighbone (femur) when moving. Runner's knee may be caused by a structural defect, or a certain way of walking or running.
Fractures
Fractures are breaks in the bone that are often caused by a blow or a fall. A fracture can range from a simple hairline fracture (a thin fracture that may not run through the entire bone) to a compound fracture, in which the broken bone protrudes through the skin. Most fractures occur in the arms and legs.
Stress fractures
Stress fractures are weak spots or small cracks in the bone caused by continuous overuse. Stress fractures often occur in the foot after training for basketball, running, and other sports. The bones in the midfoot (metatarsals) in runners are especially vulnerable to stress fractures.
Dislocation
A dislocation occurs when extreme force is put on a ligament, allowing the ends of two connected bones to separate. Ligaments are flexible bands of fibrous tissue that connect various bones and cartilage. Ligaments also bind the bones in a joint together. Stress on joint ligaments can lead to dislocation of the joint. The most commonly dislocated joint is the shoulder.
Rehabilitation for sports injuries:
A rehabilitation program for sports injuries is designed to meet the needs of the individual patient, depending upon the type and severity of the injury. In order to help reach these goals, sports injury rehabilitation programs may include the following:
Activity restrictions
Physical or occupational therapy
Exercise programs to stretch and strengthen the area
Conditioning exercises to help prevent further injury
Heat or cold applications
Applications of braces, or splints to immobilize the area
Pain management techniques
Education
The sports injury rehabilitation team:
Rehabilitation programs for sports injuries are usually conducted on an outpatient basis. Many skilled professionals are part of the sports injury rehabilitation team, including any/all of the following:
Orthopaedist/orthopaedic surgeon
Physiatrist
Physical therapist
Occupational therapist
Exercise physiologist
Sports medicine specialist
Athletic trainer
Parent
Spouse
Significant other
Etiology of Soft Tissue Injuries, Direct and Indirect Trauma
Many soft tissue injuries come from direct trauma such as being struck by a moving object or a fall; other injuries may be classified as indirect trauma and result from overloading or chronic overuse, thus giving us the classification of direct and indirect etiology. Indirect can be further divided into three sub-classes: acute -- which occurs from sudden overloading as seen in many lifting injuries; chronic or overuse -- which are often seen in many assembly line or factory workers who must perform repetitive movements hundreds of times daily; acute on chronic -- occurs when a chronic conditions hits an acute phase. This third sub-class is also very common in the work environment where the same job is performed day in and day out. By first defining the etiology of a condition, we are on the proper course toward treatment and the prevention of further injury.
Phases of Healing -- Phase I
The current literature describes three main phases of soft tissue healing. An initial reaction phase which lasts up to 72 hours post-injury. This phase is also referred to as the acute inflammation phase. The reaction phase displays with the classic signs of inflammation with pain, swelling, redness and warmth.
The long-used application ice is still supported by numerous studies as very effective treatment in this initial phase. Ice slows the inflammatory process as well as provides an analgesic effect. Ultrasound may also be used to decrease swelling in this inflammatory phase, but must be used for short periods to prevent hyperemia. The use of continuous passive motion (CPM) has been shown to clear blood present in the synovial joints (hemoarthrosis) post-trauma during the initial reaction phase. In the 24 hours following trauma, the synovial fluid in joints treated with CPM displayed less blood than immobilized joints. At 48 hours the joints treated by CPM demonstrated the synovial fluid was clear where as the immobilized joint remained grossly bloody.
The use of manipulation can also be employed in the reaction phase. This will expedite the removal of hemoarthrosis, reduce spasms, edema and pain as well as reduce nerve root irritation when present. When free mobility was encouraged from the onset, the fibers in the scar were arranged lengthwise as in a normal ligament. Gentle passive movements do not detach fibrils from their proper formation at the healing breach, but prevent their continued adherence at abnormal sites.
In the initial reaction phase, the use of CPM and manipulations (which are both mobilization techniques) must be used in a controlled protective manner to prevent any further damage to the healing ligaments.
Phase of Healing -- Phases II and III
The second stage of healing, the repair phase, may last from 48 up to 6 weeks. This phase is characterized by the production and laying down of new collagen. During this phase, the collagen is not fully oriented in the direction of tensile strength.
The third phase, the remodeling phase, which lasts from 3 weeks to 12 months or more, is the phase in which the collagen is remodeled and along with phase II determines the functional capabilities of the soft tissue after the healing process is completed. True rehabilitation must focus on maintaining these functional capabilities. Oakes describes the aims of rehabilitation as regaining pain-free movement with full strength, power and range of motion, thus describing the functional capabilities of the soft tissue.
To regain the functional capabilities, stresses of function must be put on the healing tissue. If a limb is completely immobilized during the recovery process, the tissues may emerge fully healed but poorly adapted functionally with little chance for change, particularly if the immobilization has been prolonged. Mobilization techniques must take place throughout the repair and remodeling phases to insure proper tissue adaptation. Several benefits of mobilization have been defined which include increased strength and flexibility of healed tissue, less scar formation and adhesions increased cartilage nutrition and lesser incidence of recurrence of injury.
Rehabilitation Protocol
Rehabilitation protocol following soft tissue injury must include mobilization techniques to insure good functional adaptation. A program combining manipulations, the use of modalities, mobilization technique, and a strengthening program will insure optimal rehabilitation.
Manipulations and modalities should be used during all three phases of healing to limit fixations, control pain and spasms as well as maintain neurologic integrity. Mobilization should be carried out within the limits of pain on the patient, starting with controlled passive motion. Controlled passive motion should be employed until a maximum range of motion is reached. At this point, active assistive motion should be employed. As the injury heals and the tissue adapts, the patient can be graduated to active resistive motion. A strengthening program of kinetic resistive exercise should follow active resistive motion. This will insure a return to maximum strength for the patient. Keep in mind all rehabilitation should be performed within the patient's limits of pain and periodic re-evaluation and testing such as muscle testing and surface EMG should be performed to evaluate the patient's progress. Also remember that the final remodeling phase can last over a year post injury; rehabilitation should be directed accordingly.
By following this rehabilitation protocol and progression, a return to maximum functional capabilities can be insured, returning the patient to maximum pain free range of motion and strength.
First Aid For Sprains And Strains
Sprains and strains are two different types of injuries but the first aid treatment is the same for both. If you suffer from symptoms of a sprain or strain, keep the word RICE in mind: Rest, Ice, Compression, and Elevation. It is important to remember that in all but the mildest of cases, a medical doctor must evaluate the injury to establish a treatment and rehabilitation plan.
Rest - The first and most important part of the treatment is resting Discontinue use of the injured joint immediately. Immobilize the injured muscle or ligament to help stop internal bleeding. Surround the injured area with pillows, towels, or rolled-up blankets, and keep it still for the first day by using splints.
Ice - Apply ice to the affected joint as soon as possible after the injury occurs to reduce swelling and pain, and to minimize the inflammatory process. (A bag of frozen peas makes a good ice pack.) The cold slows down the blood flow to the area reducing swelling and pain. Always place a cloth between the ice and your skin to prevent frostbite. Apply the ice pack for 10 minutes out of each hour or two for the first day, or as long as the doctor recommends.
Compression - compression also helps reduce swelling and prevent bleeding. Wrap the injured joint with an elastic bandage the bandage should be worn during periods of activity – preferably following ice application and elevation. It should not be worn while sleeping. The bandage should be applied from the furthest point of the body to the closest. For example, an injured ankle should be wrapped from the toes toward the knees; an injured wrist, from the fingers toward the elbow; and an injured knee, from the calf toward the thigh.
Elevation - Elevating an injured joint will help reduce the pain, swelling, and bruising by draining fluids from the swollen area The joint should be elevated during ice application and prior to applying compression. The injured area should be placed higher than the heart.
You can take care of most muscle strain at home. You can even treat bruised muscles at home. If a child gets a bruise on a joint (the knee, hip, or elbow), most of the time it is not serious.
Broken bones need care by a doctor. Twisting injuries of the ligaments between the muscles also need a doctor's care.
How to care for a child's pulled or sore muscles. :
Massage the sore muscles with ice for 10 minutes. Repeat this three to four times the first day.
If the muscle is still stiff after 48 hours, have your child soak in a hot bath for 20 minutes. If the pain is in one certain area, use a heating pad or hot, wet washcloth. Apply heat for 10 minutes, three times a day until the pain goes away.
Have your child do stretching exercises. Have your child get back to exercise a little at a time.
How to care for a child's bruised muscle or bone:
Put an ice bag on the area for 10 minutes. Or massage it with ice cubes for 10 minutes. Repeat this three to four times the first day. After 48 hours, apply heat with a heating pad or hot, wet washcloths for 10 minutes, three times a day.
Make sure your child rests as much as he or she can for the first 2 days.
Call the doctor during office hours if:
The pain is not getting better by the third day.
The pain is not gone by 2 weeks.
There are other concerns or questions.
Final tip
Premature return to full activity may slow down the healing process and lead to a re-injury. Carefully follow a physician's advice for resuming normal activities. In general, the return to full activity should be done gradually.
