Tuesday, 10 July 2012

Injury Management

A few months ago I did an injury management presentation at a running festival in Canberra. I covered a few basics and although it's not rocket science it goes over some of the common misconceptions and beliefs that runners adhere to when they are injured.

  • Anti-inflammatories - over used and abused would be the words of choice here. Unless you must race at all costs use these on medical advice or in the sub acute stage when there is some stubborn inflammation hanging around. Generally try not to use them in the first 2-3 days as this is when the 'foundation' for the healing process takes place. It set's the stage for fibroplasia and the laying down of a weak collagen network to start the healing process. If you take anti-inflammatories and the inflammation keeps returning - further investigation is warranted. As I always say you need to find the causative factor or in this case the driving force behind the inflammatory process.
  • Another important tip about anti-inflammatories - the gel form will only penetrate about 10mm,    this means if you have an injury deep in your glutes or an area that is not superficial you are wasting your money and time - it simply will not penetrate this deep. The older oral versions may also irritate your gut. They inhibit the inflammatory process at the prostaglandin level (one of the steps in the chemical cascade forming inflammation), prostaglandins are also a vital ingredient in the formation of the gut mucosa protecting the gut wall from the volatile acids secreted after a meal. The newer age Cox 2 inhibitors are more selective in their action and are generally easier on the gut wall.
  • Heat Gels - these are really a novelty as they are counter-irritants irritating the free nerve endings sitting in the skin. Once irritated they send a fast message to the brain providing a feeling of heat or cold. Amusement to the brain would be the best words here. Most provide a localised (superficial) action on the site and again will not penetrate into deeper areas. There is no increase in systemic blood flow and I doubt there would be a significant change in local blood flow.They really do not provide a means of helping sports inuries. Of course, if you like the feeling they provide then there is little harm in using them.
  • Cortisone - I am not a medical doctor nor do I pretend to be one! Cortsione (injections) is a very emotive topic in sport, running is no exception! Cortisone is an anti-iflammatory cutting off the inflammatory process at the first step of the cycle. Cortisone is generally indicated in cases of acute inflammation where the inflammatory process is either not controlled or has created it's own pain cycle and further irritates the injury itself. Tissues that generally do well with cortisone include joint spaces, inflamed bursa's, inflamed fat pads and irritated tendon sheaths. Generally it is not recommended (contra-indicated) to inject into tendons due to it's collagen degrading effect. It is believed to increase the risk of tendon rupture (though I have not seen a specific study on this). Having said that I do know of a number of sports physicians and have personally witnessed cortisone injections under ultrasound into tendinous tissue with no apparent issues
  • Taping (rigid) - taping can be valuable in terms of proprioception and feedback of certain body positions. It provides a means of allowing the body to control it's position through certain movements by activating nociceptors and mechano receptors situated in the skin and joints. For example low dye taping around the foot can provide a means of controlling foot pronation. The drawbacks are skin irritation from the tape and not a means of long term rehab. Relying on the tape longer term will decrease activation in certain muscles.
  • Kinesio Taping - this is a form of taping that has various means of use and has found it's way into the market via a very simple but clever marketing strategy! Use brightly coloured tape that cannot be missed!! It can be used in acute situations to draw subcutaneous fluid away from the injury site or it can be used as a means to increase neuromuscular firing through certain movement patterns. it can be very effective as a management technique. 
  • Heat - generally used as comfort or distraction to an injury, not indicated in the acute phase of injury, having said that the heat will only penetrate about 10mm to the subcutaneous tissue as the bodies protective mechanisms will increase cutaneous vasodilation to off load the heat. 
  • Ice - a stayer in terms of use in the acute injury stage. Having recently looked at the evidence for this in sports injuries here is not a strong consensus on how often to use in the first 48 hrs! Recommendations vary from 1-2x day to every waking hr of the day for 15- 20 mins. Best advice find what works for you and use for the first 48 hrs to control the inflammatory process. It does appear to be effective in setting the stage for a better healing outcome when compared to no ice at all. Ice immersion if available leads to a quicker and deeper cooling and has the advantage of maintaining joint movement/mobility in a pain free range (once you know what the injury is)
  • Soft tissue Therapy - Soft tissue treatment is invaluable in treating acute and chronic soft tissue injuries and also as a means of maintaining the runners body. Soft tissue treatment allows physical assessment and a hands on approach in dealing with musculoskeletal aches and pains. Treatment allows the assessment of tight joints, overloaded tissue, decreased tone in soft tissue structures and poor pelvic position, hence running posture. A hands on approach gives feed back and awareness to the runner allowing identification of driving factors towards injury.     
  • Tens (transcutaneous electrical nerve stimulation) - probably more common in the clinical environment that at home. Might be useful in the initial stage of injury in terms of breaking the pain cycle, but little evidence to support their use of rehabilitation long term. 
  • Stretching - another very emotive topic and a topic with a lot of research, but still a long way to go before we get some conclusive evidence as to what can be achieved. There are different forms of stretching (passive, active, assisted). This can be further broken down to ballistic, dynamic and static and even further variations to PNF etc. Most of the research has been conducted on static alone. The body of research tends to indicate that static stretching does not help reduce DOMS (delayed onset muscle soreness) or increase performance especially in sprint type running events or power events. Further it does not prevent injury, nor does it increase blood flow to any notice able effect. The recent forms of power yoga in heat rooms may be different, I haven't looked at this specifically.
    • So why would we stretch? Firstly I think the research has a lot further to before we have conclusive evidence. We do know that it does increase range of motion short (2hrs)  and long term (6 weeks) so there is definitely scope to increase range of motion with decreased joint mobility. The area of most interest to the runner is musculoskeletal imbalance, a major source of injury in the runner and maybe this is where some good long term studies investigating the effects of stretching specific muscles prone to tightness and poor activation may prove handy (this would be a complex study though having aged matched subjects for previous injury and a control group with no previous injury). Further to this a lot of the current research does not seem to be able to capture what is actually done in practice. Since when do we do 3x 30 sec hamstring stretches and we are done?
    • PNF appears to produce better results but often relies on a partner. Dynamic mobility is probably the best as part of an aerobic warm up as it educates and 'primes' the nervous system on the actual movement pattern you are about to go through. The great marathon runner Robert De Castella (2.07.51) preferred to do no stretching before his training instead doing a good aerobic warm up followed by run throughs and some dynamic stretches. I also know that Steve Monaghetti (2.08.16) is not exactly in love with pre run stretching! If you are like me and you felt that stretching helped with your recovery and you believe it helps with injury then go for it!!  
So there you have it, some of the injury management strategies that might be used, I will report on more in the coming weeks as they come to mind and time is freely available

For Now,

No comments:

Post a Comment