Although participation in sport and recreational activities are actively encouraged in our society, they carry with them a risk of potential injury. Data from Statistics Canada’s General Social Survey (1987) indicates that for people 15 years of age and older sports and recreation injuries are the most common type of injury, accounting for about 29% of all injuries, a percentage that rises to 42% for people aged 15-24. In the United States, sports and recreation injuries number more than 10 million annually (Berkow 1992). The largest numbers of injuries from sport and recreation in Canada are associated with sports such as hockey, martial arts, basketball, football, rugby and wrestling. Injuries associated with activities such as snowmobiling, equestrianism, boating, swimming and bicycling tend to be more serious than those sustained in other sports that don’t use the same type of equipment. Surveys suggest that strains and sprains constitute about half of all injuries sustained during physical activity, whereas contusions, dislocations, fractures and lacerations constitute most of the remainder. About 70% of all injuries involve the extremities (arm, leg, hand, foot), the remainder comprised of injuries to the back, neck, head and torso
While such injuries are typically related to sports and recreation, in many cases these injuries occur while carrying out normal activities. Thus conditions such as ‘tennis elbow’ (lateral and medial epicondylitis) could be caused by carrying a heavy basket of laundry or working with tools such a screwdriver. ‘Runner’s knee’ (patellofemoral pain syndrome) can be the result of excessive pronation while walking, usually attributed to poor footwear. Thus while sports are a more frequent cause of such injuries, similar non-sport injuries can occur, and are treated identically.
Susceptibility to injury can be caused by a number of factors, such as an inherent weakness in the area of injury or from dysfunctional biomechanical factors that place undue stress on the tissues involved. The most common cause of muscle or joint injury is overuse, or exercising an injured body part despite the fact that there are clear indications that it is injured. The usage of OTC drugs that provide temporary pain relief (ASA) or inhibit local inflammation (e.g. NSAIDs, corticosteroids) are particularly important causes of this dynamic. Some patients also display a high threshold for pain, or are so engrossed in their activity that they can ignore it and continue exercising the injured part.
Every act of physical movement causes some degree of damage to the body, but in most cases this damage is minimal or rapidly compensated by the restorative systems of the body. As glycogen is used up during sustained exercise however, the body’s capacity to both resist and compensate for this injury decreases – further, the increasing weakness of muscle during exercise begins to place more stress on accessory muscles, tendons and ligaments, that may not be able to assume this burden, – all of which increases the likelihood of injury. In most people it takes approximately 48 hours to restore muscle glycogen, and thus athletes are typically recommended to alternate muscle groups in exercise programs, and set regular intervals in between training days. If an injury occurs frequently in the same location, such as the knee or shoulder, the muscles, tendons, and ligaments associated with the area of injury may be too weak for the exercise. To correct this problem a controlled program of resistance-type exercises using progressively heavier weights should be used to strengthen the area of injury.
Physical movement of course is also dependent upon the health of the bones and joints, which can be weakened by a deficiency of nutritional factors, or from diseases such as osteoporosis and inflammatory joint disease. Structural abnormalities in either the axial and appendicular skeleton can also increase the likelihood of injury, placing an uneven stress on body parts, e.g. scoliosis. The most common cause of foot, leg, or hip injury for example is excessive pronation (rolling in of the feet after they strike the ground) while running or walking. Excessive pronation causes an exaggerated medial twisting of the lower leg, resulting in foot, leg, hip, and knee pain.
The various methods that are used to prevent sports-related injuries are poorly researched. Generally speaking, these methods consist of warm-up exercises and stretching before exercising, and a cool-down period after. Warm-ups consist of a series of simple exercises performed at a relaxed tempo to increase the metabolic activity and temperature of the various muscle groups, making them stronger and more pliable. This might consists of simple calesthenic exercises such as neck rolls, shoulder shrugs, trunk rotations and light jogging. Intensive stretching prior to exercise is also highly recommended by many athletes and coaches, but is a somewhat controversial subject with several studies indicating little statistical benefit (Herbert and Gabriel 2002). Research indicates that most forms of muscle strain occur during eccentric activity, a contraction in which a muscle is forced to lengthen while simultaneously trying to shorten, essentially being used as a brake to absorb energy, such as contracting the quadriceps or knee extensors while walking down hill. Stretching prior to these types of exercises have specifically been shown to have no benefit (Shrier 1999). At best, stretching lengthens the muscle groups and can provide greater torque, and at worst can over-stretch the muscle group and promote injury during intense burst of muscle contraction. Some types of stretching however are recommended to prevent injury, including stretching the Achilles tendon to prevent tendonitis or rupture. Cooling down, or gradually slowing down before stopping exercise can help to prevent dizziness and syncope caused by peripheral vasodilation and blood pooling the extremities. The cool down period also helps to maintain proper circulation and clears lactic acid. Additional research suggests that stretching during the cool down period may increase the energy absorbing capabilities of muscle, and thereby reduce the risk of injury.
Connecting the two calf muscles (gastrocnemius and soleus) to the heel bone is the large tendon called Achilles tendon. Under excess physical stress the fatty areolar tissue surrounding the tendon that separates it from the tendon sheath becomes inflamed. Upon squeezing the tendon the patient complains of tenderness. If this is not allowed to heal the inflammation spreads to the tendon itself, causing it to become progressively more fibrotic, decreasing flexibility – in some cases the scar tissue can be felt over the tendon, and ankle movement usually causes a cracking sound caused by the scar tissue. A cracking sound can be heard with ankle movement, caused by the fibrotic tissue rubbing against tendon. If the inflamed tendon continues to be stressed, it can even tear or rupture.
The causes of Achilles tendonitis usually relates to either muscle fatigue or tight muscles, either before or beginning or ending physical exercise, which shifts the burden of leg stability to the tendon. Improper footwear, such as hard or excessively soft-soled shoes can also facilitate damage to the tendon, causing it to twist or contort with movement.
Patellofemoral pain syndrome, also called chondromalacia of the patella, or ‘runner’s knee,’ is a painful condition that affects the patella or ‘knee cap.’ The patella is attached to the quadriceps of the femur by the femoris tendon above and to the tibia bone below by the patellar ligament. The patella fits into the grooves in the end of the femur called the femoral condyle. With repeated uneven bending and straightening of the knee, the inside surface of the patella can become irritated and inflamed causing pain (patellofemoral syndrome), and if this continues unchecked, will eventually manifest as a softening and wearing away of the cartilage (chondromalacia of the patella). As the cartilage wears away there may be fissuring, and bits of cartilage may break off and float in the joint. At this stage the condition may progress to synovitis, and eventually the underlying bone becomes exposed, and the cartilage is unable to heal. In response to this injury the irritated bone develops osteophytes at the joint surfaces and in the notch where the cruciate ligaments lie. Symptoms include pain and swelling beneath or on the sides of the kneecap, and crepitus (a cracking or grinding noise) caused by the cartilage as it rubs when the knee is flexed. Eventually the joint becomes restricted and painful, throbbing especially at night. Ligament damage or unequal destruction may also cause instability of the joint. Causes include excessive pronation, causing the kneecap to twist sideways, and weakness or fatigue of the quadriceps muscles, preventing the kneecap from tracking smoothly. Another important cause of excessive pronation is genu valgum (‘knock knee’), a condition in which the legs are bowed inwards in the standing position. The bowing usually occurs at or around the knee, so that on standing with the knees together, the feet are far apart. Females are more susceptible to genu valgum due to the greater Q angle, or quadriceps femoris muscle angle, derived by drawing a line from the anterior superior iliac spine to the center of the patella. This angle is increased in females due to their wider pelvis, predisposing it to greater stress due to the torsion applied between the femur and the tibia.
Iliotibial band syndrome
The iliotibial band is a thick band of fibrous tissue that runs down the outside of the leg, beginning at the hip and extending to the outer side of the tibia just below the knee. Iliotibial band syndrome (ITBS) occurs when there is irritation to this band of fibrous tissue, usually occurring over the outside of the knee joint, at the end of the femur bone. The initial symptoms include a dull ache during exercise that disappears upon cessation. With continued stress however a severe sharp pain that is worse when running downhill or on uneven surfaces may be present. The cause of ITBS is any movement that causes the leg to bend inwards, stretching the ITB against the femur. Excessive pronation, tightness of the ITB muscle, incorrect or worn shoes, and excessive running down hills or on uneven surfaces are dominant factors in ITBS.
The plantar fascia is a thickened broad band of non-elastic fibrous tissue that attaches to the calcaneus (heel bone), and fans out along the plantar surface of the foot, attaching to the bottom of the metatarsal bones. The tension of the plantar fascia is very tight, and it acts like a bowstring to maintain the arch of the foot. With excessive stretching or tension the point at which the plantar fascia attaches to the calcaneus can become injured and inflamed, called plantar fasciitis. With repeated trauma microscopic tears can form and overtime an inflammatory reaction of the calcaneus facilitates the growth of osteophytes called heel spurs. The initial symptoms of plantar fasciitis are a dull to sharp constant pain, usually worse in the morning or after sitting, and then decreases as the patient begins to move. Causes include excessive pronation, a foot with an unusually high arch, a sudden increase in physical activity, excessive weight bearing (i.e. obesity, pregnancy), and improper footwear.
Medial tibial stress syndrome
The term ‘shin splints’ is a generic term used to refer to a wide variety of exercise-induced shin pain, and is often considered synonymous with medial tibial stress syndrome (MTSS). MTSS is caused by tiny tears in the calf muscles where they attach to the tibia, and are of two kinds: anterior shin splints, which occur on the anterior portion of the shin bone; and posterior shin splints, which occur on the medial part of the leg along the tibia. Some practitioners believe that the small tears seen in MTSS are accompanied by inflammation of the periosteum where the muscles attach. In anterior shin splints the pain begins immediately after the heel strikes the ground during running, and if exercise is continued the pain becomes constant. In contrast, the pain of posterior shin splints is dominant when rising up on the toes or everting the foot, and with continued stress the pain may move forward to involve the medial aspect of the tibia. Shin splints can be caused by inflexible calf muscles and a tight Achilles tendon, which places more stress on the muscle attachments. Other causes include over-training, exercising after a period of relative inactivity, insufficient shock absorption, running on the toes and excessive pronation.
Posterior femoral muscle strain
The quadriceps muscles function to flex the hip and extend the knee during running and jumping, while the hamstrings (i.e. the semitendinous, biceps femoris, semimembranous) balance this action by extending the thigh and flexing the leg. In activities that require the simultaneous contraction of the hamstrings and quadriceps, such as stopping or starting quickly while running (e.g. soccer, football), there is a greater potential for injury to the hamstrings, especially if they are relatively weaker than the quadriceps. The ratio of the contractile strength between the quadriceps and the hamstrings is about 60:40, and if the strength of the hamstrings is less than 60% as strong as the quadriceps, injury is more likely to occur. The loss of this normal ratio may be due to excessive development of the quadriceps, or due to weaknesses of the hamstrings due to improper training, muscle fatigue and incomplete rehabilitation. A hamstring injury usually identified as an acute pain in the posterior aspect of the thigh when the muscles contract suddenly and violently.
Epicondylitis is divided into two categories based on whether the injury has been sustained by the muscles, tendons and ligaments that either extend or flex wrist, i.e. lateral epicondylitis (‘tennis elbow’) and medial epicondylitis (‘golfer’s elbow’). Lateral epicondylitis is caused by damage to the muscles that are used by the hand to grasp an object, such as in painting, tennis, wind-surfing and kayaking. These include the extensor carpi radialis brevis and longus, as well as the supinator muscles that supinate the radio-ulnar joint. When these muscles extend and roll over the lateral epicondyle and radial head it can damage the extensor tendons, first noted as pain when the wrist is forced to extend against a resistant force (i.e. a back-hand tennis shot). If adequate measures aren’t taken to promote healing the condition can progress to periosteal inflammation and hemorrhage, calcification and the development of spurs on the lateral epicondyle.
Medial epicondylitis, or “golfer’s elbow,” is caused by the forceful extension and pronation of the wrist, requiring the contraction of the superficial and deep flexors and pronators of the arm. Such activities, which can include hitting a gold ball, pitching a baseball or a forehand tennis swing can damage the tendons that attach these muscles to the medial epicondyle of the humerus. The patient will complain of pain in the area of the medial epicondyle when the wrist is flexed or pronated against resistance. A common clinical test is to ask the patient to place their hands palm-down on a table, and while the practitioner holds the hands down the patient is asked to raise the hands. If medial epicondylitis is allowed to continue unchecked, the tendon can eventually be pulled from the bone, causing periosteal inflammation and hemorrhage, and the formation of bone spurs.
Rotator cuff tendinitis
The head of the humerus is bound to the scapula in a ball and socket joint called the glenohumeral joint by a series of ligaments, tendons and muscles. Situated above the coracohumeral ligament is a subacromial bursa, and lying anterior to the articular capsule is a subscapular bursa, both of which serve to cushion the friction between the ligaments and the muscles as they contract and stretch. The term “rotator cuff” refers to four tendons derived from four muscles (i.e. the supraspinatus, infraspinatus, subscapularis, and teres minor) that surround the head of the humerus, and rotate the arm out and away from the body. A strain, tear or inflammation of these tendons often occurs as the result of activities that require the hand be moved over the head with some force, such as in pitching a baseball or cricket ball, or activities such as weight-lifting and swimming. In such activities the various movements that rotate the glenohumeral joint also involve the much larger and more powerful pectorals and latissimus dorsi, and an imbalance of the strength of these muscle groups versus the weaker scapular muscles can place too much stress upon the scapular muscles, tendons, ligaments and bursae. Acute excessive force can actually tear the rotator cuff, whereas with chronic irritation movement can inflame the bursae, ligaments and tendons. Over time this can lead to periosteal inflammation, calcification and a gradual erosion of the tendons. Signs and symptoms are noted as pain and swelling of the burase and a limited range of motion. Pain will be noted when rotating the arm internally with the elbow straight, or adducting the arm across the chest. Sometimes one of the tendons in the rotator cuff will be pinched between the upper part of the humerus and the acromion of the scapula when the arms are lifted above the head, called an impingement. This is more common in previously injured joints with calcium deposition in the tendon, and also in patients with loose joints and/or joint deformities.
Medical treatment of sports injuries
The medical treatment of the various sports injuries is focused upon prevention. Measures include a review of the warm-up procedures used by the patient, and an assessment of the patient’s biomechanics to ensure that muscle activity is balanced and strong. Corrective devices such as orthotics are used for conditions such as excessive promation, and support devices such as knee and wrist braces are used in to support and protect injured tissues. Proper equipment is an important component to sports injury prevention, and among these is footwear that stabilizes the heel and foot and prevents slipping during running, and restricts the ankle from rolling inward. Physiotherapists will often recommend a series of exercises and stretches that can be used to prevent injury.
Acute injuries are immediately treated by the components of the acronym RICE: rest, ice, compression, and elevation. Rest is instituted immediately to minimize hemorrhage, injury, and swelling; ice is used to inhibit inflammation, which is thought to promote damage, and reduce pain; and compression and elevation are used to limit edema. The typical procedure involves elevating and placing a bag of crushed ice to the injured part, and wrapping a bandage loosely around the injured part to permit blood flow. The bandage and ice bag are removed in 10 minutes for a 10 minute period, and then applied again, in alternating fashion for about 60-90 minutes – this specific technique promotes a rebound vasodilation that can help to improve blood flow to the injury. Some athletes may receive local corticosteroid injections, but this will delay healing and if used on a chronic basis will contribute to joint degeneration. NSAIDs such as ibuprofen and naproxen are also used to inhibit inflammation and in analgesia. While the injured tissue heals alternative physical activities are recommended to maintain fitness levels, supplemented later with a carefully designed exercise regimen to strengthen the injured tissues. For both healing and chronic injuries physiotherapists use a variety of modalities to promote healing including ultrasound, electrical stimulation and electromagnetism to increase local circulation, electrical stimulation of muscles to prevent or counter atrophy, and procedures such as transcutaneous electric nerve stimulation (TENS) to manage chronic pain.
Holistic treatment of sports injuries
Sports medicine is quite justifiably a discipline unto itself, intensively focused on the biomechanics of the body and utilizing unique methods of prevention and treatment that extend beyond the knowledge level of many general medical practitioners. Rather than being a simple pastime, sport has taken on entirely new dimensions in our modern culture, and the knowledge that sports medicine brings to it has had a significant impact upon consumerism, and now sports technology is synonymous with fashion, influence and money. Despite the excesses, hype and wastefulness of all this, the technology of sport perhaps reaches is most malignant when the goal of performance enhancement extends beyond what is normal, healthy and safe. In general, there is widespread agreement about the dangers of performance enhancing drugs such as testosterone, but there is little useful opinion on the benefit of the various supplements and diets used in particular by body-builders and professional athletes. Some of these supplements, which have yielded huge profits for their manufactures and distributors, include those that have given herbal medication a bad name, such as using Ma Huang (Ephedra sinica) in weight loss formulations. While herbal medicine advocates for a healthy body, the primary focus is upon removing any obstruction to vital function so that one’s full potential in all areas of life can be achieved.
The focus of performance enhancement in herbal medicine is upon solid nutrition that emphasizes whole food over supplements, and the usage of time-honored herbal remedies such as Ashwagandha, Epimdeium, Saw Palmetto, Gokshura, and Ginseng that have been used for centuries to strengthen and promote anabolic changes in the body. Among these are the animal-derived anabolic agents such as Elk antler, Gecko, Walrus penis and Sea Horse, which are commonly used in Chinese medicine. Apart from any ethical issues regarding their sustainable harvest, these medicaments may contain natural compounds such as steroids that may yield a false-positive in drug tests, and thus their usage among competitive athletes may be problematic. The mineral-rich musculoskeletal trophorestoratives used in Western herbal medicine however, such as Nettle, Horsetail and seaweed, are safe and important adjuncts to help prevent and treat any sports injury.
The treatment of acute sports injuries in herbal medicine is somewhat different than it is conventional sports medicine. While the focus in modern medicine is upon RICE (rest, ice, compression and elevation), and the inhibition of inflammation by drugs such as corticosteroids and NSAIDs, traditional herbal practices consist of therapies that encourage local blood-flow in the damaged tissue, which is in striking contrast to the use of ice, compression and anti-inflammatory drugs in modern. While promoting blood flow to the injured area may be experienced as a transient increase in pain, experienced herbal practitioners suggest that these techniques result in faster healing and prevent chronic injury and arthritis. The herbal perspective is that medical therapies such as ice, compression and anti-inflammatories suppress local immune responses and impair the clearance of metabolic wastes, and thus promote chronic injury.
Athletes in China have access to a broad array or traditional treatments that are often used in conjunction with or in preference to conventional sports medicine. Acute injuries with unbroken skin are treated topically with rubefacient liniments such as Zheng Gu Shui, which contains the herb San Qi (Panax notoginseng) that has antihemorrhagic properties, and from a TCM perspective, helps to overcome the blockage of Qi and Blood that occurs in damaged tissues. The liniment can be rubbed into the affected area, or a piece of linen can be soaked in the liniment and then applied to the injury, and then wrapped in plastic wrap and left on for several hours while resting. Transient burning of the skin may occur, depending upon the volume used and the sensitivity of the individual. San Qi is also taken internally, along with other medicaments such as Mo Yao (Commiphora myrrha) and Ru Xiang (Boswellia carterii) in the patent remedy Jin Gu Die Shang Wan, and with Jiang Huang (Curcuma longa) and Dang Gui (Angelica sinensis) in Xiong Dan Die Da Wan. Other methods in TCM used in the treatment of sports injury include acupuncture and acupressure, moxibustion, tui na massage, energy work such as qi gong, and strengthening and stretching exercises found in Tai chi.
Within Ayurvedic medicine the treatment of sports injuries accesses the knowledge contained in the allied discipline of Kalarippayattu (‘Kalari’), an ancient martial art originated in Kerala. Practitioners of Kalarippayattu claim to access a system of knowledge that utilizes marma or “death” points, a collection of 107 highly energized nodes that represent the inter-junction of vata, pitta and kapha, and the junctions between the physical and subtle bodies. If these spots are struck forcefully, cut into or otherwise disrupted it is thought that disease or even death may occur. The famed author of the Sushruta samhita, an ancient Ayurvedic text on surgery, indicates that these points are particularly important for surgeons to observe. Kalarippayattu practitioners in particular claim to have an ability to counter the effect of such injuries by specialized massage techniques such as uzhichil, the simultaneous application of a medicated oil along with massage techniques that apply pressure at certain locations on the body. Other techniques include dhara, pizzichil and pinda sveda. Among the more important medicated oils used in traumatic and chronic injury are Mahanarayana taila, Murivenna taila, Kshirabala taila, Chandanadi taila, Gandha taila and Pinda taila. Individual herbs used both topically and internally internal usage include Guggulu (Commiphora mukul), Haritaki (Terminalia chebula), Ashwagandha (Withania somnifera), Arjuna (Terminalia arjuna), Haridra (Curcuma), and Manjishta (Rubia cordifolia). A simple medication used in Ayurveda is a combination of four parts Haridra (Curcuma longa) powder and one part Shunthi (Zingiber officinalis) powder, mixed with honey to make a paste, and applied generously over the injured area, covered with plastic wrap for several hours, changing the dressing a few times a day until the injury is healed. Haridra in particular is favored among yoga practitioners to strengthen the ligaments and tendons. Long-term strategies to heal injured tissue includes the practice of hatha yoga, which seeks to provide the ultimate in physical coordination, physical strength and endurance, flexibility and mental relaxation.
Traumatic injuries in Western herbal medicine seek to restore function to the afflicted area as soon as possible by ensuring the proper microcirculation in the damaged tissues, which is more or less the same approach taken in Ayurvedic and Chinese medicine. Topical treatments such as a liniment, salve or cream prepared with Arnica (Arnica spp.) is used topically on unbroken skin, and in small doses internally, to promote venous circulation, and relieve inflammation. Internal doses for Arnica are low, because it can cause muco-epithelial ulceration in larger doses, between 3 and 10 drops in water bid-tid. Bruising can also be helped by the topical and internal application of herbs such as Chickeweed (Stellaria media), Selfheal (Prunella vulgaris), Comfrey (Symphytum officinale), St John’s Wort (Hypericum perforatum), and Calendula (Calendula officinalis). For pain and spasm medicated oils prepared from St John’s Wort and Cow Parsnip root (Heracleum maximum) can be used topically. To improve tissue healing botanicals high in flavonoids are consumed in generous amounts, including Hawthorn (Crataegus oxycanthoides), Rosehips (Rosa spp.), Japapushpa (Hibiscus rosa-sinensis), Haridra (Curcuma longa), Amalaki (Phyllanthus emblica) and Bilberry (Vaccinium myrtillus).
Like Ayurveda and TCM, Western herbal medicine calls for the use of stimulating rubifacient topical remedies for sprains and tears, where the skin is unbroken. One notable remedy is Compound Tincture of Myrrh, originally formulated by Samuel Thomson as his “number six” remedy. This remedy is used following traumatic injuries both internally in drop doses and externally as a liniment. The following recipe is given in King’s American Dispensatory (1898):
- Cayenne (Capsicum annuum) powder, 32 g
- Myrrh (Commiphora myrrha) resin powder, 125 g
Percolated with 90% alcohol to yield one liter of tincture
In more recent years herbalist John Christopher’s “Bone, Flesh and Cartilage” (BF&C) formula has been recommended, used topically as a cream, oil, salve, fomentation and bath, and internally as a tincture or tea, in both acute and chronic injury. While there are many variations, the original formula is as follows, made from equal parts:
- Oak bark (Quercus alba)
- Marshmallow root (Althaea officinalis)
- Mullein herb (Verbascum thapsus)
- Wormwood herb (Artemisia vulgaris)
- Lobelia herb (Lobelia inflata)
- Skullcap herb (Scutellaria lateriflora)
- Comfrey (Symphytum officinalis)
- Black Walnut leaf (Juglans nigra)
- Gravel root (Eupatorium purpurea)
Rx: 2-3 cups daily, and/or applied topically as required as a fomention or medicated oil
Generally speaking, herbal medicine avoids using high doses of individual supplements, although in injury supplementation is warranted. Thus nutrients important in tissue healing may be important to include as part of the overall protocol, including vitamins A, B, C, D, E, K, bioflavonoids, and minerals such as calcium, magnesium and zinc. Adequate protein in the diet is key to rebuilding damaged tissue, and this attention may also be directed to the efficiency of the digestion, assimilation, and the excretion of wastes.