General Medical Officer (GMO) Manual: Clinical Section
Sports Related Injury Management
Department of the Navy
Bureau of Medicine and Surgery
Sudden, traumatic, or acute injuries to the musculoskeletal tissue quickly result in inflammation, a process characterized by localized warmth, swelling, redness, and pain. If left unchecked, however, the inflammatory process rapidly leads to:
- Tissue congestion.
- Stiffness.
- Weakness.
- Decreased range of motion.
- Loss of normal function.
- A highly successful sports medicine approach to accelerate the healing of any injury is to first decrease the inflammatory process (swelling, pain, and warmth), then increase the range of motion at the joint. Approaches to achieving this goal are:
- Rest, Ice, Compression and Elevation (RICE).
- Range of motion (ROM) at the joint is achieved through the continued use of ice, stretching of the injured ligament or tendon, and weight bearing exercises.
- Ice, stretching, and exercise (ISE) reduces inflammation.
- RICE (rest, ice, compression, elevation) is appropriate for all strains and sprains. In general, if a patient cannot bear weight on the extremity, rest is indicated and x-rays to rule out a fracture should be completed as soon as practical.
- Rest means applying no weight or only partial weight to the extremity. Crutches should be used for locomotion. Relative rest means decreasing activities that cause pain and replacing them with other activities that are pain-free.
- Ice means applying ice to the injured area, in 20 min on 20 min off cycles. This will prevent a hypothermic injury. This should continue until swelling has stabilized.
- Compression means applying an Ace wrap or similar compression wrap to the injured part for periods of 2 to 4 hours. Never sleep with a compression wrap applied unless medically advised.
- Elevation means placing the injured part above the level of the heart; this allows gravity to help reduce the swelling and fluid accumulation.
Ice serves a variety of important roles in the treatment of training induced injuries including the following reasons:
- Reduces swelling that accompanies inflammation.
- Decreases muscle spasm and pain.
- Provides some pain relief during range of motion activities.
- Enhances blood flow back to the site after it has been removed.
Recommendations for the patient
The patient should not wait for a medical evaluation before using ice. All soft tissue or joint injuries, except open wounds, will benefit by the immediate application of ice. Ice can be applied either passively or actively. Passive application is when you take some form of ice: crushed ice, ice slush, an ice pack, or snow and apply it to the injured body part. Active application is when you take the ice (perhaps water frozen in a cup or bag) and massage the injured part with the ice. At home, a bag of frozen peas is an excellent way to passively ice the injured part, as the peas easily conform to the swollen area. After 20 minutes, the bag of peas can be tossed back into the freezer for application later. The normal response to ice includes cold, burning, aching and finally numbness over the affected part. This progression occurs over 7-10 minutes.
Apply ice to the area for 20 minutes as soon after the injury as possible. Repeat this every other hour the first day, then 3 times a day after the first day. Use ice until swelling decreases, usually 2-3 days. Caution: To prevent skin or nerve damage, do not keep ice on for more than 20 minutes, especially when applying to the elbow, wrist, or behind/ side of the knee.
The term "range of motion" is used to describe the extent to which a particular joint can be moved. Achieving complete range of motion is the goal, but sometimes injuries restrict the range of motion. During the 20 minute icing session, you should attempt to move the injured part through a pain-free range of motion (ROM). Days later or when pain free, you can attempt a resistance activity that stresses the injured part while moving the joint through a range of motion that can be tolerated. An example would be moving the ankle up and down against resistance applied by holding a towel under the foot. Continued elevation and use of a compression wrap while doing these exercises will retard swelling.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
NSAIDs are often used as the first treatment for overuse injuries because they are effective. NSAIDs decrease the symptoms due to inflammation (i.e. swelling, pain, tenderness, fever associated with injury). Although they are usually available over-the-counter, they are not a medication to take lightly. NSAIDs are used in training related injuries when there is inflammation caused by:
- Tendonitis.
- Bursitis.
- Sprains/Strains.
Important points about NSAIDs
In the case of an acute injury that involves bleeding (including bruising) or swelling, NSAIDsshould not be started for 2 to 3 days, until the bleeding has stopped and/or the swelling has stabilized.
NSAIDs may cause side effects. The most frequently reported side effects include: (A) Gastrointestinal distress such as nausea, heartburn, or vomiting (B) Gastrointestinal ulcers/bleeding (C) Increased blood pressure (D) Decreased ability of blood to clot (E) Exacerbation of asthma (F) Potential kidney damage with long-term use. Remember, NSAIDs should not be used, or should be used with caution in conjunction with alcohol, as both irritate the stomach.
Generic names (and common names) for various nonsteroidal anti-inflammatory agents:
Aspirin (Bayer, Aspirin, Ecotrin)
Ketoprofen (Orudis),
Diclofenac (Voltaren)
Moclofenamate (Meclomen)
Diflunisal (Dolobid)
Nabumetone (Relafen)
Etodolac (Lodine)
Naproxen (Naprosyn, Anaprox)
Fenoproten (Nalfon)
Oxaprozin (Daypro)
Flurbiprofen (Ansaid)
Piroxicam (Feldene, Antiflog)
Ibuprofen (Advil, Motrin)
Sulindac (Clinoril)
Indomethacin (Indocin, Indocin SR)
Tolmetin (Tolectin 200, Tolectin 600)
The goal for reconditioning is to get the patient to return to full activity. After the pain and swelling are reduced and the desired range of motion is achieved, the physician, therapist, or trainer should design a reconditioning exercise program with the overall goal of rapid return to full activity. The exercises prescribed will be specific to the site and type of injury, and will work towards the maximizing the following specific goals:
- Strength.
- Flexibility.
- Endurance.
- Power.
- Speed.
- Specific duty tasks.
Important points about reconditioning
Each step should be successfully completed in a step-wise manner before returning to unrestricted activity.
- Strength and flexibility are closely linked. If flexibility is not balanced around a joint, or strength is maintained through only part of the range of motion, the risk of delayed healing or re-injury is high.
- With respect to endurance, the muscle becomes quickly deconditioned during the body's repair process and fatigues easily. Endurance is important in an injured ankle for example, as it may feel strong when rested, but be prone to re-injury as the muscles and tendons become fatigued with activity. The strategies for any rehabilitation program include both improving individual muscle endurance while maintaining cardiovascular or total body endurance.
- In terms of power, a weak, deconditioned muscle is prone to re-injury when called upon to perform a power move. Strategies for developing power include rapid motion against resistance, use of rubber bands, medicine balls or weight machines.
- Sustained speed provides for reconditioning the injured part to anaerobic (without oxygen) activity and coordination of movement. Interval training (e.g. sets of 440 yards over 90 seconds) several times per week is an excellent supplement to the rehabilitation of a lower extremity injury, provided the patient performs the activity below the pain threshold. Continued use of ice and intermittent applicator of electrical stimulation, ultrasound and other therapeutic modalities will help accelerate the rapid return to full activity.
Ultimately, the patient must return to performing specific tasks required to complete the mission. This component of reconditioning MUST NOT be overlooked. Determine the specific mission related tasks or training that puts the patient at risk for re-injury. These tasks should be practiced at slower speeds in a controlled setting, and proficiency should be demonstrated prior to a return to full duty. The ultimate goal is to return the patient to controlled physical activity in 4-7 days for a mild to moderate injury, and 1 to 2 weeks for a severe strain or sprain.
General guidelines for resuming to physical activity
A number of general rules apply during the repair and reconditioning period. These include the following points:
- If the patient has pain with flexibility work, vary the degrees of motion.
- If there is pain with strength and power work, vary the repetitions and/or weight.
- If there is pain with endurance or speed work, vary the distance and/or time.
- If there is pain with specific mission related tasks, vary the quickness and/or time required to complete these tasks.
In summary, rehabilitation and reconditioning places it's greatest emphasis on rapidly decreasing pain and increasing range of motion about the injured joint by "RICE" and "ISE", followed by specific exercises to maximize flexibility, strength, endurance, power and speed, and using ice as necessary.
Types of Injuries
A variety of injuries can be encountered during physical training. In this section we will start with those problems that may be relatively minor, and cause mild discomfort, and then proceed to more serious injuries that may limit your activities.
Delayed soreness in a deconditioned muscle is normal, and is caused by micro-injury. Pain and tenderness typically appear 12 to 48 hours after beginning a training session. Stiffness and soreness are worse after the cool down and resolve again after warming up activities. This normal process usually persists for 7-12 days and then disappears.
A Process of Alleviating Muscle Soreness:
- Ice.
- Stretch.
- Extended Warm-Up.
- Work-Out.
- Stretch.
- Ice.
A blow to the muscle belly, tendon, or bony prominence may cause swelling and bleeding into the tissue and form a contusion. The blood may coagulate and eventually form scar tissue, impeding normal function. Passive ice therapy needs to be started as soon as possible. After swelling has stabilized, start with active icing and then use cross friction massage. This is a simple technique used to reduce the swelling and congestion. The thumb or index and long fingers are used to apply firm pressure perpendicular to the axis of the tendon or muscle. The injured part is rubbed in this manner for 10 minutes, four times a day.
Ligaments attach bone to adjacent bone, and can be damaged in a fall, an accident, or through overuse. Such injuries are called sprains and include acute back sprains, knee sprains, or ankle sprains. Sprains are graded as mild, moderate, or severe. Mild sprains refer to overstretching and micro-tears of the fibers. A partial tear with or without instability or looseness is considered moderate. A severe sprain implies a complete or near complete tear of tendon fibers that results in looseness or instability at the joint.
- A sprain is a damaged ligament. Ligaments attach bone to bone. An example is the talo-fibular or talo-tibial ligaments.
- A strain is an injury to a muscle or tendon. Tendons connect muscle to bone. Tendonitis is an inflammation of the muscle, tendon, and or bone insertion site.
- Mild to moderate sprains and strains heal without residual problems if treated early. Primary treatment includes ice and NSAIDs, partial weight bearing with crutches as necessary, and early therapy to maintain range of motion at the joint.
Muscle cramps are common and may be precipitated by prolonged physical activity, high heat and humidity (black flag conditions), dehydration, and/or poor conditioning. Cramps are characterized by the sudden onset of moderately severe to incapacitating pain in the muscle belly, and may progress to involve other adjacent muscle groups. The first treatment consists of immediate rehydration with a fluid containing electrolytes. After beginning rehydration, further treatment should consist of grasping and applying pressure to the muscle belly and immediately putting the muscle on stretch until the cramp resolves.
Flexing the foot toward the head for example, would stretch the calf muscle, whereas a thigh cramp would be treated by flexing the knee, bringing the foot to the buttocks. In addition to these procedures, adequate rest should help prevent recurrences.
A true fracture involves a break or chip in the hard outer surface of the bone. With few exceptions, true fractures of the lower extremity require a period of immobilization in a cast, and supervised care by a medical officer.
Stress fractures differ from true fractures and are most commonly seen in the load-bearing bones of the lower extremities, i.e. pelvis, femur, tibia, fibula, and bones of the foot. They are caused by excessive strain on the bone. Bone constantly undergoes remodeling and repairs in response to the stress of weight bearing. The repair process is accelerated by rest, and is slowed in times of heavy exercise as with runs, hikes, marches, and prolonged training. When the breakdown process exceeds the bone's ability to repair itself, a stress fracture may result. As the lower extremity bone becomes weakened, weight-bearing activity, such as running, may cause a vague, aching pain at or near the weakened site.
The first symptoms of stress fractures are initially poorly localized and often ignored. Later, as the process continues, the bone will become tender in a very localized area and will often ache at night or at rest. Ultimately, if left untreated, continued weight bearing may cause a true fracture within the weakened area of bone. Physical training factors that increase the risk for stress fractures include the following activities:
- A change in training surface (grass to asphalt, dirt to concrete).
- A change in shoe wear (worn out or new shoes, boots, or running shoes.
- An increase in physical activity (too much, too fast, too soon).
Important points about stress fractures
All suspected stress fractures should be evaluated and followed by the medical officer. Treatment includes:
- Reduction or avoidance of impact and load bearing activities.
- Partial weight bearing with crutches and advancing to full weight bearing when pain free.
This process typically takes 2 to 4 weeks. Stress fractures are usually not casted when strict non-weight bearing or partial weightbearing instructions can be assured. The reconditioning process should include swimming or water exercises (such as deep water running) to maintain flexibility and aerobic endurance. A program of lower extremity strengthening exercises should be started as soon as tolerated.
True fractures require a period of immobilization that varies depending on the bone involved. However, after the cast has been removed, the extremity should undergo a reconditioning program. After the weight-bearing restriction has been lifted, the individual can begin a reconditioning program for running. A return to running should ideally be initiated on a treadmill. This allows the individual to customize increases in duration and speed, while monitoring pain at the stress fracture site.
A typical "return-to-running" program
- Run on soft and even surfaces, treadmill, or track.
- Run 5 minutes at a slow pace and increase time by 2 minutes every other day.
- When running pain free for 15 minutes, increase pace.
- Advance to figure-of-eight runs, begin at 100 yard intervals and progress to tighter turns.
- Gradually increase distance.
- Resume regular running program.
It is not surprising that injuries occur during training and mission-related scenarios. Clearly, the type of injury will depend on the specific physical tasks and the environments under which the tasks are performed. Other than these platforms, many of the injuries are a result of activities all active duty populations participate in, namely swimming and running.
Swimming is a non-impact activity involving maximum tension on the muscle-tendon unit. Most injuries result from overuse and over training, rather than from one traumatic event. Consequently, once an injury occurs, healing can prove difficult.
- The older, experienced patient, faces the added challenge of tendons and joint capsules that are less resilient, muscles that take longer to warm up, and flexibility which is more difficult to maintain. All of these factors can lead to an increased risk of overuse and acute injury in this age group. The most common injuries arising from endurance swimming are sprains, strains and overuse injuries of the shoulder, knee, and back.
- Freestyle, butterfly, and backstroke place a great amount of stress on the shoulder joint. Use alternate or bilateral breathing on freestyle and be sure to get plenty of roll on backstroke. Before beginning a butterfly set, be sure you are well warmed up. This will allow the shoulder to stay in a more neutral position during the activity of arm recovery and this neutral position helps prevent what is known as "impingement syndrome." Freestyle swimming and kicking with a kickboard places a great amount of stress on the low back because of hyperextension; doing the backstroke relieves the stress. A pullbuoy is also helpful as it raise the hips and allows the spine to assume a more neutral posture.
- Kicking with fins may aggravate the knee (especially the knee cap), and result in a degenerative condition known as patellofemoral syndrome which commonly afflicts athletic individuals. The breaststroke kick helps balance the knee joint by increasing muscular tone on the inside of the quadriceps muscle and serves to balance the effect that running has; increasing muscular tone on the outside portion of the quadric muscle. However, the breaststroke may actually intensify iliotibial band syndrome. Swimmers may need to avoid doing breaststroke if they feel increased pain over the outside of the knee.
Running and Hiking
Running and hiking work large muscle groups and enhance cardiovascular fitness in a short period of time. Hiking transmits a force to the spine of approximately three times load-bearing weight. Running transmits an impact force to the spine of up to five times load-bearing weight. These forces are minimized with good body mechanics, shock-absorbing shoes and crosstraining for overall fitness.
Submitted by CDR J. Moore, MC, USN, Sports Medicine Specialty Leader, Naval Hospital Camp Lejeune, NC.