The Fundamentals of Injury and Injury Management for ...

Dr Claire Minshull

E-mail: [email protected] Twitter: @getbacktosport

Web: www.getbacktosport.com

Understanding Injury;The Fundamentals of Injury and Injury Management for Fitness Professionals

Scheme of workMODULE FOCUS AIMS

MOUDULE 1 Definitions & Terms; Common Musculoskeletal Problems/Injuries

Develop awareness of common terms and musculoskeletal (MSK) problems and injuriesDevelop awareness of typical population profiles of those who suffer specific conditions

MODULE 2 Injury; signs and symptoms Outline signs and symptoms of common MSK problems and understand consequences

MODULE 3 Injury; healing and recovery Introduce basic process of healing by tissue type. Typical recovery profiles by injury type

MODULE 4 Psychology and Communication

Understanding the client journey

Introduce issues of psychology and communication - understanding the client’s injury ‘journey’ and needs

MODULE 5 Accommodating injury within exercise and training

Introduce to methods of accommodating injury and MSK problems within personal training and exercise conditioning

MODULE 6 Workshop Recap; Full case-study evaluation

Recap and recall workshop knowledgeApply knowledge to hypothetical case-study to generate training solution

In this module we will cover:

● Tissue remodelling ● Basic stages and processes of healing by /injury and

tissue type● Guidelines for return to sport

MODULE 3:Injury; healing and recovery

Tissue remodellingAll tissues such as muscle, tendons, ligaments and bone respond to disuse as well as training

Scientific study of these changes usually involves immobilising the area of interest (or the person) and measuring very accurately the changes compared to a control group.

You may be surprised by the results…

Andrew IwanickiNovember 4, 2014https://www.vice.com/en_uk/read/nasa-patient-8179-100

Some classic immobilisation studies:

Tissue Length of immobilisation

Effect Reference

Muscle 5 days of plastercast of single limb (healthy males)

9% reduction in quadriceps strength

Wall et al (2014). Acta Physiol. 210: 600–611

Ligament 9-12 weeks of hind limb immobilisation (rabbit)

70% reduction in failure strength of ligaments

Woo et al. (1982). Biorhellogy. 19: 397-408

Bone 3-weeks bed rest (humans with lumbar disc protrusion)

0.9% reduction of bone mineral content per week

Krolner et al (1983). Clin Sci. 64: 537-540

Tissue remodellingIt’s important to take these changes into consideration during exercise and training.

For example. A patient may have suffered a fracture, which required 6-weeks of immobilisation by plastercast.

After they have been discharged from clinical care considerable changes in bone density AND muscle strength may have occurred.

You can see the changes in muscles size,however, you can’t see the changes to bone or tendon.

Tissue remodellingBear mind also, that training-related changes happen at different rates in different tissues. For example, increases in muscle strength will happen more quickly than increases in tendon and bone strength

If you see a client who has recently suffered a fracture, liaise with their physiotherapist to check what exercise are safe for them to do.

Clearly, high-impact loading would not be advisable in the early phases of recovery, but structured, progressive strengthening exercises may be.

Stages of Healing

Stages of HealingThere are a set of basic processes of healing that underlie all treatment techniques.

Whilst as an exercise/fitness professional you’re not treating injury or prescribing rehabilitation, it’s a good idea to have an appreciation of these stages of healing

These stages enable clinicians to effectively treat and rehabilitate their patients

For example, it would be inappropriate to deploy strategies to reduce formation of swelling when swelling has stopped forming

Norris, 1993

Inflammation• Up to 5 days• Heat & redness• Pain• Swelling• Muscle Spasm• Vascular changes• Sensory receptor

stimulation

Repair• Phagocytes clear area• Cell division• Increased capillary &

drainage systems• New collagen by 5

days• Collagen requires

mobilisation to avid ‘haphazard matrix’

Remodelling• Overlaps with repair• 3 weeks – 12 months• Collagen functionally

modified (scar tissue)• Increased strength of

new collagen by 3-weeks

Stages of Healing (soft tissue)

The rate of healing is dependant on many factors including:

• Severity • Type • Acute management • Location of injury • Age • Availability of treatment

The same principles apply to fractures

Firm fracture union usually occurs within 4-6 weeks; it can take up to 12 weeks though in unfavourable circumstances

Stages of Healing (Bone)

Inflammation - Repair - Remodelling

● Name 3 symptoms during the inflammation stage of healing ______

● When does new collagen start to be laid down during the repair stage of healing? _______

● Up to how long can it take for collagen to remodel ________

Recap

What about exercise-induced injury??

In the next few slides we’re going to talk about a type of muscle ‘injury’ induced by exercise. However, it’s not a ‘bad’ injury per se. The term we’ll use is Exercise-Induced Muscle Damage. It’s an injury on a micro level, but this process is actually important in training situations to stimulate neuromuscular adaptations and muscle hypertrophy

Other types of injury?

Muscles are made up of functional units called sarcomeres

During eccentric muscle activation the sarcomeres are lengthened whilst under load. If the load is too great, some of these units are overstretched and become damaged.

This is called exercise-induced muscle damage and is characterised by delayed-onset muscle soreness (DOMS). DOMS is that sore feeling that peaks 24-48 hours after activity involving lots of eccentric muscle activation

Exercise-Induced Skeletal Muscle Injury

Sarcomeres die

Eccentric activation. Sarcomeres overstretched (sometimes irreversibly)

Irreversibly damaged sarcomeres unable to produce force

Delayed Onset Muscle Soreness (DOMS)

Recovery: Quicker process for Mild Injuries vs. Severe

Depending on severity, recovery from muscle damage can be within 3-10 days

Skeletal muscle then remodels and adapts to be able to accommodate the same load without the same damage and symptoms (Repeated Bout Effect).

Notice how if you repeat the same exercise a couple of weeks later you don’t feel as sore..?

Exercise-Induced Muscle Damage

http://www.ncbi.nlm.nih.gov/pubmed/18489195 (Here’s the abstract of a good review on the topic- a good paper if you can get hold of it)

We published some research a few years ago on how muscle damage and fatigue affect muscle performance.

Click the link below to access the paper. It may be a bit of a ‘heavy’ read - you’re welcome to get in touch if you have any questions

https://www.researchgate.net/publication/224938020_Knee_joint_neuromuscular_activation_performance_during_muscle_damage_and_superimposed_fatigue

Figure 5. Ratings of perceived soreness of the knee flexors over the three treatment conditions (group mean +/- SD ). CON: no exercise; FAT: fatigue only; FAT-EIMD: eccentric exercise and fatigue. 

Peak soreness in hamstringsExperienced 48-hoursfollowing eccentric exercise

Minshull C. et al. (2012). J Sport Sciences, 30(10):1015-24

Interestingly, peak soreness happens at different times for different muscles. Quadriceps soreness tends to be worst 24-h

after exercise

Guidelines for return to sports/activities

Hopefully now you’ve increased, or refreshed, your understanding of the difference between exercise-induced muscle damage and DOMS vs. traumatic clinical injuries and chronic conditions.Accordingly, soreness induced by exercise that should start to get better 48-hours following the inciting activity. If symptoms don’t resolve, or they get worse then the client should be suspected of having an injury and the appropriate processes followed.

We’re going to snap-back now to injuries and chronic conditions and look at the recovery profiles

Guidelines for return to sports/activities

ACL: Following surgery, a minimum of 6-months of rehabilitation is required. Often it can take between 6-12 months of structured and progressive rehabilitation. Depending on the success of the surgery and initial phases of rehabilitation, sports specific training may start as soon as 5-months post-surgery. Be guided by your client’s physiotherapist’s instructions.

Anterior Knee Pain: This is a difficult one to gauge. It depends on the cause of the pain and for how long the person has been suffering the symptoms. It could have resulted as a secondary problem following surgery due to AMI, or it could have simply resulted from a change in running shoes. Swapping your shoes back to the old style and a few weeks of thigh muscle conditioning and stretching may do the trick for the latter. Again, pay attention to the clinical guidelines provided by the physiotherapist.

Knee Osteoarthritis: This is very much a process of being guided by severity and type of symptoms. Symptoms may prompt a reduction in activity, however, this will exacerbate stiffness and pain and reduced function in the long run. Exercise is a recommended treatment for OA (ARUK; ACSM; NICE)

Rotator Cuff: How long is a piece of string? This is a difficult question to answer because it depends on the severity of injury and for how long the person has had the injury. Be guided by the individual’s physiotherapist. Acute injuries can heal within 2-4 weeks, however, longer-term injures may take up to 6-months or more

Further reading. Exercise & OA: https://www.acsm.org/public-information/articles/2012/01/19/exercise-and-arthritishttps://www.nice.org.uk/news/press-and-media/nice-updated-osteoarthritis-guideline-highlights-importance-of-exercise

Guidelines for return to sports/activities

Guidelines for return to sports/activities

Ankle sprain: As with a rotator cuff injury, return to sport depends very much on the severity of injury. Grade I injuries are less severe than grade III and as such may take less time to properly rehabilitate. A physiotherapist diagnose the grade of injury and stipulate the appropriate time frames and training schedules to ensure a safe return to sport. Time-frames can vary from 1-6 months.

Further reading: consensus statement -Diagnosis, treatment and prevention of ankle sprainshttp://bjsm.bmj.com/content/46/12/854.full.pdf+html

Summary● Different tissues remodel at different rates, both in response to training

and disuse● Substantial losses to muscle and ligament strength can be caused by

limb immobilisation. Rehabilitation and conditioning programmes should thus be progressive and take into account the remodelling rates.

● There are a set of basic processes of healing common to all tissues and which underlies all treatment techniques.

● Exercise induced muscle damage is brought about by eccentric exercise, whereby the weakest sarcomeres are irreversibly over-stretched

● Delayed-onset muscle soreness (DOMS), peaks 24-48 hours following the 'damaging’ exercise

Module 3: Test of knowledge: 1.  The three stages of healing are:_____________________________________________________________________________________________

2.  On average, how ling does it take for a fracture to heal5-weeks6-weeks7-weeks8-weeks

3.  Muscle, bone and tendon remodel at the same rateTrueFalse

4. The symptoms of knee osteoarthritis can include:Swelling Pain Knee is arm to the touchFeeling unstableAll of the above  

5. DOMS stands for:Delayed Overuse Muscle StrainDelayed Onset Muscle SorenessDetailed Overstress Muscle SyndromeDelayed Overstress Muscle Syndrome

6. The functional unit of a muscle fibre is called:A myofibrilMyosin heavy chainsActin-myosin sheaths A sarcomere 7. The expected return to sport following successful ACL surgery 3-4 months3-6 months6-12 monthsNone of the above

8. What causes exercise-induced muscle damage?Concentric exercise that causes the sarcomeres to over-shorten Concentric exercise that causes the sarcomeres to over-lengthenEccentric exercise that causes the sarcomeres to over-shortenEccentric exercise that causes the sarcomeres to over-lengthen