Spring 1982 - Athletic Training History

After the history is obtained, the physical examinationis performed and frequently this is initially conducted bythe trainer in the Training Room or on the field. Afrequent physical finding associated with groin orhamstring injuries is pseudoparalysis. Pseudoparalysis isa false paralysis of the extremity involved and can occuras a result of pain and guarding. It can also occur becauseof hemorrhage about the sciatic nerve which is intimatelyassociated with the hamstring muscles. It can result in aninability or unwillingness to move the extremity.Tenderness is an invariable adjunct and the maximumarea of tenderness will most frequently be in the area ofthe injury. A palpable gap in the tendon or muscle may bepresent in severe injuries and local swelling can occurrapidly with subsequent hemorrhage. As time passes, thehemorrhage becomes visible in the subcutaneous tissue.The athlete will have pain on contraction of the muscle aswell as pain on passive stretching of the involved muscle.The next step in diagnosing the injury is x-ray. X-raysshould be obtained prior to initiation of any form oftreatment as occasionally the x-ray will show fracture or,potentially, a tumor that was unsuspected. The treatmentfor these injuries differs substantially from the treatmentfor musculotendinous injuries.TreatmentThe initial treatment in all soft tissue injuries calls forrest, ice, compression and elevation. This can be initiatedprior to obtaining an x-ray of the involved area. If the x-ray reveals bony injury, surgery may be indicated. Afterx-ray has been obtained and it has been determined thereis no fracture or bony problem requiring furthertreatment, an attempt should be made to reduceinflammatory response and decrease the edema and scartissue characteristic of the healing process. The use ofsteroids is controversial. However, the use of injectableor phoresed steroids is not contra-indicated and can bebeneficial in obtaining more rapid healing with lessresidual scar formation in injuries of the muscle belly. Theuse of steroids proves less effective in treatingmusculotendinous injuries and least effective in treatingintratendinous injuries. Steroids should never be usedwithout the knowledge and consent of the team physician.The use of DMSO (dimethyl sulfoxide) is morecontroversial in treating musculotendinous injuries thanis the use of steroids. The advertisement, availability, andopen discussion of the use of DMSO in athleticpublications and daily newspapers has led many athletesand non-athletes to try it on their own. The use of DMSOin treating acute strains of groin or hamstringmusculature has proven extremely effective in reducingthe inflammatory response, initial swelling, and thediscomfort associated with gentle early stretching andmotion associated with this type of injury. If the patientrequests this form of therapy, it is most efficacious whenused in conjunction with an inert dilutent bringing thepercentage of DMSO to sixty percent. Skin reactions aremore prevalent when the more concentrated forms ofDMSO, available in the local hobby shops and health foodstores, are used.Oral non-steroid anti-inflammatory agents are effectivein reducing both the pain and edema accompanying thistype of injury. These non-cortisone, anti-inflammatoryagents function to reduce the inflammatory responsewhile releasing endogenous endorphins, the natural painkiller, which is present in the human central nervoussystem. The use of injectible local anesthetics can behelpful in reducing spasm when therapy is initiated. It isimportant to note that none of these treatment modalitiesare recommended solely for the purpose of allowing theathlete to return to competition. They serve as adjunctsto maximize the healing rate and insure a rapid return toconventional therapy. They should never be used as apanacea to allow the athlete to return to competition priorto the healing of the injury. These patients should beplaced on crutches until their acute pain has subsided oruntil they are able to ambulate without discomfort.During this time, the modality treatment available in theTraining Room can be initiated. These agents also areaimed at reducing the scar tissue and edema associatedwith the healing process. Ultrasound is helpful as is theuse of transcutaneous nerve stimulation andelectromuscular stimulation: the transcutaneous nervestimulator to diminish the discomfort and theelectromuscular stimulator (EMS) to initiate isotoniccontractions. Friction massage as described by Cyriax isvery helpful in mobilizing scar tissue. The use of whirlpooland local heat can also be helpful. When full range ofmotion can be obtained without pain, gradual progressiveresistance activities, exercises utilizing free weightsand/or pulley systems, Nautilus and Universal systemsshould be initiated. Gradual resumption of activities, totolerance, can then be allowed.Of these forms of treatment, rest is perhaps the mostimportant followed by a stretching program which ismaintained until a full range of motion is achieved.There are multiple predisposing factors that can beidentified prior to the actual injury. These predisposingfactors include selective muscle weakness, imbalance ofthe quadriceps and hamstrings, and muscle/ligamenttightness. The quadriceps-hamstring ratio can be a factorand Klein and Allman have suggested a .60 ratio. That is,the hamstrings should be 60% as strong as thequadriceps. Liemohn has demonstrated in athletes thathip joints injured were less flexible than the opposinguninjured joints. Hamstring-quadricep strength ratios, aswell as strength imbalances between the left and rightlegs may be a predisposing factor in causing injuries.Burkett found there was a relationship in differentialstrength between the hamstrings (right and left). That is,an unequal bilateral flexion-extension strength ratiopredisposed one to hamstring injuries.The time the athlete loses from activity is significantfor any of these injuries and pre-activity evaluation isessential in prevention. This pre-season evaluation shouldbe done prior to competition and should consist offlexibility and strength evaluations, and identification ofpotential injuries. Preventative measures such asstrengthening and stretching programs should beinitiated under the guidance of the trainer. Once theappropriate strength ratios and flexibilities have beenobtained, it is important to continue with a warmup andstretching period prior to vigorous physical exercise,either practice or competition. It is the duty of the trainerto clarify this to the coaches involved. +NOTE: "A special thank you to Mary Roberts for allowing thepictures of herself to be usedin the illustrations."References1. Grant JC, Basmajian JV: Grant's Method of Anatomy.Baltimore, Md., The Williams and Wilkins Company, 1965.2. Burkett LN: Investigation into Hamstring Strains: TheCase of the Hybrid Muscle, Journal of Sports Medicine, 3(5):228-231,1975.3. Burkett LN: Causative Factors in Hamstring Strains,Medicine and Science in Sports, 2(1): 39-42,1970.4. Liemohn W: Factors Related to Hamstring Strains, Journalof Sports Medicine, 18: 71-76,1978.5. Klein KK, Allman FL: The Knee in Sports, Austin,Pemberton Press, 1969.Athletic Training • Spring 1982 45