Soft Tissue Injuries

Soft tissue injury is a term used in relation to body structure damage. This includes muscle, tendon, ligament and surface tissue—including skin, fat and bursae. These tissues can be injured by either extrinsic or intrinsic trauma.

Extrinsic trauma

Extrinsic trauma refers to contact made with a sharp or blunt object that causes damage either open or closed to the tissue. This could be by contact with an opponent, or other sporting equipment involved in the game such as a stick, racquet, ball or goal post etc.

Intrinsic trauma

Intrinsic trauma is damage caused to the tissue from within by over-stretching, over-contracting or uncontrolled internal stress. Repetitive overuse is also a cause of intrinsic tissue damage.

Common extrinsic trauma injuries to muscle are usually known as corkies, which usually occur in the thigh in football, but this can also happen in the biceps and the calf. The external force causes macro and micro break down in the tissue with a leaking of fluids into the surrounding areas.

Common intrinsic trauma injuries are muscle strains and the most common in football is hamstring tear. Calf and thigh strains are also common. The breakdown of the tissue causes leakage of fluids into surrounding tissues as well as the localized breakdown of muscle fibres.

Ligament damage

Ligament damage can be extrinsic (being struck) or intrinsic (twisting injury), causing similar local damage along with fluid leakage into the area.

Repetitive strain

Repetitive strain causes local inflammation and fluid accumulation in tendons—the most common site being the Achilles tendon.

RICER still stands as the gold standard for management of soft tissue injuries:

Rest—not complete rest, but active rest. This can be achieved by keeping the muscle switched on with mini contractions or tightening which prevents it from shutting down, resulting in the ability to contract the muscle.

Ice—(or cold pack) around the injured part to close down the vessels that have dilated or been damaged in the trauma. This should be repeated for 15-20 minutes every two to three hours for the first 24-36 hours.

Compression—compress the area above and below and over the injured tissue to constrict flow of fluids out of vessels that are damaged. This needs to be firm, but not enough to become a ligature that cuts off blood supply to the rest of the limb.

Elevation—of the injured part at a level that is comfortable, but reduces the effect of gravity draining fluids to more distal tissues.

Referral—arrange to see a qualified health professional (doctor or physiotherapist) immediately. This will determine the extent of your injury and provide advice on the treatment and rehabilitation required.

Managing Basic Injuries

Treating injuries: heat v ice

Ice is used in the first 72 hours for any new injury from muscle strains to direct contact - “corks”. Ice works in tandem with other components of the RICER regime. Initially the application is every two hours for 20 minutes and then eased off to two to three times a day.

Heat is best used to pre-warm muscles prior to exercises using a heat pack or heat rubs. It can be used during activity to ease stiffness and tightness but be aware not to apply heat to new injuries.

When to return to sport after a muscle injury

A simple assessment protocol to predict how many weeks will be missed with a muscle injury is:

  1. Ran from the playing field with some restriction and pain
    Grade I muscle injury - miss 1-2 weeks
  2. Limped from the playing field but could not run
    Grade II muscle injury - miss 2-4 weeks
  3. Assisted from the field, needed support
    Grade III muscle injury -miss 4-6 weeks

This is only a guideline and return to sport should be assessed with specific functional and muscle testing.

The benefits of core stability

In recent years research has shown that specific exercises to strengthen the pelvic, lower back and lower abdominal muscles together to gain a coupling effect is very beneficial for preventing injuries and improving an athlete's performance. Sit ups, Roman Chair - trunk extension, and swimming were historical exercises that were prescribed to strengthen the abdominals and lower back.

However with a new understanding on the need to have the "internal corset" effect, the approach to exercise prescription has changed markedly. Specific mat, fit-ball and Pilates-type exercises used in isolation or with other exercises to improve core strength are now mandatory in athlete preparation.

Does muscle turn into fat?

This is one of those old wives tales which has proved to be incorrect. Someone who is healthy and fit, with good muscle mass, who then stops training, will find in time that the muscle size is reduced.

This is a separate process to fat accumulation. What often happens is that people maintain the same eating habits but reduce their activity levels. This is the main reason that muscle mass decreases in size, and the extra kilograms of fat around the waist, the legs and the butt then become more pronounced.

Shin splints

Shin splints are a condition where an individual complains of pain along the inside border of the larger lower leg bone - the tibia. The main cause is the tractioning effect of the muscles that attach to the bone. This can be due to a sudden increase in training loads, poor supporting shoes or pronated (flat) feet.

You can often feel a very tender and painful lump in the area which makes running very difficult. Advice and assistance in settling down your symptoms and safely returning you to playing can be obtained from your club or local physiotherapist.

Soft Tissue Rehabilitation

Rehabilitation following soft tissue injury involves the management of the athlete from the time of injury to return to sport. Soft tissue injuries vary in type (e.g. tendon, muscle, ligament, muscle contusion etc) and severity; however, a generalised program of staged rehabilitation is relevant for all injuries. The length of the program will vary depending on the severity of injury but all stages will still need to be addressed.

The stages of rehabilitation from injury to return to sport are:
  1. Unloading Phase (Tissue Recovery/Regeneration)
  2. Restoration of Normal Physiology (Early)
  3. Restoration of Normal Physiology (Late)
  4. Functional Training (Sport Specific Demands)

If we briefly consider each of these stages and the rehabilitation aspects it helps us to more effectively guide our management.

1. Unloading Phase (Tissue Recovery/Regeneration)

This commences immediately following trauma and involves protecting the injured structure from excessive loads likely to impact on normal tissue healing. Total rest is not necessary, rather protection at an appropriate level is required.

The length of time for protection is dependent on the severity of trauma involved.Utilisation of RICER principle (Rest, Compression, Elevation and Referral) is vital in the early stages with emphasis on compression. Compression at all times immediately following injury is arguably the most important of the RICER principles. Thus keep compression on even when undertaking other aspect of RICER management.

2. Restoration of Normal Physiology (Early)

This involves the introduction of increasing loads/demands on the tissue after suitable time for tissue recovery has been allowed.Loads need to be kept at an appropriate level for timeframe of tissue healing. This involves both stretching and strengthening aimed at tissue involved without causing excessive pain or any post exercise swelling/prolonged soreness.

Additional techniques (home and clinic based) may be incorporated to assist in tissue healing or movement restoration (e.g. massage, mobilisation, electrotherapy etc.). The intensity of massage needs to be kept at a suitable level for the tissue healing time (i.e. not too strong as may cause further tissue damage/bleeding!).

3. Restoration of Normal Physiology (Late)

Continuation of loading of tissues to full strength/stretching loads.Loading through this phase will begin to mimic normal daily and sporting loads.Loading is progressed through from slower to faster rates of application and from short to longer duration.

Should have normal tissue strength at the end of this stage in preparation for the final stage.

4. Functional Training (Sport Specific Demands)

Final stage of rehabilitation to be completed before full return to sporting activity.This stage is vital to ensure athlete has suitable ‘dynamic joint stability’ via appropriate activation of muscle to prevent recurrence or new injuries. Utilisation of dynamic balance/loading activities is important during this stage. Techniques such as plyometrics and agility training are very useful in mimicking sport specific demands.Frequently final stage rehabilitation is poorly directed, leaving the athlete vulnerable to injury on return to competitive environment.

For successful return to sport all stages of rehabilitation need to be addressed! Recurrence of injuries do occur, even if we follow all stages. However, failure to adequately rehabilitate players, especially the final sport specific stage, significantly increases re-injury rates!

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