13/05/2012
Pain
"an unpleasant sensory and emotional experience
associated with actual or potential tissue damage,
or described in terms of such damage.“
g
PAIN &
SPORTS
INJURIES
Total pain encompasses
multidimensional factors
It may include all of the following:
 Intellectual Pain
 Emotional Pain
 Interpersonal
I
l PPain
 Financial Pain
 Spiritual Pain
 Bureaucratic Pain, and
 Physical Pain
(McCaffery, M & Beebe, A. Pain: Clinical manual for nursing practice. 1989. St
Luis: CV Mosby Co.)
Perception of pain can be subjectively
modified
(The International Association for the Study of Pain.)
Subjective sensation


The patient’s experience of pain is expressed
within the context of the illness, and the personal,
emotional, social, cultural, and spiritual orientation
of the individual.
Suffering, like pain, is subjective. Suffering is
characterised as a person’s evaluation of the
significance of an event such as pain - or the
meaning of an event in relationship to self and to
the quality of life.
Pain has a purpose

by past experiences & expectations
- provoke a withdrawal response

thi iis often
this
ft th
the aim
i off ttreatment
t
t
- warning
i off d
danger or harm
h

“Pain is what the patient says it is, and exists
whenever the patient says it does.”
(McCaffery & Beebe, 1989)
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13/05/2012
Components of pain
Pain can persist longer than it is useful


enhancing disability
inhibiting effects to rehabilitate injury
eg. prolonged spasm leads to;
- decreases circulation
- muscle atrophy
- disuse habits
- conscious / unconscious guarding which can lead
to severe loss of function, changed biomechanics,
overuse injuries, development of chronic pain and
chronic injuries

Chronic pain = disease state (cause??)

Physical + Psychological components of pain

Types of pain







Acute
Chronic
Persistent
R f
Referred
d
Radiating
Somatic
Trigger Point Pain
Types of Pain

Persistent Pain
-

Continuing pain
Symptom of a treatable condition
Types of Pain

Acute
- of sudden onset
- Usually short lived
- occurs when tissue damage is impending or after it has occurred
- Muscle
M l strains, lligament sprains, contusions, surgery

Chronic
- pain that persists after noxious stimulus has been removed
- pain lasting for more than 6 months
- defies intervention
Types of Pain

Trigger Points
- hyperirritable points within a taut band of muscle (latent or
active)
- may refer pain
Referred Pain
- pain that is perceived to be in an area that seems to have
little relation to the existing pathology (either acute or chronic)
- outlast causative factors because altered reflex patterns /
mechanical stress on muscles, guarding habits or development
of T.P.'s
Therefore massage treatment must attempt to
modify or control pain on all levels
- modalities (massage, stretching, exercise, etc)
- medication / drug therapy
- coping behaviours

Radiating Pain
- irritation of nerves and nerve root

Somatic Pain
- associated deep musculature, skin, joints and bone
- often a discrepancy b/w site & location of pain and disorder
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13/05/2012
Tissue Sensitivity & Pain Response
Most sensitive to noxious stimuli
periosteum and joint capsule
subchondral
b h d l bone,
b
tendon,
d & liligaments
muscle and cortical bone
synovium and articular cartilage
1.
2.
3.
4.
Tissue Sensitivity & Pain Response

Nerve ending: termination of nerve fibre in a
peripheral structure
 Sensory
 Motor

ending (receptor)
ending (effector)
Several types of sensory receptors
 Activation
of some of these sense organs with therapeutic
agents can decrease the perception of pain
eg. avulsion # - tear periosteum
A nociceptive neuron is one which
transmits pain signals






the cell body is in the dorsal root ganglion near the spinal cord
afferent neurons conduct impulses from the periphery toward the
brain
efferent neurons (eg. motor neurons) conduct impulses from the brain
toward the periphery
p p y
Nociceptors are stimulated and release a neuropeptide (substance P)
this initiates an electrical impulse to be conducted along the afferent
fibre to the spinal cord
the electrical impulses are sensory messages of pain, warmth, or
touch to sensory centres in the brain where they are integrated,
interpreted, and acted upon.
2nd Order afferent fibres

Carry sensory message from dorsal horn to the brain



Nociceptive
p
specific
p
Exclusive to noxious stimulation
Aδ and C fibres
 Serve smaller receptor fields

From sensory receptor to the dorsal horn
Four different types of 1st order neurons;
 Aα
and Aβ
 Large
 High
 Aδ
diameter
conduction velocity
and C fibres
 Small
diameter
conduction velocity
 (aching/ throbbing pain may continue long after stimulus is
removed)
 Low
3rd Order

Input from Aβ, Aδ and C fibres
Overlapping receptor fields



Wide dynamic range


1st Order (Primary Afferents)

3rd order neurons project to sensory cortex and
various other centres in the CNS
This allows for perception of pain and permits
integration of past experiences and emotions, which
form our response.
All these neurons synapse with 3rd order fibres.
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Lateral spinothalamic tract
Neurophysiologic Explanations of Pain Control
3 models of analgesic mechanisms response to cutaneous
receptor stimulation:
1. Stimulation from ascending Aβ afferents results in blocking of
impulses (pain messages) carried along Aδ and C afferent
fibres.
2. Stimulation along descending pathways in the dorsal horn of
the spinal cord results in a blocking of the impulses carried
along the Aδ and C afferent fibres (central biasing).
3. The stimulation of Aδ and C afferent fibres causes the release
of endogenous opioids (β-endorphin) into the central nervous
system, resulting in an narcotic-like suppression of the central
nervous system and a generalised analgesic response.
1.

These theories or models are not necessarily
mutually exclusive.



Pain relief may result from combinations of dorsal
horn and central nervous system activity.





The "pain message" carried along the smaller diameter
fibres is not transmitted to the second order neuron.
The pain message never reaches the sensory centres.



Balance between input to afferents determines how much
pain is blocked or gated
eg. Rubbing a contusion, moist heat, or massaging decreases
perception of pain.
This is attributed to increased stimulation of large
diameter afferents Aβ
Blocking the Pain Impulses with Ascending Aβ Input
Pain modulation due to sensory stimulation and the
resultant increases in the impulses in the large diameter Aβ
afferent fibres
Impulses ascending on Aβ afferent fibres stimulate the
substantia gelatinosa as they enter the dorsal horn of the
spinal cord.
Stimulation of the substantia gelatinosa inhibits synaptic
transmission in the Aδ and C fibre afferent pathways.
2.
Blocking the Pain Impulses with Ascending Aβ Input


Gate Control Theory:
(Spinal Level Pain Modulation)
Descending Pain Control Mechanisms
(Supraspinal Level)
The central control originating in higher centres of the CNS
could affect the dorsal horn gating process.
Impulses from the thalamus and brain stem (central biasing) are
carried into the dorsal horn on efferent fibres in the dorsal or
dorsal lateral paths.
Impulses from the higher centres act to close the gate and block
transmission of the pain message at the dorsal horn synapse.
Through this system, previous experiences, emotional influences,
sensory perception, and other factors could influence the
transmission of the pain message and the perception of pain.
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Endogenous Opioids in the Descending Pathways


Stimulation of the periaqueductal grey region sends
impulses along the efferent fibres in the dorsal lateral
tract, which synapse with encephalin interneurons.
The interneurons
Th
i
release
l
encephalin
h li iinto the
h d
dorsall hhorn,
inhibiting the synaptic transmission of impulses to the
second order afferent neurons.
Explains the analgesic response to brief, intense stimulation.
ie, acupressure, TENS, Trigger Point Therapy
Summary




The body's pain control mechanisms are probably not
mutually exclusive.
Rather, analgesia is the result of overlapping processes.
Also, these are only models, conceptualisations of how
pain relief occurs.
They give explanations that assist in understanding the
effects of therapeutic modalities and form a rationale for
their use or application.
Managing Pain





3. β-Endorphin





Electro-acupuncture and TENS can cause this release.
Pain perception and the response to a painful experience
may be influenced by a variety of cognitive processes,
including anxiety, attention, depression, past pain
experiences, and cultural influences.
Mediated by higher centres in the brain.
Goals in Dealing with Pain

Unidentified pain may hide a serious disorder, and treatment
of such pain may delay the appropriate treatment of the
disorder.

The therapist must match the therapeutic technique for pain
control with the situation.
A therapeutic agent should not be applied without first
developing a clear rationale for the treatment.
Prolonged (20 - 40 mins.) C fibre afferent stimulation has
been thought to trigger the release of β-Endorphin from
the anterior pituitary gland.
Cognitive Influences
The source of pain must be identified.
There is not one "best" therapeutic agent for pain control.
β-Endorphin is a neuroactive peptide with potent
analgesic affects.


Regardless of the cause of pain the aim of treatment is to
decrease the pain.
Once diagnosed - pain serves little purpose in relation
to treatment or rehabilitation other than a guide to
treatment delivery or limits of treatment
Pain will inhibit massage treatment programs
Therefore control acute pain and protect from further
injury
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13/05/2012
Pain and Therapeutic Massage Techniques


Massage Technique
the application of some form of stress to the body for
the purpose of eliciting an adaptive response
Therapeutic
to be deemed therapeutic the stress applied to the
body must be conducive to the healing process of the
injury in its current state
Summary - PAIN




Pain is a response to an injury / noxious stimulus that is
subjectively modified by past experiences and
expectations.
Sports Injury Pain is classified as either acute or chronic
and can exhibit many different patterns.
Early reduction of pain in a treatment program will
facilitate return to movement, exercise an full sports
participation
Stimulation of sensory receptors via the application of
therapeutic massage techniques can modify the athlete's
perception of pain.
Assessment


Ongoing comprehensive assessment is the foundation of
effective pain management
Including
interview,
physical
h i l assessment,t
 medications,
 medical and surgical history,
 psychosocial measures



Pain and Therapeutic Massage Techniques


Therapeutic massage techniques do not actually
hasten the healing process but attempt to provide
the optimal environment for healing to take place
The application of thermal, mechanical, electrical or
chemical energy to the body.
Goal of Pain Assessment





to capture the individual’s pain experience in a
standardised way
to help determine type of pain and possible aetiology
to determine
d
i the
h effect
ff and
d impact
i
the
h pain
i experience
i
has on the individual and their ability to function.
basis on which to develop treatment plan to manage
pain
to aid communication between interdisciplinary team
members.
Re-Assessment
A comprehensive pain assessment should be re-done if
there is:
 a significant change in the pain,
 any modification
difi ti to
t the
th pain
i managementt plan,
l or
 if a new pain has been identified
Assessment must determine the cause of pain, effectiveness
of treatments and impact on sporting participation for the
athlete
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Establish a Plan
includes physical, psychological, and behavioural interventions
includes treatments and selection of analgesia/adjuvants
which are individualised and consistent with the athlete’s goals
for pain relief.
These goals may also relate to:
 o maintenance of training / sporting involvement
 o acceptable competitive involvement
 o quality of sporting / competitive life
 o capacity for adequate rest and sleep
 o medication side effects minimal or at least tolerable
 Assess and document the effectiveness of the plan on an
ongoing basis

Education


Some athletes may under report pain







Have not been taken seriously in the past
Fear being labelled a “wimp”
Want to appear stoic, an important characteristic in most sports
Expect pain with training / competition (pain should be viewed as
common but not a normal)
Choose to avoid medications (especially if banned as part of
competition)
Education for athlete should occur regarding these concerns to
ensure they report their pain in a trusting and caring environment.
Include the athlete, trainer and coaches and family in decision
making to determine a treatment plan that meets the athlete’s
wishes, emphasising the shared goals of care.
Pain Severity Scales

Assessment of pain severity on a scale of 0-10 using a pain scale
would be the minimum assessment to be completed to monitor
effectiveness of treatment in decreasing patient’s pain
Use of a standard pain scale matched to the patient’s cognitive and
communication abilities
Visual Analogue Scale (VAS)
Numeric Rating Scale (NRS 0-10)
Faces Scale
Body maps
Pain Charts
Verbal Scale

ALL Pain assessments should be documented









It is important to explain to the athlete that pain may
get worse as the injury and treatment progresses
Discuss the concept of pain management with the
athlete in an effort to lessen the p
pain experience
p
before pain becomes difficult to manage.
Teach athlete to report changes in pain, pain that is
new, and pain that does not improve after treatment
Pain Assessment Scales

Pain is a complex phenomenon that is difficult to
evaluate and quantify because of its subjective
nature and it is influenced by the attitudes and
beliefs of the therapist and the athlete
Visual Analogue Scales




Quick and simple
Client required to mark the line at the point
corresponding to the severity of the pain.
A similar scale can be used to assess treatment
effectiveness.
Scales can be completed daily or used as pre and
post treatment assessments
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VAS
Numeric Pain Scale




Client asked to rate his/her pain on a scale from 1 to 10 with
10 representing the worst pain s/he has experienced or could
imagine.
Asked before and after treatment
When the treatment offers pain relief the client is asked about
the
h extent and
d duration
d
off pain relief.
l f
Also could ask
- portion of the day that they experience pain relief
- specific activities that offer relief
- sleep patterns in the last 24 hours
- medication required (amount)

NRS
Therefore can assess pain and any changes to pain with regard
to treatment.
Faces / Numeric scale

Athlete circles which one is appropriate
Body Map



Place a number (eg 1, 2, 3
on the body indicating the
locations of pain / discomfort
Use 1 for worst pain and 2
for next pain etc.
In the order of how
distressing each pain is
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Pain Charts




Can be used to determine spatial properties of pain.
Used to assess location and number of subjective
components.
Different colours or patterns can be used to define
different types of pain or pain sensations
Descriptions can be added to enhance the
communication.
Pain Words

Words the athlete uses to describe pain / discomfort








Discomfort
Pins & needles
Shooting
Constant
Dull ache
Stabbing
Electric like
Occasional







Sharp
Cramping
p g
Surface
Burning
Throbbing
Deep
Other
The McGill Pain Questionnaire (MPQ)





A tool with words to describe pain.
20 sets of 4 categories of words representing the pain
experience.
20 minutes to complete - can be frustrating from a
language point of view.
Commonly used for clients with low back pain.
Can demonstrate changes in status quite clearly (when
administered every 2-4 weeks)
Activity Pattern Indicators Profile


64 question, self-report tool that may be used to
assess functional impairment associated with pain.
The instrument measures the frequency of certain
behaviours such as work,, housework,, recreation and
social activities.
Non-Verbal Pain Indicators







Verbally excessive
Moans / sighs
Weeps /cries
C i outt when
Cries
h
moved
Grimaces / grunts
Rubs body part
Restless







Rocks
Guards
Retracts
H ld body
Holds
b d partt
Fidgets
Resistive to
touch
Lethargic
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Other symptoms

General

Has the pain / discomfort or treatment produced any
other symptoms






Nausea
Drowsiness
Change in mood
Loss of appetite
Dizziness
Disturbed sleep





Diarrheoa
Unclear thinking
Constipation
Anxiety
Other

Often in a long recovery clients lose sight of the
progress made in terms of functional activities.
A review of the pain scales can reassure the client
and foster a more positive outlook, or reinforce the
commitment to the plan of treatment.
Role of massage treatment in sports injuries

The therapist employs massage techniques to
 create
an optimum environment for tissue healing
minimising
i i i i th
the symptoms
t
associated
i t d with
ith
neuromuscular pain
 while
hil
THE HEALING PROCESS –
SPORTS INJURIES
Understanding the Healing Process
Pain and the healing process



Recognition of signs and symptoms
Awareness of timeframes associated with the
healing process of various types of tissue.


Knowing as much as you can about the healing
process is important in developing a safe and
effective massage treatment
Performing a massage technique before the injured
area is ready to tolerate that level of stress can
impede healing and cause additional injury
You have a duty to understand healing and realise the
impact of therapeutic massage
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Repair vs Regeneration

Most healing results in scar tissue formation
Primary and Secondary Healing

Dependent on
 the

extent of injury
of the wound site’s ends
 approximation
Tissues in the body can regenerate themselves?

Healing by Primary Intention
 If
separation is small, a bridge of cells binds the
ends together
eg. Minor wounds, surgical incisions
Understanding the Healing Process

Healing by Secondary Intention
severe wounds where stump ends are further
apart and cannot be bridged
 Wound
W d hheals
l by
b producing
d i scar tissue
ti
 Heals from the bottom and sides of the wound to fill
in the space created by the wound
eg. 2° ligament sprain
 Tissue is torn but not surgically repaired
 Takes longer and results in a larger scar

 More
Primary Injury


Described as either chronic or acute
Macrotraumatic injuries
Result of acute trauma
 Produce immediate pain and disability
 Fractures, dislocations, sprains, strains



Programs must be
based on healing
process framework
Phases
Inflammatory
Fibroblastic-repair
 Maturation-remodelling



No definitive beginning
or end
Inflammatory Response Phase
Injury results in altered cellular metabolism and
chemical mediators
 Macroscopic characteristics

Microtraumatic injuries
 Swelling
S lli
Overuse injuries, resulting from repetitive overload,
incorrect mechanics
 Tendinitis, tenosynovitis bursitis
 Tenderness

Secondary injury

 Redness
 Increased

temperature
Initial response is critical in healing process
Inflammatory or hypoxia response
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13/05/2012
Fibroblastic-Repair Phase
Chronic Inflammatory Response


Chronic inflammation
Fibroplasia
 Active
scar formation
last 4-6 weeks
 Signs and symptoms will
subside
b d
 Endothelial capillary
buds develop allowing
for aerobic healing
 Increased blood flow
for nutrient delivery
Occurs when acute inflammation does not eliminate injuring
agents and restore normal physiological state
 Leucocytes are replaced with macrophages, lymphocytes and
plasma cells
 Specific mechanism is unknown


 May
Overuse and overload related
No specific time frame in which acute becomes chronic
inflammation
 Resistant to physical and pharmacological agents
 Introduction of non-steroidal anti-inflammatory drugs (NSAID’s)

Maturation-Remodelling Phase





Role of Massage

Realignment of collagen
Bone and soft tissue will respond to physical demands placed
upon them
 Remodelling and realignment

Continued breakdown and
synthesis of collagen
Increased stress and strain results
in increased collagen realignment


Nonvascular, contracted, strong,
firm scar present after 3 weeks
Scar formation
Revascularisation
 Muscle regeneration and fibre reorientation
 Tensile properties













Corticosteroids
Keloids and
hypertrophic scars
Infection
Humidity, climate, and
oxygen tension
Health, age, and
nutrition
Progressive and controlled massage techniques allows
for gradual return to normal levels of function
Sports Injury to Various Tissues
Factors that Impede Healing
Extent of Injury
Oedema
Haemorrhage
P
Poor
V
Vascular
l SSupply
l
Separation of tissue
Muscle spasm
Atrophy
Initial immobilisation is necessary
y
Controlled mobilisation enhances

Maturation may require several
years to complete

Wolff’s Law
Ligament Sprains


Sprains involve damage
to a ligament
Li
Ligaments


Inelastic band of tissue
Provides joint stability,
controls bone position
during joint motion,
provides proprioceptive
input
12
13/05/2012
Ligament Healing
Sports Injury to Various Tissues

Grades of Ligament Sprains

Grade I - some pain, minimal loss of function, no abnormal
motion, and mild point tenderness

Grade II - pain, moderate loss of function, swelling, and
instability

Grade III - extremely painful, inevitable loss of function,
severe instability and swelling, and may also represent
subluxation
Factors Affecting Ligament Healing

Surgically repaired extra-articular ligaments



Intra-articular ligament damage



Injuries to Musculo-tendinous
Structures


Results in synovial fluid presence, diluting haematoma, disrupting
clot and healing
Strains occur when the musculo-tendinous unit is:
Overstretched
 Forced to contract against too great a resistance
Muscle Strain Classifications



Skeletal muscle exhibits 4 traits
 Elasticity
 Extensibility
 Irritability
 Contractility
Muscle size and architecture often
contribute to type and magnitude
of motion (gross vs. fine, powerful
vs. coordinated)
Ligament healing and immobilisation
Muscle strength training can enhance joint stability
Muscle Strains

Ligaments sprained extra-articularly result in bleeding in the
subcutaneous space
p
 Intra-articular ligament sprains result in bleeding within the
capsule
 Vascular proliferation, fibroblastic activity and clot formation
occur during the initial 6 weeks of recovery
 Collagen and ground substance work to bridge torn ends of
ligaments via scarring
 Scar maturation will gradually occur and collagen tensile
strength will increase
Heal with less scarring
Stronger than un-repaired ligaments
Heal via fibrous scarring resulting in ligament lengthening and
increased joint instability
Follows same course of repair events as with other
vascular tissues

Non-surgically repaired ligaments



Damage occurs
Muscle
 Tendon
 Musculo-tendinous junction
 Tendon-bone interface
Grade I :



G d II:
Grade
II


some fibres have been stretched or actually torn resulting in
tenderness and pain on active ROM, movement painful but full
range present
number of fibres have been torn and active contraction is
painful, usually a depression or divot is palpable, some swelling
and discoloration result
Grade III:

Complete rupture of muscle or musculotendinous junction,
significant impairment, with initially a great deal of pain that
diminishes due to nerve damage
13
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Muscle Healing







Similar healing to other soft tissues
Haemorrhaging and oedema lead to phagocytosis
Fibroblasts and ground substance produce a gel-like
matrix leading to fibrosis and scarring
Myoblastic cells infiltrate the region promoting myofibril
regeneration
Collagen undergoes maturation – with active contractions
being critical to apply tensile stress
Lengthy recovery for each grade
Patience is a must
Chronic Tendinitis
Tendon degeneration
Loss of normal collagen and cellularity
 No inflammatory cellular response
 Signs and symptoms
Tendinitis








Pain with movement
Swelling
Crepitus








Large amounts of collagen are required for adequate
healing
However, collagen synthesis can become excessive
resulting in fibrosis and interfering with tendon sliding
action
Scar tissue will gradually elongate allowing for
appropriate tendon motion
If a synovial sheath surrounds an injured tendon the injury
could be devastating
Typical tendon healing may require 4-5 weeks before
strong contractions can be imparted on tendon
Due to friction and decreased space for sliding synovial
sheaths are necessary in tendons
Overuse results in inflammation and development of
sticky
ti k adhesions
dh i
within
ithi th
the sheath
h th
Signs and symptoms
Similar to tendinitis
Movement may be more limited with tenosynovitis
 Treatment is the same as if treating tendinitis


NSAID’s and modalities
Alternative activities
Tendon Healing
Degenerative tendon changes with no clinical or histological
signs of inflammation
Tenosynovitis
Key treatment = rest
 Additional treatment options

Inflammation of tendon outer layer
Friction injury
Tendinosis



Inflammation of tendon, with no involvement of paratenon
Paratenonitis



Term used to describe multiple pathological tendon
conditions
Injury to Nerve Tissue


Generally involve contusion or inflammation
More severe injuries involve crushing or severing


Causes life-long disability
Paraplegia
p g or quadriplegia
q
p g
14
13/05/2012
Injury to Nerve Tissue

Peripheral nerves can regenerate if injury does not
impact cell body


Injury to Nerve Tissue
New axon buds will develop on the proximal axon
One sprout will form new axon
 Contact with Schwann cells will allow for Schwann cell
proliferation = new myelin


Slower regeneration with proximity to cell body
Regeneration
g
requires
q
an optimal
p
environment
Degenerative changes occur
Increased metabolism and protein production for
regeneration
 While cell body contains genetic material necessary to
maintain axon it does not transmit to distal segments of axon
 Schwann cells


Regeneration is slow






Additional Musculoskeletal Injuries
Bursitis
Dislocations and Subluxations

Dislocations present with total disunion of bone apposition
between articular surfaces- requiring manual or surgical
realignment
 High level of incidence in fingers and shoulder
 Subluxations are partial dislocations causing incomplete
separation of two bones
 Reduction should not occur without an X-ray (necessary to rule
out fractures)
 Inappropriate reduction may complicate the injury
 Return to play is largely governed by the degree of soft tissue
injury

Muscle Soreness

Overexertion in strenuous exercise resulting in muscular
pain
Two types of soreness



pain that occurs 24-48 hours following activity that gradually subsides
Caused by slight microtrauma to muscle or connective tissue structures

Gradual build-up of intensity
Some form of stretching
May
y continue to become inflamed with repeat
p
irritation with
increasingly more pain
Commonly impacted bursa
Pre-patellar
Olecranon
 Subacromial


Contusions



Result of sudden blow to body
Can be both deep and superficial
Haematoma results from blood and lymph flow into
surrounding tissue
Localisation of extravasated blood into clot, encapsulated by
connective tissue
 Speed of healing dependent on the extent of damage

accompanies fatigue, muscle pain experienced immediately after
exercise
Prevention and treatment


Delayed-onset muscle soreness (DOMS)

Result of excessive movement or trauma to bursa
Causes irritation, inflammation and increased synovial
fluid production

Acute-onset
Acute
onset muscle soreness


CNS nerves regenerate poorly due to lack of
connective tissue support
If cut contacts Schwann cells re-innervation of distal segments is more
likely


Occurs at a rate of 3-4 mm per day
Can be obstructed by scar formation


If muscle damage occurs ROM will be impacted
Incidents of repeated blows may result in myositis ossificans
development


Prevention = rest and protection
Allow for calcium re-absorption
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13/05/2012
Classification of injury

Considerations of the Healing Stage
Classification of an injury should be made according
to the existing signs and symptoms that include the
various stages of the healing process and not
according
g to time frames or mechanisms of injury.
j y

Phase 1: Acute Injury Phase


Phase 1: Acute Injury Phase
SSx
includes the classic symptoms of tenderness,
swelling, redness, increased temperature, loss of
function and p
pain.
Goals
 Control but not eliminate the amount of active
inflammation
 Contain the original injury by reducing the
secondary hypoxic reaction
 Control oedema and spasm
 Control pain
 If
active inflammation is present , even after several
months, the injury should be considered acute and must
be treated accordingly.
Phase 1: Acute Injury Phase
Phase 1: Acute Injury Phase
Modalities







R.I.C.E
Cold modalities are used to reduce the amount of secondary
hypoxic injury, reduce pain and eliminate spasm.
Compression devices and elevation are used to encourage
venous and lymphatic return.
Immobilisation devices are used to limit ROM.
Electrical stimulation may assist in decreasing vascular
permeability, limiting the amount of oedema formed and help
reduce pain.
Use of NSAID’s
Exercise in the form of gentle pain-free ROM and possibly
isometric exercises within the patient's pain tolerance
Based on this definition of acute and
chronic injury the massage treatmnet
progression may be determined by the
three phases of healing and may show
h
extreme variation between individuals
 If
the therapist is too aggressive during the first 48 hours
the inflammatory process may not have time to
accomplish what it needs to
 Immobilisation for 24-48 hours is a must.

By days 3-4 the patient should be engaged in some
form of mobilising massage and should be
encouraged to gradually bear weight if it is a lower
extremity injury
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13/05/2012
Massage Treatment
Phase 2: Repair Phase
Goals




Assist the body in delivering nutrients and materials
necessary to repair the injured tissues
Assist in removing the inflammatory debris
Increasing blood flow to and from the injured tissues
As the inflammatory process has subsided and pain
decreases massage should be added with an aim to;
Restore full ROM
Realign scar tissue to increase strength
 Re-establish neuromuscular control


Phase 2: Repair Phase
Massage Treatment
Modalities
Continued massage use for pain modulation and swelling control


Cryotherapy / ? Heat ?
Longitundinal pressure to stretch the tissues, prevent shortening of
the fibres and encourage the alignment of collagen along the lines
of stress.
Low-intensity tension is placed on the structures to slowly increase
their tensile strength and to assist in the formation of
proprioceptive nerves.
Proprioceptive activities and muscle re-education movements to
help protect the scar.
Newly formed capillary buds are fragile so care must be taken
not to damage them through excessive pressure, movement or
increased tension.




Phase 3: Maturation/ Remodelling Phase
Goals

Modalities
Longest phase with the ultimate goal being return to
playy
p
 Continued
 Pain


Phase 3: Maturation/ Remodelling Phase
collagen realignment
continues to decrease with activity
Regain sports-specific, ADLs, workplace skills
Functional testing
 Determine
specific skill weakness

Heating


Massage therapy



Increase circulation in deeper tissue
Reduce guarding, spasm, pain
Enhanced blood and lymphatic flow will deliver essential nutrients
and increase breakdown/removal of waste, respectively
Dynamic sports activities

Sports - directed strengthening activities
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13/05/2012
Massage Treatment
Approach to the Healing Process


Assist the natural process of the body while doing no harm
Primary goals

Have a positive influence on inflammation and repair process
Expediate recovery of function

Minimise early effects of inflammatory process

Prevent recurrence of injury






ROM, strength, cardiorespiratory fitness, neuromuscular control
Pain, spasm, oedema accumulation, decreased motion
Resist future periods of tissue overload through strengthening
PAIN AND SPORTS INJURIES
ASSESSMENT & TREATMENT
The efficacy of many of the treatments used by
sports/rehabilitation therapists has not been fully
substantiated.
These scales are one source of data that can help the
therapist identify the most effective approaches to
managing common injuries.
Deborah A. Pascoe

These assessment tools can also be useful when reviewing
a client’s progress with their doctor or third party payers.
Workshop Aim
This workshop will explore techniques to measure pain
during the assessment and treatment of some of the more
common sports injuries
PhD scholar, MA Grad Dip Ex Rehab, B App Sc (PE) Cert Hydro
Dip Rem Mass Cert Sports Cert Relax.
Overview

Assessment of the pain associated with different
sports injuries


Discussion and practice of the most appropriate
treatment strategies for the respective tissue(s) and
stage(s) of healing
Contractile Tissue - Muscle and tendon
Non-contractile Tissue (inert structures)



Ligament, fascia, joint capsule, cartilage, nerve, skin, blood vessels,
bone.
Use of pain measures to monitor healing and effects
of treatment
Massage and other soft tissue techniques in the
treatment of sports injuries
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13/05/2012
Assessment of tissues affected by sports
injuries
Assessment of Sports Injuries


Contractile Tissue
Muscle and tendon
Observation
AROM
 RROM
 PROM
 Special Tests
 Functional Testing – sports specific skills
 Palpation


Non-contractile Tissue (inert structures)
Ligament, fascia, joint capsule, cartilage,
nerve, skin, blood vessels, bone.


Active ROM
Pain /NO Pain
End-feel
Radiating / defining
Compare passive ROM to AROM.
Describe the end-feel
 Soft, firm, hard, or empty.
 Springy,
Springy muscle guarding
guarding, muscle spasm
spasm, muscle
spasticity, abnormal.
Determine the stage of pathology by observing when the
pain is experienced relative to the ROM.

Is the pain or muscle guarding experienced



Passive ROM
Record using the following grades:
Ankylosed
Hypomobile / Considerable limitation
Slight limitation
Normal
Hypermobile / Slight increase
Considerable increase
Unstable

before the end feel (acute)
concurrent with the end feel (sub-acute)
after application of over-pressure (chronic)?
Resisted Tests
Determine the stability and mobility of the joint.

Assessment
Plan
Passive ROM
Because both contractile and inert structures are
influenced by active ROM, specific pain response(s) will
not be limited or isolated to one tissue
Note:
 abnormal movement
 any experience of pain
 any changes in sensation
Subjective
Objective

0
1
2
3
4
5
6
Note whether there is a painful arc in either active or passive ROM
A painful arc indicates some sensitive structure is being pinched at
that part of the ROM.



Resist the related muscles so that they contract
isometrically in the mid-range to determine whether
there is pain or decreased strength
Mid-range
g isometric contractions are used for minimal
movement or stress on non-contractile structures around
the joint or if pain is severe
Initially tests performed on groups of muscles then if a
problem is noted each muscle potentially involved is
isolated and tested
Note individual pain response to determine extent of
injury
19
13/05/2012
Assessment of Muscles & Tendons

Assessment of Inert
Structures
Muscle & tendon
-
Active ROM
Resisted ROM
Passive ROM
Shorten = contract
Shorten = contract
Lengthen = stretch
Non-contractile Tissue (inert structures)
Ligament, fascia, joint capsule,
cartilage,
Pain and / or weakness
AROM
- pain/weakness mid-range
RROM
- increase pain/weakness response
PROM
- only at end ROM (stretch / tightness)
Assessment of Inert Structures



PROM
- stability & mobility
- compression
- distraction
- gliding
Special Test
- stability & mobility
Functional / Sports Specific Tests
End Feels for passive ROM
Normal End-points




End Feels for passive ROM
Abnormal End-points




Loose
Occurs in extreme hypermobility.
Capsular
p
feel
An abrupt, hard, firm end-point where two hard surfaces come
in contact with one another.
Bone to Bone
A distinct and abrupt end-point where two hard surfaces come
in contact with one another.
Muscular
Springy feel with some associated discomfort.
Nerve Injuries & pain

Injury indicated by
 Muscular
Empty feel
Movement is definitely beyond the anatomical limit, and pain
occurs before end of range or not at all.
Spasm
Involuntary muscle contraction that prevents motion because of
pain; should also be called guarding.
Soft Tissue Approximation
Soft and spongy, a gradual painless stop.
 Changes
weakness (AROM & RROM)
in sensation (palpation, sensation testing)
 Reflexes



Percussion
Stretch / elongation
Compression
Springy Block
A rebound at the end-point.
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13/05/2012
Nerve Tests for Sports Injuries









Slump Test – sciatic nerve
ULTT / quick test – thoracic outlet
Tinel’s sign – ulna, median
Piriformis syndrome
Median nerve entrapment
Ulna nerve palsy
Subluxed ulna nerve
Peroneal nerve palsy
Disc related radiating pain
Vascular Injuries

Generally caused by compression
 Decreased
pulse (rate and volume)
 Discolouration




Pain associated with changes in sensation
Pain associated with Swelling
Thoracic outlet syndrome
Compartment syndromes
Palpation






Usually performed following tests of provocation in order not to
increase the irritability of the structures prior to testing.
Massage Treatment of
pain caused by sports
injuries
Skin and subcutaneous tissue (temperature, texture and
crepitus)
p )
Muscles, tendons and attachments (tenderness, trigger points
and contractures)
Tendon sheaths and bursae (tenderness, temperature and
crepitus)
Joints (effusion, tenderness, changes in position or shape,
ligaments)
Nerves and blood vessels (neuroma and pulse)
Treatment of pain caused by sports injuries
Role of Massage and choice of therapeutic
technique
Treatment of tissues affected by sports injuries


Contractile Tissue - Muscle and tendon
Non-contractile Tissue (inert structures)








Ligament, fascia, joint capsule, cartilage, nerve, skin, blood vessels,
bone.
Muscles
Ligaments
Fascia
Joint capsule
Skin & adipose
Bone
Nerve
= progressive deep muscle massage
= deep transverse frictions
= myofascial release
= deep transverse frictions
= rolling & wringing
= mechanical stress and pressure
= positioning / fascial stretching

The therapist employs Massage and other soft tissue
techniques to
 Decrease
pain symptoms
an optimum environment for tissue healing
 Minimising the symptoms associated with treatment of
soft tissue / neuromuscular pain
 Create
21
13/05/2012
Pain Symptoms of Sports Injuries





Swelling
Inflammation (chemical release)
M l SSpasm
Muscle
Muscle and/or joint dysfunction / injury
Soft Tissue Oedema – arterial effusion
Clinical Decision Making
Phases of Injury
Healing Continuum




Acute Injury / Inflammatory Response Phase
Fibroblastic Repair Phase
M t ti – Remodelling
Maturation
R
d lli Ph
Phase
What are massage and other soft tissue technique’s
biophysical effects?





Pain symptoms and testing indicates what structures
are injured?
Contractile
Non-contractile (inert)
What structures are affected?
What Phase of Injury – Healing?

Depth of Penetration

Ti
Tissue
Affinity
Affi it





Resources available – your knowledge, skill and
confidence?
What are the parameters which guide massage
and other soft tissue technique’s application
Direct Effects
Indirect Effects
What are the massage and other soft tissue
technique’s Indications?
What are the massage and other soft tissue
technique’s Contraindications?
Choice of massage and
other soft tissue
technique’s
Dosage, Duration, Frequency
22
13/05/2012
Massage Techniques for Pain



Positioning
Pain Relieving
and

Superficial to deep
In accordance with the phase of healing (as needed)
Balance



Techniques for each area / muscle
General Massage Techniques (Effleurage, Petrissage,
Longitudinal, Cross-fibre, Attachments)
 Deep
p Tissue Techniques
q
– including
g on stretch
 Trigger Points – with movement
 Myofascial release – with movement
 Frictions – longitudinal & transverse
 Stretching – static, PNF
 Exercise prescription

Any movement or massage technique that causes the
pain to radiate or spread over a large area should
not be included during treatment
Principles of Massage Treatment

General Massage Treatment
Developing a strategy

- Strong and weak
- Long and short
Stretch – to maintain and enhance effects of
treatment
Exercises – to help balance strength and length
Sports – advice on sports movements to enhance injury
healing and movements to avoid
Contraindications / Precautions of
Treatment
GOALS of ALL TREATMENT






A useful strategy for all treatments is to identify the
involved section, treat it and then treat the sections
above and below it.
Myositis ossificans
Inflammation (unresolved or worsening)
Increasing or Unrelieved Pain
Continued restriction in soft tissues
Identified restrictions in other tissues










Minimise Inflammation
Promote Healing
Prevent Re-injury
Maintain Fitness
M i i SStrengthh
Maintain
Restore Muscle Balance
Restore Proprioception
Decrease Pain
Reduce Swelling
Restore ROM (active, resisted & passive)
Return to full training and sports competition
23
13/05/2012
Ongoing Treatment



Teach management of injury to avoid recurrences of
problems
Educate client in preventive stretches and exercises
for relief of musculoskeletal stress in sports
p
activities
Help client recognise sports techniques that influence
risk of injury
Sport Injuries & Massage Therapy


Injuries which occur during sports participation include
injuries from both internal and external trauma.
Massage therapists must be able to identify and assess
the
extent and severity of the injury,
tissue(s) which have been damaged, and
 stage of healing and
 select an appropriate treatment protocol to enhance recovery
and return to sport.


Complementary Treatment Techniques







Cold
Heat
Other Massage Techniques
St t hi
Stretching
Strengthening Exercises
Pilates
Feldenkrais
TREATMENT OF SPECIFIC SPORTS
INJURIES
Deborah A. Pascoe
PhD scholar, MA Grad Dip Ex Rehab, B App Sc (PE) Cert Hydro
Dip Rem Mass Cert Sports Cert Relax.
Sports Injury Pain – Specific Treatments











Delayed onset muscle soreness (DOMS) / (EIMS)
Quadriceps contusion
Knee ligament sprains
Achilles tendinosis
Rotator cuff (impingement)
ITBFS / fascial tightness
Hamstring strain
Muscle cramps
Plantar fasciitis
Shin Splints / MTSS
Lateral epicondylitis
24