The body’s response to injury

When an acute soft tissue injury occurs the body responds with bleeding and inflammation. So if you tear a muscle, sprain a ligament or irritate a tendon, there will be a rapid response to an injury. This will vary in severity and significance in relation to the size and extent of the injury. Let’s use an ankle sprain as an example.

When you roll your ankle in to inversion (rolling the foot in) the ligaments on the outside of the ankle can be damaged and bruising can occur to the inside of the ankle. Tearing of the ligaments will release bleeding and the boney impact on the inside of the ankle will also cause bruising and swelling.

We want to slow down the impact of an injury like this by minimising the amount of bleeding and swelling. This allows for more rapid healing due to less direct tissue damage and indirect pressure on tissues from the swelling and bleeding.

What should I do in the first few days?

When is the best time to start treating an injury? The answer to this question is straight away! The earlier you get into treating an injury correctly, the less tissue damage there will be and the quicker your recovery.

Immediately after a soft tissue injury you should apply the RICER principle. This very well known principle stands for:

1) R – Rest the injured area

In the case of the injured ankle reduce your weight bearing stress by using crutches if the injury is to a shoulder or other part of the arm use a sling. Resting reduces tissue damage by minimising movement of torn fibers.

2) I – Ice the injured area

Apply ice to the region of the injury. This may be in the form of a bag of crushed ice, commercial ice pack or bucket of cold water with ice in it. Apply an ice pack for 15 to 20 minutes. In the case of submerging the area in icy cold water, 10 minutes will generally be enough.

Make sure that you wrap you ice pack in a thin tea towel or piece of paper toweling to prevent ice burn to the skin. Also, if you do use a commercial ice pack, make sure that it stays cold!! I have come across plenty of packs that don’t stay very cold and this can be a waste of time. The pack should still be quite icy cold after being on your body for 15 minutes.

Ice has a terrific effect on the injured area. It dramatically slows down the activity in the region of the icing and thus decreases the bleeding, swelling and thus subsequent damage.

I have had plenty of players over the years proudly report to me that they iced for 45 minutes after a game. Unfortunately these guys have probably defeated the purpose of icing. Research has shown that if you ice for greater than 25 minutes, you can get the reverse effect of what you are trying to achieve. This is because the muscles around the small blood vessels get frozen and allow for blood to rush back into the area. Therefore stick to the 15 to 20 minutes rule.

How often should you ice. In the first 72 hours after an injury it can be beneficial to ice for 15 minutes every hour. Some professional sports people have been known to set an alarm clock at night so that they continue to ice 24 hours a day. For most of us time is an issue, so icing 4 to 6 times a day is a good goal / target.

3) C – Compress the injured area

At one point I read an article that suggested that compression was the most important facet of the RICE formula. Compression continues the goal of decreasing swelling by applying pressure to the injured area and helping “push” the waste products back into the bloodstream to be removed by the body.

Compression can be applied using a tubular stocking (tubigrip), compression bandage or taping. I favour using tubigrip as it can be easily removed and thus makes icing easier. Most of us get sick of re-applying a compression bandage every hour and give up on icing.

Make sure the compression you apply isn’t too strong. The compression should be firm but not uncomfortable. I usually recommend to my patients to remove or soften the compression at night.

4) E – Elevate the injured area

Elevation helps drain the swelling and bleeding back into the system. If possible, raise the injured area above the level of the heart. This can be pretty tough if you’ve injured a hip or shoulder, but do your best.

5) R – Referral to appropriate sports medicine professional

The often forgotten second R in the RICER principle! A crucial facet to quality injury treatment and player recovery is to get to a qualified physiotherapist or sport doctor as soon as is practical. With the use of testing and experience you can get an accurate diagnosis and plan to treat and recover from an injury.

If you or your football trainer suspect the possibility of a fracture, then make sure you get to an emergency department to get assessed and have an X-ray. However, even if you have been to hospital, I would still recommend getting the advice of a good physio with an interest in sports injuries as soon as you can.

What happens if I don’t do the RICER principle?

The effect of swelling and bleeding can slow down the healing process and cause extra scar tissue if the RICER principle is not followed. This can mean a significantly slower recovery period and the greater chance of re-injury once you return to the game.

Take your injury treatment seriously in the first few days and you may be able to reduce your missed games by 1 or 2, which is good for you and your team.

What shouldn’t I do in the early stages?

The RICE principle aims at reducing swelling and bleeding by slowing down the metabolic rate in the area of the injury. There are things that we can do to increase bleeding and these should be seriously avoided in the first 72 hours after a soft tissue injury. These are the HARM factors and stand for:

F Heat – don’t heat the area as it causes more bleeding

F Alcohol – don’t drink alcohol as it increases bleeding

F Re-injury – be prepared to rest the area to avoid re-injury

F Massage – early massage can cause further damage

The Last Word!

Once you have successfully negotiated the first 3 days (72 hours) after an injury it is time to start with the sub-acute treatment regime with your physio. This will often involve massage, stretching, strengthening and modalities like ultrasound. We will deal with these things when we talk about specific injuries in future articles.

I have recently found that the use of compressive garments like “skins” have helped in post exercise recovery and may have a part to play in providing compression after soft tissue injury. This can be a good way to get significant compression to an area over the course of the day and night.

Finally, I would again emphasise the value of getting things right in the first few days after an injury. No amount of fancy treatments can replace the importance of getting the basics right, and the RICER and no HARM principles are basics that can really help in the short and long term management of football injuries.

Matthew Clark
Physiotherapist, B.Physio, MAPA MCPhysio

For further information contact MCPhysio at mcphysio@vic.chariot.com.au .

When I was asked to provide a football based article for this website, it didn’t take long to come up with a topic that most people in the football would have come across numerous times – hamstring strains. These injuries seem to attack an alarming number of our players, and the horror stories and magic cures find their way into the media through the course of most seasons.

Facts from the Research

Between 1997 and 2002, the AFL medical association conducted a review of injuries in the country’s premier AFL competition. The research showed that 13% of injuries sustained by players were to the hamstring. This equated to a rate of 6.1 hamstring injuries per team, per year and a loss of 20.8 games per year. When these games lost are from the leading players in the side, this figure can be the difference between finishing top four or missing out on the finals.

Fortunately, this knowledge has lead to a gradually lower injury rate in recent years, and a steady decline in recurrence of injury which was at 33% at the time of the study.

The important thing for Physio’s and Sports Med practitioners is to focus on having a thorough understanding of what is going on with an injury and applying a scientific approach to treatment. In the end, most injuries will respond well if treated correctly, so the main battle is getting your players understanding the need for appropriate management of their injuries.
Where are the hamstring muscles?

The hamstrings is a group of three muscles situated at the back of the thigh. They are the biceps femoris, semitendinosus and semimembranosus. The biceps makes up the outside part of the muscle group while the other two are on the inside. All the muscles come from the ischial tuberosity which is the bone that we sit on and attach into the tibia and fibula.

The biceps has a double nerve supply, which leads to one theory about injury to this muscle, with the suggestion that if both nerves don’t fire at the same time an injury can occur. All three muscles are involved with pulling the hip backwards and bending the knee.
What is a hammy tear?

Muscle strains are divided into three grades. A grade one injury involves a minor degree of damage, grade two injuries see more fibre damage as a partial tear, while grade three describes a severe or complete tear.

Players describe hearing or feeling a “pop” in the posterior thigh with swelling and bleeding developing on the first or second day. On assessment, muscle strains are diagnosed by finding one or all of palpable tenderness, decrease in stretch range of motion and a decrease in strength of the affected muscle.
What do I do next?

The first 48 to 72 hours following injury are some of the most important. Players, trainers and physiotherapists need to have a commitment to correct management in the first few days to accelerate rehab and recovery.

So, make sure you follow the important principles of good injury care by doing the following:
1) Follow the RICE principles

F Rest the injury – using crutches may be helpful

F Ice – 15 to 20 minutes every 1 to 2 hours

F Compression – bandage or stocking

F Elevation – can be difficult unless you are in bed
2) Avoid the HARM factors

F Heat – don’t heat the area as it causes more bleeding

F Alcohol – don’t drink alcohol as it increases bleeding

F Re-injury – be prepared to rest the area to avoid re-injury

F Massage – early massage can cause further damage
3) Sub-acute care –
supervised by a physiotherapist

F Begin massage, ultrasound, stretching, bike and pool after day 3

F Progress to strengthening work at day 6

F Light running can usually start at the end of the first week

F A functional running program is vital for full recovery
Recurrent or Difficult Hamstrings

There are a number of factors that can lead to ongoing problems with a hamstring injury. These are the frustrating ones that don’t respond to treatment initially and we need to look at other issues. Some of the most important factors to consider include: referred pain from the low back, adhesions of the sciatic nerve and its surrounding sheath, abnormal quadriceps power and postural problems including muscle tightness and weakness around the pelvis.

It is important to consider the lumbo-pelvic region and its stability. Programs like Pilates, Yoga and Swiss Ball regimes can be helpful in establishing excellent core stability.
Preventing Injuries

Prevention of injury is always better than trying to find a cure. Appropriate training programs seem to be vital in preventing injury including components of flexibility, functional strength, correct running training and core stability.

During the driest time in recent history in Victoria we have seen an increase in injury due to hard grounds and muscle fatigue in the heat. Watering grounds when able and providing adequate hydration for players are important. Consider the extra cost of providing sports drinks for players before, during and after games as an investment in decreasing gun players missed game time.

I would also recommend compressive sports garments such as Skins or LineBreakers to provide support and prevent injury.

The Last Word!

The first and most important thing to remember with hamstring injuries is to address the basics of injury management initially and then seek qualified care from a Physio or sports medicine professional. They can look at some of the associated problems and guide you through a correct rehab program.

Don’t rush your return. There has been a gradual decrease in re-injury in the AFL as clubs show a more conservative approach to getting players back on the park. The 21 day rule before returning to sport is a good guide, however more time may be required and advice is recommended.

For further information contact Matt. Clark MCPhysio at mcphysio@vic.chariot.com.au.