Injuries such as fractures and cruciate ligament tears tend to grab the headlines. The injured player needs surgery and can be out of play for a whole season. As we have mentioned before in ‘body of evidence', these types of injury form the minority of injuries overall. Soft tissue injury, such as muscle injury is more common, and the most common type to cause missed games in ball sports is damage to the hamstring.
We will look at a recently published paper in the British Journal of Sports Medicine where a group of experts agree upon the best means of treating muscle injury. Their suggestions are based on research and many years of experience in dealing with athletes and teams. A number of important messages which will be of use in every day practice are delivered:
1. Ice and compression:
Time is of the essence; an essential part of every pitch side kit bag should be bagged ice and compression bandage. The area should be immediately iced for 15-20 minutes, and then compressed. In the first 24 hours it should be re-iced for 10 minutes of every hour as often as practical. Remember ice can burn so prepare the skin with a little Vaseline or oil.
2. Early mobilisation & motion of the injured area:
We should try and keep the injured area mobile as much as possible (but not to the point of pain or aggressive stretching or overloading the muscle in question) even in the first 24 hours. This helps prevent shortening of the muscle (a natural protective response which may increase the time to recovery).
3. Early massage of the affected muscle :
This recommendation must be taken very much in context, if an injured muscle is massaged over the injured area in the first 72 hrs this may increase the risk of ‘myositis ossificans' the affected muscle is massaged away from the site of injury (in the hamstring; above and below the site of injury). Gentle massage to the affected muscle also helps to avoid the muscle shortening mentioned previously.
4. Imaging:
Examination of the injury is the most important means of assessing the extent but in many circumstances imaging may help to differentiate different muscle structures involved. Ultrasound examination has the benefit of allowing muscle to move while being examined but should be interpreted with extreme care as its accuracy depends on the experience and training of the operator. MRI (magnetic resonance imaging) is an excellent alternative which provides great anatomical detail, though it should be used in conjunction with, not instead of. Both provide an opportunity to measure the extent of damage which is useful in predicting return to play.
5. Strain Vs Muscle tear:
The time back to play is significantly shorter for a strain than a tear. A strain usually occurs early in a match, a tear (where there is actual fibre damage) is usually seen where muscle fatigue is a factor later on in the game and leads to a slower time to recovery. This may be palpable but can be differentiated well by either ultrasound or MRI scanning.
6. Early return to activity:
Early activity is beneficial but has to be tailored to the individual, the sport and the position played. A gradual re-entry to training avoids overloading of injured muscle and scar tissue. Unfortunately there is a minority who appear to have settled fully but on returning to play quickly fail. The mechanism of why this happens in some players and not others is currently not known. The player's chances are significantly improved, however, if they gradually build up activity under the guidance of the team conditioning and medical staff without undue pressure from management.
7. Anti-inflammatory medicines:
While normally the first line of treatment of all sports injuries, these medicines have recently come under scrutiny in a number of publications. While no clear guidelines exist their automatic use whatever the injury is certainly not correct. Concerns exist as to whether or not some of the inflammation (migration of inflammatory cells to the injury site) seen in tissue post injury is necessary and by blocking them (using anti-inflammatories) we may in fact slow healing. Using anti-inflammatories to ‘block' pain might also facilitate return to play too early and predispose to re-injury. Dr Tom Best (MD, PhD, Columbus, Ohio), a leading researcher in this area recommends not using antiinflammatories in the first 72 hrs post injury.
8. Infiltration therapy:
A more novel approach, not regularly performed in Ireland or the United Kingdom, is widely used in Germany and the continent. Local anaesthetic followed by a herbal compound Traumeel S, and a physiological amino acid mixture Actovegin are injected into, and in a line above and below, the area of injured muscle. These compounds are said to control certain aspects of inflammation which may be beneficial in minimising the early damage and subsequent loss of function.
Dr Mueller-Wohlfahrt, team physician to Bayern Munich and the German soccer team champions this work. Professional soccer players from all over Europe visit him in his clinic in Munich. Having visited his clinic it is clear that his methods are successful and may become a useful part of the tool kit of the sports physician in the future.
Muscle injury is common but provides one of the most difficult challenges a medical team faces. Application of the above principles often requires patience and success is improved when there is a ‘buy in' from all of the team, including conditioning, coaching and management.