As warm weather nears, many organizations ramp up sports programs and planning for summer training. Sport-related injury occurs frequently ranking as the second highest cause of injury (7). These injuries are often passed off as simple sprains or strains. Nevertheless, the athlete may feel “off” because of repeat injury or pain. These same injuries often effect performance and function when needed most. Complaints of ankle sprains, hamstring or groin strains, joint stiffness, rib pain, shoulder injuries, pain on running, etc., accumulate and are left untreated. The impact of these injuries can become a nuisance and set the stage for chronic pain patterns (7). While R.I.C.E. (rest, ice, compression, elevation) is an excellent first approach for athletic injuries, they can also be treated with soft-tissue therapy and joint manipulation.
Doctors of Chiropractic spend more time studying muscles and joints than the typical family doctor. In fact, they spend more time treating common muscle and joint injuries than the average doctor or orthopedist because many injuries respond well to conservative care. However, an orthopedist is your best choice in cases of severe injury with grade 3 ligamentous tears or compromised joint integrity. Nevertheless, a good orthopedic exam will help determine the difference.
Soft tissue therapy targeting muscles, tendons, and certain ligaments can alleviate painful movement, repetitive strains, and promote rapid healing. One study noted that half of the patients seen by 330 pain specialist, orthopedists, and rheumatologists were treated for myofascial pain. Most of these patients were prescribed medications and/or physical therapy. The doctors rated the effectiveness as moderate noting that treatment options were insufficient (1). But research shows that manual therapy for soft tissue pain and sport-related injury provides favorable outcomes (12).
Joint manipulation complements soft tissue treatment. Manipulation improves involuntary and voluntary coordination between muscles and joints that affect balance, coordination and performance. A recent review of scientific literature noted that hands-on care provides favorable results for many common sport related injury (12). The outcome is faster return to sport and consistent performance with less injury.
Shoulder injuries, for example, occur in 71% of athletes. However, shoulder injuries are often missed in general practice. This delays early treatment (2). The most frequent shoulder conditions involve the rotator cuff muscles, the shoulder joint—glenohumeral or acromioclavicular–and pain referral from the neck (2, 4). In fact, many athletes experience multiple shoulder problems simultaneously. This issue stems from delayed treatment. Consider that almost half of patients complain of persistent pain twelve months after initial consultation (2). Early and specific intervention is critical. The key factor lies in using a combination of shoulder tests to locate injury around the joint or inside the joint (2, 3). Injuries within the joint may require surgical intervention but can be rehabilitated depending on the severity of the injury. In either case, early and accurate treatment improves results. Initial treatment should include supervised rehabilitation including restoration of the scapular and arm movement. Correcting faulty movement patterns reduces pain and improves functional motion while reducing joint dysfunction associated with compensation (3, 5). Strengthening exercises do not decrease hypermobility–excessive joint movement–but they improve overall control and function. When conservative treatment fails, surgical options may be indicated (3, 4). However, research shows that conservatively treated patients experience less immobilization time (casting/slinging) and faster return to sport activities than patients undergoing surgery. Not to mention, the added advantage of avoiding complications associated with surgery (4).
Common elbow and wrist injuries can also be treated with manual therapy, manipulation and mobilization. For example, tennis elbow and golfer’s elbow respond well to various types of myofascial release and exercises targeting the muscle origins at the elbow. This approach provides better long term results than steroid injections (12). Wrist injuries can be rehabilitated using finger and wrist extension exercises as these tend to be weaker compared to the opposing muscle group. Moreover, joint manipulation/mobilization may add value to soft tissue treatment by improving communication between joints and muscles (12).
Many people do not realize that muscles stabilizing the back contract before limb movement. Gross motor movement is an orchestrated effect of smaller actions that depend on stable structures and appropriate muscle response. The spine acts as in important anchor for arm and leg motion. Remember that low back pain is prevalent, affecting 80% of the general population. Some sports like, football, tennis, and golf create excessive torque and stress to discs and joints. The spine was designed to withstand vertical loads, not twisting forces. In general, compressive (vertical) loads to unstable structures results in injury. This insult can accumulate with repetitive motion or result in significant pain when these motions occur abruptly. Also, motion that combines twisting with bending (either forward or backward), i.e. “corkscrewing”, sets the stage for potential injury. After repetitive movements, the body takes time to regain its original position. In the spine, this is known as creep. Creep reduces the resistance to load and interferes with the distribution of forces. In addition, torque generated from twisting the upper body instead of the hips creates rotational stress on discs and joints (6). Combined, these factors contribute to mechanical stress that promotes injury and affects involuntary muscle balance, coordination and response.
Moving down the body, knee injuries account for 40% of sport injury. Interestingly, over 70% of ACL injuries occur in non-contact situations that involve landing, decelerating and changing direction. Biomechanics research has also shown that unplanned cutting is identified as a risk factor of non-contact ACL injury. The rotation mechanism during pivoting movement also contributes to added stress on the knee. Some athletes rotate the upper body and thigh on pivoting. However, when the fore foot is sticking on the ground, the tibia is rotated internally–the opposite direction (7). This is example of torsional (twisting) stress on the knee and in particular the ACL. Repetitive stress causes micro injury in the ligament that can eventually lead to larger tears. While there is no direct treatment for torn or tethered ACL, functional stability determines return to sport. Conservative care might encompass decreased quadriceps inhibition (9), neuromuscular re-education, tibial manipulation, muscle activation as well as addressing the ripple effects on the spine caused by the lower kinetic chain (12). Functional stability can then be gauged in terms of jumping, cutting, quick stopping and pivoting (7).
Shin splints—medial tibial stress syndrome—represent another example of sport-related injury that effects performance. While you cannot manipulate shins you can mobilize the fibula and bones in the ankle that contribute to forces transferred to the shins. Cold laser treats inflammation (12). Soft tissue treatment addresses micro trauma to irritated muscles and ligaments. Lastly, balance exercises and eccentric strengthening may also help address dynamic stability of the ankle: another factor associated with shin splints (8, 9).
Sports related injuries affect more than joints and muscle. School sport concussions are gaining attention. Many states, including NY/NJ, are considering return to play legislation for concussion and head collision due to a high number of recorded injuries. The CDC estimates 300,000 head injuries every year. An internet search will yield significantly higher figures. The National High School Sports-Related Injury Surveillance Study reported 68,000 concussions in the 2008 football season. Those figures do not include unreported cases that increase the risk of repeat or more severe injury. One potential solution to this is “baselining” athletes. Baselining refers to a health screen before play or injury occurs. By pre-screening athletes, the doctor and coach can get a better sense for changes in neurological and mental status to determine safer return to play (11). Of importance, sports play a big role in inner-city life for the same reasons it predisposes this population to injury. Social-economic status often impacts health directly via access and affordability, as well as, indirectly in terms of emotional/physical stressors and nutritional choices. Ironically, sports provide a much needed distraction (11, 12). Thankfully, Wells Fargo joined forces with the Sport Concussions Institute (SCI) to introduce the first insurance policy specifically for scholastic sports concussions. “This removes the financial barrier for players to receive the specialty care they deserve, especially those from underprivileged communities who play high-velocity sports. The cost is very low – you can get $10,000 worth of coverage for about $4 per player per year, and it covers them across the entire season (11).” For more information search Play It Safe Concussion Care Program on the web.
In closing, consider these tips in preparation for spring sports.
- Don’t wait to address “sprains” or “strains.” These generally do not require intensive treatment. Early intervention keeps the athlete performing well and avoids chronic injury.
- Adding core and functional exercises to a fitness regime will help increase dynamic stability of the spine that acts as the anchor for all arm/leg movement.
- Neuromuscular training helps the body respond to unplanned motion.
- Understanding body mechanics helps avoid injuries.
- Joint manipulation improves communication between joint motion and muscle response.
- “Baselining” athletes provides a good tool for quicker/safer return to play.
- Anti-inflammatory nutrition plays a critical role in rapid healing.
- Fleckenstein J, Zaps D, Ruger LJ, Lehmeyer L, Freiberg F, Lang PM, Irnich D. Discrepancy between prevalence and perceived effectiveness of treatment methods in myofascial pain syndrome: Results of a cross-sectional, nationwide survey. BMC Musculoskeletal Disorders 2010, 11:32.
- Fowler EM, Horsley IG, Rolf CG. Clinical and arthroscopic findings in recreationally active patients. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2010, 2:2.
- Kim S. Multidirectional instability of the shoulder – current concept. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2009, 1:12.
- Gumina S, Carbone S, Arceri V, Rita A, Vestri AR, Postacchini F. The relationship between chronic type III acromioclavicular joint dislocation and cervical spine pain. BMC Musculoskeletal Disorders 2009, 10:157
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- Lam M, Fong DT, Yung PS, Ho EP, Chan W, Chan K. Knee stability assessment on anterior cruciate ligament injury: clinical and biomechanical approaches. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2009, 1:20.
- Raissi GD, Safar Cherati AD, Mansoori KD, Razi MD. The relationship between lower extremity alignment and Medial Tibial Stress Syndrome among non-professional athletes. Sports Medicine, Arthroscopy, Rehabilitation, Therapy & Technology 2009, 1:11.
- Alfredson H, Pietela T, Johnsson P, Lorentzon R. Heavy Load Eccentric Calf muscle training for the treatment of Chronic Achilles tendonosis. The American Jouranl of Sports Medicine. May 1998, 26 (3).
- Suter E, McMorland G, Herzog W, Bray R. Conservative lower back treatment reduces inhibition in knee-extensor muscles: a randomized controlled trial. J Manipulative Physiol Ther. 2000 Feb;23(2):76-80.
- SAMSON, K. School Sport Concussions Draw National Attention as More States Draft Return-to-Play Laws. Neurology Today: 4 March 2010 – Volume 10 – Issue 5 – pp 1,12–13.
- Parker R, Jelsma J. The prevalence and functional impact of musculoskeletal conditions amongst clients of a primary health care facility in an under-resourced area of Cape Town. BMC Musculoskeletal Disorders 2010, 11:2.
- Bronfort G, Haas M, Evans R, Leiniger B, Triano J. Effectiveness of manual Therapies: The UK Evidence report. Chiropractic & Osteopathy 2010, 18:3
- Murphy DR, Hurwitz EL. A theoretical model for the development of a diagnosis-based clinical decision rule for the management of patients with spinal pain. BMC Musculoskeletal Disorders 2007, 8:75
- Murphy DR, Hurwitz EL, Nelson CF. A diagnosis-based clinical decision rule for spinal pain part 2: review of the literature. Chiropractic & Osteopathy 2008, 16:7
- Seaman D. Clinical Nutrition for Pain, Inflammation, and Tissue Healing. NutrAnalysis, Inc., 1998