Chapter 3: Injuries and The Healing Process

EDUCATIONAL OBJECTIVES

The learner should, at the completion of the chapter, be able to perform the following:

Successful management of athletic injuries requires an understanding of what happens within the body in response to an injury. An awareness of how healing subsequently occurs is also required. With this understanding and awareness, the student athletic trainer can do more than take a textbook approach to first aid and follow-up treatments. Treatments can be individually structured to each athlete and to the body part injured. In this chapter, basic principles of healing will be discussed. The student athletic trainer will then be able to apply these principles to each of the anatomical sections covered in the following chapters. A complete understanding of this chapter is necessary before advancing to further chapters.

THE INFLAMMATION PROCESS

When an athletic injury occurs, whether it is a strain, sprain, contusion, or open wound, the body immediately begins a process that eventually results in healing. This process is known as inflammation. In an acute injury, such as a muscle strain or ligament sprain, tissue is torn, capillaries are damaged, and cells die because of the interference in the blood and oxygen supply.

In response, the body reacts by sending specialized cells into the injury area in an attempt to limit damage and to begin healing. Among the functions of these cells is the initiation of blood clotting. In an attempt to limit the size of the damaged area, the body also reacts by contracting muscles in the injured area. This involuntary muscle spasm splints the area to restrict further movement and also reduces the local blood flow.

In acute injuries, the trauma and the body's reaction to the trauma result in pain, swelling, redness, heat and loss of function. The pain is caused by increased pressure on nerve endings from internal hemorrhage and from the cellular response to lack of oxygen. Swelling, or edema, is caused by the accumulation of fluids in the damaged area. Hemorrhage, lymph fluid, and synovial fluid contribute to the swelling, increasing pressure on nerve endings. Gravity could also increase swelling if the limb is not elevated. Redness and a feeling of heat (warmth) occur once the healing process begins. The redness is due to the increased blood supply as the body attempts to provide the injury site with nutrients for repair. Loss of function will result in the athlete’s inability to utilize the injured anatomical structure.

When referring to an athletic injury, removal of unwanted items from the injured area precedes rebuilding. All the fluids and dead cells that have resulted in swelling must be removed from the injury site by the circulatory and lymphatic systems before oxygen and nutrient-supplying capillaries can be formed to assist repair. Removing the waste products and allowing oxygen and other nutrients to get to the damaged area will create a good environment for the formation of replacement tissue. Scar tissue is usually the end result due to ideal situations for regeneration not often being present.

VITAL SIGNS

When evaluating an injured athlete, it is essential that the athletic trainer have a sound understanding of how to check the athlete’s vital signs and the standard values for the vital signs. By knowing what the standard values are, the athletic trainer will be able to distinguish whether an athlete’s vital signs are abnormal. Vital signs would be evaluated in the primary survey of an emergency evaluation and, if necessary, are monitored throughout the entire evaluation and the initial treatment.

Pulse: Adult 60-80/minute, Child 80-100/minute

Rapid but weak pulse could indicate shock, bleeding, diabetic coma, and/or heat exhaustion. A rapid and strong pulse typically indicates heat stroke and/or severe fright. A strong but slow pulse usually indicates a skull fracture and/or stroke. No pulse indicates cardiac arrest and/or death. The two most convenient sites for taking the pulse are the neck (carotid artery) and the wrist (radial artery).

Respiration: Adult 12/minute, Child 20-25/minute

Breathing that is shallow usually indicates shock. Irregular or gasping breath could be cardiac related. Frothy blood from the mouth typically indicates a chest fracture (rib fracture) in the upper lateral portion of the chest (arm pit). Measurement for respiration is taken by watching, feeling and counting the rise and fall of the chest.

Temperature: Oral 98.6 F, Rectal 99.6 F, Axillary 97.6 F

Hot, dry skin usually indicates disease, infection, and/or over-exposure to environmental heat. Typically, cool, clammy skin is an indicator of trauma, shock, and/or heat exhaustion. Overexposure to cold is displayed by cool, dry skin.

Skin Color

Red skin indicates heat stroke, diabetic coma, and/or high blood pressure. White (pale) skin means that the individual has insufficient circulation, shock, fright, hemorrhage, heat exhaustion, and/or insulin shock. Blue (cyanotic) skin indicates circulated blood is poorly oxygenated. The non-white athlete will still exhibit a paling of the skin, but you should examine the inner lip, gum area and fingernail beds.

Pupils: Constricted (sunlight), Dilated (dark room) or Unequal

In traumatic situations, pupils that are constricted usually indicate injury to the central nervous system and/or intake of a depressant drug. Dilated pupils (one or both eyes) could indicate head injury, shock, heat stroke, hemorrhage, and intake of a stimulant drug. When pupils fail to accommodate to light or are unequal this could indicate brain injury, intake of alcohol, or drug poisoning.

State Of Consciousness

When evaluating an individual’s state of consciousness, three items to review are the athlete's mental awareness, memory and ability to recall, and response to commands, such as direction, events, etc.

Movement

Movement is classified into four basic patterns: Active (athlete provides movement), Passive (athletic trainer moves the body part), Assistive (athlete trainer assists the athlete with movement) and Resistive (athletic trainer provides resistance to oppose the movement of the body part).

Abnormal Nerve Stimulation

When evaluating nerve stimulation, always check for motor (movement) and sensory (feeling) to determine if the affected area has nerve damage. Ensuring that the athlete is able to contract the affected muscle confirms this. To check sensation, have the athlete touch will distinguish the quality of sensation (i.e. sharp vs. soft).

Blood Pressure: 120/80

When the heart contracts, systolic pressure can be determined; as the heart relaxes, diastolic pressure can be determined. Normal blood pressure in healthy adults is usually 120/80 (systolic/diastolic).

TREATMENT RATIONALE: ICE VS. HEAT

When treating athletic injuries, selection of ice or heat application as a modality is critical. In most situations, ice should be used for the first 48 to 72 hours. Then, re-evaluate the injury and determine if pain, swelling and redness are present. If they exist, continue the use of ice. The philosophy of the medical staff will indicate when to use ice or heat. Listed below is a brief outline of types of ice and heat applications.

Application of ICE

The basic physiological changes that occur through the use of ice on an injury include:

Cold Packs: Cold packs can be used for initial first aid or follow-up treatments. After placing crushed ice in a plastic bag, place a wet towel between the ice pack and affected body part and apply for a ten- to fifteen- minute period. This is the most economical way. Because of' the danger of frostbite, the ice pack should not be applied directly to the skin. Also, the cold pack should be placed on the injury, not under the body where pressure can magnify possible damaging effects such as blistering or burning. Over a period of time, reusable cold packs may be more convenient than ice. Instant cold packs are also available for times when pre-frozen packs are not practical, but these are expensive and chemical burns can result if a leak occurs in the container.

Ice Massage: The technique of rubbing ice over an injured area is called ice massage. Applied by the athletic trainer or athlete, this treatment is applied directly to the skin. A paper or insulated cup is filled with water, then frozen. The cup is gradually peeled back as the athlete massages the injury site and the ice melts. The treatment should last from 5-10 minutes depending on the depth and severity of the injury. To prevent skin damage the athlete should move the ice cup continuously with a circular or back-and-forth motion. Ice massage should be avoided over bony areas.

Cold Whirlpool/Cold Water Immersion: Before immersing the injured extremity in cool water, the water temperature in a whirlpool tank or bucket should be 50-65 degrees. Under supervised conditions, the injured extremity is kept in the cool water for five to fifteen minutes. In certain situations, a thermal barrier is placed around the extremity for patient comfort. With physician approval, the injured athlete then performs rehabilitation movements. The whirlpool offers a massaging effect.

Cold Spray: In certain situations, the use of cold sprays (ethyl chloride) can be beneficial. Using caution, apply the spray to the affected area for no longer than 10 seconds. Since damage to the skin can occur, read the instructions prior to application. The application of cold spray to an injury will assist in reducing pain and swelling. Because this technique only cools the surface, it is not nearly as effective as cold treatments. In certain supervised situations, this application of ice is utilized in spray and stretch techniques.

Application of HEAT

The basic physiological changes that occur through the use of heat on an injury includes:

Hot Packs: Pre-heated commercial hot packs are an efficient way to apply moist heat. Towels are used to insulate the pack and protect the skin from burning. Towels soaked in very hot water have the same effect as hot packs during the period of follow-up treatments, provided that proper insulation is placed between the skin and the heat.

Hot Whirlpool: Also used for cold water immersion, the whirlpool bath is a popular method for warm water immersion. Used as a follow-up treatment, the disadvantages of whirlpool treatment include placing the injured part in a non-elevated, dependent position. Also, the equipment must be thoroughly cleaned daily to prevent the spread of disease. Duration of the treatment and temperature depend on the area of the body to be treated. Buckets of warm water can provide the same water-immersion effect as whirlpools. However, the whirlpool also offers a massaging effect.

Application of ICE and HEAT

Contrast Bath: The contrast bath is a follow-up treatment that combines hot and cold water immersion. In a non-gravity dependent position, the use of moist heat pack and cold/ice packs are commonly utilized. Many types of injuries that have an increased amount of swelling seem to respond to the alternating of cold and heat. This type of treatment provides a pumping action, which assists in the removal of waste products caused by swelling.

ADDITIONAL THERAPEUTIC TECHNIQUES

Exercise: Too often, EXERCISE is overlooked as a treatment. The movement of the body by the muscles increases circulation at a deeper level than the modalities that have been discussed. Exercise is used to maintain or increase strength and to regain lost range of motion in order to assist in the healing process.

Therapeutic Modalities: Various electrical modalities are used to decrease pain, swelling, and muscle spasm. Therapeutic modalities may be utilized as adjuncts to therapeutic exercise by decreasing pain and swelling and by enhancing range of motion, strength and flexibility. Modalities may consist of heat, cold, light, air, water, massage and electricity. When determining which modalities to use, target the tissue to be treated, determine desired treatment effect and again, look for indications and contraindications. Below is a brief list of commonly utilized modalities:

Massage: Because the friction of massage increases the temperature of the tissues and, therefore, increases local circulation, massage can be considered a heat treatment. Massage is used as a follow-up treatment for musculoskeletal injuries and for scar tissue/adhesion breakdown. Besides increasing temperature, a massage can help to relax a muscle spasm in injured muscles. As with other heat treatments, massage started too soon after an injury can restart internal bleeding. Additionally, massage is often used as an adjunct to stretching and warm-up exercises in many sports and can assist the body in the removal of toxins from an injured site.

Counterirritants: Counterirritants are substances which, when applied to the skin, cause a reaction. This reaction can produce a sensation that is stronger than the sensation of minor pain. Long used by athletes, analgesic balms irritate the skin to provide a perception of warmth, which can help relax tight, aching muscles. Penetration of these analgesics is minimal. Their advantages include ease of application and availability. By covering the analgesic balm with a plastic-backed compress roll, the athletic trainer creates an analgesic pack. The pack can provide relief and a feeling of warmth to an athlete for hours. The compress roll also protects the clothes from staining. Some counterirritants can also provide a cooling sensation. Care should be taken not to apply counterirritants to an opened wound.

Joint Mobilization: This technique is used to improve joint mobility by restoring accessory movement to allow non-restricted, pain-free range of motion. Under the direction of a highly qualified and trained allied health professional, joint mobilization is an effective therapeutic treatment.

ACUTE VS CHRONIC INJURY MANAGEMENT

Acute Injuries:

Regardless of the mechanism of injury, the student athletic trainer's response to an acute injury should include the basic treatment of protection, rest, ice, compression, elevation, and support (P.R.I.C.E.S.), followed by referral to a physician. Listed below is a brief description of the P.R.I.C.E.S. protocol.

Protection: Once an injury has occurred, protect that injury from further damage by removing the athlete from participation.

Rest: After the evaluation is completed, rest the injury. The length of rest is dependent on the severity of the injury, therefore rest could easily be longer than 24 hours.

Ice: Apply cold to the injured area. This will aid in controlling bleeding and the associated swelling. Apply in one of two ways:

Compression: Utilizing a compression wrap to control swelling, begin the elastic wrap distally (farthest from the heart) to the injury and spiral the wrap toward the heart. Remove the wrap every 4 hours. Note: Compression wraps applied too tight could interfere with circulation or nerve function. Signs and symptoms include extremities turning blue or pink, numbness and tingling of extremities, and increased pain.

Elevation: Keep the injured body part elevated higher than the heart. This will allow gravity to keep excessive blood and associated swelling out of the injured area.

Support: Various techniques can be used to support an injury. If necessary, place the injured athlete on crutches for a lower extremity injury or use of a sling for an upper extremity injury. This external support will allow the injury to be managed with better control.

Chronic Injuries

The management of chronic injuries is characterized by the continued use of PRICES, but is coupled with exercise, therapeutic modalities, heat, and contract bath treatments. Even though these injuries can be challenging, the athlete's return to physical activity without chronic pain and disability if important.

PHYSICAL REHABILITATION

The goal of a sound physical rehabilitation program is to return the injured athlete to pre-injury levels of strength, power, endurance, flexibility, and confidence as quickly and safely as possible. A rehabilitation program focuses on the injured body part and also with preventing de-conditioning of the rest of the body. If the athlete returns to activity without undergoing physical rehabilitation, that athlete could easily become re-injured. Typically, the injured athlete is an exceptional patient, motivated to get well and to overcome the injury. Some athletes will need encouragement daily during their rehabilitation, while others will need to be restrained from trying to rush their recovery. Open communication between the coach and the sports medicine team members regarding the athlete’s progress is critical.

In an ideal situation, the athletic trainer will arrange an individual rehabilitation program based upon the physician protocol standards. After approving initiation of the program, there are two principles that must be observed: pain should be avoided, and the athlete must be encouraged to follow the program. However, an aggressive rehabilitation program will require a particular exercise program by the athlete at a level slightly less than what causes pain. Daily adherence to a rehabilitation program benefits the athlete in several ways. First, the athlete stays in the habit of working out. Also, daily exercise will result in tangible results; missing even one day can affect strength or conditioning. Psychologically, the athlete will feel better about himself/herself if allowed to participate in his/her own recovery, rather than watching practice. The athletic trainer should set specific times each day for the athlete to work on the rehabilitation program. A comprehensive rehabilitation program is critical to the injured athlete. In designing this program, the following five phases of physical rehabilitation need to be addressed.

An athlete will move through all five phases of the rehabilitation program on the way to complete recovery. The athletic trainer must keep in mind that each athlete and each injury is different. Various rates of recovery should be expected.

While rehabilitation uses prescribed exercise to return individuals to activity, rehabilitation techniques can also help prevent injuries. In planning a physical rehabilitation program, the athletic trainer must deal with decreasing pain, effusion, and inflammatory response to trauma. Once this is addressed, returning the athlete to a pain-free, active range of motion that will increase muscular strength, power, and endurance to the injured anatomical structures is critical. The three basic components of any physical rehabilitation program are:

    1. Therapeutic exercise
    2. Therapeutic modalities
    3. Athlete education
When determining the purpose of an exercise, always consider joint range of motion, muscle flexibility, muscular strength, power and endurance, balance, proprioception, and kinesthetic awareness and cardiovascular fitness (total body conditioning). Progressive resistive exercises are used to increase muscular strength, power, and endurance.

RANGE OF MOTION

Assessing joint range of motion (R.O.M.) is critical in evaluating injuries. The athletic trainer should gain experience in using a goniometer, an instrument that objectively measures joint range of motion. Typical ranges of motion for anatomical joints are.

Ankle
Dorsiflexion - 20 degrees
Plantarflexion - 45 degrees
Inversion - 40 degrees
Eversion - 20 degrees

Knee
Flexion - 140 degrees
Extension - 0 degree

Hip
Flexion - 125 degrees
Extension - 10 degrees
Adduction - 40 degrees
Abduction - 45 degrees

Shoulder
Flexion - 180 degrees
Extension - 45 degrees
Adduction - 40 degrees
Abduction - 180 degrees
Internal Rotation - 90 degrees
External Rotation - 90 degrees

Elbow
Flexion - 140 degrees
Extension - 0 degrees

Forearm
Pronation - 80 degrees
Supination - 85 degrees

Wrist
Flexion - 80 degrees
Extension - 70 degrees
Adduction - 45 degrees
Abduction - 20 degrees
 

GENERAL MUSCULOSKELETAL DISORDERS

When treating injuries, an understanding of specific disorders is important. Review these disorders and discuss the specific treatment required with your certified athletic trainer and team physician.

Arthritis: inflammation of a joint
Atrophy: decreasing in size of a developed organ or tissue due to degeneration of cells
Bursitis: inflammation of a bursa sac
Contracture: fibrosis of muscle tissue producing shrinkage and shortening of the muscle without generating any strength
Contusion: a bruise; an injury usually caused by a blow in which the skin is not broken
Dislocation: displacement of one or more bones or a joint, or of any organ from the original position
Epicondylitis: inflammation of the epicondyle and the tissues adjoining the epicondyle to the humerus (Pitcher's elbow-medial epicondyle, Tennis elbow-lateral epicondyle)
Fascitis: inflammation of a fascia
Myositis: inflammation of muscle tissue
Myositis Ossificans: inflammation of muscle, with formation of bone
Sprain: a stretching or tearing of joint structures (ligaments and joint capsule)
Strain: a stretching or tearing of muscles and tendons
Subluxation: a partial or incomplete dislocation
Synovitis: inflammation of the synovial membrane
Tendinitis: inflammation to the tendon
Tenosynovitis: inflammation of tendon sheath


SUMMARY

The healing process begins almost immediately after the injury occurs. Athletic trainers must recognize the components of that process and provide the best environment and care. Vital signs help assess the athlete's condition. This chapter also identified the application of both heat (thermotherapy) and cold (cryotherapy) for either acute or chronic injury. Finally, with most injuries, rehabilitation is a vital component of the healing process. Rehabilitation is more successful when both exercise and modality are combined. With all rehabilitation, the athletic trainer should work closely with the physician and physical therapist.

REFERENCES

Arnheim D. & Prentice, W. (1997) Principles of Athletic Training (9th ed.). St. Louis: McGraw-Hill.

Cailliet, R. (1997) Soft Tissue Pain and Disability. Philadelphia: F.A. Davis.

Gould, J. (1990) Orthopaedic and Sports Physical Therapy. St. Louis: Mosby

Kissane, J. (1990) Anderson's Pathology (vol 1, 9th ed.) St. Louis: Mosby.

Kloth, L., McCulloch J. & Feedar, J. (1990) Wound Healing: Alternatives in Management. Philadelphia: F.A. Davis.

Knight, K. (1995) Cryotherapy in Sport Injury Management. Champaign, IL: Human Kinetics.

Prentice, W. (1994) Rehabiliation Techniques in Sports Medicine. St. Louis: Mosby.

Starkey, C. (1993) Therapeutic Modalities for Athletic Trainers. Philadelphia: F.A. Davis.

Chapter 3 - Review Questions

Completion:

1. The body’s reactions to trauma are ____, ____, ____, ____, and ____.
2. Redness and a feeling of warmth around an injury are signs of an increase of ____ to that body part.
3. Normal pulse readings for adults are _____ and children are ______.
4. Normal blood pressure of a healthy adult is ___/___.
5. Ice is used initially on an injury to control _____, _____, and ____.
6. Range of motion of a joint can be measured by using a ______.
7. All the fluids and dead cells that have resulted in swelling must be removed from the injury site by the _____ and _____ systems.
8. A rehabilitation program should not only focus on the injured body part, but also on preventing ______ of the rest of the body.

Short Answer:

1. What five phases of physical rehabilitation need to be included in a comprehensive rehabilitation program?
 
 

2. List three physiological factors associated with ice:
 
 

3. List three physiological factors associated with heat:
 
 
 
 

4. Explain the difference between arthritis and bursitis.
 
 
 
 

5. Explain the difference between a sprain and strain.
 


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